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Dissecting the Continuum of Care (CoC)

By Dr. Kiran Iqbal


Introduction


The continuum of Care (CoC), or for the ease of understanding, long-term care, is defined as:


“A client-oriented system comprising of health care services combined with integrating mechanisms that guide and track clients over time and provide a comprehensive array of physical and mental health services covering all levels of intensity of care.”


Continuum of care, however, is different from the traditional definition of long-term care. It is a comprehensive, coordinated, and ongoing system of services designed to meet the needs of people falling on all different levels of an extended spectrum of healthcare needs. It deals with both complex acute and chronic conditions efficiently and effectively.


In short, CoC deals with more than a collection of fragmented services distributed over a period of time; it includes mechanisms for organizing these services and imparting them, as needed by the client, as part of an integrated system.


The most effective continuums are designed depending upon individual needs. Several continuums of care can exist within the same organization. For example, a medical center can have a continuum designed to care for different groups such as at-risk, acute, post-acute, and chronic patients. In addition, a continuum may follow the same patient through time, providing services as needed starting from preventive healthcare to acute, post-acute, and chronic care services.


Attributes of a Continuum of Care (CoC)


Holistic Approach:

The continuum takes a holistic approach, dealing with all aspects, whether physical or mental, that affect the well-being of a person. The interaction and cumulative effect of these factors are considered and coordinated services—rather than fragmented, disjointed services—are provided over a period of time.


Preventive Approach:

The continuum emphasizes wellness instead of illness. Once an individual is part of a continuum, both spells of sickness and health are tracked and taken into account. In contrast to traditional healthcare, one does not need to be sick in order to be a part of a continuum. This way, the focus is on preventative approaches. Those at a higher risk of developing certain illnesses can be identified and interventions can be made early. Early intervention can not only delay the onset of a disease, but it can prevent it altogether. In addition, early intervention is associated with better long-term treatment outcomes. As part of a continuum, individuals participate in wellness and health promotion activities and are also assured easy access to healthcare services when needed.


Ideally, a continuum of care:

· Ensures appropriate allocation of resources to avoid unnecessary duplication and administration of redundant services

· Uses a multifaceted approach to the individual’s situation

· Continually follows the individual and monitors their condition in order to modify services as and when needed

· Coordinates care from different disciplines and professionals

· Integrates and coordinates care provided in a range of different settings

· Maintains a comprehensive patient record

· Enhances quality and satisfaction by providing easy access to appropriate and continual healthcare when needed

· Achieves cost-effectiveness with a smart allocation of resources


Categories and Services of a Continuum of Care (CoC)


CoC refers to a range of services tailored to individual needs, from preventive healthcare for those at risk of developing a particular medical condition to complex care and ongoing support for those with multiple chronic disorders. The continuum covers both acute as well as chronic healthcare needs.


Preventive Services:

The preventive approach utilizes data from health records in order to identify those at risk of developing a particular disease. For example, several physical and mental health conditions run in families, including diabetes and depression. When a patient is tracked through periods of sickness and health and the provider is kept updated about symptoms and the results of different screening tests, mainly by the use of technology, a prediction can be made about an impending medical condition.

Furthermore, regular testing can identify borderline diabetics, allowing the healthcare provider to incorporate specific lifestyle changes such as regular exercise and dietary restrictions that can potentially delay and regress type-2 diabetes. Likewise, symptoms related to mood and general behavior, combined with a family history, can help identify those at risk of developing depression and other mental disorders. Early intervention can help revert the disease and assure better outcomes.


Acute and Post-Acute Services:

Continuum of care ensures the provision of appropriate healthcare services when needed. It includes acute as well as post-acute services extending beyond the point-of-care (POC). For example, Patient A needs immediate care after a fall resulting in a hip fracture. This patient also has diabetes, which slows his recovery. Instead of prolonging a hospital stay, the patient can be discharged, and home care services can be provided using technology. This reduces hospital costs and promotes independence. Continuum of care ensures the progress of the patient is carefully monitored, and interventions are planned accordingly and promptly.


Chronic/Long-term Services:

People in need of long-term, complex care are often subjected to repeated assessment and enrollment procedures for various services they use. Not only are the patients unaware of the range of services that are available for their condition, the ones that are administered are provided in an uncoordinated manner. In addition, owing to a lack of a centralized system, patients themselves act as a conduit of information across the different service providers, even though they lack clinical knowledge.


Insurance coverage is equally varied, which substantially increases the cost. In most cases, fragmented healthcare services are paid for by clients out of pocket. Being a part of a care continuum can ensure the provision of healthcare services in a systemic way, avoiding repetitions, imparting appropriate services, and cutting down on overall cost. This is particularly useful for patients with comorbidities who require management for a number of chronic conditions such as hypertension, diabetes, cardiovascular diseases, and more. The coexistence of multiple conditions can significantly complicate the treatment process and increase the cost. Availability of patient records in an online, coordinated system can make the delivery of tailor-made treatment possible for every patient, which is beneficial, cost-effective and time saving both for the patient and healthcare provider.


Fitango Health’s Technology Supports the Continuum of Care


Fitango Health’s integrated, end-to-end digital health technology allows for bilateral communication across the care continuum. All stakeholders involved in an individual’s care are united on one platform, allowing for improved transparency and exchange of information, monitoring of individuals in both times of sickness and wellness, preventative health and outreach efforts, early intervention, and monitoring of both post-acute and long-term or chronic conditions.


Fitango Health’s customized Education Plans and ActionPlans feature allows care providers to target individual patients or patient sub-populations with educational material, self-assessments, and interactive health guides for a variety of use cases. Education Plans and ActionPlans can help a patient recover in a post-acute setting with daily instructions for care following a surgery, can help a chronically ill patient track symptoms and help providers monitor progress and provide early interventions for better long-term outcomes, and can provide general health and wellness guides to support the continuum of care for patients during periods of wellness.


Patients can self-report on progress and symptoms via the Fitango Health patient portal, accessible via web or iOS or Android application. Providers can then continually monitor the patient remotely, and provide interventions based on patient-reported data. These efforts will lead to long-term better outcomes and cost savings.


Further, Fitango Health’s preventive screenings module allows care providers to target at-risk groups of patients. Care providers can target interventions to specific patients flagged as higher risk based on test results and symptoms. Outreach campaigns coordinated directly through the Fitango platform can be sent to target populations via email, SMS, or to the Fitango Health mobile application for easy self-reporting. ActionPlans and assessments can be easily configured to meet the needs of individual patients or targeted sub-populations.


Conclusion


The seamless integration of different healthcare delivery systems is useful for the individual looking to address complex, chronic needs and also the provider looking for efficient allocation of resources.


In conclusion, the continuum of care concept suggests that a person remains a part of an organized, efficient, coordinated, and high-quality plan of care. It also implies that, rather than the patient deciding on services they need, the services are arranged by a healthcare facility, keeping a comprehensive sickness and wellness record of the client in mind.

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