How to Improve Continuity of Care: 5 Best Practices

For decades, healthcare has trended toward increasing specialization—and with it, growing fragmentation. Patients often found themselves bouncing between providers, with little coordination and no single point of contact guiding their care.

Today, that’s changing. As the healthcare industry moves toward greater continuity of care (COC), the focus is on breaking down data silos and fostering real-time information sharing across systems. The result? Fewer delays, less duplication, and safer, more cohesive care for every patient.

Why is continuity of care important?

Continuity of care reduces medical errors, lowers mortality rates, betters the patient experience, fosters patient trust and engagement, and leads to safer, more effective healthcare.

In addition to improving patient outcomes, COC drives system-wide advances regarding efficiency, costs, and trust by enhancing collaboration and communication.

Prevention of unnecessary or duplicative services, for example, repeated tests or polypharmacy
Optimization of healthcare utilization and costs, especially important for patients with complex or chronic conditions who interact with multiple providers
Heightened communication, trust, and collaboration among providers and with the patient

The power of continuity of care lies in its ability to unite providers and patients through shared information, trust, communication, efficiency, and coordination—transforming healthcare delivery at every level.

Related: How to achieve staffing efficiency at your facility

What does continuity of care mean?

Continuity of care means consistent provision of ongoing healthcare over time and throughout settings and providers, ensuring coordinated and high-quality treatment.

It allows for comprehensive knowledge and grasp of the patient's medical history, preferences, and evolving health needs.

Which is the primary goal of continuity of care?

The primary goal of COC is to support quality and efficiency in healthcare delivery by ensuring consistent, coordinated, and patient-centered care.

This is achieved through effective information sharing among providers, sustained patient-provider relationships, reduced fragmentation of care, and timely interventions.

What are the consequences of poor continuity of care?

A lack of COC undermines trust and engagement, making effective communication and long-term health planning more difficult. This disconnect can also leave patients feeling isolated and less motivated to participate actively in managing their health.

Poor COC negatively affects facilities and patients in several ways.

Increased emergency hospital admissions
Higher rates of readmission
Elevated risk of mortality, especially among patients with severe illnesses
Higher overall spending due to overuse of diagnostic and therapeutic interventions
Lower patient satisfaction

Research confirms a clear link between COC and healthcare use and costs, as well as healthcare quality and outcomes. Individual, institutional, and social needs call for improving continuity of care.

Poor COC not only impacts patients directly but also places additional burdens on healthcare facilities, hindering the delivery of timely, bold, and well-informed services.

What are the three distinct types of continuity of care?

Continuity of care ensures that care remains consistent, coherent, and patient-centered, regardless of provider or setting changes, boosting quality as well as satisfaction for patients and clinicians.

To effectively manage continuity of care, consider that these three types interact and form a strong and reliable framework.

Informational continuity

Informational continuity uses comprehensive patient information to guide current and future care decisions.

Continuity of care examples:

Keep centralized, up-to-date electronic health records (EHRs) accessible to all relevant providers.
Provide continuity of care documents (CCDs) or a detailed discharge summary, especially for transitions between care settings or providers.
Establish protocols for handoff notes, which are vital and instrumental communication tools for continuity between shifts.

Management continuity

Management continuity involves a coordinated and adaptive approach to managing the patient’s health conditions over time.

Examples:

Case managers or care coordinators provide oversight across care settings, specialists, and primary care.
Involve providers from various disciplines to collaborate on the development of care plans and regularly update them.

Relational continuity

Building and sustaining trusting relationships between patients and healthcare providers, is the hallmark of relational continuity.

Examples:

Personalize care by learning about the patient’s life context and social situation, not just medical facts, strengthening the patient-provider bond.
Improve early diagnosis and management of complex conditions like diabetes by drawing on accumulated knowledge of the patient’s health.
Provide the patient with a stable point of contact for care navigation.

Related: How to reach staffing efficiency at your facility

Five best practices for improving continuity of care

Today’s complex healthcare environment calls for effective continuity to optimize top outcomes, reduce errors, lower readmissions, and strengthen patient-provider relationships.

This section describes five proven best practices— from nurse‑led transitional care to creating and using continuity of care documents—that enable your facility to lead the way from healthcare fragmentation to continuity of care and meet constantly emerging patient needs.

1. Co-create nurse‑led transitional care models at your facility

The following eight components of transitional care prepare you to co-create transitional care plans for high-risk patients. Nurses lead the process and involve patients, the healthcare team, specialists, and caregivers to create and implement the plan.

