Continuity of care is a cornerstone of effective healthcare, ensuring patients receive seamless and coordinated medical services over time. When you hear about a “continuity of care program” from a doctor’s office, it refers to a structured approach designed to provide consistent and connected healthcare experiences. This is especially vital for patients with chronic conditions, those undergoing complex treatments, or anyone needing ongoing medical management.
This article delves into the concept of continuity of care programs, drawing insights from the robust model implemented by the U.S. Department of Veterans Affairs (VA). While our focus is on understanding these programs in general, we’ll use the VA’s comprehensive system as a prime example of how healthcare providers can ensure veterans, and indeed all patients, receive timely, high-quality, and coordinated care.
The Essence of Continuity in Healthcare
At its heart, continuity of care means that your healthcare journey is connected and cohesive. It’s about more than just seeing the same doctor; it encompasses a system where different healthcare providers and services work together seamlessly to meet your needs. A well-designed continuity of care program aims to prevent fragmented care, reduce medical errors, and improve overall patient outcomes and satisfaction.
For a doctor’s office, implementing a continuity of care program involves several key components, often including:
- Team-Based Approach: Moving beyond individual doctor-patient interactions to a team that may include physicians, nurses, care coordinators, and other specialists.
- Care Coordination: Actively managing and organizing a patient’s care across different settings and providers.
- Communication: Ensuring smooth information flow between all members of the care team and the patient.
- Planning and Follow-up: Developing individualized care plans and proactively monitoring patient progress.
- Utilizing Technology: Leveraging electronic health records and other digital tools to enhance communication and coordination.
Let’s examine how the VA, a large healthcare system known for its commitment to veteran care, puts these principles into action through its care coordination model.
The VA’s Veteran-Centered Care Coordination Model: A 5-Step Approach
The VA’s care coordination model provides a clear framework for ensuring continuity of care for veterans. This model is built around a veteran-centered, team-based approach, emphasizing proactive management and seamless transitions. It operates through five key steps:
1. Receiving a Request for Community Care: The Starting Point
The need for community care, meaning care provided outside of VA facilities, can arise from various situations. For veterans, this might be triggered by:
- A New Veteran Clinical Appointment: During a routine or initial appointment, a VA provider may identify the need for specialized care not readily available within the VA system.
- A Hospital Notification: If a veteran is admitted to a community hospital, the VA needs to be informed to ensure coordinated follow-up care.
- Referral from VA or Community Provider: Either a VA doctor or a community-based physician might initiate a referral for specialized services.
- An Inpatient Admission or Emergency Department Visit: Similar to hospital notifications, these events signal a need for care coordination to manage the veteran’s health journey effectively.
Figure 1: HSRM Registration Steps for Community Providers. This illustrates the process for community healthcare providers to gain access to the VA’s HealthShare Referral Manager system, a tool designed to facilitate care coordination for veterans receiving community care.
The VA facility’s community care team is responsible for receiving these requests, assigning staff to manage them, verifying eligibility for community care, and authorizing the necessary services as indicated in the medical consultation. The HealthShare Referral Manager (HSRM) system plays a central role in managing these referrals and authorizations, streamlining the process for both VA staff and community providers.
2. Assessing Veteran Needs: Tailoring Care Coordination
Once a request for community care is received, the VA facility’s community care staff undertakes a crucial step: assessing the veteran’s individual needs. This assessment determines the appropriate level of care coordination required for each veteran.
The VA utilizes a Screening Triage Tool, combined with the clinical judgment of healthcare professionals, to evaluate the complexity of a veteran’s healthcare needs. Factors considered during this assessment may include:
- Medical Complexity: The number and severity of the veteran’s health conditions.
- Functional Status: The veteran’s ability to perform daily activities and their level of independence.
- Social Support: The availability of family, friends, or community resources to support the veteran’s care.
- Veteran Preferences: The veteran’s own goals and preferences regarding their care.
This thorough assessment ensures that care coordination efforts are tailored to the specific needs of each veteran, maximizing the effectiveness of the program.
3. Developing a Care Coordination Plan: A Collaborative Approach
The development of a care coordination plan is a collaborative effort involving both community providers and the VA facility’s integrated community care team. This plan serves as a roadmap for the veteran’s care journey within the community.
An individualized care coordination plan typically includes:
- Scheduling: Arranging appointments with community providers, ensuring timely access to needed services.
- Navigation: Assisting veterans in navigating the community healthcare system, including finding providers, understanding insurance, and accessing transportation if needed.
- Follow-up Activities: Planning for ongoing communication, monitoring, and necessary adjustments to the care plan.
- Transition Planning: Addressing the transition of care back to the VA system when community care is completed.
By clearly outlining these elements, the care coordination plan ensures that all parties are aligned and working towards the veteran’s best interests.
4. Implementing the Care Coordination Plan: Streamlining Information Flow
Effective implementation hinges on strong communication and collaboration. The VA facility’s community care integrated team takes the lead in fostering a collaborative relationship among all stakeholders. This includes:
- Veterans: Keeping veterans informed and engaged in their care.
- VA Community Care Integrated Teams: Ensuring internal coordination within the VA system.
- VA Providers: Maintaining communication with the veteran’s primary VA care team.
