1 True Health Care Management

Continuity of Care: High-Quality, Patient-Centered Healthcare

A woman talking to a doctor on video call.

In today’s post-pandemic healthcare landscape, the need to ensure the seamless delivery of quality patient care across multiple medical disciplines has never been greater. All too often, the most vulnerable among us are balancing the care of multiple chronic conditions while trying to navigate a complex and fragmented system of healthcare services. Your typical senior patient may be receiving care from a primary care physician (PCP), one or more medical specialists, or home health or nursing services, among others. The reality is, the traditional fee-for-services model of healthcare delivery has created silos within the system, resulting in poor continuity of care and, ultimately, suboptimal patient outcomes.

Enter the continuity of care model, a value-based healthcare delivery system that stresses coordinated care among all members of a patient’s healthcare team for a lifetime. This type of care management puts people first and has been shown to improve patient outcomes, decrease hospital readmissions and ER visits, and save on overall healthcare costs. In order to truly provide this type of care, doctors and nursing staff must be able to coordinate care across the continuum—from inpatient to outpatient settings, and across different provider specialties. At 1 True Health, continuity of care is at the heart of all we do. Our team of compassionate and experienced healthcare professionals work together to provide each patient with the coordinated services they need for comprehensive care and improved quality of life. This also helps ease the burden on already stressed nurses and other staff members. This article will discuss the aspects of continuity of care and how 1 True Health helps healthcare providers deliver top-tier care to seniors while making their own life-saving work easier and more effective.

Coordinated continuity of care is how you deliver better care, improve outcomes, and reduce expenses.

The Multi-Dimensional Model

The continuity of care model is built on the premise that care should be patient-centered, team-based, and data-driven. To achieve this, 1 True Health has developed a multi-dimensional model that includes several key components:
All members of the patient’s healthcare team work together to develop a comprehensive care plan that considers the individual’s needs (medications and treatments) as well as health goals. This requires ongoing communication and collaboration among all team members—from the PCP to other medical specialists, home health nursing services, and other care providers. 1 True Health seeks to provide every patient with a “medical home” where their comprehensive care needs can be met and their progress tracked over time.
Continuity of care is not a one-time event but rather an ongoing process that should span (and improve) people’s lives. 1 True Health is committed to providing our people with the long-term care they require to achieve the quality of life they deserve. We are dedicated to being a partner in our patients’ health journey, every step of the way. Whether it’s helping to manage a chronic condition, providing guidance on preventative care measures and medications, or offering support during a health crisis, 1 True Health will be there for the long haul.
Technology plays a vital role in continuity of care by providing the means for real-time communication and information sharing among all members of the healthcare team. 1 True Health utilizes leading-edge telehealth technologies to facilitate continuity of care and collect important information about patient health. This information allows us to identify opportunities for improving health outcomes and optimizing care delivery. Our team uses data to drive decision-making and continually evolve our continuity of care model. Such Is the model of future healthcare delivery, and we’re proud to be at the forefront of this movement. Even better, all designated members of the senior patient’s care team will be able to access this data. This gives healthcare providers the essential information they need to deliver the highest level of care.
Continuity of care is only possible when patients and their family members are actively involved in their own healthcare. Family engagement becomes especially important as people begin to age and tend to experience more chronic health conditions. 1 True Health works with clients and their family members to ensure they have the information and support they need to make informed decisions about their health. We believe that continuity of care is a team effort, and we are committed to working together with our clients and their families to achieve the best possible outcomes.
Continuity of care goes beyond simply managing an individual’s chronic conditions and mediations. 1 True Health proactively manages a patient’s overall health and well-being, while also providing reactive care in the event of an acute illness or injury. We believe that care should be proactive, preventive, and responsive to the needs of each individual patient. We are dedicated to providing the highest quality care possible and to continuously improve our care delivery model.
The continuity of care model has been shown to be a more cost-effective way of delivering healthcare. Let’s face it, Medicare and Medicaid are under a lot of pressure to cut costs. But at 1 True Health, we believe that by implementing the preventative practices of a value-based model, we can help to improve patient outcomes while also reducing healthcare costs. We are committed to being good stewards of our clients’ healthcare dollars and making sure they work to deliver the most efficient, effective care possible. This is the basis of our business model and one of the reasons we believe care coordination is the future of healthcare.
At 1 True Health, each patient is assigned a Care Navigator who serves as the main point of contact for any and all healthcare needs of the patient, such as nursing services, refills on medications, and appointments with specialists. The Care Navigator facilitates continuity of care via careful coordination and communication among all members of the healthcare team. Care Navigators also ensure that clients and their family members have the support and information they must have to make informed decisions about their health.
1 True Health provides the people we serve with the highest quality care possible. Our holistic services continuously monitor their progress and outcomes to ensure that they are receiving the best care possible. From monitoring a patient’s prescribed daily medications to coordinating with medical specialists and well visits, we are committed to providing the seamless care that people need to achieve optimal health for the long term. We’ve put together a team of the best and brightest in healthcare to provide people with the care they need and deserve.

