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Evidence-Based Care Across
the Continuum: Its Time Is (Finally) Now
White Paper
Authors:
Grant G. Campbell MSN, RN
Michele Norton MS, RN
Clyde Wesp, Jr., MD, MA
Executive Summary
Healthcare industry leaders are likely to relate to Einstein’s observation.
Achieving optimal patient outcomes by planning and coordinating clinical care
across the entire continuum always has been a challenge. Nothing new about it.
A confluence of industry forces, however, is creating an increased sense of
urgency for reaching this long-standing goal. Understanding why there is a
need for change is easy; it’s the “how” that’s difficult.
Indeed, the real challenge for healthcare leaders rests in navigating the myriad
challenges associated with the move toward the delivery of standardized
evidence-based healthcare across the continuum of care. The results, however,
are apt to be well worth the effort as the utilization of best practices across
the continuum is expected to exponentially result in better patient outcomes,
improved processes, and reduced costs.
A LONG HELD CARE CONCERN
Continuity of care refers to the degree that care is coherent and linked. The value associated with
“The release of atomic
energy has not created a
new problem. It has merely
made more urgent the
necessity of solving an
existing one.”
- Albert Einstein
coordinating care across the continuum has been recognized for quite some time. In fact, a British
Medical Journal literature review that examined publications dated from 1996 to 2001 identified 2,439
unique documents related to the subject.1
After analyzing these documents, researchers defined achievement of continuity of care as “bridging
discrete elements in the care pathway — whether different episodes, interventions by different
providers, or changes in illness status — as well as by supporting aspects that endure intrinsically over
time, such as patients’ values, sustained relationships, and care plans.” In addition, the researchers
found that “for continuity to exist, care must be experienced as connected and coherent.”
The researchers also identified 3 different types of continuity:
I nformational continuity. The use of information on past events and personal circumstances to
make current care appropriate for each individual.
M
anagement continuity. A consistent and coherent approach to the management of a health
condition that is responsive to a patient’s changing needs.
Relational continuity. An ongoing therapeutic relationship between a patient and ≥ 1 providers.1
A variety of studies suggest that continuity of care does, in fact, deliver value. For example, a study
published in the Journal of the Royal Society of Medicine suggests that continuity results in benefits
such as improved:
• Preventive care
• Quality of diabetes care
• Adherence to treatment
• Patient and physician satisfaction2
Other studies illustrate the power of continuity as well. For example, research presented in the
Archives of Family Medicine showed that higher provider continuity was associated with lower
emergency department (ED) use among patients supported by Medicaid.3 Similarly, a study in
Pediatrics found that increased continuity of care was associated with a decreased number of visits to
the ED and admissions to the hospital.4
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Evidence-Based Care Across the Continuum
2
The importance of carrying this continuity across providers also is coming into play. The National
Quality Forum (NQF) has stated that care coordination “helps ensure a patient’s needs and preferences
for care are understood, and that those needs and preferences are shared between providers,
patients, and families as a patient moves from one healthcare setting to another.” Care coordination
is considered especially important for people with chronic or complex conditions who receive care
in multiple settings from numerous providers. The NQF also has stated that care coordination
“maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and highquality patient experiences and improved healthcare outcomes.”5
THE NEED FOR SPEED
Although the concept of coordinated care across the continuum has been around for quite some time,
the constant call to improve care quality has healthcare organizations feeling increased pressure to
make such coordination a reality — not just a “nice-to-have.” An examination of emerging trends sheds
light on exactly what’s behind this ever-more pervasive push to deliver evidence-based health care
across the continuum.
Increased consumer involvement in healthcare decision-making. Although patients were once content
to accept what their healthcare practitioners offered as the unquestionable gold standard, they no
longer do so. Today’s patients are much more informed and are likely to question what healthcare
professionals are providing and demand the best care possible.
Of course, patients are garnering much of their knowledge from the Internet. According to a recent
study, about 80% of Internet users have searched online for healthcare information.6 Patients don’t
just acquire the knowledge in a vacuum. Instead, they are interested in applying it to their own situation
— and, therefore, they have become more focused on staying on top of their health status as well. To
support this consumer involvement, US Department of Health & Human Services Secretary Kathleen
Sebelius recently proposed new rules that would expand the rights of patients to access their health
information, specifically laboratory results, through the use of health information technology.
“When it comes to healthcare, information is power. When patients have their lab results, they are
more likely to ask the right questions, make better decisions, and receive better care,” said Secretary
Sebelius.7
Health reform and value-based purchasing. Under the Patient Protection and Affordable Care Act,
health providers are no longer reimbursed solely on the quantity of services provided — but instead on
the quality of services.
