Partnering with Others to Ensure a Continuum of Care

Caring for the health of each patient is what we do best. Here, entire teams work together to achieve the best possible outcomes. As our patients and their family members prepare to transition to post-acute care or for continued services in the community, we partner with preferred providers to make sure patients receive the help they need each step of the way.

The Continuum of Care team includes hospital leadership, social workers, nurses and providers. They partner with specialized areas across the health system to understand the care needs of our patients and to support community partners in meeting those needs. Our post-acute medical director helps provide clinical oversight of the Continuum of Care network and coordinates with the hospital team, other specialists and primary care physicians to support our community partners.

How we serve patients and their physicians

• We understand the patient’s medical condition and how each transition affects that patient’s experience.
• We monitor monthly outcomes, provide on-site education and review areas of improvement to ensure quality care is delivered at each level of care.
• We implement clinical care expectations in key areas, including heart failure, diabetes, sepsis, advance care planning and other common patient needs.
• We communicate with the patient’s healthcare team (physicians, nurses and other care providers) about any concerns to prevent hospitalization.
• We help coordinate care by providing access to the patient’s medical record to ensure effective communication for continued care needs.
• We provide care from the post-acute geriatric medicine team for those who are recovering from recent hospitalizations at skilled nursing facilities, assisted living communities and long-term care venues.

Patients have a choice where they receive their ongoing care. Our Continuum of Care network follows specific quality and service practices and participates in monthly meetings with our health system to support quality outcomes for our mutual patients.

The University of Kansas Health System has identified preferred partners in all levels of care to support our patients in their continued recovery. The care team works with each patient’s physician to understand the recommendations for continued care and helps patients in planning for and arranging services.