3 Care Coordination and Continuity

Purpose of care coordination

Care coordination deliberately organizes activities among the patient and the people involved in their care. It connects services, shares relevant information, and helps prevent gaps when needs or care settings change. The patient's goals and preferences help guide the plan.

Interdisciplinary teamwork

Care may involve nurses, prescribers, pharmacists, therapists, social workers, case managers, community services, the patient, and caregivers chosen by the patient. Team members should understand their roles, share concerns, and agree on who will complete each action and follow up on it.

Assign tasks to people whose roles and competence fit the task. Clarify who remains responsible for oversight and decisions so that important actions have clear ownership.

Use clear, respectful communication. A structured format such as SBAR—Situation, Background, Assessment, Recommendation—can help organize a message when raising a concern or requesting a decision. Confirm important instructions and clarify disagreements or uncertainty rather than assuming everyone has the same understanding.

Handoffs and transitions

A handoff transfers both information and responsibility for care. The sending clinician remains accountable for a clear transfer until the receiving clinician understands and accepts responsibility. A written or electronic handoff can support the exchange, but direct communication may be needed to confirm key information and resolve questions.

A useful handoff includes:

• Patient identification and the reason for the transfer.

• The patient's current condition, relevant history, allergies, and risks.

• Treatments and medication changes, including what needs monitoring.

• Pending tests or results, and who will review and communicate them.

• Current care goals, preferences, and relevant care instructions.

• Next steps, contingency plans, and contact information for questions.

Use a confirmation step, such as read-back of a critical instruction or explicit acceptance of responsibility, to reduce ambiguity. Document what was communicated, to whom, and any outstanding actions according to workplace policy.

Referrals and follow-up

A referral is more than giving the patient a name or phone number. Explain its purpose and check that it fits the patient's needs and preferences. With the patient's involvement, send relevant information to the receiving service, confirm that the referral was received, and clarify who will act if an appointment is delayed or the service cannot accept the patient. Share information in accordance with applicable privacy requirements and the patient's choices.

Before discharge or transfer, help the patient and caregiver understand what to do, when to do it, which symptoms require urgent help, and whom to contact. Identify practical barriers—such as transportation, medication access, language, or caregiver availability—and coordinate support when possible.

Discharge planning emphasizes the patient's goals and preferences, participation by the patient and caregiver, and transfer of necessary information to providers responsible for follow-up care.

Example: hospital to home

A patient with heart failure is discharged with a changed medication regimen and a referral for home nursing. The nurse reviews the medication list with the patient, checks understanding, and asks about barriers to obtaining the medicines.

The discharge handoff communicates the patient's current status, medication changes, monitoring instructions, pending results, and follow-up plan to the receiving team. The referral is sent with relevant information, receipt is confirmed, and responsibility for reviewing any pending result is assigned. If the home nurse cannot visit as planned, the team knows whom to contact to prevent a gap in care.

Maintaining continuity of care

Continuity of care depends on coordinated teamwork, clear transfer of information and responsibility, and follow-through on referrals. Include the patient in decisions, communicate goals and preferences, make ownership of next steps explicit, and confirm that important information has reached the people who need it.