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      Provider connectedness and communication patterns: extending continuity of care in the context of the circle of care

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          Abstract

          Background

          Continuity is an important aspect of quality of care, especially for complex patients in the community. We explored provider perceptions of continuity through a system’s lens. The circle of care was used as the system.

          Methods

          Soft systems methodology was used to understand and improve continuity for end of life patients in two communities. Participants: Physicians, nurses, pharmacists in two communities in British Columbia, involved in end of life care. Two debates/discussion groups were completed after the interviews and initial analysis to confirm findings. Interview recordings were qualitatively analyzed to extract components and enablers of continuity.

          Results

          32 provider interviews were completed. Findings from this study support the three types of continuity described by Haggerty and Reid (information, management, and relationship continuity). This work extends their model by adding features of the circle of care that influence and enable continuity: Provider Connectedness the sense of knowing and trust between providers who share care of a patient; a set of ten communication patterns that are used to support continuity across the circle of care; and environmental factors outside the circle that can indirectly influence continuity.

          Conclusions

          We present an extended model of continuity of care. The components in the model can support health planners consider how health care is organized to promote continuity and by researchers when considering future continuity research.

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          Most cited references25

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          Interpersonal continuity of care and care outcomes: a critical review.

          We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care. A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to find original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence. Forty-one research articles reporting the results of 40 studies were identified that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were significantly improved and only 2 were significantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported significantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity. Although the available literature reflects persistent methodologic problems, it is likely that a significant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specific and measurable outcomes and more direct costs and should seek to define and measure interpersonal continuity more explicitly.
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            Does continuity of care improve patient outcomes?

            Continuity of care is a cornerstone of primary care that has been promoted by recent trends in medical education and in the way health care delivery is organized. We sought to determine the effect of sustained continuity of care (SCOC) on the quality of patient care. We conducted a systematic review of all articles in Medline (January 1966 to January 2002), Educational Resources Information Center (ERIC), and PSYCH INFO using the terms "continuity of care" or "continuity of patient care." We identified additional titles of candidate articles by reviewing the bibliographies of articles from our original MEDLINE search, contacting experts in primary care, health care management, and health services research, and by reviewing bibliographies of textbooks of primary care and public health. Two investigators (MDC, SHJ) independently reviewed the full text to exclude articles that did not fulfill search criteria. Articles excluded were those that focused on physicians-in-training, on SCOC in a non-primary care setting, such as an inpatient ward, or on transitions from inpatient to the outpatient setting. We also excluded articles that did not correlate SCOC to a quality of care measure. From 5070 candidate titles, we examined the full text of 260 articles and found 18 (12 cross-sectional studies, 5 cohort studies and 1 randomized controlled trial) that fulfilled our criteria. Five studies focused on patients with chronic illness (eg, asthma, diabetes). No studies documented negative effects of increased SCOC on quality of care. SCOC is associated with patient satisfaction (4 studies), decreased hospitalizations and emergency department visits (7 studies), and improved receipt of preventive services (5 studies). SCOC improves quality of care, and this association is consistently documented for patients with chronic conditions. Programs to promote SCOC may best maximize impact by focusing on populations with chronic conditions.
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              Defining and measuring interpersonal continuity of care.

              In an effort to learn more about the importance of continuity of care to physicians and patients, I reviewed the medical literature on continuity of care to define interpersonal continuity and describe how it has been measured and studied. A search of the MEDLINE database from 1966 through April 2002 was conducted to find articles focusing on the keyword "continuity of patient care," including all subheadings. Titles and abstracts of the resulting articles were screened to select articles focusing on interpersonal continuity in the physician-patient relationship or on the definition of continuity of care. These articles were systematically reviewed and analyzed for study method, measurement technique, and research theme. A total of 379 original articles were found that addressed any aspect of continuity as an attribute of general medical care. One hundred forty-two articles directly related to the definition of continuity or to the concept of interpersonal continuity in the physician-patient relationship. Although the available literature reflects little agreement on how to define continuity of care, it is best defined as a hierarchy of 3 dimensions; informational, longitudinal, and interpersonal continuity. Interpersonal continuity is of particular interest for primary care. Twenty-one measurement techniques have been defined to study continuity, many of which relate to visit patterns and concentration rather than the interpersonal nature of the continuity relationship. Future inquiry in family medicine should focus on better understanding the interpersonal dimension of continuity of care.
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                Author and article information

                Contributors
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central
                1472-6963
                2013
                14 August 2013
                : 13
                : 309
                Affiliations
                [1 ]School of Health Information Science, University of Victoria, 3800 Finnerty Road Victoria, V8P 5C2 Victoria, British Columbia, Canada
                [2 ]Department of Family Practice, University of British Columbia, Vancouver, Canada
                [3 ]Medical Science Building, University of Victoria, PO Box 1700, STN CSC, Victoria BC V8W 2Y2 Canada
                Article
                1472-6963-13-309
                10.1186/1472-6963-13-309
                3751828
                23941179
                d16fad76-6335-494c-95e0-d1ba6baba1f8
                Copyright © 2013 Price and Lau; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 18 February 2013
                : 7 August 2013
                Categories
                Research Article

                Health & Social care
                continuity of care,circle of care,quality of care,communication,systems thinking

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