ABSTRACT:
Across public health and healthcare systems, continuity of care is often described as an aspirational goal constrained by limited resources, workforce shortages, or patient non-adherence. This framing obscures a more uncomfortable truth: fragmentation is not accidental. It is routinely produced by a system design choice that separate medical care from community support, shirt coordination burdens onto individuals, and reward episodic interventions over sustained relationships, particularly for people navigating serious illness, trauma, or chronic conditions. This presentation challenges the assumption that continuity failures are inevitable and argues instead that continuity of care is a deliberate design choice. It introduces a practice-informed framework for re-architecting health systems to integrate community-based capacity as essential infrastructure rather than optional support. Drawing on cross-sector implementation experience across health systems, public agencies, and community organizations, this session applies systems design and governance analysis to identify how fragmentation is structurally reinforced through contracting models, referral pathways, accountability mechanisms, and data practices. The framework focuses on redesigning existing structures, rather than creating new programs or parallel systems. When community integration is treated as a core function, continuity improves across care transitions, and the burden of navigation shifts away from individuals at moments of vulnerability. The framework highlights both successful integration strategies and common failure models, including extractive partnerships, unfunded mandates placed on community organizations, and close-loop models that prioritize reporting over relational care. Health equity initiatives frequently fail not because communities lack capacity, but because systems are designed to exclude it. Continuity of care does not emerge from goodwill or pilot projects, but from architecture. Leaders must confront fragmentation as a design outcome and intentionally choose to build systems that support whole-person care across medical, social, and community contexts.