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Continuity of care: Putting children first

by Heather Carter


About a month after being hired as the new director of a college lab school, I met with the department to discuss my observations of the program, its current state, and our goals for the future. It was there that I learned the department had always envisioned implementing continuity of care within the school.

I thought, “That’s a huge undertaking.” But I agreed to research our options for potential implementation in a couple of years.

Fast forward a few months later…. I had to fire an employee for continually putting her needs first. I couldn’t deny that a few others were behaving similarly, but this one did it the loudest and most consistently. Something needed to change in order to get the team, as a whole, to embrace the core of our philosophy—that the child is the center of the program.


What is continuity of care?
The idea of continuity of care is neither new nor innovative. The term was first noted in published medical research dating back to the 1950s. It shifted by the 1970s to a more modern definition that included uninterrupted and coordinated care (Uijen, Schers, Schellevis, & van den Bosh, 2012). In the newer multidimensional models, continuity of care has expanded to consider the quality of care over time (Gulliford, Naithani, & Morgan, 2006), focus on the relationship between patient and caregiver, communication, flexibility, and accessibility to the services provided (Uijen et. al., 2012).

In an early childhood environment, continuity of care focuses on many of these same aspects. Quality learning environments may be defined by how the classroom structure (curriculum, materials, and standards) is intertwined with the classroom processes (for example, how we implement the structure, have meaningful interactions, develop relationships with children and families, and maintain communication). The outcomes of how structure meets process are what we observe in children’s learning and development.

Research has proven that our processes—specifically, interactions and relationships—directly support children’s learning through exploration, expression of feelings, and the ability to solve problems (Sparks, 2019). Additionally, the effects of such positive relationships, specifically with regard to cognitive development and children’s behavior, are long lasting, well into 3rd grade (Maldonado-Carreño & Vortruba-Drazl, 2011).

Therefore, it could easily be argued that continuity of care ensures these teacher-child relationships stay intact as well as provide an effective tool in managing the classroom.


The logistics
I introduced the idea of implementing continuity of care to the teachers at a large group staff meeting after having visited another lab school that had already successfully realized the concept. Our staff welcomed the idea with enthusiasm. Many had learned about the concept through their college course work or professional development and believed the idea could have a major impact. We then defined what continuity of care would mean for our program by identifying that one or both infant teachers would transition with children to the toddler room, and one or both teachers in the 2- to 3-year-old class would transition to the 3- to 4-year-old room with the children.

We chose these ages for two reasons. First, both Zero to Three and the National Association for the Education of Young Children (NAEYC) have expressed the importance of limiting the number of transitions children experience, both in classroom environments as well as caregivers. Both organizations also advocate for children to remain with caregivers until age 3 (Zero to Three, 2010; McMullen, 2018). Because we were new to the practice of continuity of care, I felt more realistic in implementing for two years by looping teachers from the infant to the toddler room.

Second, our program often observed challenging behaviors (some considered developmentally appropriate) once children moved into the 3- to 4-year-old room. After discussion with staff and the department, we agreed that facilitating the relationships developed in our proposed transition could have significant impact on managing behaviors.

With our plan in mind, we took the following logistical steps:
1. I redefined the ages for each classroom. Initially, we had six classrooms:
an infant room (3 to 12 months),
a younger toddler room (12 to 18 months),
an older toddler classroom (18 to 24 months),
a young preschool room (2 to 3 years),
a middle preschool room (3 to 4 years), and
an older preschool classroom (4 to 5 years).

I combined the younger and older toddler age groups to create one classroom of children 12 to 24 months old and used the older toddler classroom to create a young multi-age room (18 to 36 months) where half the children could transition the following year to younger preschool and the other half to middle preschool. This alleviated some of the bottlenecking on the wait list for the younger classrooms, while still maintaining our low ratios.
2. Prior to the change, children were enrolled in a room for a specific timeframe correlated to their date of birth. I adjusted this by enrolling children based on age effective September 1 of the school year with the intention of keeping them in the room for a full year. I used the same age groupings as my base for how old children needed to be as of September 1.
3. I redefined our transition process for both teachers and parents. See the description below.
4. I offered teachers the opportunity to get together and discuss children’s development, strengths, and needs. Meetings had to be scheduled well in advance, in order for me to include flex time on the schedule to stay within budget constraints.
5. We considered how to ensure the rooms remained developmentally appropriate for all children since some might enroll with an earlier birthdate. We already routinely observed and documented children’s development, as well as rotated materials frequently. Therefore, it was simply deciding when new, more challenging activities and materials should be implemented, in addition to maintaining a working wish list of materials and furniture for when funds became available.


