Guest Column

Formalize planning for continuum of care

Identify gaps and develop solutions

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Health care organizations now are recognizing the clinical and economic value of continuum-of-care planning. The goal is to ensure access to health care services at all levels of intensity. This can be accomplished only through efficiencies in clinical process and effective management of resources. To ensure patients are cared for in the most appropriate, least-restrictive environment, a variety of treatment and service options must be available.

This includes providers’ facilities as well as family and community support systems. While not all people in your community will need access to every service, all necessary patient care options must be present and coordinated. A community-based continuum-of-care planning process, ideally led by the hospital, is key to the success of patient care coordination. Through the development of a continuum-of-care plan, caregivers in all settings will be better able to meet the specific needs of patients. The plan includes action steps that encourage better resource utilization and maximum self-sufficiency for patients.

Continuum-of-care planning provides health care organizations and community providers with an opportunity to step back, critically assess health service capacity, and develop solutions where gaps are identified. Providers can be proactive rather than reactive. Service or demographic changes in the community can be responded to more quickly (e.g., new drug therapies for people living with HIV/AIDS, which change the health care delivery models for this population).

Historically, health care services have been fragmented. Continuum-of-care planning helps providers identify ways of coordinating and linking resources to avoid duplication and facilitate seamless movement among care settings.

Communities can develop a common vision of the health care continuum and a set of common goals. Most importantly, continuum-of-care planning involves stakeholders in all settings and services with the goal of educating these stakeholders and getting them to become part of the solution.

The plan for patient care continuity in your community should address and deal with all people who may need health care services and involve the breadth of service options. Solutions to complex health care problems require carefully developed action plans with input from all stakeholders. The steps of continuum-of-care planning are listed below:

  • Organize an annual continuum-of-care planning process.
  • Collect needs data and inventory capacity.
  • Determine and prioritize gaps in the continuum of care for patients.
  • Develop short- and long-range strategies with action plans.
  • Implement action plans for improving the continuum of care.

The steps in the planning process are described in greater detail below:

A core working group of stakeholders that represent all aspects of patient care services, including people representing the patient’s viewpoint, should be selected. Be sure that the major players in the health care community are involved; don’t overlook public and private support services.

It may be important to tie in with existing health care planning efforts at the local or state level. Start by helping the work group understand the concept of the patient care continuum. For example:

  • What should the continuum of care system include?
  • How should it operate?
  • Whom should it serve?
  • What relationships should exist?

From this understanding, the work group can develop a common vision of the ideal continuum of care and consider its desired outcomes. When embarking on a continuum-of-care planning process for the first time, it is particularly important for the core work group to communicate the continuum-of-care concept throughout the community. Create opportunities for providers and patients to look at the health care system as a whole and develop a common understanding of the gaps and a vision for what the ideal continuum would look like. Depending on the size and diversity of your community, this initial visioning process may be best accomplished through a single meeting with stakeholders or a series of smaller meetings.

The hospital can take the lead in organizing the continuum-of-care planning process in the community. The potential benefit of hospital leadership is that people may view the hospital as having the capacity to get tasks done and coordinate key links with health care resources. However, the hospital must be sensitive to concerns that the continuum-of-care process may be too directive, top-down driven, or not inclusive enough. It is important that whatever group leads the planning process be able to effectively recommend change and oversee continuity of care improvements.

Capacity assessment

Various data sources will be needed to identify critical gaps in the continuum of care. Start this process by asking people in the initial community meetings to provide firsthand experiences of where they’ve had problems providing patients with appropriate health care services. The information will be useful as you begin to identify methods and resources to more rigorously gather the data that is needed.

An essential foundation of a continuum-of-care plan is an assessment of the extent and types of needs experienced by people who are seeking health care services in the community. There isn’t one correct way to collect needs data, but the core work group, in cooperation with the broader community of providers and stakeholders, must decide on a methodology and identify the resources and systems necessary for carrying out data collection. You’ll need to inventory the existing capacity available in the community to meet health care needs. This assessment should be conducted in the context of the continuum-of-care concept (i.e., acute care, skilled care, rehabilitative services, home health, outpatient care, community services, emergency care, transitional programs, assisted living, and other health care services). The inventory provides the work group with an opportunity to look at existing capacity within the framework of the patient care continuum.