The Act’s value-based purchasing program zeros in on how closely hospitals follow best clinical
practices and how well hospitals enhance patients’ care experiences. Beginning in 2013, hospitals
will incur a payment reduction if they have readmissions within 30 days of discharge for patients with
myocardial infarctions, heart failure, and pneumonia. By 2015, most hospitals will face reductions in
Medicare payments if they do not meaningfully use information technology to deliver better, safer,
more coordinated care. As such, health care organizations can no longer focus only on the static
inpatient care experience but also must focus on the entire spectrum of services across the continuum
that ultimately contribute to patient outcomes.
Partnership for Patients program. Introduced in 2011, this federally funded program focuses on
preventing injuries and complications in hospital patients. While the program aims to address all forms
of harm to patients, it is initially focusing on 9 types of medical errors and complications where the
potential for dramatic reductions in harm rates has been demonstrated by pioneering hospitals and
systems across the country. Examples include preventing adverse drug reactions, pressure ulcers,
childbirth complications, and surgical site infections. Overall, the program aims to save 60,000 lives
over 3 years by avoiding millions of preventable injuries and complications in patient care. In addition,
the Partnership for Patients initiative also has the potential to save up to $35 billion in healthcare costs
over 3 years, including up to $10 billion in Medicare expenditures alone.
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Evidence-Based Care Across the Continuum
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Emerging Meaningful Use requirements. Meaningful Use Stage 2 requirements focus more closely
on advancing clinical processes. For example, the Stage 2 requirements include a more robust
“transitions of care” measure that actually requires the electronic exchange of summary of care
records, not merely the exchange of key clinical information. More ambitious patient engagement
requirements are also included. For instance, CMS replaced the “provide patients with an electronic
copy of their health information” Stage 1 objective with a “provide patients with the ability to view
online, download, and transmit their health information” Stage 2 core objective. Meaningful Use
Stage 3 requirements are expected to zero in on outcomes by requiring providers to improve quality,
safety, and efficiency that will lead to improved health outcomes; adopt decision support for national
high-priority conditions; provide patients with access to self-management tools; enable access to
comprehensive patient data through patient-centered health information exchanges; and support
population health improvements.
The rise of accountable care organizations. From its inception, the reform legislation generated
significant interest in accountable care organizations (ACOs). An ACO is a group of providers that
is willing to work together to manage and coordinate the care of the group’s assigned Medicare
fee-for-services beneficiaries and to be accountable for the quality, cost, and overall care of
these beneficiaries. If the group — through the management and coordination of these Medicare
beneficiaries’ care — is able to provide high-quality, accessible care at a significant savings to
Medicare, then the providers in the group share this savings. The ultimate goal is not to pay providers
on the basis of the number of tests they order and procedures they perform, but rather on the basis of
their provision of high-quality, accessible, coordinated, low-cost care. Various permutations of the ACO
concept are already emerging separately from Medicare, incorporating a variety of models for provider
cost and quality incentives as well as patient care coordination by a wide range of providers. While the
ACOs are likely to take on a variety of forms, the goal is to create the relational continuity that will help
providers and patients interact more consistently and effectively.
ALL TYPES OF CARE
With these trends providing the motivation, healthcare organizations are seeking to coordinate care
across the continuum and, therefore, improve outcomes in a variety of situations. For example,
improvements in informational continuity can help enhance preventive care efforts. Currently, in most
cases, there is no system in place to monitor if a patient is receiving the appropriate preventive care
across providers. Because providers do not share patient information, it’s difficult to determine if
patients get the appropriate services — whether it immunizations, dental exams, or colonoscopies —
at the appropriate ages.
Management continuity can also lead to improved preventive care. Clinical decision support (CDS),
for instance, can help prompt individual providers to offer needed services. At the same time, health
information exchanges could provide a “source of truth,” enabling individual care providers to ensure
that patients are receiving all recommended preventive services.
If care is coordinated across the continuum, preventive services could be offered and tracked as the
consumer moves from care venue to care venue or from provider to provider — ie, as a child moves
from pediatrician to college health center to internist.
Continuity of care also can help improve outcomes in acute care situations. For example, a study in
the Journal of Nursing Care Quality illustrates how a coordinated initiative for patients with heart
failure was planned and implemented across an entire healthcare system to: (1) incorporate best
evidence-based practice to rapidly stabilize the patients, and (2) establish early, coordinated patient
education to promote self-care at home with the support of appropriate resources. Because of this
coordinated effort, management continuity was improved — and length of stay and readmissions
were significantly reduced.8
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Evidence-Based Care Across the Continuum
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Indeed, information technology can be leveraged to greatly improve care transitions. For example, by
sharing information electronically, SBAR (situation – background – assessment – recommendation)
reporting can be streamlined. Under this scenario, information can be quickly relayed or transmitted to
rapid response teams, expediting the treatment of conditions such as sepsis, which could prove fatal if
not treated immediately.
