Continuity of care

Definition of continuity of care

A Dictionary of Nursing
continuity of care (kon-tin-yoo-iti) n. a continuous relationship between a patient and an identified health-care professional who is the sole source of care and information for the patient. However, as a patient's health-care needs over time can rarely be met by a single professional, multiprofessional pathways of continuity exist to achieve both quality of care and patient satisfaction.

APA "continuity of care." A Dictionary of Nursing. 2008. Retrieved August 04, 2012 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O62continuityofcare.html

Continuity of Care Components of a Meaningful Primary Care Visit

Pre-Visit
Review notes your last note, any notes by other MDs in the interim, ER or discharge summaries

Visit
Inform patient of their PCP and nurse provide resources (business card and team photo composite)

Post-Visit
Assign PCP in EMR

Inter-Visit
Complete timely DC summary including the PCP name and H & P.

Review interim labs

Review all meds (purpose, frequency, dose, other) with patient and give them a copy of the updated med list

Document diagnostic tests and studies ordered and pending (IP) and follow up on them

If patients meds change when admitted based on MUSCs Automatic Therapeutic Substitution, change them back to patients insurance formulary at the time of discharge

Review interim studies ex. mammogram, stress test, colonoscopy, etc.

Give the patient a medication bag and encourage taking it with them to all provider visits

Notify UIM PCP when seeing another providers patient by using the .cc code. (OP)

Visit or call the patient during hospitalization when notified of their admission

Review any consults

Look up provider codes in EMR through knowledge base.

Set up any needed health maintenance

Notify patient of test results

Continuity of Care
Patients 65 years and older have multiple medical problems, are on multiple medications, and are seen by multiple providers. Having a primary care physician, communicating among all providers, and reconciling medications are all essential for quality patient care.
Ask the patient

Medication Reconciliation Steps

Obtain medication list from patient Obtain medical record medication and problem list

MD action

1. What are the names of the medications (including OTC, vitamins, herbal supplements and eye drops) you are currently taking?

1. Compare home list to the list in the patients chart. Identify discrepancies Call pharmacy or call family 2. Ensure dose and frequency are the same and there is a clear indication for every medication. Enumerate all meds Evaluate ongoing need of each med. Reconcile list Consolidate meds Optimize the list Incorporate into med list Document updated medication list 3. If patient doesnt understand what meds are for, educate using plain, non-medical language; speak slowly; break down information into short statements.

2. How do you take your medications and how much have you been taking?

3. Do you understand what the medication is for?

4. Where do you get your prescriptions filled?

Give patient a copy of updated medication list

Include updated list in clinic note

4. Call the pharmacy if there is any discrepancy between the patients reported meds and your list. Rectify in the patients chart.

References: Wenger, N.S. and R.T. Young (2007) Quality Indicators for Continuity and Coordination of Care in Vulnerable El ders. JAGS 55:S285-292. Varkey, P. et al (2007) Improving Medication Reconciliation in the Outpatient Setting. Jt. Comm J on Quality & Patient Safety 33:5.

Funding provided by D.W. Reynolds Foundation

Continuity and Comprehensiveness of Care

What is Continuity of Care?

Traditional Family Doctor: = single provider and single patient in a longitudinal, personal relationship Mental Health Worker: = coordination of many services over time. Common plans and goals.. many providers Nurse: = smooth information transfer Diabetic clinic: = continuum of care, multiple providers, protocol and result driven

Can we define Continuity of Care in context of: ..

Doctor: ie Dr X always looks after all of my problems in a timely fashion Patient : ie Patient X always has her problems looked after in a timely fashion by a group of providers

Doctor / patient relationship is key

BUT. Are we
QUARTERBACKS

Or

ORCHESTRA CONDUCTORS

What about PROVIDER / patient relationships in a multidisciplinary team model ?

3 types of Continuity
Informational

Management

Relational

Why revisit Continuity of Care?

Disease Complexity Determinants of Health Chronic Disease Burden Increased focus on teaching Increased focus on Multidisciplinary care Access issues How do we deliver 24/7 Marcus Whelby is dead

Saint John CHC

Greater Saint John access: 80 Family Doctors 125,000 citizens 140,000 ER visits p.a. 140,000 FD/walk in visits CHC catchment access 12 Family doctors 35,000 citizens

CHC
5 Family doctors, 4 Nurse Practitioners 3 LPN 2 dieticians 1 Social worker And a..

CHC
OT , Domestic Violence Worker, Teen Resource workers Numerous outreach workers and programs Base patient number : 9000 Chronic Disease Clinics, Mental Health, Teen Clinic, Outreach to Sal Army, Soup Kitchens, Homeless etc etc Medical services: Prenatal/Antenatal, Palliative Care ,Hospital Care , Shared Mental Health , Minor Surgeries , House calls etc, etc Vital partnerships with community agencies

How can you have Continuity of Care in such a model????

Information Technology (informational continuity of care) Multidisciplinary Teams (managerial continuity) Every patient has a primary provider and MD/NP team( relational continuity)

Issues in development of new Continuity of care Models

Change Management Government Expectations Evaluation models.Audits outcome based ..patient satisfaction. Problem: What do we compare it to? Marketing Co location Realistic numbers and expectations Don Quixote syndrome say no to protect your yeses

Lessons Learned
Need Community Needs Assessment (not just practice needs assessment) Triage Navigation Patients need to know about informational continuity Marketing Linked appointments Time resource management Some patients prefer old model .They should have options available