Continuity of Patient Care

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  Subject Areas on Research

  • "Getting to Zero" Among Men Who Have Sex with Men in China: a Review of the HIV Care Continuum. 
  • "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. 
  • A Framework for Improving Chronic Critical Illness Care: Adapting the Medical Home's Central Tenets. 
  • A Novel Rehabilitation Intervention for Older Patients With Acute Decompensated Heart Failure: The REHAB-HF Pilot Study. 
  • A comparison of the adoption of electronic health records in North Carolina and South Carolina HIV systems. 
  • A major barrier to universal hepatitis B immunization of infants. 
  • A pilot study of assertive community treatment for patients with chronic psychotic disorders. 
  • A qualitative analysis of communication workflows between adult day service centers and primary care providers. 
  • A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period. 
  • A systematic review of interventions to improve outcomes for elders discharged from the emergency department. 
  • A trial of increased access to primary care. 
  • A typology of longitudinal integrated clerkships. 
  • Adaptation of a postoperative handoff communication process for children with heart disease: a quantitative study. 
  • Adult cancer survivors discuss follow-up in primary care: 'not what i want, but maybe what i need'. 
  • Adults' lack of a usual source of care: a matter of preference? 
  • Advancing the HIV Pre-Exposure Prophylaxis Continuum: A Collaboration Between a Public Health Department and a Federally Qualified Health Center in the Southern United States. 
  • An analysis of returning patients in family practice. 
  • Application of assessing care of vulnerable elders-3 quality indicators to patients with advanced dementia and poor prognosis. 
  • Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature. 
  • Assessment of follow-up completeness and notification preferences for imaging findings of possible cancer: what happens after radiologists submit their reports? 
  • Association of patient and physician characteristics with follow-up of abnormal laboratory results. 
  • CARE-PARTNER: a computerized knowledge-support system for stem-cell post-transplant long-term follow-up on the World-Wide-Web. 
  • COVID-19: maintaining essential rehabilitation services across the care continuum. 
  • Can we make postoperative patient handovers safer? A systematic review of the literature. 
  • Care Coordination and Comprehensive Electronic Health Records are Associated With Increased Transition Planning Activities. 
  • Care continuity impacts medicare expenditures of older adults: Fact or fiction? 
  • Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol. 
  • Care of cancer survivors. 
  • Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences. 
  • Caring for survivors of childhood cancer: it takes a village. 
  • Changing preferences for survival after hospitalization with advanced heart failure. 
  • Climbing out of the black hole of subacute care. 
  • Clinical perspectives on portable do-not-resuscitate orders. 
  • Code Abdomen: An Assessment Coding Scheme for Abdominal Imaging Findings Possibly Representing Cancer. 
  • Colon cancer. 
  • Communication factors in the follow-up of abnormal mammograms. 
  • Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. 
  • Complexities of Medication Management Across Care Transitions: A Case Report. 
  • Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs. 
  • Continuity of antipsychotic medication management for Medicaid patients with schizophrenia. 
  • Continuity of care (COC) and amyloid-β PET scan: the CARE-IDEAS study. 
  • Continuity of care in the 80-hour workweek era? 
  • Continuity of medical care, health insurance, and nonmedical advice in the first 3 years of life. 
  • Continuity of medication management in Medicaid patients with chronic comorbid conditions: An examination by mental health status. 
  • Continuum of care in the treatment of ST-segment elevation myocardial infarction (STEMI): importance of platelet and coagulation inhibition. 
  • Cost-effectiveness of osteo-odonto keratoprosthesis in Singapore. 
  • Defining High-Quality Palliative Care in Oncology Practice: An American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement. 
  • Defining the HIV pre-exposure prophylaxis care continuum. 
  • Determinants of remaining in the community after discharge: results from New Jersey's Nursing Home Transition Program. 
  • Developing physicians as catalysts for change. 
  • Discharge huddle outfitted with mobile technology improves efficiency of transitioning stroke patients into follow-up care. 
  • Discharge information and support for veterans Receiving Outpatient Care in the Emergency Department: study design and methods. 
  • Early outcomes following low dose naltrexone enhancement of opioid detoxification. 
  • Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy. 
  • Effectively identifying the inpatient with hyperglycemia to increase patient care and lower costs. 
  • Effects of Acute-Postacute Continuity on Community Discharge and 30-Day Rehospitalization Following Inpatient Rehabilitation. 
  • End of study transition from study drug to open-label vitamin K antagonist therapy: the ROCKET AF experience. 
  • End-of-life care at an academic medical center: are attending physicians, house staff, nurses, and bereaved family members equally satisfied? Implications for palliative care. 
  • Enhanced immigration enforcement in the USA and the transnational continuity of HIV care for Latin American immigrants in deportation proceedings. 
