Enhancing the Continuity of Care with Telehealth

Overview of Continuity of Care

Continuity of care is the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high quality, cost-effective medical care, as noted by the AAFP. It reduces fragmentation of care, thus improving patient safety and quality of care.

The patient population with chronic illnesses may see many different providers, at many different settings / facilities.  Coordination and collaboration are not necessarily universal; little or no communication across providers and venues may negatively impact patient experiences, related costs, and overall outcomes.  With the increase in the aging population, more and more patients will face a turning point in their care and require better continuity of care processes, reflective of the best patient-centered care from a team-based approach.

Role of Virtual Care

The use of virtual care can ensure that patient-centric care is the focus of all providers and facilities delivering care at each turning point.  From reducing travel time and related costs to resolving miscommunication amongst care providers and facilities, virtual meetings improve the continuity of care in the following ways:

  • Real-time Communication: The various providers can conduct video calls to bring together the key care team members, regardless of role and facility.   This eliminates the need for providers to travel to other locations to ensure patient care is coordinated, impactful, and patient-centric.
  • Responsive Concern: As needed, care team members can escalate critical questions and concerns to appropriate providers and specialists.  A care team member can also arrange for an in-person visit from the home health clinician or the provider depending on the patient’s changing condition.
  • Reduced Readmissions:  The broader care team can reinforce core patient education by aligning on how and when to communicate the rationale of a new treatment plan.  Patients can remain comfortably at home and on track with their evolving treatment plan vs. returning to the provider or the hospital to have questions answered and care administered.

SynziMD’s telehealth platform enables providers to exchange essential information by connecting care team members and chronic care patients in a more efficient and effective manner.  With SynziMD, the broader care team can better monitor and manage the patient in real-time.  The initial provider can share the detailed care plans to colleagues, specialists, and others who are part of the patient’s broader care team.  The patient’s family can also be included – along with home health nurses who are continuing to provide care if the patient is remaining at home.  Questions can be answered in real-time and all involved can observe visual cues signifying that everyone is aligned on their respective roles and responsibilities.

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