Patient engagement: Encourage active involvement of patients in shaping their care goals.
Caregiver engagement: Include and support caregivers as partners in care.
Complexity/medication management: Coordinate the management of complex conditions and medications, including alerts to primary care providers about critical issues such as depressive symptoms, dementia, delirium, suicidal ideation, or medication problems.
Patient education: Provide tailored information to promote patient self-care.
Caregiver education: Provide training and resources for caregivers to support patient care.
Patient and caregiver well-being: Address emotional and psychological needs during transitions.
Care continuity: Ensure uninterrupted, coordinated care across settings and providers.
Accountability: Hold clinicians, teams, and organizations accountable for care quality.

These components represent critical elements to ensure safe discharges and optimize positive health outcomes through effective and comprehensive transitional care.

Well-proven tools are available to facilitate the creation of transitional care models. TCM, BOOST, and RED are often considered standard or foundational models for building transitional care programs across the U.S. due to their strong evidence base and broad applicability.

TCM: The Transitional Care Model is particularly useful for cases of older adults with complex needs.
BOOST: Better Outcomes for Older Adults through Safe Transitions provides a practical and mentored toolkit.
Project RED: Re-Engineered Discharge focuses on redesigning discharge processes.

If you are interested in more tools, such as the Medicare 30-Day Readmission rule or readmission reduction strategies, Nine Ways to Reduce Hospital Readmissions offers additional information.

2. Create a Continuity of Care Document

Interoperability is fundamental as care expands across diverse settings. The Continuity of Care Document (CCD) was designed to give facilities, healthcare systems, and clinicians a standard way to share a comprehensive and concise report of a patient’s medical history and current condition.

It is an official and regulated document that contains multiple data elements across several categories:

Alerts
Encounters
Family history
Functional status
Immunizations
Medical equipment
Medications
Payers
Plan of care
Problem
Procedures
Purpose
Results
Social history
Advance directives
Vital signs

What is the difference between an EHR and a CCD?

A CCD provides a snapshot of the full EHR. It is formatted to allow interoperability, enabling quick, secure sharing of core patient information between different EHR systems.

Although CCDs represent only a fraction of all medical data, standardization makes them available to systems beyond the originating EHR.

Use of CCDs is strongly recommended for hospitals or healthcare facilities that utilize per diem staff to cover patient census surges, staff call outs, and schedule gaps.

How can you create a CCD?

A CCD can be generated from any of the 600+ certified EHRs. Templates are also available for specific uses.

Another key document for continuity of care is the emergency operations plan, formulated to ensure continuity and safety during emergencies in healthcare settings.

3. Handoff communication protocols

Handoff communication protocols and reports using tools such as the SBAR framework, I-PASS, or ISHAPED are one of the most frequent types of communication in hospitals.

By providing a standardized approach, they minimize misunderstandings and protect patient safety throughout every transition in care.

4. Building a united system: Evaluate and optimize the processes

Effective continuity of care is essential to building coordinated, high-quality healthcare and bridging gaps among providers and settings. To achieve this, we start with evaluation of our current continuity practices to identify strengths and areas needing improvement.

This evaluation involves a systematic approach that includes two basic and interconnected elements.

An audit to understand existing workflows and continuity across informational, longitudinal, and interpersonal domains.
Methods such as surveys, medical record reviews, and feedback from patients and providers to enrich the audit and gather insights from both patients and providers.

The evaluation identifies voids and barriers in communication, coordination, and patient engagement, leading to valid and productive optimization.

Optimizing continuity of care means making deliberate improvements, often developing practical tools and standardized processes. These tools help mitigate common challenges such as communication breakdowns, inconsistent provider interactions, and fragmented care information.

5. Measure success, evaluate, and improve

To test feasibility and impact, pilot small changes, for example:

New communication protocols
Care coordination tools

Select small-scale changes can be piloted, evaluated, and refined.

How do you measure continuity of care?

Key performance indicators (KPIs), such as readmission rates, patient satisfaction scores, average handoffs per patient, and staff turnover, will provide measurable data and reveal sometimes unexpected results. Once tested, refined, and tested again, you can scale and implement the changes widely.

How to maintain continuity of care?

Using handoff templates, scheduling matrices, continuity of care documents, and patient-centered continuity logs helps healthcare teams and organizations share accurate information, maintain strong relationships, and respect patient preferences.

Together, documentation, evaluation, and optimization form a continuous cycle that maintains and improves continuity of care.

From the ground up

Improving continuity of care starts from the ground up—with nurses on the front lines of every patient’s journey. Facilities play a defining role in ensuring that nurses are well-trained and aligned with continuity protocols, which directly impacts patient outcomes.

When call-outs or staffing shortages happen, continuity can suffer. Nursa is a fast and trusted way to fill those vacancies quickly, with access to a pool of local, qualified nurses who can integrate smoothly into your hard-working team.

Sources:

Building connection: How to maintain continuity of care

Key takeaways:

Why is continuity of care important?

What does continuity of care mean?

Which is the primary goal of continuity of care?

What are the consequences of poor continuity of care?