Primary Care: The Health Care Continuum Every Community Needs

Print Friendly, PDF & Email

In health care, the continuum of care describes how health care providers follow a patient from preventive care through medical incidents, rehabilitation and maintenance. Depending on the patient, this might involve the use of acute care hospitals, ambulatory care or long-term care facilities. The coordinated effort to medical care means better outcomes for the patient.

Primary care clinics, especially those that follow the Patient-Centered Medical Home (PCMH) model, are at the forefront of the move to provide a community health care continuum. Focusing on building strong patient-provider relationships that encourage patients to be proactive, primary care providers guide integrated cradle-to-grave care.

A health care continuum requires team-based care, which was found by the Institute of Medicine to have a positive impact on patient outcomes, patient experience and the cost of treatment. Collaboration between medical team members allows them to share knowledge and work toward a common goal of improved patient outcomes and patient experience, enabling them to better provide patient-centered care. Improved communication can decrease instances of misdiagnosis, overlap and redundancy for reduced health care costs. The team-based care approach looks critically at the source of a patient’s ailments, rather than simply focusing on symptoms, which can also eliminate emergency department visits – another savings benefit, especially for high-risk, high-need populations.

Sign Up for News, Resources, and Event Invites

The Primary Care Development Corporation’s (PCDC) Performance Improvement team offers the Essentials of Care Management course, This two-day curriculum focuses on the principles of care coordination, specifically on two significant aspects that affect the populations served by PCDC providers: the social determinants of health and motivational interviewing.

As health systems continue to evolve, greater emphasis will be placed on population health. Population health takes a broad look at the management of outcomes for all of a health system’s patients. Specifically, population health includes efforts to use health care resources more effectively and efficiently to improve the lifetime health and well-being of a specific population. In addition to disease prevention, population health activities include promoting health and well-being. In recent years, there has been an increased focus on the social determinants of health, and the recognition by health care stakeholders that many of the factors that influence our health have less to do with health care and more to do with our environment, our stressors, our income and education and our level of social interactions and sense of community. While health care organizations might be grappling with how to measure the return on investment (ROI) of these efforts, they can be critical as we shift to a focus on wellness. 

Another rationale for integrating health care services is to provide the highest quality and most cost-effective care for people who have complex and chronic conditions. Integration of services implies that multiple services are delivered, either simultaneously or sequentially, that they are appropriate and coordinated, and that they are neither duplicated nor omitted. Integrated delivery systems are especially relevant for people with complex and chronic illnesses. The integrated-service approach contrasts with the current US health care delivery system, which historically has been organized to provide acute, episodic care.

The population of the United States includes vast numbers of people with chronic and disabling conditions, and these numbers are expected to increase significantly in coming years. An estimated 133 million Americans had one or more chronic conditions in 2005. By 2030, the number is projected to increase to 171 million. The argument for developing integrated systems is undeniable to the extent that integrated systems are more cost-effective for people with complex, chronic illnesses.

Effective treatment over the continuum of care requires attention to many moving parts. It requires coordinated medical care between a variety of providers and efficient and accessible financing. The advent of electronic health records, managed care (quality of care), and payer networks have helped the logistics involved in supporting the continuum of care.

Join the growing number of practices PCDC has helped attain PCMH certification, or learn more about our programs that build healthy, thriving communities through community investments, capacity-building, and policy initiatives.

100% Success Rate: PCMH Recognition

PCDC supports primary care practices across the nation — including community health centers, hospital clinics, private practices, and specialty practices — to improve the quality of their care and the sustainability of their practices.

Learn More