Continuity of care is more than just a catchphrase

Continuity of care

The practice I work for recently took over another practice. As is not uncommon in acquisitions, this caused a temporary increase in staff turnover, including GPs.

The response from patients was interesting: just about every other patient asked if I was going to stay. And most patients – not just those with chronic or complex health conditions – expressed their dissatisfaction with the lack of continuity of care.

I’m sure that many colleagues can recall similar anecdotes. This seems to indicate that our patients value personal and longitudinal primary care. Yet, we are seeing many proposals, trials and projects at the moment that threaten this model, and will create fragmented care.

Two examples

For example, Queensland Health is running several trials at the moment that bypass the usual GP, including a hospital-avoidance project where the ambulance service brings patients to selected GP clinics that receive state funding.

However, usual practices do not receive funding or support to increase capacity to manage these extra presentations. Although projects like the one in Queensland may reduce visits to the ED, they don’t support a stable and enduring relationship between GPs and patients.

In another Queensland Health project, pharmacies are being encouraged to administer MMR vaccinations. That vaccinations in general practice are an opportunity for screening and prevention does not seem important to policy-makers.

In primary care literature, ‘continuity’ is often described as the relationship between a practitioner and a patient that extends beyond specific episodes of illness or disease. Unfortunately, other terms are often used synonymously, such as ‘care co-ordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’.

The experience of continuity may be different for the patient and the health practitioner, adding to more misunderstandings.

According to a 2003 BMJ article by Haggerty et al, there are three types of continuity of care: informational continuity, management continuity and relational continuity. Of course, continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an e-health database.

What is continuity of care?

Understanding individual patients’ preferences, values, background and circumstances cannot always be captured in health records. Practitioners who have longstanding relationships with their patients often know this information.

The RACGP describes continuity of care as “the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers”.

There is abundant evidence that continuity in primary care results in improved patient health outcomes and satisfaction, and reduced costs. For example, relational continuity reduces both elective and emergency admissions. In other words, the rate of hospital admissions drops when people have their own GP.

Better aligned funding that supports primary care practitioners to provide long-term quality care is much needed at the moment.

Team care

A sustainable health system should free up GP teams and other health practitioners to deliver clinical co-ordination and integration of care across disciplines, especially for people living with complex and chronic health conditions.

Avoiding hospital admissions and increasing immunisation rates are laudable objectives, but it’s not a good idea to do this at the expense of continuity of care by the GP. If patients don’t have a GP they should be encouraged or assisted to find a doctor of their choice.

There is nothing wrong with new models of care as long as they don’t impact on the many benefits general practice has to offer.

This article was originally published in Australian Doctor Magazine.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

17 thoughts on “Continuity of care is more than just a catchphrase

  1. Sadly, in our local community, our provincial government and medical society are hatching a plan which will have the effect of reducing continuity of care, while asking doctors to work more evenings and weekends. Collaborative care is the new buzzphrase that has become the darling of politicians and healthcare administrators. I have a different term for it: “McMedicine,” the sort of slap-dash episodic care whose key – or perhaps only – defining characteristic is instant access to some form of “health care provider” on demand. Collaborative care has a nice ring to it, however, its tolling may be the death knell of Family Medicine as we know it. Certainly there are changes we could make to improve the health of our public, but ensuring emergent-type access for all manner of non-urgent concerns is not one of them. Far better to focus our attention on health promotion and encouraging our patients to learn how to better manage their own health through diet and exercise, than to foster even more reliance on an overburdened and expensive system. But hey, what do I know. I’m only a doctor.

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    • Thanks Doug, this is happening a lot at the moment, and in many places: convenience over quality. Don’t get me wrong, I think many medical services could do more to make the patient experience more convenient, but at the same time there is lots of evidence that receiving care from one general practitioner/practice is beneficial for a variety of health outcomes. Relational continuity of care also seems to reduce both elective and emergency admissions. And of course it’s less expensive for tax payers than McMedicine (love the term!).

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  2. How does Queensland justify taking patients by ambulance to a practice that is not the patient’s usual practice? This is outrageous.

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    • Queensland Health say that of the 113,000 patients who attended the ED in that particular area, an estimated 16,500 could have been managed by a GP. Their argument is that Queensland Health only aim to ‘redirect’ patients who would otherwise end up at the ED. They call it ‘the right care, at the right place and in the right time’. They seem to argue that as long as it is not in the hospital it is the right place. Many of my colleagues believe that patients should choose their own GP, at a convenient location – and not because the ambulance brought them to a GP clinic, contracted by Queensland Health, on the other side of town (and where they may never come again).

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      • I have seen GP Practices established very close to QH hospitals to take advantage of this policy decision. Maybe there needs to be an ‘allowance’ that subsidises the existing practices such as yours to have the facilities and staff available to triage and provide services. I know when I chaired many committees for QH that category 4-5patients in ED were very large percentage of the patient cohort which is why QH then established primary health clinics beside ED’s using nurse practitioners to see the cat 4-5’s while having access to a Doctor if needed.

        for many patients where I work it is also about financial cost. The surgery next to us charge between $95-$117 per consult depending on who the GP is. This is a lot of money for patients in a town where work is scarce and unemployment is sitting at 10%. ED is free-you just need to wait. Will the surgeries that QH contracts with for the hospital avoidance scheme be bulk billing?