Ready to discover more about continuity of care services for your patients? Contact us today to learn more about how we can help you coordinate care and cut costs today!

The Mutually Beneficial Model

There are many benefits to continuity of care, both for people we serve and our healthcare system as a whole. With its primary focus on prevention and proactive management, continuity of care has been shown to improve patient outcomes while also reducing healthcare costs. Continuity of care is indeed a more efficient and effective way to deliver healthcare, and it is quickly becoming the new standard in chronic care management. So how can this model benefit both your patients and your practice?

Your patients will have:

  • 24/7 access to care (nurse line)
  • A dedicated Care Navigator and care team
  • Improved coordination among PCPs and specialists
  • Reduced hospitalizations, readmissions, and emergency room visits
  • Improved health outcomes
  • Greater engagement and satisfaction with their healthcare plan

Your practice will have:

  • Decreased overall healthcare costs
  • Improved chronic disease management
  • Lower costs associated with chronic care management
  • Care plans tailored to the unique needs of your patient population
  • Stronger rapport and relationships with the people you serve and their family members
  • Health equity among your patient population

1 True Health is committed to providing continuity of care that meets the needs of both the people we serve and our healthcare system. We believe that continuity of care is a win-win for everyone involved. When you outsource care continuity to 1 True Health, you can be confident that the people you serve will receive the high-quality, coordinated care they need to stay healthy and happy, and reduce the risk of ending up in a hospital emergency room.

Threats to Continuity of Care

Despite its many benefits, continuity of care is often interrupted. These interruptions, also known as care fragmentation, can have a negative impact on both patients and healthcare providers. When fragmentation occurs, it can lead to duplication of services, conflicting treatment plans, and a lack of coordination among doctors and nursing staff. This can be especially dangerous for older people who have multiple chronic conditions. There are many potential causes of care fragmentation, but some of the most common include the following:

When different providers do not communicate with one another, serious consequences can occur. Uninterrupted quality care relies on communication and coordination among all members of the healthcare team, but often this communication breaks down. After all, if doctors, nurses, and other medical professionals aren’t communicating with one another, how can they possibly coordinate care? Lack of communication among medical professionals can have a number of dangerous consequences for those you serve, including duplicative services, errors in medications or contraindications, and conflicting treatment plans.
One of the most common reasons for continuity of care disruption is a change in an individual’s insurance coverage. When a patient’s insurance coverage changes, their continuity of care is often disrupted as they are forced to switch providers. This can be a major inconvenience for people, and even lead to a lapse in care. Elderly people are generally more susceptible to the confusing and ever-changing coverage landscape, as they are more likely to be on Medicare and less likely to have employer-sponsored insurance. Similarly, provider turnover is another common reason for care fragmentation. When a patient’s primary care physician or nurse practitioner leaves the practice, many people are forced to find a new provider. This can be a major inconvenience and even lead to gaps in care.
Simply put, when patients don’t follow their care plan, continuity of care is disrupted. This can be due to a number of different factors, including forgetfulness, lack of understanding, or inability to afford medications. Regardless of the reason, patient non-adherence can have dangerous consequences, including worsening chronic conditions, hospitalizations, and even death. Patient engagement and education are vital to the continuity of care because when people are more involved in their own care, they are more likely to stick with their care plan. 1 True Health helps alleviate this problem with regular follow up and the ability to respond knowledgably and quickly to patient concerns.
For some people, geographic isolation can be a barrier to continuity of care. This is often the case for people living in rural communities who may have to travel long distances to see a medical specialist or receive certain treatments. This can make it difficult for them to keep appointments and follow their care plans. Additionally, it can be difficult for providers to coordinate care and communicate with one another when cases are geographically dispersed.

