Continuity of Care is an organized and carefully coordinated process essential to high quality patient/client care which involves the patient, family, and an interdisciplinary team working together to facilitate the transition of the patient/client from one level of care to another.





Purpose 1:  To define the role of the Continuity of Care professional

Standard A:  The role shall require a specialized body of knowledge of continuity of care principles.



The continuity of care professional shall asses the patient/client's total care according to his /her level of expertise including educational needs; nutritional needs; special therapy needs; supply and equipment needs; support systems; financial needs; transportation needs; and home care needs. The continuity of care professional shall develop and implement a plan of care matching the patient/client's needs with available resources.

The continuity of care professional would meet the educational requirements and adhere to the standards of his/her own discipline, demonstrating professional accountability by:

a. maintaining current State license
b. attending workshops and programs on continuity
of care related issues.
c. seeking and utilizing knowledge of legislative and regulatory changes
d. demonstrating knowledge and understanding of the roles, responsibilities, and educational background of the multi-disciplinary team
e. demonstrating knowledge of community
f. utilizing knowledge and experience in the health care industry
g. maintaining patient/client and family confidentiality
h. educating consumers and professionals regarding discharge planning



Purpose 2:  To define Continuity of Care program guideline

Standard B:
The scope, goals, objectives, and organization of the continuity of care program shall be delineated by each organization


A written description of the program will include the philosophy and scope.
Goals and objectives shall address institutional, professional and patient/client situations.
Written policy, procedures and job descriptions must be updated.
The discharge planning function should be assigned to a person or persons in order to assure professional accountability.



Purpose 3:  To evaluate the Continuity of Care program

Standard C:
Mechanisms for evaluation of the program shall be developed and used to assure quality of care and appropriateness of services.


The following should be used in accordance with each specific program:

a. ongoing quality assurance activities
b. written and telephone surveys
c. peer review 

Problem identification with documentation corrective action.

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