The approach used to inventory capacity will vary depending on the size and complexity of the health services system.

The hospital may want to take the lead in conducting an inventory and then present its findings to the work group for input and reality testing.

Gap analysis

The first step for determining gaps in the continuum of patient care is to quantify unmet needs. This involves a calculation between the estimated amount of need (based on the needs data collected) and the current capacity of the continuum of care. When completing the gap analysis, the work group will discuss issues such as:

  • Are there major gaps in one or more types of health-related services?
  • Are there length of stay or waiting list issues?
  • What is preventing people from obtaining needed services?
  • Are links in place for people in post-acute facilities for transitioning to home or residential care?

Determining gaps and their relative priority are fundamental steps in the continuum-of-care planning process. Decisions regarding the relative priority of gaps (i.e., low, medium, and high) are the basis for developing strategies to add new resources or strengthen existing resources to best assist people who need health care services. In order to help prioritize among the list of gaps, the core work group can use a set of qualitative criteria. Look at relative need among subpopulations (e.g., people with chronic conditions, terminal patients, high-risk pediatrics, etc.). Consider the vulnerability of the populations (e.g., age, diagnosis, financial resources, etc.). Decide whether the need for health care services is growing, and if so, how rapidly.

This analysis will help providers and key stakeholders agree on what problem areas need to be addressed first (i.e., whether a gap gets a low, medium, or high priority).

It is important to note that low priority does not mean that there is not an unmet health care need. Rather, it means that, relative to other unmet needs or gaps, it is less of a priority.

After determining and prioritizing gaps, strategy development and action planning begins. That can occur through the creation of subcommittees, each of which is responsible for developing strategy statements and preliminary action steps for resolving high-priority gaps. These subcommittees should be encouraged to enlist the expertise of other community members in the process of developing strategies.

Consider strategies that do not require additional resources but merely require changes in policies, procedures, or reallocation of existing resources. Assess the availability of federal, state, local, and private resources that might be used to fund various initiatives.

To ensure that the continuum of care plan is outcome-oriented, each strategy should include action steps, point(s) of accountability, and a time frame. Identify which organization(s) are responsible for each "next step." The strategy statement and action plan worksheet can be useful for documenting subcommittee decisions. Once developed, strategies and action steps should be made available for community input and comment. Find how whether key stakeholders agree that the strategies are critical and the proposed actions feasible.

Improving the continuum of patient care in your community will require that responsibilities are clearly established and progress is monitored.

If the hospital has taken the lead in the planning process, it will likely be hospital staff who are responsible for monitoring the implementation of the action steps. It is important to schedule regular meetings of the core work group meetings where progress on the plan’s implementation is reported. Measures of success, based on the original continuum of care plan goals, are useful tools for evaluating goal attainment.

Continuum-of-care planning is critical

High-quality patient care is not merely health services provided over a defined time period, but rather a full and sustained continuum of care — promotion, prevention, interventions (minor to major) — leading to cure or maintenance at some level, regardless of an individual’s age or condition. Interventions include primary and specialty medical care, a wide array of support services, rehabilitation services, and environmental structuring. An effective continuum of care promotes optimal personal autonomy, human dignity, and quality of life. Effective continuity of patient care in a community does not happen without significant planning and work by all care providers. Development and periodic updating of the community’s continuum of care plan can help to assure that people needing health care services will get them.

[Editor’s note: The newly released book, Measuring and Improving Continuity of Patient Care, will help you take a critical look at how patients move through the systems of care in your organization. It will stimulate your thinking about the links among care components, patients, and families and help you identify how continuity of care can be optimized. For ordering information contact Brown-Spath & Associates at (503) 357-9185, or visit their web site at:]