Establishing effective co-teaching teams
As described earlier, the center was small, with only 6 classrooms and 2 full-time teachers assigned to each room. Teachers were concerned about how we could logistically meet the parameters for continuity of care in light of conflicting personalities and differing classroom management techniques.

Additionally, transitions of children from one classroom to another had a firm precedent of occurring shortly after a child was age-eligible for the next room. The department and I proposed that one or both infant staff move with the children to the toddler room and one or both of the 2- and 3-year-old teachers move with the children to the 3- and 4-year-old room. This proposal led to concerns about teacher burnout from trying to work through challenging behaviors over possibly two years.

While these concerns were legitimate, if we wanted to move forward, my first goal had to be adjusting the culture that defined an effective co-teaching team. The strategies I used, in order, were the following:
I used whole-group staff meetings to create a stronger sense of staff buy-in to be willing to work together for possibly two years by getting back to basics and reviewing the center’s philosophy. We discussed what it meant to us and focused on commonalities that could be used as springboards to encourage conversation between staff who may not have previously gotten along.
I offered teachers the opportunity to give feedback on where they wanted to work (children’s age group) and whom they wanted to work with.
I observed staff at least weekly, to see what strengths and areas for improvement they brought to the table.
Based on teacher feedback and my personal observations, I consolidated all the information and paired staff together accordingly. Once I was firm on the logistics of who was working with whom and where, I coordinated brief 10-15-minute individual meetings with each teacher on a day when I had ideal staffing.

During this one-on-one, I informed them of their placements and offered a strong rationale based on specific and positive examples in support of the decision so each teacher would understand why. Teachers could ask questions, have dialogue, or even take a few minutes to internalize what I had shared before returning to the classroom.
During a large staff meeting after the teaching teams were announced, I communicated my expectations for working together throughout an entire school year, with the possibility of two.
I notified parents of teaching teams via a special edition of our quarterly newsletter.
During a professional development day, I implemented mandatory training on understanding leadership and communication styles, so all staff had more insight to their tendencies as well as those of their co-workers. Later in the day, I followed this up with a hands-on collaboration that intentionally grouped the teachers based on conflicting styles (the Marshmallow Challenge---see below).
I met with the teaching teams individually on a monthly basis to discuss ongoing collaborations, achievements, and challenges. Meetings were typically scheduled during rest time when I had some overlap in the schedule to allow staff out.
I offered teaching teams the opportunity to meet outside work for an hour a month to discuss matters that needed a more private setting. Often these meetings led to a resolution before it got to my office. I was able to manage this cost by requiring that staff give me at least a week’s notice of when they intended to meet. In this way, I could try to absorb the time in that week’s schedule by staggering them off early or arriving late one day. Otherwise, it was accrued as compensatory time.
We often discussed strategies for maintaining daily communication in our large-group monthly staff meeting: pass-along book, sticky notes, whiteboard hung in the teacher closet or inside a teacher-only cabinet.
I held staff accountable when they could and couldn’t find ways to make it work. I learned to be comfortable with taking on the role as both mediator and leader to help staff work through the difficult challenges. Two books that helped me achieve this were The Five Dysfunctions of Team by Patrick Lencioni and How Good People Make Tough Decisions by Rushworth Kidder.
I also read as much as I could find on strategies for mediating: using active listening, attacking the problem and not the person, ensuring everyone was clear in understanding what was needed moving forward, and supporting the teaching teams’ decisions regarding their working relationship as often as possible.

Interestingly, by year two, the way in which the teachers viewed each other’s attributes as a potential work partner had shifted. Many initially ranked those they wanted to work with based on personal preferences. By year two, the teachers were reflecting more on who displayed the behaviors/practices for what they might need to achieve a balance in the room. Around the time I would put out the teaching team feedback form that would help me determine the following year’s co-teachers, I would often find the teachers observing each other from the student observation booths on their 15-minute breaks.