The primary care physician is often the cornerstone of care continuity. They are typically the first points of contact for people seeking basic medical attention and act as coordinators for the rest of the healthcare team. However, a shortage of primary care physicians in the United States has made left many PCPs feeling overwhelmed and unable to provide continuity of care on their own. [AAMC Report Reinforces Mounting Physician Shortage | AAMC] It’s also left many people without a regular source of care. For this reason, it’s become increasingly important to find ways to supplement primary care with other care services.

While medical specialization has many obvious benefits, it can also potentially lead to disruptions in the continuity of care. When clients see multiple specialists for different (especially chronic) conditions, it can be difficult to coordinate care among all their providers. A typical senior may see as many as four different specialists, which can make it hard for them to keep track of all of their appointments, medications, and care instructions. Additionally, specialists often have little interaction with the patient’s primary care physician, which can lead to a lack of communication and coordination.

Interested in how we use data to drive decision-making and continually evolve our practice?

1 True Health: Offering Interventions for Care Continuity

Fortunately, for nearly every disruption in continuity of care, 1 True Health has an intervention. Our approach to care continuity is proactive, patient-centered, and data-driven. We use a combination of technology and clinical expertise to close care gaps and improve patient outcomes. Continuity of care is our passion, and we are proud to be a leader in this growing field. When it comes to continuity of care, 1 True Health is your partner for success. We offer a number of interventions to promote the best possible patient outcomes, including:

Continuity of Care in Action

For those living with one or more chronic conditions, continuity of care is essential to maintaining their health and well-being. Specific continuity of care interventions, like those offered by 1 True Health, can make a big difference in the lives of these patients.

Consider the fictitious but all-too-common case of Mr. Smith, a 72-year-old man with COPD and type 2 diabetes. Mr. Smith is on continuous oxygen therapy and must use a nebulizer several times a day. He also takes multiple medications for his diabetes. His family would like to place him in a nursing home, but they haven’t actively pursued placement, and they don’t know how they’ll pay for it. He sees a pulmonologist, but his PCP has been managing his diabetes. And because the two providers are not coordinating care, Mr. Smith has started to slip through the proverbial cracks. He’s been forgetting to use his inhaler, and his blood glucose levels have been all over the place. As a result, he’s been making frequent trips to the emergency department and been admitted to the hospital several times in the past year.

Mr. Smith’s story is not unique. In fact, it’s all too common.

Or perhaps the example of Ms. Jackson, a retired nurse aged 79 is more relatable.

Ms. Jackson is a retired registered nurse who, at 79 years old, is relatively healthy for her age. And because of her background as a nurse, she is very proactive about her health. She has a regular routine of going to the gym, taking her vitamins, and getting her annual physical. But lately she has begun to experience some memory loss and struggles to remember to take her medications that she takes daily to manage her mild hypertension. Her family is supportive, but they live out of state and are unable to check on her daily. Ms. Jackson is starting to feel isolated, and her health is beginning to suffer as a result.

This retired nurse’s story is one that will likely resonate with many providers. Memory loss and cognitive decline are common among older adults and can lead to serious health problems if not properly managed.

1 True Health can help patients like these and the medical professionals who care for them by providing continuity of care services that focus on disease prevention and health maintenance. These services can include regular check-ins, management of medications, and disease education. These preventative services can help to keep people like Mr. Smith and Ms. Jackson healthy and out of the hospital.

Don’t let your patients or your staff suffer due to lack of continuity of care. Let 1 True Health be your partner in delivering value-based healthcare that makes a difference in patient lives.

