STEP-DOWN CONCEPTS

IN HEALTH CARE
CONTINUITY OF CARE
The role of the Family Practitioner

Definitions
What

is CONTINUITY OF CARE

Definitions
CONTINUITY

OF CARE is:

Continuing

care after specialist care

Life long care
CONTINUITY

OF CARE - between different levels of

health care
Primary

health care

Secondary

and tertiary Care

Long-term

Follow up care

Case

Mrs

Anita is a 32 yrs old overweight female presents to the General

Practitioners clinic with excessive thirst, hunger and polyuria.

Her

mother is a known diabetic

The GP makes a clinical diagnosis and refers her to the internist

at Siloam hospital requesting admission and investigation.

WRITE A REFERRAL LETTER

 Referral

communications

Primary complaint

Reason for referral

Diagnosis

Management

Specific issue

Urgency

 Case

The Internist confirms the diagnosis and she is started on

injectable insulin.
She is discharged to the care of her General Practitioner

WRITE A DISCHARGE SUMMARY AND

RECOMMENDATIONS FOR THE GP

Discharge summary
Identification:
Discharge date:
Discharge Diagnosis:
Summary:.
- brief summary of history and PE
- brief summary of in-hospital care

Special Procedures:
Discharge medications.
Postoperative Plan:

Discharge summary
Identification:
Ibu Anita age 32
DoB: 11,04,78
Discharge date: 20,02,11
Discharge Diagnosis: Diabetes Mellitus
Summary:.
This 32 yrs presents with typical thirst and polyuria. Investigation shows fasting BS of
(N). GTT demonstrates (XXX)
She was stabilized with diet, and Insulin. Following 1 week she required Insulin (XXXX).
At discharge her condition is stable and she is discharged with the following plan
(XXXXX)

Discharge medications.
Insulin (XXXXX)
Recommended Plan:
(XXXXXXXXXXXX)

Discharge summary - a surgical example

Coast Regional Hospital
Thomas 1962 5 21
MRN 553210
Admitting Physician: Dr. T.K. Spineguy
Admission date: 14, 09, 08
Discharge date: 15, 09, 08
Admitting Diagnosis: Acute L5-S1 disc protrusion
Discharge Diagnosis: Acute L5-S1 disc extrusion
Operative Procedure: L5-S1 Lumbar Discectomy (14, 09, 07)
Summary: This 45 years male admitted to hospital with back and intractable Right leg
pain of 3 months duration. Examination showed root tension signs and moderate S1
root deficit. MRI imaging demonstrated multiple level degenerative changes and a large
Right posterolateral disc herniation at L5-S1.
At surgery on 14, 09, 07, a large partly extruded disc was found and removed.
There were no intraoperative or postoperative problems. His pain was relieved
immediately and neurological deficit showed some initial improvement.
Discharge medications are Tylenol # 3 prn. He should continue his preoperative
medications.
Postoperative Plan: office follow-up planned for 2 weeks time.

 Case

1
Continuity of Care
The Family Practitioner resumes her care
If you are her FP, what are your considerations for
ongoing care

Continuity of Care Planning

Immediate

issues

Post

operative care
Medications management
Patient Education
Special

issues

Continuing
Short

Care plan

term care plan

Long-term care plan

DESIGN A PLAN FOR HER ONGOING CARE

Continuing Care Plan Diabetes

Mellitus
Immediate
Diet

post discharge plan

plan

Activities

plan

Medications
Education

plan

plan