Creating continuity of care across disciplines also can help improve chronic conditions. For example, a
patient with rheumatoid arthritis might receive services from several providers, including an internist,
rheumatologist, acupuncturist, physical therapist, wound specialist, and podiatrist. If all of these
providers are providing care as prescribed by a coordinated care plan — and providing evidencebased best practice at each juncture — management continuity and subsequently the quality of care
is likely to improve. In addition, if each provider has access to the patient’s complete medical history,
informational continuity will improve and the providers will then have a better understanding of what
types of treatments work and what types do not. For example, a wide spectrum of drugs is used to
treat rheumatoid arthritis, but patients respond to these drugs very differently. By sharing information
about the individual patient, the caregivers are likely to more expediently zero in on effective and
complementary treatments. As such, costs are likely to decrease as the various providers would be
less likely to provide duplicative services.
FROM VISION TO REALITY
Acknowledging the benefits of care coordination across the continuum is only the first step. Healthcare
organizations also need to implement a variety of strategies to bring the vision to fruition:
Embracing a culture of safety and accountability. Healthcare leaders need to make continuity of care
across the continuum a vital component of the organization’s culture. As such, leaders need to make
care coordination among providers an absolute imperative, not an occasional choice.
The New Jersey Hospital Association Pressure Ulcer Collaborative, which includes about 150
healthcare organizations, provides an example of what can be accomplished simply by committing to
— and supporting — change. The effort resulted in a 70% reduction in the incidence of new pressure
ulcers. The improvement did not emanate from a revolutionary treatment but instead from utilizing
a commonly known best practice skin assessment — and, perhaps more importantly, supporting the
intervention by “getting all stakeholders involved, developing a customized patient-centered process,
and having the right tools for the staff to use at the point of care.”9
Creating a plan. For each patient, healthcare organizations should create and sustain a “longitudinal
care plan,” which will direct how care is delivered across the continuum. Such a document can be
thought of as “a single aligned plan of care, semantically available to all disciplines involved, containing
information from disparate health and non-health sources, and fully available to the care/service
recipient and capable of guiding care and interacting with health IT systems to maintain alignment.”10
Under the government’s Meaningful Use Stage 2 requirements, providers will be required to share
such care plans. At a minimum, these plans should contain basic data about the patient, summaries
of the patient’s episodes of care and updated status of current problems. As such, when a patient
presents at a new organization, the caregiver will already have a basic understanding of the patient’s
health and his or her response to various interventions. The care plan could drill down so far as to
offer insight into the type of communication that a patient is more likely to respond to. For example,
a plan might note that a teen patient is more likely to comply with care instructions delivered via text
messages than those delivered in person.
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Evidence-Based Care Across the Continuum
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Designing and implementing a technology infrastructure that supports communication and data
exchange. Healthcare organizations should provide a vehicle that will transfer information from one
provider to the next in an efficient, safe, and secure manner. For example, if a child is showing early
signs of diabetes, it would be necessary to share historical information regarding the child and his
parents among the primary care physician, obstetrician, pediatrician, and endocrinologist. To do so,
all of these providers need to work from an integrated electronic system that shares information
seamlessly.
Organizations are exploring a variety of ways to improve the sharing and exchanging of patient
information, including innovative technologies to connect disparate electronic health record
(EHR) systems. For example, cloud technology could help organizations safely and securely share
information. In addition, organizations are relying on existing methods such as the phone and fax,
or simply providing the information to a patient to share with other providers, while waiting for
more advanced technologies to be adopted in their facilities. To effectively exchange information,
organizations need to agree on the critical information to be shared and how they share
the information.
Forging collaboration. To move forward, healthcare organizations need to create an environment
where clinicians have the capacity and willingness to invest the time and energy in specific care
coordination efforts. Organizational leaders, therefore, need to demonstrate a real commitment to
safety by investing in leadership to manage these initiatives. In addition, the organization needs to set
standards and establish accountability. With such expectations in place, organizations will need to
define new roles and responsibilities for caregivers and other staff members, all designed to improve
care collaboration.
Realizing community engagement. To truly experience the best outcomes, the continuum of care
should be thought of in broad terms — and should include the family, community, schools, and
other community organizations. As such, the healthcare industry can move away from the concept of
healthcare being delivered by a clinician during an episode of treatment to wellness being maintained
through a variety of educational, preventive, and treatment interventions.
