Abstract
Continuity of care, defined as the patient experiencing coherent care over time and place, is challenged when a rural senior with multiple medical problems is transferred to a regional hospital for acute care. From an illustrative case of an older patient with pneumonia and atrial fibrillation, we catalogue potential breaks in continuity of care. Optimal continuity of care is characterised not only by regular contact with the providers who establish collaboration with patients and their caregivers, but also by communication, co-ordination, contingency, convenience, and consistency. Because it is not possible to have the same providers continuously available (relational continuity), for continuity of care, there is a need for integrative system approaches, such as: (1) policy and standards, disease management programs, integrated clinical pathways (management continuity), (2) electronic health information systems and telecommunications technology (communication continuity). The evaluation of these approaches requires measures that account for the multi-faceted nature of continuity of care.