Continuum of Care

The Continuum of Care refers to the full range of health or care services a person may interact with or use, it can even include self-care.

When applied practically the Continuum of Care is a model of health and care where people move between coordinated treatment or service types as their care needs and conditions change, for example from secondary care to community social care, or from community social care to residential care.  

The Continuum of Care model aims to adopt a coordinated, collaborative approach to health and care. It aims to address many of the challenges associated with fragmented health and care systems, which are based on episodic changes in health and similarly episodic interventions.

Instead, the Continuum of Care model seeks to treat and care for the whole person and take a preventative approach to health and care wherever possible.  

The Continuum of Care is important because it places the person at the centre of how health and care services are organized.

Within a health and care model that realizes and adopts a Continuum of Care approach, a person should be able to move seamlessly between treatment types and providers, who are all working together in a coordinated manner, to deliver the best outcomes possible for that person.  

The benefits of the continuum of care for the individual are that they receive the most appropriate service or treatment for their care needs, faster.  

They should spend less time waiting to transition from one part of the Continuum to another. They spend less time waiting for treatment, or repeating steps such as tests, questionnaires or diagnostics that they have already been through with other service providers in the Continuum. 

The benefits of the Continuum of Care for providers of services are less time spent re-performing tests or assessment activities where these have already been performed by other providers, if the results are still relevant and applicable. This gives them more time to focus on treatment itself.  

Greater coordination and communication between different areas of the Care Continuum means faster movement of people to the most appropriate area for them, reducing strain on resources and creating greater capacity within the health and care system.  

They can also use information from other service providers to gain a greater understanding and fuller picture of the person, faster. This enables them to make more informed decisions about that persons care. It means clinicians, health and care professionals can collaborate to make better recommendations for a person’s health and care, to improve outcomes.  

Sharing insights and learnings can allow partners in the Continuum of Care to understand how they can work better together, share mutually applicable best practice, or to improve specific parts of the overall health and care system. 

Technology can enable and enhance the Continuum of Care model in many different ways. Here are just some of the most important.  

Fundamental to the Continuum of Care model is the sharing of information between different services and providers. Without this seamless sharing of information people cannot easily transition from one part of the Care Continuum to another.

Nor can clinicians or health and care professionals access all the relevant information on a person as they enter their part of the Care Continuum, or easily collaborate to find the best treatment for people and help progress towards outcomes.  

Technology, specifically in the form of electronic health and care records and the ability to electronically share, or easily access information and records, between different parts of the Care Continuum is clearly essential to its proper functioning. Without electronic records and sharing of information digitally, the benefits detailed above cannot be realized.   

Certain technologies, including at-home health monitoring and AI can enable early detection of health deterioration, which may suggest a person should engage with another part of the Care Continuum, such as primary care.    

Finally technology can support more efficient, targeted placement of people within the Care Continuum. For example technology can help healthcare providers or local authorities to quickly identify providers of social care that have capacity for people being discharged from Secondary Care. Similarly, primary care, such as general practitioners can use online portals to quickly identify and refer people to, appropriate social prescribing programmes. 

Technology helps reposition the individual, the person, as the focal point. It enables the joining up of different health and care services to deliver a real continuum of care, rather than a fractured and dislocated series of disparate service types and providers.  

Enabling people to live at home for longer, and to make proactive interventions earlier are an essential part of improving people’s wellbeing, dignity and outcomes, while reducing pressure on other areas in the Care Continuum. 

The Access Group has pioneered a full-service digital alarm ecosystem, which both enables health and care professionals to react and intervene as needed if the alarm is rasied, but also to utilise the data collected through a range of monitoring methods in order to predict, rather than detect care needs with minimal human effort.  

Small but indicative changes in a person’s health or wellbeing, that may otherwise go unnoticed, can be flagged to appropriate users. This means interventions can be made before, rather than after a person’s condition deteriorates and may require a more severe intervention. 

Organisations with access to the system, whether social care providers, health providers or local authorities, can use objective, real-time data to better plan provision according to people’s current needs and prioritise resources where they are needed most. 

The Access Group provides integrated, best of breed solutions across Primary Care and GP Services, Community and Mental Health, and Acute Services. These integrated solutions empower teams with real-time information, reduce operational costs and errors, and regains time for care by reducing time spent on administrative tasks.

Over 45 NHS Trusts use Access software. Crucially we also provide integrated solutions used in local authority commissioning of care, social prescribing referral and every other part of the Care Continuum. This enables greater coordination, collaboration, improved decision making and patient flow.

Social prescribing has demonstrated remarkable outcomes for people in recent years, helping to improve their mental and physical health and offering a range of social, emotional and practical support that can address key contributors to reduced well-being or ill health.  

Social prescribing is often held back by difficulties in Primary Care and GP Services locating available social prescribing services and identifying the right one for the person and their current needs. Further difficulties, inefficiencies and dead-ends can arise when trying to refer people to social prescribing services.  

The Access Group’s social prescribing software overcomes these difficulties with a digital social prescribing platform that uses a two-way integration with leading GP systems.

The platform makes is much easier for social prescribing services to make themselves known and available, for primary care services to identify the right service for a person and delivers a fully flexible referral pathway, including self-referral.

Inbuilt analytics enable social prescribing services and local stakeholders to robustly assess and demonstrate the impact and outcomes of social prescribing services for people and communities.  

The Access Group’s software for social care providers are the most widely used in the UK and give providers an unrivalled eco-system of software to digitise, automate or improve all the processes involved with delivering care each and every day. 

From best in class rostering, to flexible and configurable electronic care planning, medicines management, eLearning, compliance and governance tools, Access Workspace for Care brings all the care software providers would ever need into one place. With reporting and analytics to give them unprecedented insights into the quality of care, safety, recruitment and financial performance and other key indicators they need to monitor.  

Access’ software is used by providers of social care in all settings and complexities, including care homes, domiciliary care, supported living, acquired brain injury, forensic mental health and more. With customers ranging from large national providers, to brand new care agencies who are just registering with their regulator.