Different Nursing Roles in the Continuum of Care

One of the major criticisms of our current healthcare system is that it is too often focused on providing episodic care – that is, treating patients for an acute condition without following up, establishing a patient/provider relationship, or focusing on wellness and prevention. Episodic care has disadvantages for everyone involved. Providers are unable to view patients holistically, for example by taking their socio-economic circumstances or family history into consideration. Patients with a chronic illness become especially vulnerable to complications and adverse effects. And insurers often end up paying for high-cost emergency room interventions, rather than ongoing primary care that supports health and wellness.

Ideally, our system must evolve toward greater continuity of care, as well as greater integration across the entire continuum of care. The concept of the continuum of care has been defined in many different ways. The most comprehensive definition, perhaps, is this one:

A patient-oriented system of care that spans an entire lifetime, is composed of both services and integrating mechanisms, and guides and tracks patients over time through a comprehensive array of health, mental health, and social services across all levels of intensity of care.

Since the continuum comprises such a wide range of services (acute care, ambulatory care, home care, extended care, wellness programs, etc.), it will probably never be completely seamless. Yet the healthcare industry is making great strides toward adopting integrating mechanisms that support continuity of care and transitions of care.  The goal of integrating health services is to provide high quality, cost-effective care for everyone, but particularly for patients with complex or chronic conditions.

Four integrating mechanisms in particular rely on nursing specialties that support continuity of care. They are:

  • Community-based services. Home health nurses can help to expand the continuum by visiting patients at home to perform assessments and provide essential services. Telemedicine functions like remote monitoring can expand the continuum even further by allowing nurses to coordinate services and plan interventions for rural residents.
  • Disease management programs. Patients with a chronic illness like diabetes or congestive heart failure can benefit from nurse-led quality initiatives that are designed to meet the specific needs of the group. Nurses with a specialty in disease management can coordinate an entire spectrum of services aimed at correcting behavioral, economic, and environmental barriers to care, in order to promote healthy behaviors and the self-management of chronic conditions.
  • Health information systems. An integrated information system is essential to seamless transitions along the continuum. In order to provide high-quality, cost-effective care, providers need data that follows the patient over time across various health settings and geographic borders. Nurse informaticians can have a positive impact on the design of patient-centric systems.
  • Case management services. Across the continuum of care, no where are patients more vulnerable than at transition points, when they move from one level of care to another. Nurse case managers can effectively coordinate transitions of care, including discharge planning and end-of-life planning.

As the industry shifts from episodic care to a seamless continuum of care, hospitals and providers will have to provide better follow-up care and work toward smoother transitions. This is likely to increase job opportunities for nurses specializing in case management, who can connect the dots to formulate transitional care plans. And as the EMR becomes more and more essential as a care integration mechanism, healthcare will need nurse informaticians who can analyze technologies from both the bedside and IT perspectives. Online nursing degrees like American Sentinel’s MSN with a case management specialization and MSN with a nursing informatics specialization with can make you attractive to employers, provide you with cutting-edge knowledge and skills, and give you the academic background you’ll need to pass a credentialing exam.

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