CONTINUITY OF CARE

Planning for and providing nursing interventions that promote health, prevent illness,
and support coping with disability
are critical in today’s culturally diverse society.
- must also consider how those needs will be met as the patient makes the
transition from the acute care
setting to care at home with support and services from his or her
community

I. CONTINUITY OF CARE
- process by which healthcare providers give appropriate, uninterrupted
care and facilitate the patient’s
transition between different settings and levels of care
- ensures smooth transition between ambulatory or acute care and home
healthcare or other types of
healthcare settings in the patient’s community
- coordination helps ensure a patient-focused and individualized
continuum of healthcare so that the
patient may attain maximum recovery and health
- the nurse is often the primary person responsible for communicating the
patient’s needs, teaching
self-care, and in many instances, providing care
- primary responsibility of the nurse as caregiver is ensuring
continuity of care

A. ADMISSION TO A HEALTHCARE SETTING

- all people who enter a healthcare setting (an environment where they
are surrounded by strangers
and different sounds, sights and smells) take on a new role (most
often as patient)
- nurses provide holistic care and establish the basis for how patients will
respond to and evaluate the
remainder of their stay
- nurse acts as practitioner and advocate
- standards assert that each patient’s need for nursing care related to
admission should be assessed
(consideration of biophysical, psychosocial, environmental, self-
care, educational, discharge
planning) by a registered nurse
- information collected includes full name, address, date of birth, name of
admitting physician, gender,
marital status, nearest relative, occupation and employer, financial
status for healthcare
payment, religious preference, date and time of admission,
identification number, admitting
diagnosis

1. Ambulatory Care Facility

 - facilities in which the patient receives healthcare services but
does not remain overnight
- goal is to provide patients who are able to provide self-care at
home with assistance as
necessary from healthcare providers
- patients are seeking health promotion, health maintenance, or
medical or surgical treatment

a. Same Day Surgery – screening tests, teaching and admission

procedures are usually
completed before patients enter the setting
- patient arrives at the setting, has the procedure, and goes
home when recovery is
satisfactory
-if outpatient or short-stay surgery is in the hospital setting,
the regular admission
procedures are completed on arrival; in most instances,
screening tests and
teaching are done the day before the procedure
- it is the nurse’s responsibility to asses what has been done
and tailor the care plan
to the patient’s needs

2. Hospital
- admission begins in the admitting office
- identification bracelet is issued
- includes patient’s and physician’s name
- important because it ac curately identifies the individual
for procedures and
treatments (administering meds, diagnostic tests,
surgery)

a. Preparing the Room – position bed, open bed by folding back the
top bed linens, assemble
routine equipment and supplies (bath basin, water pitcher,
drinking glass, tissues,
soap, lotion, gown), assemble special equipment and supplies
(oxygen therapy,
cardiac monitoring, suction equipment), and adjust the
physical environment of room
(lights and temperature)

b. Welcoming the Client to the Unit – patients should be welcomed in

the same courteous
manner that would be used in welcoming a guest into one’
own home
- nurse should assess the needs of the patient and family and
they should mutually
agree about whether family should be present during
admission
B. TRANSFER WITHIN AND BETWEEN SETTINGS
1. Transfer Within the Hospital – all personal belongings must be moved and
put in the new room
- patient’s chart, Kardex, care plan, and medications must be
correctly labeled
- other hospital departments (dietary, pharmacy, physical therapy)
must be notified of the
move
- nurse in original area give a verbal report about the patient to the
nurse in the new area
- should include patient’s name, age, physician(s), admitting
diagnosis, surgical
procedure (if any), current condition and manifestations,
allergies, medications and
treatments, laboratory data, and any special equipment
(ventilators) that will be
needed to provide care
- nursing care priorities are identified and existence of
advance directives are noted