- Community Providers: Establishing clear lines of communication with external healthcare professionals.
This collaborative approach is critical to streamline the flow of information, ensuring that everyone involved has the necessary details to provide seamless and coordinated care. It minimizes duplication of effort, reduces the risk of miscommunication, and ultimately enhances the veteran’s experience.
5. Follow-up and Episode Completion: Ensuring Quality and Closure
The final step in the VA’s care coordination model involves follow-up and episode completion. The VA facility community care team proactively follows up with the veteran to:
- Ensure Service Appropriateness: Confirm that the veteran received the authorized services and that these services were delivered appropriately.
- Perform Necessary Handoffs: Manage the transition of care back to the VA or to other providers as needed.
- Close the Consult: Officially conclude the episode of community care within the VA system.
Throughout the entire episode of care, the facility community care staff plays a vital role in monitoring and tracking the veteran’s progress. This ongoing oversight helps to identify and address any issues promptly, ensuring a positive and effective care experience.
Tools Supporting Continuity of Care: HSRM, Azure RMS, and VHIE
To effectively implement its care coordination model, the VA leverages several key technological tools that enhance communication, information sharing, and administrative efficiency. These tools are also valuable examples of how doctor’s offices and healthcare systems can improve continuity of care in general.
HealthShare Referral Manager (HSRM)
HSRM is a secure, web-based system used by the VA to manage referrals and authorizations for community care. It serves as a central platform connecting the VA with community providers, facilitating smoother care transitions.
Benefits of HSRM include: streamlined referrals, improved communication, and efficient claims processing for community providers working with the VA.
Key Benefits of HSRM:
- Facilitates Health Information Exchange (HIE): Enables secure sharing of veteran health information between community providers and the VA through a unified platform.
- Streamlines Referrals: Simplifies the process of referring veterans for specialized care in the community.
- Request for Service (RFS) Submission: Allows community providers to electronically submit requests for additional services or continued care.
- Reporting and Workflow Tracking: Generates reports to support decision-making and monitor the referral workflow.
- Clinical Viewer Module: Provides access to a clinical summary of a veteran’s medical history, including diagnoses, procedures, and medications.
HSRM significantly reduces administrative burden, improves communication, and accelerates the process of referrals, care delivery, and claims processing.
Azure Rights Management Services (Azure RMS)
Azure RMS is a secure email encryption service used by the VA to protect sensitive veteran health information when communicating electronically with community providers.
How Azure RMS Enhances Continuity:
- Secure Communication: Enables the secure exchange of emails containing protected health information (PHI), ensuring patient privacy and HIPAA compliance.
- Seamless Access: Community providers can easily read and respond to encrypted emails without needing to install special software in most cases.
- Timely Information Sharing: Reduces reliance on slower methods like fax or mail for sharing sensitive patient data.
Azure RMS facilitates faster and more secure communication, which is essential for timely and coordinated care.
Veterans Health Information Exchange (VHIE)
VHIE is a program that enables the bi-directional sharing of veteran health information between the VA and participating community providers.
VHIE’s Role in Continuity:
- Comprehensive Patient Records: Provides a more complete picture of a veteran’s health history by integrating records from both VA and community providers.
- Improved Care Coordination: Gives providers access to the information they need to make informed decisions and avoid duplication of tests or procedures.
- Enhanced Quality of Care: Contributes to safer and more effective care by ensuring providers have a holistic understanding of the veteran’s health status.
VHIE breaks down information silos, fostering a more connected healthcare ecosystem for veterans.
Request for Service (RFS): Ensuring Continued Care
A crucial component of the VA’s continuity of care program is the Request for Service (RFS) form, VA Form 10-10172. This form is used by community providers to request additional services or continued care for a veteran from the VA.
Key Aspects of the RFS Form:
- Authorization for Further Care: The RFS is essential for obtaining authorization for ongoing or additional community-based services for veterans.
- Documentation Requirements: Community providers must submit the completed RFS form along with supporting medical documentation, such as progress notes, lab results, and radiology reports.
- Timely Processing: The VA processes RFS requests within three business days, ensuring prompt decisions regarding care authorization.
- Communication of Outcome: Community providers are notified of the VA’s decision, indicating whether the requested care will be provided within the VA or in the community.
The RFS form provides a standardized process for requesting and authorizing continued care, ensuring veterans receive the necessary services without delays.
Conclusion: The Importance of Continuity of Care Programs
Continuity of care programs are indispensable for delivering effective, patient-centered healthcare. They move beyond episodic care to create a connected and coordinated healthcare experience, leading to improved health outcomes, greater patient satisfaction, and reduced healthcare costs.
The VA’s comprehensive care coordination model, along with its supporting tools like HSRM, Azure RMS, and VHIE, serves as a valuable example for doctor’s offices and healthcare systems striving to enhance continuity of care. By adopting similar principles – a team-based approach, robust care coordination, effective communication, and strategic use of technology – healthcare providers can significantly improve the quality and experience of care for all patients.
For community providers working with veterans, understanding and utilizing the VA’s resources is key to ensuring seamless continuity of care for those who have served our nation. And for all patients, knowing that their doctor’s office has a continuity of care program in place provides peace of mind and confidence in their healthcare journey.
