Editorial
Pensar Enfermagem / v.28 n.01 / December 2024
DOI: 10.71861/pensarenf.v28i1.415 4
Ensuring continuity of care in healthcare requires that the care provided to a person is
coordinated and uninterrupted, being traceable regardless of the complexity of the health-
care system and the involvement of dierent professionals across various care institutions
and dierent stages of the health-disease process. Additionally, in a culture centered on the
patient, all people involved in the patient's care, including the patient themselves and their
family, communicate and collaborate to plan and coordinate care according to goals esta-
blished together with healthcare professionals.1 Continuity of care refers to the delivery
of healthcare as a consistent and interconnected process with three key dimensions: rela-
tional continuity, informational continuity, and management continuity.2 e relational
dimension involves establishing an ongoing therapeutic relationship between the patient
and the healthcare professional, linking past, present, and future care. e informational
dimension relates to the eective and ecient transfer of accumulated knowledge about
the patient to connect separate episodes of care. e management dimension reects the
ability to ensure that care from dierent professionals complements each other and is
delivered in a timely manner. ere is a consensus within the scientic community that
the concept of continuity of care is based on at least two fundamental ideas: continuity
over time and individualized care based on the patient’s health needs.2 However, achieving
continuity of care is not always easy, especially when healthcare is fragmented and there is
no backup healthcare system to ensure this function. us, when continuity is lost, people
may not fully understand their health issues, fail to adhere to therapeutic processes, or be
unsure which professional to contact when they have problems or questions. In extreme
cases, essential information may be lost, compromising the quality of care or putting the
patient’s safety at risk.
Promoting a safety culture is crucial to reducing incidents in healthcare delivery, with
tools ensuring continuity of care playing an increasingly important role.3 Systematic and
continuous data collection requires communication based on transparency and eciency.
Information transfer between healthcare professionals is critical for promoting continuity
of care. Ensuring continuity in healthcare requires recalling the Direção Geral da Saúde
guidelines on health communication, as it is a strategic goal to improve communication
safety during care transitions, according to Directive No. 001/2017, which establishes the
ISBAR tool to ensure eective communication during healthcare transitions.4 e ISBAR
technique applies at all levels of care delivery involving transitions. e ISBAR mnemonic
is a communication standardization tool that serves as a memory aid:4 I – Identication
– Clear identication and location of the communicators (sender and receiver) and the
patient concerned; S – Situation – Description of the current reason for needing health-
care; B – Background – Description of relevant clinical, nursing, and other relevant facts;
A – Assessment – Information about the patient’s condition, prescribed medications, non-
-pharmacological treatments, treatment strategies, and signicant health status changes;
R – Recommendations – Description of appropriate actions and treatment plan for the
patient's clinical situation. Information transfer between healthcare professionals should
be prioritized during vulnerable or critical moments of care transitions, with the individu-
als responsible for information transmission clearly identied (name, category, and role).
is transmission should be written and uninterrupted, ensuring clarity and legibility.
e World Health Organization’s Global Patient Safety Action Plan 2021-2030 empha-
sizes the importance of leadership in creating a safe environment. is leadership com-
mitment includes several requirements, with one of the key ones being healthcare system
EDITORIAL
Continuity of Healthcare: A Glance
Florinda Galinha de Sá
https://orcid.org/0000-0002-4523-1721
Adjunct Editor Nursing School of Lisbon
ESEL Lisbon; Nursing Research Innovation
and Development Centre of Lisbon CIDNUR
Lisbon Portugal
Corresponding author:
Florinda Galinha de Sá
E-mail: fgalinha@esel.pt
How to cite this article: Sá FG. Continuidade do Cuidado em Saúde: Um olhar. Pensar Enf [In-
ternet]. 2024 Dec; 28(1): 4-5. Available from: https://doi.org/10.71861/pensarenf.v28i1.415
Editorial
Galinha-de-Sá, F.
5
communication.3 Communication must be transparent and ecient throughout the patient’s experience of complex care, ensuring conti-
nuity of care across the patient's journey, involving various healthcare professionals. Since improving the quality of healthcare is primarily
measured by gains in eciency and eectiveness, it is indisputable that these gains will only be signicant if safety is optimized.3,4 us,
institutions must ensure that their annual training plan includes specic training for all professionals involved in information transfer,
including the ISBAR technique. is information transfer process should also be monitored through internal audits.
Recognizing the priority of ensuring safety and quality in healthcare delivery, transdisciplinary teamwork is essential for achieving health
outcomes through collaborative work. Care transitions require a transdisciplinary approach to ensure the patient moves safely from one
care institution to another and from one healthcare professional to another. Transdisciplinary teamwork also ensures that the most qua-
lied healthcare professional provides care for each issue, preventing duplication or contradictions with the care plan. Transdisciplinary
care is particularly important when treatment is complex or involves changing from one care institution to another.
e adoption of a Transitional Care Model has shown reductions in healthcare costs and hospital readmissions, with key components
including: screening/surveillance; healthcare professionals; maintaining relationships; involving patients and family caregivers; assessing
and managing risks and symptoms; educating and promoting self-management; collaboration; promoting continuity; and promoting
coordination.5 Although each element is dened separately, it is important to note that they are all interconnected and part of a holistic
care process.
Continuity of care impacts the eective use of healthcare services and health outcomes for the population.2,5 Patients, especially those
with multiple or complex health needs, value continuity of care in terms of forming a long-term, trusting relationship with healthcare
professionals. Currently, various strategies in healthcare systems aim to achieve high continuity of care, such as case management, advan-
ced nursing practice, and integrated care.2 New healthcare technologies bring transformational changes, enhancing health literacy with
the involvement of the patient, family, and society in the health-disease process.
e articles published in issue 28 of the Pensar Enfermagem Journal of Nursing address topics intrinsically linked to continuity of care,
either by promoting care for dierent population groups or through the implementation and analysis of services, such as nursing con-
sultations. e focus on health communication as a means of ensuring continuity also emerges in various articles discussing new tools
and technologies for community engagement. It is essential to reect on how promoting safety in healthcare is based on these signicant
dimensions, challenging the advancement of research and its dissemination in this area.
References
1. Mccormack B, McCance T. e Person-Centred Nursing Framework. In book: Person-centred Nursing Research: Methodology, Me-
thods and Outcomes, April 2021. https://doi.org/10.1007/978-3-030-27868-7_2
2. Forstner J, Arnold C. Continuity of Care: New Approaches to a Classic Topic of Health Services Research. In: Wensing, M., Ullrich,
C. (eds) Foundations of Health Services Research. Springer, Cham., 2023. https://doi.org/10.1007/978-3-031-29998-8_21
3. World Health Organization. WHO Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care.
World Health Organization, 2021. https://iris.who.int/handle/10665/343477
4. Direção Geral de Saúde. DGS - Norma nº 001/2017, de 08.02.2017. Comunicação ecaz na transição de cuidados de saúde. Direção
Geral de Saúde.
5. Hirschman K, Shaid E, McCauley K, Pauly M, Naylor M. Continuity of Care: e Transitional Care Model, OJIN: e Online Jour-
nal of Issues in Nursing Vol. 20, No. 3, Manuscript 1, September 30, 2015.https://doi.org/10.3912/OJIN.Vol20No03Man01
