What is Continuity of Care?

What is Continuity of Care?

Everyone talks about Continuity of Care. But what IS Continuity of Care? How do we define it? What are the boundaries? Most organizations cannot provide a definition or standard when asked.

• Continuity of Care is roughly defined as having the same caregivers coming at roughly the same times, with reasonable turnover over time.
• Reasonable turnover occurs over months and years. Revolving door continuity problems are usually due to weekly changes.
• The boundaries of care continuity shift with the type of service, the number of hours each week and the number of visits each week.

The “Minimum Team Size” is the number of Caregivers adequate to provide stable ongoing service under ideal circumstances. The majority of absences are covered within the consistent group. There will still be exceptional circumstance where none of those Caregivers are available and the options are sending a new caregiver or the client’s backup service plan is enacted. For a once a day service, the ideal would be 2 caregivers covering all 7 days of the week. However, inevitably circumstances arise where one caregiver cannot work and the other caregiver cannot cover their absence. Thus a 3rd caregiver is required and needs to be in regular rotation so they know the routines and what is normal for the client. And that is the ideal minimum team for a daily service, 3 caregivers. Inevitably there will be situations where none of those three caregivers can cover a visit. This is when a 4th or 5th caregiver may eventually be needed. These replacements should be caregivers who are well suited to cover future scheduling exceptions and potential to become long-term replacements. Eventually a daily service is likely to have 4-6 caregivers who are known to the client. There should be a bell shaped curve with a smaller number 3-4 providing the majority of services and the others providing backup. If a service is less than daily it is not usually considered an essential service that must be provided on that particular day and time. Often non-essential visits can be moved or cancelled when the regular caregiver is not available instead of having a new caregiver. Sometimes cancelling a service is preferable to having a new caregiver, especially when starting out or with someone who is particularly resistant to support. However, having only one or two Caregivers over a long period can foster unhealthy dependency and resistance to other Caregivers when the time comes. Daily services are typically essential services that cannot be skipped.

• At one visit per day the minimum team size is 3-4 Caregivers
• At two visits per day the minimum team size is 5-6 Caregivers
• At three visits per day the minimum team size is 6-8 Caregivers
• At four visits per day the minimum team size is 7-9 Caregivers

Few services require more than 10 caregivers in regular rotation unless there are exceptional circumstances. Live-in (Homestay) which are 21-24 hours long and Overnight services which are 8-12 hours long typically offer the best Continuity of Care for larger service needs.

• It may be possible to start with 2 Caregivers, each covering 3 or 4 days each week. 
• For stable ongoing service a 3rd Caregiver is required. In most circumstances a three person Caregiver team can cover absences, vacations and illnesses that may occur.
• Live-in services normally have a 3 hour unbilled break in the afternoon. When Caregivers are needed to cover the 3 hour break it is usually a different group of Hourly Caregivers although some Live-in Caregivers are able and willing to cover their own breaks.

Starting a new service often means meeting several new people in the same week for a daily service, especially when there are multiple visits per day. It can take a lot of energy to meet new people so the first week of service can be challenging. Starting provides some insight into how bad continuity with new caregivers each week can feel. Poor continuity feels like starting over again and again. For individuals who are resistant to care we can talk about ways to start service more gradually and improve chances of a successful reception. Reasonable Turnover happens over months and years. It should not be happening every week. Having new Caregivers each week wears Clients out and takes away the joy of meeting new people.

• Every new caregiver requires ‘training’ on how someone wants things done. Good care plans can reduce this burden but there are always idiosyncrasies that remain uncaptured, especially at the beginning of service.
• It takes energy getting to know new people. Additions should be infrequent and planned when possible.
• Exceptional additions should be Caregivers with the possibility to become regular members of a Client’s team. In other words, if we have to bring in someone new we’re going to try to make sure it’s a caregiver who can continue coming back to mitigate future capacity issue with someone familiar.
• There is a greater chance for multiple absences from the same team during periods of the year with more vacation and illness. Situations like this are when exceptional additions are more likely to show up for essential daily services.
• At CommunityPlus one of our unofficial mottos is “Each lovelier than the last”. Meeting new Caregivers is not always a bad thing, it can also bring joy!

