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What Nurses Should Know about Continuum Care Management

Higher Education Articles July 27, 2013

Continuum care management promotes health improvement by raising quality of care. People with chronic conditions needing long-term care will benefit from this approach. Along with improving the quality of care, continuum care management, properly applied, can reduce health care costs for those with or at risk of facing chronic conditions.

Nurses and Continuum Care

Caregivers should have a clear picture of continuum care management. Nurses should be well versed on what services are common components and the concept of improving “population health” for patients, regardless of age.

The Care Continuum Alliance, formerly the Disease Management Association of America, the preeminent trade group, promotes the importance of continuum care and the ways it helps individuals and the health care system as a whole. The popular concept of continuum care involves the following components, at a minimum.

•Concentration on good health and wellness.
•Effective disease management.
•Coordination of care to achieve best practices management activities.
•Support for research to improve the quality of long-term care delivered by medical professionals.

Often acting as primary caregivers, nurses may function in an elder care facility, hospital, chronic care facility, or home care environment. Regardless of their physical location, registered nurses should focus on procedures and practices that contribute to and ensure the best available continuum of care.

Specialty Clinical Care

Continuum care management should not be focused on younger or middle aged adults. Chronic conditions have no age boundaries. Nurses may encounter or specialize in elder adult, adolescent or pediatric care, along with general expertise with adult patients.

Nurses typically interface with physicians, nutritionists, health educators, counselors, and social workers while providing quality clinical care. Those needing continuum care services, regardless of age, also need support from family members and their local community. Registered nurses should prepare to relate to patients’ family and others on a clinical and personal care level.

Home Care Quality

Most patients with chronic conditions, who are able to live at home, still need quality continuum care. In these settings, nurses implement the patient’s physician-designed treatment program to coordinate care services. Physicians usually detail their treatment plan to nurses to ensure high quality continuum care.

Since most of these patients are fully or partially ambulatory, nurses should address the potential risk of physical injury, such as falls. Home care should also include safety education to help prevent household accidents as part of the continuum care management program. Whether delivered by registered nurses or others, household safety is an important factor when treating at-home, ambulatory patients.

Nurse Responsibilities

•Focus on wellness and continuing good health.
•Commit to high quality continuum care management and services.
•Understand the concept of population health management.
•Stay current with Care Continuum Alliance news and resources.
•Consider earning a Chronic Care Professional Certification.
•Become experienced in delivering quality care for those with chronic conditions.
•Understand the principles of ambulatory care nursing (see the American Academy of Ambulatory Care Nursing).
•Become comfortable with the interface of primary care physicians and continuum care management theories

Registered nurses play a vital role in the commitment to and delivery of quality continuum care services. Patients suffering from chronic conditions face long-term issues that do not typically affect victims of trauma or physical injury. Chronic disease or debilitating conditions are best managed by a focused approach to integrating primary care physicians, family, friends, and other medical and counseling professionals into treatment and care.

Understanding the differences in continuum care from obstetrics, trauma unit activities, pure geriatric or pediatric care, and the necessity for support from others to improve the quality of life for those suffering chronic issues, helps nurses offer the high quality care these patients deserve. Nurses broadening their knowledge and experience base with continuum care management expertise become more valuable to patients, lower the cost of health care, and, enjoy a higher quality professional life.

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