Nurse leaders have been talking about, and working on, managing patients along the continuum of care for many years. Certainly, this has never been more critical as the emphasis of service shifts away from acute care settings and responsibility for providing care moves toward the patient, family, or some other health delivery entity. Nurse leaders in the acute and subacute arenas and community organizations are partnering in new ways to improve the health of our communities in a myriad of settings and forums.
This issue begins with a perspective of the last 40 years of excellence in care across the continuum by one of our pioneers, Dr. Kathleen Bower. It continues with the efforts on the part of the Department of Veterans Affairs to ensure continued availability of resources for Veteran access to quality care. Madaris and colleagues and Messina share exemplars centered around complex, chronic medical challenges (spinal cord injury and congestive heart failure, respectively) that are showing positive outcomes for health, cost, and the patient experience.
Dyess and her colleagues emphasize the framework of caring practices that can be infused into every setting along the continuum. Their story illustrates caring science and philosophy woven throughout a partnership with acute care, community services, and an academic institution.
While we are experiencing new partnerships and ways of working together for the patient's health, we must consider the changing roles, responsibilities, and skill sets of the nurse workforce needed to lead and practice in the new world. To this point, Allen presents elements of a plan within a large community practice that will smooth the transition of the acute care nurse to working in this new environment.
We hope you enjoy reading the articles presented in this issue as much as we have enjoyed getting to know these authors and their great accomplishments. In addition, we hope you are challenged to look within your own organization for successes and opportunities to expand the work you are doing to attain a more seamless continuity of care for the communities you serve.
-Mary O'Connor, PhD, RN, FACHE
Guest Editor
Associate Professor of Nursing
Notre Dame of Maryland University
Baltimore
-Elaine Cohen, EdD, RN, FAAN
Guest Editor
Chief of Nursing Education, Operations, and Quality Improvement
James A. Haley Veterans Hospital
Tampa, Florida