Chronic Care Management and Continuity of Care

Management is all about proactive care. Chronic care management (CCM) focuses on proactive disease prevention and health maintenance for those with chronic conditions. CCM services can help to improve patient outcomes by reducing hospitalizations, emergency department visits, and overall healthcare costs. For a more specific look at how continuity of care practices can help your patient population manage their chronic conditions, check out how we work together to improve care coordination among some of the following chronic conditions:
A senior couple video chatting on laptop while sitting in their living room.

COPD can be unpredictable, so it’s important that your COPD patients have a continuity of care plan in place. People who live with COPD often experience exacerbations or “flare-ups,” which can be caused by any number of things, including weather changes, infections, and air pollution. These exacerbations can be serious, and often lead to hospitalization. COPD is a tough condition to manage, and patients with the disease often, as demonstrated in this article, have high rates of hospital readmission as well as non-compliance.[Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions - PMC (nih.gov)] To make matters worse, healthcare organizations are often penalized under strict CMS regulations regarding readmissions within 30 days.

Continuity of care plans for these patients should include (at a minimum) regular check-ins with their healthcare team, education on disease management and flare-ups, and a clear understanding of what to do in case of an emergency. Remote patient monitoring (RPM) can also be a helpful tool for COPD patients, as it allows them to send data such as pulse oximetry on their symptoms and health status to their care team on a regular basis. This information can help the care team to catch exacerbations early and prevent them from becoming serious.

The goal of continuity of care for those living with COPD is to help them manage their disease, avoid exacerbations and hospitalizations, and maintain their quality of life. Our team works with patients and family members to develop a care plan that fits each individual’s needs. We also provide education on COPD, its management and typical medications, and what to do in case of a flare-up or exacerbation.


Whether diabetic patients are insulin-dependent or not, continuity of care is essential to disease management. People with diabetes are at increased risk for several medical complications such as heart disease, stroke, kidney disease, and blindness. High quality medical care, such as is associated with continuity of care practices, can help to prevent or delay the onset of these complications by providing regular check-ins, education on self-care and disease management, and early detection and treatment of problems.

Continuity of care plans for people living with diabetes revolve around maintaining acceptable glycemic levels. For those who are insulin-dependent, this often means frequent blood sugar testing and regular adjustments to insulin doses. For all diabetics, diet and exercise are important self-care activities that can help to control blood sugar levels. Education on these and other related topics is an essential part of continuity of care for people living with diabetes.

1 True Health Care Navigators work with diabetic patients to develop continuity of care plans that fit their individual needs. We provide education on medications as well as disease self-management and work with them to ensure they have all of the resources they need to incentivize healthy choices and promote glycemic control.

Congestive Heart Failure (CHF)

People living with CHF or congestive heart failure often have a difficult time managing their condition due to the progressive nature of the disease. As the heart weakens, it becomes less able to pump blood efficiently which can lead to a build-up of fluid in the lungs and other issues. This can cause shortness of breath, fatigue, and other symptoms that make it hard to live a normal life. The disease is often marked by periods of stability followed by sudden exacerbations or worsening of symptoms, which can be very dangerous. Continuity of care is essential for people living with CHF. Depending on the individual needs of the patient, care interventions for those with CHF may include regular check-ins with a care team, remote monitoring of symptoms (via wearable devices or apps), education on medications, disease self-management, and guidance on what to do in case of an exacerbation.

At 1 True Health, we work with patients and their family members to find solutions that fit their individual needs. Our care navigators provide educational resources on CHF and work with patients to ensure that they have the tools they must have to help maintain health and decrease hospital readmissions.


High blood pressure, or hypertension, is commonly known as the silent killer, and for good reason. People with hypertension often have no symptoms and may not even know they have the condition. Left untreated, hypertension can lead to heart disease, stroke, and kidney failure among other serious medical complications. Hypertensive patients, even those with no symptoms, are at risk for these complications and need continuity of care to prevent or delay their onset.

