1. The Continuum of Safety from Home to Residential and Beyond
John Sweeney, CEO

3. Required Care Continuum
Home Care
Acute Care
Residential
Care
Required Care Continuum

4. ‘Continuity of Care is the degree to which a series of discrete health care events is experienced as coherent and connected and consistent with the patient's medical needs and personal context’.
(Haggerty et al., Continuity of care: a multidisciplinary review. British Medical Journal 2003) 

5. “For patients, it is the experience of care as connected and coherent over time.
For providers, it is the experience of having sufficient information and knowledge about a patient to best apply their professional competence and the confidence that their care is recognized and pursued by other providers.”
Canadian Health Services Research Foundation (2002) Defusing the Confusion: Concepts and Measures of Continuity of Healthcare

6. “It is becoming increasingly apparent that health care providers struggle to coordinate health information exchange across care settings and are more likely to have inaccurate and incomplete clinical information.
(Olsen et al, Breakdown in informational continuity of care during hospitalization of older home-living patients: A case study. International Journal of Integrated Care. 2014;14(2). )

7. “ Older individuals, with complex needs, require seamless transitions of care to support them during this stressful period which can expose new vulnerabilities and medical complications.”
Naylor, Mary PhD, RN, FAAN, and Keating, Stacen A. PhD, RN (2008)“Transitional Care: Moving patients from one care setting to another”.

8. Types of Care Continuity
Informational Continuity—timely availability of information, the completeness of information transfer between providers, and is acknowledged or used by a provider.
Management Continuity—communication of both facts and judgements across team, institutional and professional boundaries, and between professionals and patients. Measures of management continuity focus on the delivery of one aspect of care in the continuum of the management plan, most commonly whether follow-up visits are made.
Relationship Continuity—a therapeutic relationship of the patient with one or more health professionals over time.
(CSFRF, 2002 & NCCSDO, 2007)

9. Safety Concerns - Transition of Care
In a review by JCI of the issues regarding Transitions in care, it was identified that communication breakdowns as the primary root cause of ineffective transitions of care.
JCI identified that the Providers communication processes are ineffective during care transitions. Risk factors include:
Expectations differing between senders and receivers of patients in transition.
Inadequate amount of time provided for successful hand-off.
Lack of standardized procedures in conducting successful hand-off.
(Joint Commission International (JCI), 2012)

10. How do we address?

11. Comparable Regulatory Models
Mirrored Communications
Reflective Governance Structures
Care Service Partnerships

12. Comparable Regulatory Models
Safer Better Healthcare
Standard 2.3 Service users receive integrated care which is coordinated effectively within and between services.
Active cooperation with other service providers, in particular when service users are transferring within and between services.
Sharing of necessary information to facilitate the safe transfer or sharing of care, in a timely and appropriate manner
Arrangements to facilitate effective communication.
Provision of information about the process for transfer of care, to ensure clarity for service users and other service providers.

13. Comparable Regulatory Models
JCI: Under Person Centred Care (PCC) Standard
A transfer process is required to ensure that any continuing needs are met by the outside home care organisation or professional. Such a process addresses:
how responsibility is transitioned between health professionals and settings;
who is responsible for the patient during transfer.
The receiving organization is given a written summary of the patient’s clinical and nonclinical condition and the care provided when the home care organization arranges the transfer or has knowledge of the transfer.

14. Reflective Governance Structures
“Governance Inspections found that complying with the governance outcome is the best indicator of quality across the whole service.” (HIQA 2017)
Consistency of Governance Model
Structure
MDT’s
Roles and Responsibilities
Process
Outcomes
Clinical KPI’s

15. Mirrored Communications
Use of standardised patient assessment tools
Communication of standardised patient clinical indicators
Communication of specific patient risks
Provision of a standardised structure and content for patient records
Consistent, person-centred, information transfer, incorporating clinical and non-clinical patient information.

16. Care Service Partnerships
Drive active co-operations to support the Continuum of Care between Home Care & Residential Care
Support Information Sharing (general and patient specific)
Agreement to the use of specific clinical disease protocols
Facilitate Communications between services, including patient follow up
Improve understanding of the challenges of transfer within each sector

17. Can It Be Measured?
Information Transfer via discharge plans and referral records.
Whether relevant information is transmitted and uptake of that information by the subsequent service provider.
Evidence of follow-up post-discharge.
Adherence to key parts of disease-specific protocols appears to be an appropriate way to measure this type of continuity.
Review of how closely management protocols for specific diseases are followed when a patient's treatment spans various settings and providers.
(CHSRF, 2002)

18. Case Study – Mary A. Ireland – Late 2016

19. Mary A.
Homecare – Support the family / Increased Dependency / Challenges
Residential Care – Acceptance / Impact Assessment / Deterioration / Infection
Acute Care – Clinical Management / Discharge
Residential Care – Public / Understanding of Need
Outcomes – The Individual / The Carers ??

20. Comparable Regulatory Models
Mirrored Communications
Reflective Governance Structures
Care Service Partnerships

21. References
Canadian Health Services Research Foundation (2002) Defusing the Confusion: Concepts and Measures of Continuity of Healthcare.
Haggerty, JL, Reid, RJ, Freeman, GK, Starfield, BH, Adair, CE and McKendry, R (2003). Continuity of care: a multidisciplinary review. British Medical Journal 327(7425): 1219–21.
Health Information and Quality Authority (2012) Safer Better Healthcare.
Joint Commission International (2012) Transitions of Care: The need for a more effective approach to continuing patient care
Joint Commission International (2012) Accreditation Standards for Home Care. 1st Edition.
National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (2007) “Continuity of care 2006: what have we learned since 2000 and what are policy imperatives now? Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D”.
Naylor, Mary PhD, RN, FAAN, and Keating, Stacen A. PhD, RN (2008)“Transitional Care: Moving patients from one care setting to another”.
Olsen RM, Hellzén O, Skotnes LH, Enmarker I. Breakdown in informational continuity of care during hospitalization of older home-living patients: A case study. International Journal of Integrated Care. 2014;14(2). DOI: