Continuity of care: the organising goal

Continuity of care is what the concept system exists to protect: the ability of a subject of care to move between services, organisations, and sectors without losing the thread of their care.

Whether the starting point is an injury, an illness, or a social issue, good outcomes depend on care processes that connect — within a team, across departments, and between organisations. Achieving that requires more than goodwill: it requires the processes, their sequencing, and their hand-overs to be describable in terms every party understands the same way. That is precisely what the conformant model provides.

Figure 1. The two coupled cycles of a continuity of care process
The two coupled cycles of a continuity of care processTwo connected cycles, each running through assessment, care planning, an intervention, and care evaluation, where care evaluation is of the care activities performed. In the first cycle the intervention is care investigation and each pass, concluded by a health condition assessment, deepens the understanding of the health state and its identified health conditions; that understood health state is handed over to inform the care needs assessment of the second cycle, whose intervention is care treatment, changing the health state. A return path carries the changed health state back for renewed health condition assessment, so the cycles repeat, coincident or in parallel, progressing from an input health state to an output health state. Each named activity links to its definition. Understanding the health state intervention = care investigation Changing the health state intervention = care treatment care activity in which the subject of care's health conditions are assessed Health condition assessment care activity management in which a care plan is managed Care planning care activity intended to clarify one or more health conditions Care investigation care activity in which aspects of other care activities are evaluated Care evaluation of the care activities care assessment in which a care professional considers the subject of care's health needs and determines the needed care activities Care needs assessment care activity management in which a care plan is managed Care planning care activity intended to directly improve or maintain a health state Care treatment care activity in which aspects of other care activities are evaluated Care evaluation of the care activities the overall level of health of a subject of care — present even when not yet observed Health state identified health conditions deepens understanding of informs the handover from investigation to treatment the changed health state returns for renewed health condition assessment — the process is not linear Input health statethe health state at the start of a care process Output health statethe health state at the end of a care process Care evaluation in each cycle is of the care activities performed; the cycles repeat, coincident or in parallel.

The model captures the machinery of continuity explicitly:

The standard's own master drawing of these activities appears full-size in The master diagrams.

Because these concepts are shared across clinical and social care, continuity does not stop at the sector boundary — the same episode can span a hospital ward, a community team, and a social care provider without changing vocabulary. See Social care as a first-class citizen.