Continuity of care practices for these clients may include regular check-ins with a provider or care team, remote monitoring and recording of blood pressure trends and levels, education on medications as well as disease self-management, and guidance on what to do if blood pressure levels become too high.

The compassionate team of Care Navigators at 1 True Health work with hypertensive patients to build a sense of trust and rapport. We develop continuity of care plans that provide education on health maintenance along with medications and disease management. We work with the people we serve and their family members to help them get the resources they need to stay healthy and out of the emergency room.

Cognitive Decline

Perhaps one of the most frightening aspects of getting older lies in the potential for cognitive decline. As we age, it becomes more likely that we will experience some form of cognitive decline, whether it be memory loss, difficulty concentrating, or problems with executive function. These changes can make it hard to live independently and manage our daily activities. They can also make it difficult for family members who don’t have enough experience with cognitive decline to understand and support their loved ones.

Developing a continuity of care plan for people experiencing cognitive decline can help bridge the gap for both patients and their families. Such plans may include regular check-ins with a care team, education and support for family caregivers, and guidance on how to cope with the changes that come with cognitive decline.

At 1 True Health, we understand the challenges that come with cognitive decline, and we are particularly adept at developing care interventions that meet the needs of both patients and family nurse/caregivers. Our navigators understand the importance of education and support, and they work consistently with patients and families to ensure that they have all the resources they need to cope with cognitive decline.


Looking to help your patients manage their chronic conditions more effectively? Contact us today and let our care navigators help you help your patients live their best lives!

Because Heath Begins at Home

At 1 True Health, we recognize the importance of a healthy home and value the role it plays in promoting continuity of care. We work with patients and family members to ensure that they have the resources they must have to maintain a healthy home environment. This may include education on medications and treatment safety, guidance on how to create a healthy home routine, and support in making necessary changes to the home environment.

We get it. The last thing you want is for the people you serve to end up in the hospital time and again. You want them to take their medications, follow their treatment plan, stay home and stay healthy. That’s where we come in. 1 True Health is your partner in continuity of care, working with you to ensure that your patients have everything they need to healthy at home. A healthy home is essential for quality of life, and at 1 True Health, we are committed to helping the people we serve and their family members create one.

The Future of Home Health and Continuity of Care

Recent advances in technology and telehealth have created new opportunities for the continuity of care. Remote patient monitoring, also known as RPM, is a type of technology that allows patients to send health data to their care team from home. This data can be used to identify problems early on, and it can also be used to track the progress of patients over time. Such valuable medical resources have made it easier to develop continuity of care plans that are tailored to the needs of individual patients.

RPM is just one example of how technology can be used to promote the best care possible. At 1 True Health, we are always looking for new ways to use technology to improve the continuity of care we provide to our patients. We believe that RPM and other advances in telehealth such as video conferencing will play a big role in the future of home health care for seniors and patient care at large. Our mission is to provide our patients with the best continuity of care possible, and we will continue to innovate and invest in new technologies to make that happen.

Reduce Readmissions with Quality Continuity of Care

Sometimes hospitalizations are unavoidable. Whether it’s for an acute illness or planned procedure, there will be times when your patients need to be hospitalized. However, many times readmission rates can be reduced simply by following continuity of care best practices.

Typically, when people are discharged from the hospital, a nurse or member of the nursing staff will provide a list of instructions to follow and a regimen of medications to take. These important but often complex instructions can be difficult for patients and families to remember, especially in a hospital

That’s where continuity of care comes in. By ensuring that patients have the tools they need to manage their care at home, we can help reduce the risk (and cost) of readmission. Such plans may include management of medications, wound care, diet and exercise recommendations, home nursing visits, and more. Our continuity of care Care Navigators will also follow up and provide education and support to ensure that after patients are discharged from the hospital, they have everything they need to stay healthy at home and reduce their risk of readmission.

Continuity of care doesn’t just save money—it saves lives. When people receive the continuity of care they need, they are more likely to stay healthy and out of the hospital. That’s why we are committed to providing the people we serve with the best continuity of care possible.

