Table 6 Integrative activities representing development phases

X

X

X

2a: Reaching agreements on referrals and the transfer of clients through the care chain

X

X

X

2d: Reaching agreements on procedures for the exchange of client information

X

X

5b: Evaluating the services provided in collaboration with care partners

X

X

X

X

6a: Defining with the care partners the patient-family group targeted by the care continuum

X

X

8a: Defining the collaboration objectives in the care continuum

X

X

8c: Ensuring leadership commitment from the care partners in the care continuum

X

X

8d: Describing the roles and responsibilities of the leaders and coordinators in the care continuum

X

8e: Formalizing the interdependency links between care partners and healthcare establishments

X

X

9a: Committing together to achieving the clinical objectives targeted by the care continuum

8b: Signing collaboration agreements between care partners

X

2 h: Using common care and treatments plans across the entire care continuum

X

X

X

2p: Using one or more specialized nurses to provide services in the care continuum

X

X

X

X

4d: Respecting evidence-based practice standards

X

X

X

X

6b: Working in interdisciplinary teams

X

X

7b: Making adjustments as needed to the roles of the various care partners

X

X

7c: Ensuring care partners know each others’roles and responsibilities

7f: Encouraging partner meetings on the whole care continuum

3 g: Following up on results obtained while developing the care continuum

2 m: Agreeing on leave plans among care partners

3d: Gathering information on continuum logistics (e.g. patient traffic, wait times, delays) within the continuum

X

X

X

1c: Determining the client-family’s required care plan (ITP and IIP) with the care partners

X

X

X

X

1f: Adjusting services throughout the care continuum to respond to specific patient-family needs

X

X

2e: Accessing the databases of all care partners in the care continuum

X

X

3i: Ensuring follow-up of all accident/incident reports related to the care continuum

X

X

X

X

5j: Accessing training programs and learning opportunities for care partners

X

5 l: Promoting exchanges among care partners to make innovations in services provided in the care continuum

3j: Applying a systematic method to evaluate approaches used (e.g. care delivery) and results obtained

7 g: Agreeing on how to introduce and incorporate new care partners into the care continuum

4e: Ensuring that client representatives participate in care continuum performance evaluations

3 m: Demonstrating to care partners the effect of the continuum on the care provided

X

X

3i: Ensuring follow-up of all accident/incident reports related to the care continuum

X

X

5e: Sharing knowledge among care partners on effective organization of services in the care continuum

X

5 h: Offering incentives to care partners to encourage them to achieve quality objectives

X

X

X

X

5j: Accessing training programs and learning opportunities for care partners

X

X

8 h: Reaching agreements on each care partner’s specific areas of care (who does what)

9 g: Having a single block of funding to distribute across the continuum of care

5 k: Sharing with care partners the results of achieving continuum objectives

8 k: Meeting external stakeholders: government agencies, community organizations, etc.

1i: Using standardized care protocols (e.g. systematic follow-up) adapted to client groups with specific needs

9c: Agreeing on setting up a financial budget for the care continuum