Continuity of care? Not so much ...

We strive to meet the needs of the whole patient, from care to emotional support, to the best of our ability

Many years ago, when I worked in healthcare, continuity of care was everything.
It wasn’t just a buzzword — it was a commitment.
We coordinated appointments between primary care doctors and specialists, served as the “go-between” for doctors, staff, patients — and, let’s be honest, occasionally had to navigate around the ever-popular “god complex” that some providers carried around like a badge.

Continuity of care was — and still is supposed to be — about a physician-led, team-based approach that actually puts the patient first.
It reduces the fragmentation of care, improves patient safety, and strengthens the quality of care.
Or at least, that’s how it should work.

I was digging through some old files the other day and found a brochure from my former medical group.
It said:

"We strive to meet the needs of the whole patient — from medical care to emotional support — to the best of our ability."

I just sat there for a second thinking, Wow.
I remembered when we used to do exactly that — when we made the extra phone call to coordinate a specialist appointment, when we helped secure a needed medical supply, when we intervened on a patient’s behalf to untangle billing or insurance issues.
Physicians talked to patients.
Patients talked to nurses.
Nurses talked to specialists.
And so on, and so on — real communication.
Real teamwork.
Real care.

What happened?
When did it all become so fragmented?
When did the patient stop being the center of the conversation and start being just a name in a chart?

Fast forward to a few weeks ago.

Our neurologist — who has been absolutely incredible — took one look at my husband’s declining health and immediately made the call.
He coordinated with our primary care physician (bless the fact that they actually talk to each other) and got the ball rolling for a hospital admission — fast.

Within just a few hours, we weren’t just dealing with Multiple System Atrophy anymore.
Now, Congestive Heart Failure was part of the picture too.

We found ourselves swallowed up in the system:

• Cardiac specialist

• Hospitalist

• Nurses

• Cardiac Failure specialist

• Speech therapy

• Bloodwork every day

• Swallow tests

• EKGs

• Ultrasounds

• And the endless parade of people and procedures that come with trying to manage two serious diagnoses at once.

And through it all, I kept thinking about that old brochure.
About how different healthcare feels now — and about the pockets of hope that still exist when doctors and nurses choose communication and compassion over chaos.

It shouldn’t be rare.
It should be the norm.

Because continuity of care isn't just about connecting charts and test results — it’s about connecting people.
It’s about making sure no patient, and no family, ever feels like they’re navigating a medical maze alone.

Mr. “I’m staying here” had officially dug his heels in.
There was no budging, no convincing, no carefully worded encouragement.
He made it crystal clear: he didn’t want to be hospitalized in the city.
He wanted to be closer to home — closer to the familiar, closer to his own bed just a few miles down the road, closer to everything that felt safe.

Okay then.
Gotta punt.

Cue the scramble.
With the patience of Job (and trust me, it took every ounce of it), a lot of phone calls, a few strategic sighs, and more than a few fingers crossed so tight they turned purple, we started shifting gears.

We ran back home real quick to drop off Wonder Dog — who, by the way, had her own priorities, namely dinner and a good nap after her very long, very confusing day of "wait here," "come with me," and "sit, stay, wait again."

Then, with a deep breath, we headed off to the local hospital for an admittance.
Not exactly by-the-book, not exactly the traditional chain-of-command that healthcare systems love so much, but honestly? The city team got it.
They saw him.
They heard him.
And more importantly — they respected him enough to realize that forcing him to stay where he didn’t want to be was only going to make everything worse.

They bent the rules, they worked the phones, they made it happen.
Because sometimes care isn't just about treating the body — it’s about protecting the spirit too.

I remember the first frustrating moment … the doctors couldn’t commit to a time to come see us to discuss all of the issues we were dealing with. It literally was the “roll of the dice” when they would show up and unfortunately, if I wasn’t there, their barrage of information didn’t always stick in my husband’s head. He was either confused or so overwhelmed that he didn’t retain any of the information. Now, don’t get me wrong, the nursing staff was absolutely amazing, especially trying to adequately convey what was going on to both of us. I was told that if I missed the doctor, I could try to call their respective offices to speak with them. Yeah, right …

Upon discharge, we were told what day and time to show up for a follow up with the cardiology office. When I called to see if another appointment was available (I was committed to teach the day of the appointment), I was flat out told, “No, keep your appointment”. Wait, customer service please? With my feathers all riled up and my knickers in a total wad, I proceeded to wait on hold for a supervisor for 40 minutes to try to get a different appointment. Being told “NO” again, I contacted our primary care physician who, within a day, was able to secure an appointment a day earlier.

Perfect; was that so hard?

Why did it take me calling the primary care physician to call the cardiologist to make an exception or pull a string to get an appointment changed? Just wait, it gets better … (sigh)