What strategies can you use to improve patient care continuity?

Drawing from a chapter in my career outside social services, working in oil and gas, I gained a valuable perspective that I believe can revolutionize patient care continuity. It’s all about the principle of the 'internal customer,' a philosophy that propelled Japanese automakers ahead in the 70s. They created efficiency by ensuring each department smoothed the way for the next. By adopting this mindset in healthcare, envisioning the next department or agency as your customer, you can create a ripple effect of efficiency and seamless transitions, vastly improving the continuum of care. That’s the kind of cross-industry innovation that can potentially transform patient experiences.

Empathy, empathy, and more empathy. It is important in case management to build a strong rapport with your clients so that they feel engaged in their care. It is important that the client shares their wishes and goals with the case manager so that advocacy can take place. Case managers that are client centered tailor the care coordination specifically for the needs of each individual and having that psychosocial background is important to share with the team as a whole. Providing care that meets the clients bio, psycho, and social needs will ensure that they feel supported and heard.

In my view, a medical home and case management go hand in hand in ensuring continuity of care. For families and individuals that are suffering from concerns including IPV, MH, and SUD, a case manager/ service coordination unit allows support to the family in navigating systems and receiving the supports they need. The case manager also has the resources to inform clients of services that they may not even be aware of. A Medical home works really well as a front door to entire families to access services and to meet the needs of families. Kids are often clear indications of stressors that an entire family has, meaning that a childs PCPs operating as a medical home will allow access and assessments of the needs of families.

This is also where it is extremely important for medical professionals to be culturally competent. You want to educate patients in a way that is culturally appropriate for them and not condescending or insulting.

I think that follow up is the most important step. It offers the patient the opportunity to report any problems they've had trying to access further care. It offers the provider the opportunity to assist if needed.

The listed recommendations are valuable; unfortunately, the health system and the private sectors are disconnected, and it is impossible to follow such advice.