Patient Safety Across the Continuum of Care

Older adults are frequent users of social and healthcare services as they age. Assuring patient safety across the continuum requires information standardization and transfer predictability. Continuity of care for older adults consists of care goals and information transfer. Care goals and information paradigms change as patients move from the high-tech hospital-based services of crisis stabilization, diagnostic testing and treatment initiation to the high-touch post-discharge care services of home health, social care and skilled nursing care consisting of recovery, function restoration, or end of life support. Information transfer, although in some instances dictated by law, is highly variable. Lack of knowledge, competency and information tracking threatens interdependencies across care sectors. Document transfer is not sufficient given the varying information paradigms across care sectors. Alignment of patient goals, information relevant to care management processes, and better control of the transfer process with feedback and feedforward processes are the necessary conditions for improving care continuity and outcomes.