2. Transfer to a Long-Term Care Facility – when patient is transferred, he or

she is discharged from the
hospital setting but a copy of the chart may be sent to the long-
care facility (depending on
physician’s preference and agency’s protocol)
- original chart is a legal document and remains at the
hospital
- all of the patient’s belongings are carefully packed and sent to the
new facility with the
patient

C. DISCHARGE FROM A HEALTHCARE SETTING

- patients are discharged from a healthcare facility when the expected
outcomes of care are met and
the patient or caregiver has the necessary knowledge and skills to
provide care

1. Discharge planning – also referred to as continuity care

- process by which healthcare providers give appropriate,
uninterrupted care and facilitate the
patient’s transition between different settings and levels of
care
- purpose is to ensure that patient and family needs are
consistently met as the patient moves
from the acute care setting to care at home
- key to successful discharge planning is an exchange of
information among the patient,
caregivers, and those responsible for care, while the patient
is in the acute care
 setting and after the patient returns home
- communication is important to decrease anxiety and increase the
rate of reaching maximum
potential of wellness as quickly as possible

a. Components
i. Assessment – collecting and organizing data about the
patient
- includes the family because both the patient and
family must be actively
involved if the transition from the healthcare
setting to home is to be
effective
- factors to asses are health data, personal data,
caregivers, environment,
financial and support resources, ability to carry
out activities of daily
living
- nursing diagnoses identify needs of both the patient
and family
- determine whether problems are present now or
are potential
problems

ii. Mutually Setting Goals – expected goals are set mutually and
must be realistic if they
are to be met
- patient may fail to follow the plan if the goals that are
not mutually agreed on
or are not based on a complete assessment of
the patient’s needs

iii. Teaching – important topics about self-care at home must be

covered
- include medications, procedures and treatments, diet,
referrals, and health
status
- patient needs to understand the drug names,
dosages, purpose, effects,
dosing schedule, and possible side effects
- should provide information on which pharmacies
offer the
appropriate and needed medications
- information should be given both verbally and in
writing
- all steps of a procedure (dressing changes) should be
demonstrated,
practiced, and provided in writing
- purpose of the diet and its expected outcomes should
be clearly described
 (written diet plans and meals might be helpful)
- patient and family should know how to contact the
providers of follow-up
care and should know whom to call if they have
questions or
problems

iv. Providing Home Healthcare Referrals – physician must write

an order for all services
and patient must meet the eligibility criteria
- information includes kind of surgery or injury,
medications, patient’s physical
and mental status, significant social factors and
family’s expected
needs
- patients should be aware of home health agencies
available and how other
units operate

v. Evaluating Discharge Planning Effectiveness – evaluating

discharge plan is crucial to
ensure that the planning works
- planning and referrals must be scrutinized to ensure
the quality and
appropriateness of services
- evaluation is ongoing and may require changes

2. Leaving Against Medical Advice (AMA) – although the patient is

legally free to do so, this choice
carries a risk for increased illness or complications
- patient must sign a form that releases the physician and
healthcare institution from any legal
responsibility for his or her health status
- patient must be informed of any possible risk before signing
- patient’s signature must be witnessed and the form becomes a
part of patient’s record
II. MODELS OF NURSING CARE

A. FUNCTIONAL NURSING – nurses and other staff are assigned to specific tasks for a
group of patients
- based on the assembly-line concept found in industry, specializing tasks
increases efficiency but
results in impersonal care

B. TEAM NURSING – team made up of a registered nurse and other caregivers

provides care to a designated
group of patients on a given shift
- modified the depersonalized approach of functional nursing and focused
on individual patient care
C. PRIMARY CARE NURSING – nurse is accountable for planning, evaluating, and
directing the care of a patient 24
hrs a day throughout the patient’s stay
- method of providing comprehensive, individualized, and consistent care
- expensive

D. Shared Governess (Magnate Services) – cross functional teams consisting

of groups of professionals and
assistive personnel from patient-nursing and other departments work
together as a unit-based team to
provide care to a given group of patients
- care is designed around the needs of the patients and not the needs of
the departments or
professionals