Real world example:

• An individual with ALS had another care agency providing 24 hour care with 21 eight-hour visits each week initially.
• They had over 15 different caregivers scheduled ongoing with several new caregivers added each week.
• This is a continuity nightmare for anyone but especially for someone with ALS where continuity is an absolute need.
• We took over the service changing from 21 eight-hour visits to 14 twelve-hour visits each week with 7 consistent caregivers through end-of-life.
• Even by our high standards, this was exceptional continuity, only made possible through the dedication of the caregivers on that team.

When the Caregiving Team is too small we call this a ‘brittle’ service because it is susceptible to breaking. When there are not enough Caregiver options to provide stable ongoing support at the desired times it increases the frequency of visit time changes, larger time changes, new caregivers on short notice or cancellations. Example: For a one visit per day service with two Caregivers, if one is covering 3 days and one is covering 4 days then the service is ‘brittle’ and at some point they won’t be able to cover for each other and a 3rd Caregiver will be required. 

• It is important to keep caregivers regularly involved with a Client service so they are able to form relationships and get to know what is normal for someone. 
• This is why we say the minimum team size is 3-4 for a daily service so that most absences can be covered with people who know the individual.

We get the odd complaint that someone has Too Much Continuity! When Client’s see the same Caregivers on a regular basis for a long time they sometimes request more variety in who comes so they can meet someone new to tell their stories to (and hear stories from). Variety is the spice of life when it doesn’t overwhelm and exhaust!

• Scheduling is never about a single change in isolation. Scheduling changes are like dominoes that occur in cascades of impact. The goal of good scheduling change is to prevent the need for future change.
• As visits become longer in duration it becomes easier to provide Good Continuity. Ex. It is easier to maintain continuity with 4 hour visits vs 1 hour visits. Fundamental scheduling logic dictates that larger visits are scheduled first to avoid creating more disruption than required in the change process.
• When visits do not occur during peak service times it becomes easier to provide Good Continuity. Ex It is easier to provide Good Continuity for an 11AM service than an 8AM service where there is more demand. Visits should be scheduled from the Time Boundary towards the center to avoid boxing visits in.
• Hourly services in remote areas may have smaller team sizes due to fewer local caregiver options. These services tend to have higher continuity but they are more brittle with greater chances of a time change, service reduction or cancellation.

• Changing the type of service from hourly to live-in or overnight often results in significant change to the Caregiving team. The Caregivers who provide hourly services don’t necessarily provide overnight or live-in services and vice versa. When we know the intended direction of service we will attempt to send caregivers who can transition with the service needs.
• Changing the requested times of service results in the visits being rescheduled to meet the timing requirement. It is likely that many of the same Caregivers can remain scheduled but possibly on different days than previous and possibly with some new faces. We always ask whether the visit time or team continuity is more important because scheduling decisions often come down to changing one or the other.
• Changing the duration of the visits requires schedules to be adjusted and some change can be expected. Shorter visits are more likely to be moved to accommodate longer visits. Example: If we have to cover 8-12 hour visits it is quite possible and likely that other visits on that Caregivers day are reassigned. 
• Home care is a web of connections and changing one visit rarely means a single change. Your service changes impact other clients, other clients service changes impact you and caregivers absences or availability changes impact everyone.
• Priority of the visit timing implicitly means that Caregiver continuity is the 2nd priority. When the visit timing is an ongoing priority it is advisable to have a larger team of regulars that know the Client so we can meet the timing requirement without the disruption of new Caregivers on short notice. Ex Requiring Time Firm 0800 daily service is going to have a larger team of caregivers coming regularly to ensure we can meet the time requirement with caregivers that know the client.