  • Establishing a regional, multisite database for quality improvement and service planning in community-based palliative care and hospice. 
  • Evaluation and management of the atrial fibrillation patient: a report from the Society of Cardiovascular Patient Care. 
  • Evaluation of a cancer survivorship protocol: transitioning patients to survivors. 
  • Evaluation of an intensive strategy for follow-up and surveillance of primary breast cancer. 
  • Evening continuity clinic: preserving primary care education in the face of duty hour limitations? 
  • Ever-evolving: population care coordinators. 
  • Evolution of a longitudinal, multidisciplinary, and scalable patient navigation matrix model. 
  • Exploring the HIV continuum of care among young black MSM. 
  • Exploring the use of social network analysis to measure social integration among older adults in assisted living. 
  • Follow-up of patients with new cardiovascular implantable electronic devices: are experts' recommendations implemented in routine clinical practice? 
  • Follow-up visits by provider specialty for patients with major depressive disorder initiating antidepressant treatment. 
  • Free visits: a strategy to retain patients and improve continuity in a residency program. 
  • Frequency of Malignancy and Imaging Characteristics of Probably Benign Lesions Seen at Breast MRI. 
  • From the psychiatric hospital to the community: integrating conditional release and contingency management. 
  • Geographical disparities in HIV prevalence and care among men who have sex with men in Malawi: results from a multisite cross-sectional survey. 
  • Grading of late effects in young adult survivors of childhood cancer followed in an ambulatory adult setting. 
  • Growing up with sickle cell disease: a pilot study of a transition program for adolescents with sickle cell disease. 
  • Guidelines for the use of survivorship care plans: a systematic quality appraisal using the AGREE II instrument. 
  • HIV and Sexuality Stigma Reduction Through Engagement in Online Forums: Results from the HealthMPowerment Intervention. 
  • HIV, prisoners, and human rights. 
  • Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. 
  • Health Disparities in the Hospitalized Child. 
  • Health Literacy and Demographic Disparities in HIV Care Continuum Outcomes. 
  • Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility. 
  • Health care of young adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. 
  • Health services access and use among older adults in North Carolina: urban vs rural residents. 
  • Healthcare retention and clinical outcomes among adolescents living with HIV after transition from pediatric to adult care: a systematic review. 
  • Hepatitis C Virus Elimination in the Human Immunodeficiency Virus-Coinfected Population: Leveraging the Existing Human Immunodeficiency Virus Infrastructure. 
  • Hepato-biliary late effects in survivors of childhood and adolescent cancer: a report from the Children's Oncology Group. 
  • Home surveillance program prevents interstage mortality after the Norwood procedure. 
  • Hospital discharge communications during care transitions for patients with acute kidney injury: a cross-sectional study. 
  • Impact of Patient Navigation Interventions on Timely Diagnostic Follow Up for Abnormal Cervical Screening. 
  • Impact of automated alerts on follow-up of post-discharge microbiology results: a cluster randomized controlled trial. 
  • Implementation of a Modified Bedside Handoff for a Postpartum Unit. 
  • Implementing novel models of posttreatment care for cancer survivors: Enablers, challenges and recommendations. 
  • Implementing survivorship care plans for colon cancer survivors 
  • Improvements in the HIV care continuum needed to meaningfully reduce HIV incidence among men who have sex with men in Baltimore, US: a modelling study for HPTN 078. 
  • Improving Care Coordination for Veterans Within VA and Across Healthcare Systems. 
  • Improving Transitional Care: The Role of Handoffs and Discharge Checklists in Hematologic Malignancies. 
  • Improving care transitions: current practice and future opportunities for pharmacists. 
  • Improving communication and recall of information in paediatric diabetes consultations: a qualitative study of parents' experiences and views. 
  • Improving post-intensive care unit neuropsychiatric outcomes: understanding cognitive effects of physical activity. 
  • Improving research for prostate cancer survivorship: A statement from the Survivorship Research in Prostate Cancer (SuRECaP) working group. 
  • Improving the quality of discharge communication with an educational intervention. 
  • Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay. 
  • Initial Effectiveness of a Monitoring System to Correctly Identify Inappropriate Lack of Follow-Up for Abdominal Imaging Findings of Possible Cancer. 
  • Intern Transitions of Care Curriculum Through Posthospital Home and Skilled Nursing Facility Visits. 
  • Internal Medicine Residents' Ambulatory Management of Core Geriatric Conditions. 
  • Interpersonal continuity of primary care of veterans with diabetes: a cohort study using electronic health record data. 
  • Intersectionalities and the HIV continuum of care among gay Latino men living with HIV in North Carolina. 
