Why continuity of care matters

AFTER coordinating the topic of “continuity of care” (COC) in the Flinders University MD program for 20 years and reviewing over 900 transfer-of-care letters produced by students over this time, a number of observations have become clear to me.

First, patients and GPs often have differing perspectives on the meaning and value of COC.

Second, patients with a comprehensive health care plan that includes patient preferences, highlights disease and medication interactions, and is used by all of the patient’s health care providers have better health outcomes.

Third, students who demonstrated a clear and deep understanding of the three main domains of continuity – informational, management and relationship – had consistently better transfer of care letters with high levels of both coordination and integrated care that was both seamless and holistic.

Fourth, achieving good informational, management and relationship continuity requires quite a lot of time, which is not reimbursed by the current Medicare arrangement.

Some of these observations resonate with one of the aspirational outcomes of the recently released National strategic framework for chronic conditions for improving continuity of care. Namely, care should be seamless, holistic and coordinated across the health system to manage chronic conditions.

• Related: MJA — Coordinated care versus standard care in hospital admissions of people with chronic illness: a randomised controlled trial
• Related: MJA InSight — Value in care continuity
• Related: MJA — Best-practice integrated health care governance — applying evidence to Australia’s health reform agenda

We have good evidence that national health care systems with strong primary care infrastructures have healthier populations, fewer health-related disparities and lower overall costs for health care.

While COC is a key component of primary health care and general practice, there is evidence of declining continuity of care over the past 15 years, to the detriment of patient care. COC is mentioned as a priority in the National strategic framework for chronic conditions for continuity of care but GPs are largely overlooked in the document which leaves the carriage to a “health workforce”.

Why does COC matter?

The following vignette highlights the failure of all three components of COC, partly due to the absence of a generalist to provide oversight, coordination and integration of care.

A medical colleague in his mid-70s recently had a repair of a thoracic aortic aneurysm. He received excellent technical care from his vascular surgeon and had a team of seven specialists looking after him. No one was delegated to coordinate or manage his medical problems. Most rounds by the specialists involved looking at his medical record with infrequent discussion with him about what was going on. He recruited another colleague in the hospital corridor to manage his medical problems and was found to have a haemoglobin level of 56 g/L. The colleague organised for a blood transfusion immediately after discharge from hospital. He was also dyspnoeic after the operation and could not recall any of the doctors listening to his chest. A chest x-ray was ordered after a few days and a large (3 L) pleural effusion was subsequently drained.

With the increasing fragmentation of care and the rise in prevalence of multimorbidity, the need for greater COC is even more important to facilitate better quality of care and improved patient outcomes.

Good COC contributes to both better health care delivery and health outcomes. It facilitates the development of an effective and therapeutic doctor–patient relationship and greater patient-centredness. For the patient, continuity contributes to greater trust and higher satisfaction with the care provided. For the doctor, COC enhances and achieves a more positive health outcome.

COC improves the health care provider’s awareness of the context of the whole person and the gamut of care modalities to which the patient is subjected. It involves gaining a clear comprehension of both the needs of the patient and their understanding and concerns about their illnesses.

Good COC contributes to better coordination of patient care and adherence to therapeutic regimens, both of which can improve health outcomes. Finally, COC is associated with a reduction in resource utilisation, eg, hospitalisations and costs.
 
So how can COC be improved? Three main strategies could make a difference.

Patient targeted

There is a need to improve both the patient’s awareness of the impact and importance of COC and the affordability and access to care.

Patients value access to a known and trusted health care provider when their problem is more serious or personal and quicker access to any clinician when they perceive the problem as more acute or technical.

Patients should be encouraged and supported to be more actively involved in their own care and shared decision making. More assistance is also needed to enhance patient self-management skills while remaining mindful of unintended assumptions about the responsibility, engagement and care provision which occur and serve to alienate and further stigmatise some patients.

The process should encourage the development of a collaborative and respectful self-management partnership.

Health care provider targeted

It is important to encourage practices to facilitate patient access to the same doctor.

Medical students and other health professionals need to be taught (and immersed) in training (and in practice) about:

• the value of COC and how it impacts on quality of care and health outcomes; and
• how to implement good teamwork, care planning and better care coordination (including patient care plans) to provide more integrated care.

Health service delivery

It is necessary to outline policies and provide incentives that encourage better COC through improving care coordination and integration of care at all levels of the system. This includes:

• implementing the core elements of a patient-centred medical home;
• improving both the information and communication channels for patients and health care providers and the measurement of coordination of care and patients’ experience of continuity; and
• implementing payment systems that adequately reward doctors for the time they spend coordinating care for patients with complex care needs.

The Royal Australian College of General Practitioners has released a number of position statements that are relevant to the above.

Good primary care requires easy patient access, continuity, comprehensiveness, coordination and accountability for the whole person.

Michael Balint concluded 60 years ago that generalists are best placed to take responsibility for holistic care, coordination and advocacy for the most complex patients.

This is even truer in the 21st century. If we wish to avoid the health budget consuming all of our taxes, we need to pay greater attention to improving COC as it does matter!

Dr John Litt recently retired from his position as Associate Professor in General Practice at Flinders University. He is a public health physician and an academic GP, and is the Deputy Chairman of the National Quality Committee of the Royal Australian College of General Practitioners. His major clinical and research interests are in prevention and its implementation. Dr Litt would like to acknowledge the help provided by Professor Anthony Radford and Dr Richard Clark in the writing of this article.