2 Care Coordination and Continuity
Learn how care coordination, shared plans, and reliable transitions help people receive appropriate, connected care across providers and settings.
across settings
deliberately organizes care activities and information-sharing among the people involved in a person’s care. Its purpose is to make sure the person’s needs and preferences guide safe, appropriate services, particularly when care involves multiple providers or settings.
People may receive care from hospitals, primary-care and specialty clinics, rehabilitation or skilled-nursing facilities, home-health services, pharmacies, and community organizations. Coordination helps these providers work toward shared goals instead of making decisions from disconnected records or plans. The person receiving care—and, with their agreement, a caregiver or support person—should be included in decisions and planning.
Effective coordination involves:
Identifying needs, preferences, goals, and barriers to care.
Agreeing who is responsible for each task and who will follow up.
Sharing relevant information promptly with the people who need it.
Coordinating referrals, appointments, medications, equipment, and community supports.
Monitoring progress and updating the plan when needs or circumstances change.
Transitions of care
A occurs when a person moves between settings, providers, or levels of care. Examples include moving from a hospital to home, from a hospital to rehabilitation, or from primary care to a specialist. Care can be disrupted if essential information, services, or responsibility do not follow the person.
A safe transition is a process, not simply a discharge. The sending and receiving providers should communicate a clear plan, and the person and caregiver should understand what happens next.
Prepare: Identify the person’s goals, care needs, preferences, risks, and likely support needs.
Plan: Confirm the destination, referrals, follow-up appointments, medications, equipment, and services needed.
Handoff: Send accurate, relevant information to the receiving provider in time for them to act on it. Clarify who is responsible during the transfer and confirm that the receiving provider has accepted the handoff.
Support: Explain the plan in understandable terms. Check that the person or caregiver knows how to manage care and whom to contact with questions or worsening symptoms.
Follow up: Confirm that services and appointments began, address problems, and revise the plan if needs have changed. —comparing medication lists and resolving differences—is an important part of many transitions.
Before a person with heart failure leaves the hospital for home, for example, the team confirms the medication list, arranges any ordered home-health support, shares discharge information with the primary-care clinician, schedules follow-up, and explains which symptoms require a call. The coordinator then checks whether the appointment and services were arranged and helps resolve any gaps.
Shared plans and team communication
A is a current, person-centered reference that helps the person and care team coordinate actions across providers and settings. It should reflect the person’s goals and preferences and clarify what each participant is doing. Depending on the person’s needs, it may include:
Health concerns, goals, and agreed actions.
Current medications and relevant allergies.
Services, referrals, equipment, and appointments.
The names or roles of responsible team members and how to contact them.
Follow-up steps, warning signs, and what to do if the plan is not working.
A plan is useful only if it is shared appropriately, understood, and updated when care changes. Team members should communicate changes so that different parts of the team do not act on conflicting instructions.
means arranging for needed care and supports to continue through a change in setting or provider. This may involve confirming medication access, equipment delivery, home or community services, and follow-up care.
A transition is not complete merely because a referral was made. The team should verify that the receiving provider or service is in place and address any interruption. connects people, providers, information, and services around the person’s needs and goals; safe transitions depend on a clear shared plan, timely handoffs, agreed responsibilities, coordinated medications and services, and follow-up to confirm that care continues in the new setting.