  • Interventions Designed to Improve HIV Continuum of Care Outcomes for Persons with HIV in Contact with the Carceral System in the USA. 
  • Interventions to improve transitional care between nursing homes and hospitals: a systematic review. 
  • Intraprofessional Excellence in Nursing: Collaborative Strategies for Neonatal Abstinence Syndrome. 
  • Is Discordance Between Recommended and Actual Postacute Discharge Setting a Risk Factor for Readmission in Patients With Congestive Heart Failure? 
  • Is anybody out there? Integrating HIV services in rural regions. 
  • Is there a role for survivorship care plans in advanced cancer? 
  • Just for us. 
  • Knowledge and Preferences of Primary Care Providers in Delivering Head and Neck Cancer Survivorship Care. 
  • Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE) Follow-up. 
  • Lessons learned from implementation of a computerized application for pending tests at hospital discharge. 
  • Longitudinal risk-based health care for adult survivors of childhood cancer. 
  • Maintenance Check-ups Following Treatment for Cannabis Dependence. 
  • Making the Link: A Pilot Health Navigation Intervention to Improve Timely Linkage to Care for Men Who have Sex with Men and Transgender Women Recently Diagnosed with HIV in Guatemala City. 
  • Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. 
  • Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ). 
  • Models for delivering survivorship care. 
  • Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative. 
  • Models of cancer survivorship health care: moving forward. 
  • Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents. 
  • Multiyear Outcomes of a Population-Oriented Care Redesign in an Internal Medicine Residency Continuity Clinic. 
  • Muscle mass and physical recovery in ICU: innovations for targeting of nutrition and exercise. 
  • National survey of adult transplant hepatologists on the pediatric-to-adult care transition after liver transplantation. 
  • National survey of hospital strategies to reduce heart failure readmissions: findings from the Get With the Guidelines-Heart Failure registry. 
  • Non-inferiority of fragmented care for high-risk pediatric neuroblastoma patients: a single institution analysis. 
  • Nonabandonment: medical ethics. 
  • Nonabandonment: medical ethics. 
  • Nursing Contributions to Ending the Global Adolescent and Young Adult HIV Pandemic. 
  • ONS launches strategic plans for the society through 2012. 
  • Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes. 
  • Open access in primary care: results of a North Carolina pilot project. 
  • Optimizing the efficiency and quality of sipuleucel-T delivery in an academic institution. 
  • Overwhelming Need, Insufficient Health Care for Justice-involved North Carolinians 
  • Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement. 
  • Patient and provider preferences for survivorship care plans. 
  • Patient complexity, prescriber continuity and acute care. 
  • Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients. 
  • Patient safety concerns arising from test results that return after hospital discharge. 
  • Patient satisfaction and use of Veterans Affairs versus non-Veterans Affairs healthcare services by veterans. 
  • Patients' perceptions of safety if interpersonal continuity of care were to be disrupted. 
  • Personalized Cancer Follow-Up Care Pathways: A Delphi Consensus of Research Priorities. 
  • Physician Perspectives on Long-Term Relationships and Friendships with Patients: A National Assessment. 
  • Postoperative handoff communication: a simulation-based training method. 
  • Practical and Ethical Concerns in Implementing Enhanced Surveillance Methods to Improve Continuity of HIV Care: Qualitative Expert Stakeholder Study. 
  • Predictors of discharges to a nursing home in a hospital-based cohort. 
  • Predictors of postpartum HIV care engagement for women enrolled in prevention of mother-to-child transmission (PMTCT) programs in Tanzania. 
  • Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure. 
  • Preference for place of death in a continuing care retirement community. 
  • Preferences for transitional HIV care among people living with HIV recently released from prison in Zambia: a discrete choice experiment. 
  • Prescriber Continuity and Disease Control of Older Adults. 
  • Prescriber continuity and medication adherence for complex patients. 
  • Primary care for patients infected with human immunodeficiency virus: a randomized controlled trial. 
  • Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems. 
  • Programs for adult survivors of childhood cancer. 
  • Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment. 
  • Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care. 
  • Readmissions After Acute Myocardial Infarction: How Often Do Patients Return to the Discharging Hospital? 
  • Recent changes in service use patterns of disabled Medicare beneficiaries. 
  • Recovery Focused Nutritional Therapy across the Continuum of Care: Learning from COVID-19. 
  • Reducing family stress during and after coronary artery bypass surgery. 
  • Regular sources of medical care among persons with severe mental illness at risk of hepatitis C infection. 
  • Resident compliance with the american academy of ophthalmology preferred practice pattern guidelines for primary open-angle glaucoma. 
  • Respiratory care year in review 2011: long-term oxygen therapy, pulmonary rehabilitation, airway management, acute lung injury, education, and management. 
