This book helps you evaluate and improve the linkages among caregivers, patients, and families. You’ll discover what steps are necessary to optimize continuity of care for patients and strengthen care management initiatives. The self-assessment tools in the book encourage you to take a critical look at how patients move through the systems of care in your organization and where improvements are needed. Plus you'll find lots of examples of what health care organizations are doing to improve communication and reduce continuity of care problems.
Table of Contents
Chapter 1: Continuity and Quality of Patient Care
The Patient Care Continuum
Episodic vs. Chronic Care Continuum
Fragmented Care
Manage the Hand-Offs
How this Book will Help You
Chapter 2: Defining the Patient Care Continuum
Meet Patient Needs
Critical Activities
Where Breakdowns Occur
Information Flow
Identify and Remove Barriers
Chapter 3: Plan for Effective Continuity of Care
Scope of Services
Continuity is a Strategic Goal
Chapter 4: Processes that Impact Continuity of Care
Entry to Setting or Service
Conduct an Assessment
Special assessments
Emergency department assessments
Consent and information Sharing
Documentation practices
Determine Appropriate Setting
Admission criteria
Collecting additional information
Develop the Plan of Care
Inform Patients
During Active Care
Provide Services
Documentation practices
Communication during key transitions
Conduct Reassessment
Interdisciplinary process
Follow-up systems
Provide Continuing Services
Before and During Discharge or Release from Services
Develop a Discharge Plan
Transfer Patient
Discharge Patient
Pulling it all Together
Information Integration
Chapter 5: Measuring Continuity of Care
Structure Measures
Process Measures
Outcome Measures
Satisfaction with care
Plan for Data Collection
Continuity Measures
Chapter 6: Identify and Reinforce Weak Links
Assess Linkages
Linkage Assessment Tool
Appendix
Figure A-1: Admission Assessment
Figure A-2: Factors to Consider when Making Specialty Consultation Referrals
Figure A-3 Patient Questionnaire Used to Identify Specialized Needs
Figure A-4: Interdisciplinary Care Planning Tool (clinical path)
Figure A-5: Form to Document Initial Team Evaluation
Figure A-6: Patient Education Tool for Same-Day Surgery
Figure A-7: LSUMC Multidisciplinary Documentation Tool
Figure A-8: Patient Status – Caregiver Communication Tool
Figure A-9: Documentation Tool Used by Home Health Nurses
Figure A-10: Outpatient Cardiopulmonary Rehab Patient Progress Report
Figure A-11: FIM Scoring System Documentation Tool
Figure A-12: Emergency Department Patient Call Back Form
Figure A-13: Discharge Documentation Procedure
Figure A-14: Patient Movement Form
Figure A-15: Patient Transfer Form
Figure A-16: Clinical Summary for Patients
Figure A-17: Plan of Care for Pain Control
Figure A-18: Continuing Care Path Used for Patient Education
Figure A-19: Clinic Patient Call Back Form