Continuity of Care Lessons

from two Major Research Programs in

UK and Canada 1999-2006George Freeman

Emeritus Professor of General Practice

research team

George Freeman, Maria Woloshynowych, Josip Car

– Imperial College London

Jeannie Haggerty – University of Sherbrooke, Quebec, Canada

Bruce Guthrie – University of Dundee

Richard Baker – University of Leicester

Mary Boulton – Oxford Brookes University

consultant

Ewan Ferlie - Royal Holloway, University of London

international expert advisers

USA

Dmitri Christakis Seattle

John Saultz Portland

Barbara Starfield Baltimore

Canada

Carol Adair Calgary

Norway

Per Hjortdahl Oslo

Netherlands

Henk Schers Nijmegen

why continuity?

1. top priority in SDO’s 1999 start up listening exercise

2. scoping study3. six major studies 2001-7

– all with strong user perspective

http://www.sdo.nihr.ac.uk/cpcontinuity.html

The Service Delivery and Organisation Programme is part of the National Institute for Health Research

UK - six long term projects

four diseasesdiabetes community

cancer hospital

stroke hospital

severe mental illnesscommunity

generalprimary care

community

organizational cross boundary study young people with learning disability communityolder people with a stroke community

what we did

• standardised data collection – site visits

– protocols, reports, presentations, publications

• draft report reviewed by– expert advisors

– project leaders

• common analytic framework– based on Canadian programme review - Haggerty

Canada - 34 projects

• wider variety of settings/methods

• findings match and extend UK programme

• intervention trials for severe mental illness

what is continuity?

two essential elements care of – an individual patient – delivered over time

three continuity types

Informational - timely appropriate information

Management – co-ordination between providers

Relationship - ongoing therapeutic relationship between a patient and one or more providers

lessons learned - 1

• all continuity types link with greater satisfaction

Our earliest experience of sickness is usually in a family context. We learn how

to be sick within the family

lessons learned - 2

• all continuity types link with greater satisfaction

• most users want more involvement & responsibility

• vulnerable minority need help

Our earliest experience of sickness is usually in a family context. We learn how

to be sick within the family

lessons learned - 3

• all continuity types link with greater satisfaction

• most users want more involvement & responsibility

• vulnerable minority need help

• the access trade-off

advanced medical home

all types of continuity offered

relationship continuity is key feature

- each patient has an ongoing relationship with

a personal physician

- continuous and comprehensive care

the access trade-off - how long to wait?

to see

• physician rather than nurse

• someone you know & trust

• someone with access to full medical history

how many extra days to wait?

vignette

minor new routineto see familiar uncertain check-up

doctor 1.0 3.5 3.5

known &trusted 0.9 2.4 4.2

full medicalhistory 1.6 3.9 7.8

primary care findings

patients

• are well aware of clash between access and relationship continuity

• have clear views on when they need relationship continuity

• expect good informational continuity

Sick elderly woman living alone

overall lessons

• patient-centred care is fundamental

– most users want more involvement

– more vulnerable need help

• which type of continuity?

– Relationship, Informational, Management

• give specific priority to relationship as well as

to informational and management

continuity of care when reorganising services

outstanding questions

Management and Informational continuity are almost self-evident goods

• how to deliver the goods?case for Relationship continuity is less clear• how to measure it and reward it?• more about trade-offs with

rapid accessspecialist expertise

• intervention trials needed

thank you for your attention!

questions?

primary care findings - 2

• patients value relationship continuity more

if they are older, iller or vulnerable

• some patients get less of what they want– non-white

– socially isolated or disadvantaged

– in full time work