Incentivize Health, Engage Your Patients

Of course, continuity of care is essential to keeping your patients healthy, but its also important for another reason: it’s how you’ll stay competitive in the world of value-based care.

In the past, fee-for-service reimbursement models meant that providers were paid for the number of services they provided, regardless of whether those services improved the health of their patients or not. But now, with value-based care, providers are reimbursed based on the quality of care they provide, making continuity of care practices more important than ever before. Value-based care seeks to decrease overall healthcare costs, improve care management strategies, and most importantly, provide better care for people. Models like the Medicare Shared Savings Program, for instance, now incentivize providers to keep the people they serve healthy and out of the hospital. Indeed, continuity of care is so important to value-based reimbursement that providers who don’t make it a priority will likely find themselves at a competitive disadvantage.

Simply put, value-based care models incentivize providers to keep the people they serve healthy, because they will only be reimbursed if these people stay healthy and out of the hospital. This shift has created opportunities for providers to get creative in the way they engage the people they serve and promote continuity of care. Initiatives like remote patient monitoring (RPM) for instance, allow medical professionals to remotely monitor the health of their clients in real time and intervene when necessary to prevent avoidable hospitalizations.

A nurse line is another great way to engage the people you serve and promote continuity of care. By giving your patients direct access to a nurse 24 hours a day, 7 days a week, you can help ensure that your people get the care they need when they need it. This simple line of direct access to qualified nursing staff members has long been proven to reduce emergency department visits and hospitalizations, while also saving money.

But even more than the cost savings and quality improvements, patient engagement empowers people to take control of their own health. When patients (or their family members) are actively involved in their care, they are more likely to follow their care plan and adhere to their regiment of medications. They are also more likely to make healthy lifestyle choices that can prevent chronic disease. The bottom line is this: continuity of care is essential to the success of value-based care, and patient engagement is essential to continuity of care.

When you provide quality continuity of care, you’re giving the people you serve the tools they need to take control of their health. You’re also building trust and showing that you care about their long-term health and well-being.

1 True Health is dedicated to helping our clients provide the best value-based care for their patients. Contact us today to learn more about how we can help you improve continuity of care at your practice.

Why 1 True Health?

At 1 True Health, our mission is to improve health outcomes and overall health and wellness for the seniors that are part of the 40% of the people in the U.S. population suffering from one or more chronic or acute diseases. We are a team of passionate individuals committed to making a difference in healthcare. We believe in leadership through servanthood, and that when we work together, we can make a positive impact on the lives of those we serve.

Our vision is to empower and educate people (patients and their family-member caregivers) to take control of their health, so that they can lead healthier, happier lives. We believe that continuity of care is essential to the success of real value-based care, and we are dedicated to helping our clients provide ever-improving care for the people they serve.

Our values are simple: love others, do the right thing, pursue excellence, and grow daily. These values guide everything we do, from the way we treat our patients and employees, to the products and services we provide. We are constantly striving to provide the highest and best care for the people we serve, and we would be honored to partner with you in your journey to improve how you care for others.

Who We Help and How

At 1 True Health, we offer a variety of services to help our clients improve continuity of care. We provide care management service for individuals, for clinical practices, and for senior living communities. Our continuity of care services are designed to help our clients coordinate care for people across the continuum of care. We work tirelessly for our clients to make sure that each patient receives the best possible care, and that their journey is as smooth as possible.

Contact us today to learn more about how we can help you provide better care for your senior community residents.

Ready to Outsource Your Continuity of Care Process?

If you’ve been on the fence about outsourcing your continuity of care plans, now is the time to take the plunge. 1 True Health stands ready to help you improve continuity of care practices for the people you serve in clinical practices and senior living communities. There has never been a better time for your patients or senior living residents to have access to coordinated care services. Help prepare at-risk populations for upcoming health concerns, manage conditions more proactively, and identify potential care gaps before they happen and turn into costly hospitalizations. And while you’re at it, improve operations and reduce nurse burnout rates by taking advantage of our care management services. We can help you manage your patients’ care more effectively and efficiently so you can focus on providing the best possible care. If you’re ready to get started, we are, too. Contact us today to learn more about how we can help.