Continuity of care – the coordination and integration of a patient’s medical information and care across all providers and settings – is becoming an increasing focus in the quest to improve patient outcomes and achieve cost savings. A Johns Hopkins University study published in this month’s JAMA Internal Medicine found that poor continuity of care results in overuse of unnecessary diagnostic and therapeutic procedures, and is costing the U.S. billions each year. In an analysis of 1.2 million Medicare patients, researchers found that 14% of patients received at least one unnecessary medical procedure, and those with more providers and poorer continuity measures were more likely to receive the unneeded procedures.

The study adds to a growing body of research confirming the cost savings and improved patient outcomes associated with patient continuity of care. So how can hospitals help in the quest to improve continuity? Keep the “three Ts” in mind.


Teach self-care skills to your patients and their caregivers in the hospital, and reinforce them in the home. The Wellness Network offers a series of self-care programs like the award-winning Your Care at Home series.  These programs  offer patient education on topics like post operative care, medication management, and much more on the hospital’s television system. And because learning in the hospital environment can sometimes be challenging and repetition helps to reinforce skill building, these programs can also be easily accessed from a computer or mobile device after the patient has transitioned home.


Ensure a smooth flow of information between your hospital and the extended healthcare ecosystem. EHR implementations, upgrades, and user training should support continuity of care and facilitate information sharing among all primary and specialist care providers. Ultimately, they should also integrate patient use, allowing patients easy access to important records, test results, and instructions.


Plan for an orderly and comprehensive discharge. The discharge coordinator should provide culturally appropriate patient instructions, reconcile medications, and educate caregivers as needed. In addition, they should ensure patients have follow up appointments scheduled with their primary care provider and any needed specialists before they leave the hospital. Finally, follow up calls from the hospital to the patient within 72 hours of discharge can pick up any early problems at home. For more information on improving your discharge process and decreasing 30-day readmissions, read our post on Project RED.

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