The coordination and consistency of healthcare services provided to an individual over time, ensuring seamless transitions between different healthcare providers and settings.
The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.
A healthcare professional who serves as the patient’s main point of contact for medical care, managing routine healthcare needs and coordinating referrals to specialists when necessary.
A digital version of a patient’s paper chart, containing the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results, which are shared among healthcare providers.
The electronic sharing of patient health information between different healthcare organizations and systems to improve continuity of care, reduce duplication of services, and enhance patient outcomes.
The movement of patients between different healthcare settings or providers, such as from a hospital to a primary care physician’s office or from a skilled nursing facility to home, with a focus on ensuring the continuity and safety of care.
A comprehensive outline of a patient’s healthcare needs, goals, and preferences, developed collaboratively by the patient, their family, and healthcare providers to guide the delivery of coordinated and effective care.
The involvement of patients and their families in their own healthcare decision-making process, including goal-setting, treatment planning, and self-management of chronic conditions, to promote better health outcomes.
A group of healthcare professionals from different disciplines (e.g., physicians, nurses, social workers, pharmacists) who collaborate to provide comprehensive and coordinated care to patients, incorporating their unique expertise and perspectives.
Services provided to patients during transitions between different healthcare settings or providers, typically following hospital discharge, aimed at ensuring continuity of care, preventing complications, and reducing hospital readmissions.
The use of telecommunications technology to provide remote clinical services to patients, enabling virtual consultations, remote monitoring, and electronic communication between patients and healthcare providers, thus improving access to care and continuity of services.
A collaborative approach to healthcare decision-making in which patients and healthcare providers work together to make informed decisions that align with the patient’s values, preferences, and goals, fostering continuity of care and patient satisfaction.
Systematic efforts to improve the quality, safety, and effectiveness of healthcare services, including processes and outcomes related to continuity of care, through data-driven analysis, implementation of best practices, and ongoing monitoring and evaluation.
The proactive management of the health of a defined population or patient cohort, including strategies to promote preventive care, manage chronic conditions, and improve care coordination and continuity across the healthcare continuum.
The ability of individuals to access, understand, and use health information and services to make informed decisions about their health, contributing to improved communication, adherence to treatment plans, and continuity of care.