FOCUS
INTRODUCTION
As modern healthcare has become more
specialized, it has also become more siloed.
This phenomenon has led to less coordi-
nation and continuity of care. A patient
seeing many different clinicians will often
find that communication within and among
these groups is insufficient. The result is
poor coordination of care, leading to ris-
ing costs, adverse outcomes and an unsat-
isfactory patient experience.1 Even modest
differences in care continuity have been
associated with considerable differences
in costs, use and complications among
Medicare beneficiaries. 2 This has led the
Institute of Medicine to identify care coor-
dination/continuity as a high priority. 3
The nursing plan of care has been used
for more than three quarters of a century
as a means to improve continuity of care
between nurses. While there is no definitive
historical record, the origin of the concept
is often attributed to Ellen L. Buell, RN, a
public health nurse and nursing instruc-
Improving Continuity
Of Care Through
Interdisciplinary
Plans Of Care:
A Patient-Centered
Approach Ensures
Better Outcomes
Romina Hipolito Elias, MSN, RN-BC; and Clarissa Tojos, RN-BC
ACHIEVING CONTINUITY OF CARE
FALL 2015 n VOLUME 29 / NUMBER 4 n www.himss.org 18
