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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 ofcare and information for the patient. However, as a patient's health-careneeds over time can rarely be met by a single professional, multiprofessionalpathways of continuity exist to achieve both quality of care and patientsatisfaction.

APA "continuity of care." A Diction ary of Nursing. 2008. Retrieved August 04,

2012 from Encyclope dia.com: http://www.encyclopedia.com/doc/1O62-continuityofcare.html

http://www.encyclopedia.com/A+Dictionary+of+Nursing/publications.aspx?pageNumber=1http://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/doc/1O62-continuityofcare.htmlhttp://www.encyclopedia.com/A+Dictionary+of+Nursing/publications.aspx?pageNumber=1http://www.encyclopedia.com/A+Dictionary+of+Nursing/publications.aspx?pageNumber=1

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Continuity of CareComponents of a Meaningful Primary Care Visit

Pre-Visit Visit Post-Visit Inter-Visit

Review notes your last note, anynotes by other MDs in the interim,ER or discharge summaries

Inform patient of their PCP andnurse provide resources (businesscard and team photo composite)

Assign PCP in EMR Complete timely DC summaryincluding the PCP name and H & P.

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

Document diagnostic tests andstudies ordered and pending (IP) andfollow up on them

If patients meds change whenadmitted based on MUSCsAutomatic Therapeutic Substitution ,change them back to patientsinsurance formulary at the time ofdischarge

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

Give the patient a medication bagand encourage taking it with them toall provider visits

Notify UIM PCP when seeing anotherproviders patient by using the .cccode. (OP)

Visit or call the patient duringhospitalization when notified of theiradmission

Review any consults Look up provider codes in EMRthrough knowledge base.

Set up any needed health

maintenance

Notify patient of test results

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Continuity of CarePatients 65 years and older have multiple medical problems, are

on multiple medications, and are seen by multiple providers. Havinga primary care physician, communicating among all providers, and

reconciling medications are all essential for quality patient care.

Ask the patient

1. What are the names of themedications (including OTC,vitamins, herbal supplementsand eye drops) you are currentlytaking?

2. How do you take yourmedications and how much haveyou been taking?

3. Do you understand what themedication is for?

4. Where do you get yourprescriptions filled?

MD action

1. Compare home list to the listin the patients chart.

2. Ensure dose and frequencyare the same and there is a clearindication for every medication.

3. If patient doesnt understandwhat meds are for, educate usingplain, non-medical language;speak slowly; break downinformation into shortstatements.

4. Call the pharmacy if there isany discrepancy between thepatients reported meds and yourlist. Rectify in the patients chart.

Medication Reconciliation Steps

References: Wenger, N.S. and R.T. Young (2007) Quality Indicators for Continuity and Coordination of Care in Vulnerable El der s. 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. ReynoldsFoundation

Obtain medicationlist from patient

Obtain medical recordmedication and

problem list

Identify discrepancies

Include updatedlist in clinic note

Give patient a copyof updated

medication list

Document updatedmedication list

Optimize the list

Reconcile list

Call pharmacy orcall family

Consolidatemeds

Incorporateinto med list

Enumerateall meds

Evaluateongoing needof each med.

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Continuity and

Comprehensiveness of Care

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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.. manyproviders Nurse: = smooth information transfer Diabetic clinic: = continuum of care, multiple

providers, protocol and result driven

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Can we define Continuity of Care incontext of: ..

Doctor : ie Dr X always looks after all of myproblems in a timely fashion

Patient : ie Patient X always has her problemslooked after in a timely fashion by a group ofproviders

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Doctor / patient relationship is key

BUT. Are we

QUARTERBACKS

Or ORCHESTRA CONDUCTORS

What about PROVIDER / patient relationships in amultidisciplinary team model ?

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3 types of Continuity

Informational

Management

Relational

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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

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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

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CHC

5 Family doctors, 4 Nurse Practitioners

3 LPN 2 dieticians 1 Social worker

And a..

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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 callsetc, etc

Vital partnerships with community agencies

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How can you have Continuity of Carein such a model????

Information Technology (informationalcontinuity of care)

Multidisciplinary Teams (managerialcontinuity)

Every patient has a primary provider andMD/NP team( relational continuity)

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Issues in development of newContinuity of care Models

Change Management Government Expectations Evaluation models.Audits outcome

based ..patient satisfaction. Problem: What dowe compare it to?

Marketing Co location Realistic numbers and expectations Don Quixote syndrome say no to protect your yeses

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Lessons Learned

Need Community Needs Assessment (not just practice needsassessment)

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