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        • Yes, contracted surgeries will be required to offer bulk billing. I couldn’t agree more with your statement: “Maybe there needs to be an ‘allowance’ that subsidises the existing practices such as yours to have the facilities and staff available to triage and provide services.” This would indeed allow for continuity of care – in the patients’ preferred area – which would likely prevent future ED visits and can be cost-effective – even with a subsidy – given the fact that a GP visit is roughly 10-20% of the cost of a visit to the emergency department.

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        • I would like to see the Website (assuming that it has one) of this practice that charges $95-$117 per consult – is that for an item 23 consultation? If the practice has a Website, you can give us the URL, because this info is public knowledge if it is on their Website. Standing by…

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      • if Queensland health wants to ‘redirect’ patients, why wouldn’t it simply ‘redirect’ them to their usual general practice? The ambulance service could phone the patient’s usual general practice, explain the situation and make an appointment for the patient to be seen at the patient’s usual general practice, and even take the patient there if necessary, if they are going to be taking the patient somewhere in any case.

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  3. I agree with your statements but I have two areas that I do not see continuity of care occuring:

    GP superclinics – the patients are booked in to see the available GP. You can ask for your regular GP but there is no guarantee that you will see them. Many of the GPs are not full time and worked staggered shits to make up the ‘medicare allowed ratio’ .

    The 2nd issue is rural locations where the continuim is the helath centre/medical practice but the GPs are passing through for six weeks on and then gone again. Performing medictaion reviews for these patients is really hard as the GP does not know the patient well at all. We start on a journey of continuim of care and then the GP is gone and there is a gap before a new GP comes in. Two practices I work with have not had a GP since Decemebr 2015.. For me as a trained immunisier to provide vaccinations for the residents in these locatiions would mean that the immunisation status is completed.

    I do agree with your concerns in the normal GP practice locations but I am working in a location where the community nurses and the community and conmsultant pharmacists are the only regular health care personnel.

    it is impossible to have a one size fits all answer for the issues which I did raise with Barnaby Joyce when he passed through rural Qld. He fobbed me off and gave me a flip answer.

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    • Karalyn, when you say: “GP superclinics – the patients are booked in to see the available GP. You can ask for your regular GP but there is no guarantee that you will see them. Many of the GPs are not full time and worked staggered shits to make up the ‘medicare allowed ratio’ , I tink that you may be talking not about the GP Super Cinics whose building was funded by the Commowealth, but about certain chains of large practices that seem to have the ‘you will see any doctor who is available at that minute’ policy. Is this correct?

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      • No Oliver the one that I work beside is a Govt funded GP Super Clinic. They also conduct a ‘Doctor to U’ service for their after hrs care. The owners of this clinic use every scrap of Medicare funding available to keep their clinic viable. It is a seven day GP Superclinic.

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        • Thanks for your comment Karalyn, I do agree that continuity of care is an issue in some rural areas due to the maldistribution of doctors. Thankfully there are many super clinics (and corporate clinics) that do offer appointments with a GP of choice – but I realise that the situation you describe does occur. Unfortunately, the freeze on Medicare rebates does not make it easier for clinic owners in general to continue to provide quality care – but that’s a different topic altogether…

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  4. Reblogged this on Dr Thinus' musings and commented:

    These issues are also a concern here in the ACT:
    The largest GP group in the area have a system where patients are charged an annual membership fee and in return the patient is is Bulk billed.
    The Private Health Insurer HCF has sent out a letter to all their members in the ACT that they, HCF, will pay the annual membership fee if the members would jump ship to the particular group of GPs.
    Likewise there are schemes with the Health Departments that will fund a membership in return for access to bulk billing services.

    Likewise BUPA has an arrangement with a large bulkbilling after hours medical service. This bulk billed home vist system is staffed by doctors that are very often not fully qualified GPs. These doctors see patients in the comfort of their own home and if you are BUPA member you can not only get your bloodpressure checked for free (as in taxpayer funded) at 7PM on Saturday, you will also get free medication there and then as paid for by BUPA.

    All of this does nothing to assist continuity of care – sadly the punters will follow the money and very soon they would have forgotten what type of medicine they used to have – the new free services will be all they will remember.
    Smaller independent GP clinics simply cannot compete against the commercial reality of these arrangements and slowly we will all close our doors and disappear

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    • Thinus, I reckon that if your practice sticks to its knitting of providing quality personal comprehensive care, there are enough people in Canberra who appreciate that, want it and are willing to pay for it. Your practice does not have to appeal to everybody in Canberra – only to the small proportion who like and appreciate what your practice is offering.

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  5. Pingback: Why we need to get over the Medicare Locals disappointment | Doctor's bag

  6. I am a part-time optometrist with rural/remote outreach experience. I have partnered with many rural GPs and community nurses and it has been most productive, bridging the gap between them and collaborating regional, visiting and city ophthalmologists for patients at risk. The idea of “continuity of care” needs to be applied across the spectrum of need and demography. Busy rural GPs don’t want to see patients unnecessarily. Poorer patients will often refuse referral to prIvate specialists. It is MY continuity of vision and eye health care that manages these patients eye and vision needs, and I always keep their GP or clinic nurse informed. This works very well even in locations serviced by random RFDS GPs. Think outside the box!

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    • I work as a rural HMR pharmacist and love it. The support from nurses and allied health in the towns is fantastic. The barrier is lack of ckntinuity with GPs. I need referral from a GP to see patients but that is hard to get when a different GP passes through irregularly. RFDS services have been cut which may make the existing providers have to think outside the box. We do waste resources by a lack of collaboration and coordination. Someone has to become the coordinator. Working hard to get telehealth services as then specislist appointments may be affordable

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