The transition process
I created an Excel spreadsheet that listed all enrolled children, their dates of birth, and any pertinent classroom information, with columns to fill in dates for withdrawal notices. This helped me keep a visual representation of enrollment for the entire center and provided me a workspace to easily identify when older children would be leaving to go to kindergarten, thus prompting the domino effect of our transitions.

Then I created and provided a calendar to show when each age group would transition as a tool so teachers would know what to expect. During the transition, I was able to work the schedule to allow rooms to close one-by-one for a couple of days to allow previous teaching teams to clear the space and new teaching teams to come in and set up the classroom together. The previous teaching team, after cleaning, would fill in as subs to the classrooms the new teachers were moving from.

When the room was ready, children would move up with their assigned teachers, allowing a domino effect to occur from the oldest classroom to the youngest. The teachers felt a sense of ownership in establishing their new classroom environment. My bottom line didn’t take too big of a hit because I was able to maintain operating hours for current children. Once rooms were settled, I enrolled new children from the waiting list.

I also created a notification-letter template that could easily be adjusted to reflect individual children. In it, I shared with parents when the child would make the move and re-iterated who the classroom teachers would be. These were handed out at least two weeks in advance of the move.


Feedback and results
Overall, by the third year, as a team, we had worked through the logistical quirks. I received a lot of feedback from our NAEYC parent surveys of how they appreciated the consistency in the classrooms from year to year, as well as how effective the teaching teams seemed to be. Our new approaches even had a positive effect on our ability to recruit and employ work-study students, to the point that I even had individuals seeking us out for work-study employment. More important, as a team, we had a renewed sense of pride in that children were the center of our program, and our combined passion was setting a positive example for the community.



The Marshmallow Challenge
The Marshmallow Challenge is an exercise in team building attributed to designers Peter Skillman and Tom Wujec. In the exercise, a team has 18 minutes to build the tallest free-standing structure it can, using 20 sticks of spaghetti, 1 yard of tape, 1 yard of string, and 1 marshmallow. The marshmallow must be on top.

As a result, participants learn that a successful team involves everyone, requires collaboration, and strives for continuous improvement. For a short animated video on how kindergartners outperformed MBAs on the task, see YouTube at (Skip the ads after the animated portion.)



Gulliford, M., Naithani, S. & Morgan, M. (2006). What is ‘continuity of care’? Journal of Health Services Research and Policy, 11(4), p. 248-250. Doi: 10.1258/135581906778476490.
Maldonado-Carreño, C. & Vortruba-Drazl, E. (2011). Teacher-child relationships and the development of academic and behavior skills during elementary school: A within- and between-child analysis. Child Development, 82(2), p. 601-616. Doi: 10.1111/j.1467-8624.2010.01533.x.
McMullen, M.B. (2018). The many benefits of continuity of care for infants, toddlers, families, and caregiving staff. Young Children, 73(3). Retrieved online:
Sparks, S. (2019). Why teacher-student relationships matter: New findings shed light on best approaches. Education Week, 38(25), p. 8. Retrieved online:
Uijen, A.A., Schers, H.J., Schellevis, F.G. & van den Bosh, W.J.H.M. (2012). How unique is continuity of care? A review of continuity and related concepts. Family Practice, 29(3), p. 264-271. doi: 10.1093/fampra/cmr104.
Zero to Three. (2010). Primary caregiving and continuity of care. Zero to Three: Professional Resource. Retrieved online:


For sample training materials, as well as sample transition calendars and forms, feel free to access them via my shared Google folder at:
Kidder, R.M. (1995). How good people make tough choices: Resolving the dilemmas of ethical living. New York: Fireside Publishing.
Lencioni, P. (2002). The five dysfunctions of a team: A leadership fable. San Francisco, CA: Jossey-Bass Publishing.
Rogers, J. (2012). Challenging the process with the marshmallow challenge. The Leadership Challenge. Retrieved online:


About the author
Heather Carter, Ed.D., has worked in many roles within the early childhood field over the last decade, from teacher to trainer and manager, and as college professor. She holds a master’s in child development from the University of Arkansas and a doctorate in educational leadership from Tarleton State.