  • Risk behaviors and HIV care continuum outcomes among criminal justice-involved HIV-infected transgender women and cisgender men: Data from the Seek, Test, Treat, and Retain Harmonization Initiative. 
  • Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge. 
  • S.M.A.R.T. Transitions: A Program Evaluation. 
  • Say what you mean to say: improving patient handoffs in the operating room and beyond. 
  • Seamless care: what is it; what is its value; what does it require; when might we get it? 
  • Searching for "the dying point:" providers' experiences with palliative care in pediatric acute care. 
  • Searching for evidence about health education and health behavior interventions. 
  • Shared care of adult survivors of childhood cancers. 
  • Solidifying roles, responsibilities, and the process of navigation across the continuum of cancer care: The Professional Oncology Navigation Task Force. 
  • Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility: a multiple case study. 
  • Standardizing patient-reported outcomes assessment in cancer clinical trials: a patient-reported outcomes measurement information system initiative. 
  • Substance use treatment needs among recent veterans. 
  • Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis. 
  • Survivorship care plans in research and practice. 
  • Survivorship care plans: is there buy-in from community oncology providers? 
  • Survivorship navigation outcome measures: a report from the ACS patient navigation working group on survivorship navigation. 
  • System-integrated technology-enabled model of care to improve the health of stroke patients in rural China: protocol for SINEMA-a cluster-randomized controlled trial. 
  • Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda. 
  • Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania. 
  • The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review. 
  • The Future of Childhood Cancer Survivorship: Challenges and Opportunities for Continued Progress. 
  • The HIV Care Continuum among Female Sex Workers: A Key Population in Lilongwe, Malawi. 
  • The HIV care continuum among men who have sex with men in Moscow, Russia: a cross-sectional study of infection awareness and engagement in care. 
  • The Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) Study: design and implications. 
  • The Natural Course of Adolescent Depression Treatment in the Primary Care Setting. 
  • The clinical document architecture and the continuity of care record: a critical analysis. 
  • The continuity and quality of primary care. 
  • The contributions of physician assistants in primary care systems. 
  • The depression treatment cascade in primary care: a public health perspective. 
  • The evaluation of the Fort Bragg Demonstration Project: an alternative interpretation of the findings. 
  • The intersection of patient complexity, prescriber continuity and acute care utilization. 
  • The medical home: an essential competency for pediatric residents. 
  • The resident leaves the clinic: the effects of changing physicians on appointment-keeping behavior. 
  • Transitional Care Partners: a hospital-to-home support for older adults and their caregivers. 
  • Transitional adherence and persistence in the use of aldosterone antagonist therapy in patients with heart failure. 
  • Transitional care after hospitalization for acute stroke or myocardial infarction: a systematic review. 
  • Transitions of care in heart failure: a scientific statement from the American Heart Association. 
  • Treatment retention and care transitions during and after the scale-up of HIV care and treatment in Northern Tanzania. 
  • Two-year impacts on employment and income among adults receiving antiretroviral therapy in Tamil Nadu, India: a cohort study. 
  • Understanding the HIV Epidemic Among MSM in Baltimore: A Modeling Study Estimating the Impact of Past HIV Interventions and Who Acquired and Contributed to Infections. 
  • Unintended consequences of steps to cut readmissions and reform payment may threaten care of vulnerable older adults. 
  • Use of medications for gastroesophageal reflux at discharge among extremely low birth weight infants. 
  • Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. 
  • Vulnerable at Each Step in the PMTCT Care Cascade: High Loss to Follow Up During Pregnancy and the Postpartum Period in Tanzania. 
  • Walk-in clinics in Ontario. An atmosphere of tension. 
  • Weight management and physical activity throughout the cancer care continuum. 
  • What do medical students learn when they follow patients from hospital to community? A longitudinal qualitative study. 
  • What's new in childhood organ transplantation. 
  • When is caring sharing? Primary care provider interdependence and continuity of care. 
  • Wilms tumor imaging: patient costs and protocol compliance. 
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  Keywords of People

  • Anderson, Ruth A., Professor Emerita in the School of Nursing, School of Nursing
  • Andolsek, Kathryn Marijoan, Professor in Family Medicine and Community Health, School of Medicine
  • Bettger, Janet Prvu, Adjunct Associate in the Department of Orthopaedic Surgery, Duke Science & Society
  • Brown, Gregory, Assistant Professor of Psychiatry and Behavioral Sciences, Medicine, General Internal Medicine
  • Curtis, Lesley H., Professor in Population Health Sciences, Medicine, General Internal Medicine
  • McConnell, Eleanor Schildwachter, Associate Professor in the School of Nursing, School of Nursing
  • O'Connor, Christopher Michael, Richard Sean Stack, M.D. Distinguished Professor, Medicine, Clinical Pharmacology