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Continuity of care is similar to a football team. If all the players do what they want, then there is chaos. If there is a plan, a quarterback providing leadership and co-ordination of the players, then there is a better chance of winning.

Continuity of care is the co-ordination of different types of providers, the recognition and management of active problems according to a shared plan and the management of transitions.

And continuity of care, when it is well managed, is important for achieving superior patient outcomes.

Here’s the case study of Ben, a previously active senior, who entered the hospital in lung failure. He was in the intensive care unit (ICU) on a ventilator for 4 weeks. During his 9 week hospital stay, he lost 60 pounds, could not drink fluids without choking and he could not stand unassisted. Ben had fallen through the cracks.

Who was the doctor most responsible for Ben’s management?  What was care team’s focus? How much did the team know about Ben’s changing problems? How much did Ben know about his issues?

With doctors on duty for only one week out of a seven week rotation, they lost touch with the details of the case. There was poor co-ordination and continuity of care.

Once Rupert Case Management (RCM) was retained, our job was to ” ring the bell”.

Here is what happened. RCM brought awareness of Ben’s core issues and critical decisions to all members of the treating team (doctors, nurses, physios and OTs) on a daily basis. This is very important.

Our nurse case managers were tenacious in discovering the core issues and persistent in communicating core issues and critical decisions to the treating team each day.

In fact, we have designed a matrix to communicate this information visually. To get the care team’s attention, we know that we have to communicate to their visual cortex and engage them emotionally.  This is necessary to get the right actions initiated for Ben.

By improving continuity of care and co-ordination of all the different care disciplines,  Ben got the attention that he needed. Ben started to gain weight. He ate more. He drank his  thickened fluids. He walked with assistance. He perked up and in fact, he got married while still in the hospital. We sent flowers.

We really enjoy helping complex patients by ringing the bell! And here is why we are often needed.

At times, patients’ concerns are not addressed in a systematic manner. Most care is delivered ad hoc.  Patients do not understand their management options. Patients frequently fail to recall basic elements of their care plan. All this is occurring as care becomes increasingly complex.

To manage this complexity, RCM communicated Ben’s core issues and critical decisions to all members of the treating team each day. This provided a dynamic continuity of care management process that shifted the focus to meet new and evolving needs on a real time basis. The result of introducing this process has been consistently higher quality outcomes with fewer errors.

Transitions can be sources of error. The nurse case managers and doctors at RCM act as the “coaches” to ensure that transitions are “seamless”.

We are making a commitment to talk about continuity of care as the 11th commandment.

And isn’t that what healthcare should be about?