Hospital Continuity Teams

1aiser Permanente, Oakland, CA

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 241


Many hospitals have a subset of patients who require extended inpatient care due to a combination of complex social and medical factors. Most traditional Hospitalist staffing models are suboptimal for providing continuity of care for such patients. In addition, Hospitalists may not be trained to provide long term acute care or prolonged sub‐acute care, and may perceive these patients as a burden. Patients and their families in this predicament suffer from a lack of physician continuity, with drops in information, differences in communication of plans and prognosis, and loss of trust as consequences of the discontinuity.


Our goal was to improve the experience for patients who require extended hospitalization, and the providers who care for them, through the implementation of Hospital Continuity Teams.


Each Hospital Continuity Team consists of one Lead Hospitalist (LH), one Rounding Hospitalist (RH), and an RN discharge planner. The Lead Hospitalist is responsible for providing continuity for all aspects of the patient’s care for the entirety of the prolonged hospitalization. The LH typically rounds with the patient at least weekly and attends most family meetings. They also facilitate the transfer of trust by introducing the oncoming RH to the patient and their family, and ensure the patient’s long term plan is communicated well at the clinical hand‐off. Selecting Lead Hospitalists with administrative time has been critical in maintaining oversight of these patients. In addition, providing education on Sub‐Acute Medicine topics helped increase the comfort level and engagement of our Hospitalists with this vulnerable population of patients.

Since many long term sub‐acute patients require chronic tracheostomies and mechanical ventilation, the Hospital Continuity Team may include a Lead Pulmonologist and a Lead Respiratory (RT) and Speech Therapist (ST). The Lead Pulmonologist does not need to see the patient daily, but provides continuity for the LH, patient and family. By understanding the patient’s trajectory, the consistency of communication with the LH, patient and family improves trust. The Lead RT facilitates the subtle ventilator adjustments that are required when attempting to restore speech to the chronically ventilated patient and works closely with the Lead ST during these trials.

Since our program began in July 2012 approximately 20 complex patients with stays ranging from 30 to over 800 days have been assigned to Hospital Continuity Teams. Patients, their families, front‐line staff and Hospitalists all report improved satisfaction with this model in non‐structured interviews.


Hospital Continuity Teams increase support for physicians caring for patients with prolonged hospitalizations and decrease patient and caregiver stress at provider transition points. Based on its early success, we are identifying patients with complex care needs sooner in their hospitalization who would benefit from Hospital Continuity Teams.

To cite this abstract:

Colacurcio V. Hospital Continuity Teams. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 241. Journal of Hospital Medicine. 2014; 9 (suppl 2). Accessed March 28, 2020.

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