Building consensus around standardized evidence-based best practices. Coordinating care across
the continuum also means that organizational leadership and clinicians are committed to the adoption
of standardized evidence-based best practices. Lack of care standardization often results in care
variability, confusion for patients and families, and difficulty in realizing improved outcomes.
Some healthcare organizations have employed these strategies to successfully share information and
coordinate care across the continuum. At Riverside Regional Medical Center, for example, leaders
implemented a Patient-Centered Care Coordination project (PC3@RHS), designed to streamline
the development of evidence-based protocols that span the care continuum. Previously, individual
providers working in “silos” struggled with the development of CDS capable of standardizing care
across the continuum. Under PC3@RHS, clinicians formed an enterprise-wide team that works
with a unified governance process to leverage evidence-based CDS and then efficiently deploy these
standardized best practices to the individual providers. By working collaboratively, Riverside has
reduced the time and resources required to maintain a CDS initiative.
Similarly, at Kettering Health Network, interdisciplinary specialty groups that included a team leader
and primarily bedside staff led the development of an enterprise EHR with standardized CDS. The
teams customized about 160 care plan templates from an outside resource in an effort to meet the
expectations of clinicians. After a 4-month, 3-phased implementation, these teams declared success
— as the health system is now offering standardized, evidence-based care plans and easy-to-use
computerized physician order entry to its physicians across the enterprise.
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All rights reserved.
Evidence-Based Care Across the Continuum
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Other healthcare organizations are embracing similar initiatives, as the industry is experiencing
the “perfect storm” of forces that will move the utilization of standardized evidence-based best
practices from a concept to a reality. For starters, the government is not only calling for increased
care coordination but is starting to financially reward such coordination through the Meaningful Use
initiative as well as the move toward value-based purchasing under health reform. In addition, as
consumers seek to stay well and improve their own healthcare outcomes, they will also demand
higher levels of care coordination. The fact that emerging technologies can enable data sharing and
the utilization of CDS at the point of care will accelerate the adoption of enterprise-wide best practices
across the continuum of care. While organizations will need to overcome a variety of challenges to
support the delivery of standardized best practices across the entire patient care experience, the fact
that the effort is expected to exponentially improve clinical care and financial outcomes will motivate
organizations to move forward by creating the culture, adopting the technology, and supporting the
initiatives that will make evidence-based best practices across the continuum a reality. Indeed, with all
of these forces in play, organizations essentially will have the “atomic energy” required to successfully
overcome the myriad challenges associated with coordinating care across the continuum.
References
1. H
aggerty JL, Reid R, Freeman GH, Starfield BH, Adair C, McKendry R. Continuity of care: a
multidisciplinary review. BMJ. 2003;327(725):1219-1221.
2. G
ray, DP, Evan P, Sweeney K, Lings P, Seamark C, Dixon M. Towards a theory of continuity of care.
J R Soc Med. 2003;96(4):160-166.
3. G
ill JM, Mainous AG III, Nsereko M. The effect of continuity of care on emergency department use.
Arch Fam Med. 2000;9:333-8.
4. C
hristakis DA, Mell L, Koepsell TD, et al. Association of lower continuity of care with greater risk
of emergency department use and hospitalization in children. Pediatrics. 2001;107:524-9.
5. National
Quality Forum, NQF-Endorsed Definition and Framework for Measuring Care
Coordination, May 2006, Endorsed 2010. http://www.qualityforum.org/projects/care_coordination.
aspx?section=Publicand MemberComment2009-10-26#t=1&s=&p. Accessed March 13, 2013.
6. Pew
Internet Project. Health Topics. http://www.pewinternet.org/~/media//Files/Reports/2011/
PIP_Health_Topics.pdf. Accessed March 13, 2013.
7. H
ealth and Human Services. Press Release: Secretary Sebelius spotlights new efforts to empower
patients to increase secure access to health information. September 12, 2011.
http://www.hhs.gov/news/press/2011pres/09/20110912a.html. Accessed March 13, 2013.
8. M
iranda M, Gorski L, et al. An evidence-based approach to improving care of patients with heart
failure across the continuum. Journal of Nursing Care Quality. 2002;17(1):1-14.
9. M
cKnight’s Long-Term Care News. State collaborative boasts 70% reduction in pressure ulcers.
July 18, 2007. http://www.mcknights.com/state-collaborative-boasts-70-reduction-in-pressureulcers/article/103580/. Accessed March 13, 2013.
10. S
tandards & Interoperability Framework. Longitudinal Care Plan SWG Charter.
http://wiki.siframework.org/Longitudinal+Care+Plan+SWG+Charter. Accessed March 13, 2013.
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All rights reserved.
Evidence-Based Care Across the Continuum
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