Continuum of care planning helps providers identify ways of coordinating and linking resources to avoid duplication and facilitate seamless movement among care settings. Communities should develop a common vision of the health care continuum and a set of common goals. Most importantly, continuum of care planning involves stakeholders in all settings and services with the goal of educating these stakeholders and getting them to become part of the solution.

The plan for patient care continuity in your community should address and deal with all people who may need health care services and involve the breadth of service options. Solutions to complex health care problems require carefully developed action plans with input from all stakeholders. The steps of continuum of care planning are described below.

Organize a Planning Process

A core working group of stakeholders that represent all aspects of patient care services, including people representing the patient’s viewpoint, should be selected. Be sure that the major players in the health care community are involved; don’t overlook public and private support services. It may be important to tie in with existing health care planning efforts at the local or state level. Start by helping the work group to understand the concept of the patient care continuum. For example:
- What should the continuum of care system include?
- How should it operate?
- Whom should it serve?
- What relationships should exist?

From this understanding the work group can develop a common vision of the ideal continuum of care and consider its desired outcomes. When embarking on a continuum of care planning process for the first time, it is particularly important for the core work group to communicate the continuum of care concept throughout the community. Create opportunities for providers and patients to look at the health care system as a whole, and develop a common understanding of the gaps and a vision for what the ideal continuum would look like.
The hospital can take the lead in organizing the continuum of care planning process in the community. The potential benefit of hospital leadership is that people may view the hospital as having the capacity to get tasks done and coordinate key linkages with health care resources. However, hospital representatives must be sensitive to concerns that the continuum of care process may be too directive or top-down driven or not inclusive enough. It is important that whatever group leads the planning process is able to effectively recommend change and oversee continuity of care improvements.

Capacity Assessment

Various data sources will be needed to identify critical gaps in the continuum of care. Start this process by asking people in the initial community meetings to provide first-hand experiences of where they’ve had problems providing patients with appropriate health care services. Hospital and home health case managers can also be a good source of continuity of care problems. This information will be useful as you begin to identify methods and resources to more rigorously gather the data that is needed.

An essential foundation of a continuum of care plan is an assessment of the extent and types of needs experienced by people who are seeking health care services in the community. There is not one correct way to collect needs data, but the core work group, in cooperation with the broader community of providers and stakeholders, must decide on a methodology and identify the resources and systems necessary for carrying out data collection. You’ll need to inventory the existing capacity available in the community to meet health care needs. This assessment should be conducted in the context of the continuum of care concept (i.e., acute care, skilled care, rehabilitative services, home health, outpatient care, community services, emergency care, transitional programs, assisted living, and other health care services). The inventory provides the work group with an opportunity to look at existing capacity within the framework of the patient care continuum.

Gap Analysis

The first step in determining gaps in the continuum of patient care is to quantify unmet needs. This involves a calculation between the estimated amount of need (based on the needs data collected) and the current capacity of the continuum of care. When completing the gap analysis, the work group will discuss issues such as:
- Are there major gaps in one or more types of health related services?
- Are there waiting list or length of stay issues?
- What is preventing people from obtaining needed services?
- Are linkages in place for people in post-acute facilities for transitioning to home or residential care?

Determining gaps and their relative priority are fundamental steps in the continuum of care planning process. Decisions regarding the relative priority of gaps (i.e., low, medium, and high) are the basis for developing strategies to add new resources or strengthen existing resources to best assist people who need health care services. To help prioritize among the list of gaps, the core work group can use a set of qualitative criteria. Look at relative need among sub-populations (e.g., people with chronic conditions, terminal patients, high risk pediatrics, etc.). Consider the vulnerability of the populations (e.g., age, diagnosis, financial resources, etc.). Decide whether the need for health care services is growing, and if so, how rapidly. This analysis will help providers and key stakeholders agree on what problem areas need to be addressed first (i.e., whether a gap gets a low, medium, or high priority). It is important to note that low priority does not mean that there is not an unmet health care need. Rather, it means that relative to other unmet needs or gaps, it is less of a priority.

Develop Strategies and Action Plans

After determining and prioritizing gaps, strategy development and action planning begins. This can occur through the creation of subcommittees, each of which is responsible for developing strategy statements and preliminary action steps for resolving high priority gaps. These subcommittees should be encouraged to enlist the expertise of other community members in the process of developing strategies. Consider strategies that do not require additional resources but that merely require changes in policies, procedures, or re-allocation of existing resources. Assess the availability of federal, state, local and private resources that might be used to fund various initiatives.

To ensure that the continuum of care plan is outcome-oriented, each strategy should include action steps, point(s) of accountability, and a time frame. Identify which organization(s) are responsible for each “next step.” Once developed, strategies and action steps should be made available for community input and comment. Find out whether key stakeholders agree that the strategies are critical and the proposed actions feasible.

Implement Plans

Improving the continuum of patient care in your community will require that responsibilities are clearly established and progress is monitored. If the hospital has taken the lead in the planning process, it will likely be hospital staff that are responsible for monitoring the implementation of the action steps. It is important to schedule regular meetings of the core work group meetings where progress on the plan’s implementation is reported. Measures of success, based on the original continuum of care plan goals, are useful tools for evaluating goal attainment.

Copyright 2005 by Brown-Spath & Associates

To Learn More: Patrice L. Spath is available for in-house presentations on this and other health care performance improvement topics. For further details, visit Brown-Spath & Associates on the web at: http://www.brownspath.com or write to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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