POLICY Department of Family Medicine Postgraduate Program Continuity of Care Preamble Continuity of care is a value that lies at the very heart of family medicine. 1 In his editorial in the June 2000 issue of Canadian Family Physician, Dr. Peter Newberry echoed the statement of Ian McWhinney who wrote in 1996 [General Practice] is the only discipline to define itself in terms of relationships, especially the doctor-patient relationship. In general practice the relationship is usually prior to content. We know people before we know what their illnesses will be. McWhinney also wrote continuity of care has been correctly identified as a crucial element in family practice. Continuity is not only a question of duration. Continuity in family practice is an unbroken responsibility to be available personally, or by ensuring continuity of service by a competent deputy. It involves following through when some aspect of care is delegated to a consultant. Continuity of care is based on the idea that physicians cannot be substituted for one another like replaceable parts of a machine. Benefits of Continuity of Care are Supported by the Evidence Brian Hennen originally identified four aspects of continuity of care. These are: Chronological (care over time) Geographical (care in a variety of settings) Interdisciplinary (coordination of care among a variety of health professions) Interpersonal (long term relationship between physician and patient) Subsequently a fifth dimension: continuity of information was added Continuity of care has been demonstrated to be important, particularly in chronic disease for a variety of improved patient outcomes. These include: Fewer physician visits Fewer hospitalizations Shorter stay in hospital More patient satisfaction Increased uptake of screening procedures Less expensive and less intensive care Adults who receive regular care from a family physician are more likely to receive recommended preventive services. 2 It is the sense of unbroken responsibility that is essential for our residents to learn the sense of unconditional commitment to care for a patient; whenever they need care, whatever their age or Page 1 of 5
illness and whatever the time of day or night. Since we are human there are times when we must delegate the care of our patients to a competent deputy and times when we will need the assistance of allied health professionals or consultants. Involving other people is a lending not an abdication of responsibility. After hours care should be provided by a group of family physicians who communicate with each other. We must teach our residents that they must assume the responsibility for the ongoing care of their patients; it is not sufficient to sign out their care to walk-in services or emergency departments. Many family physicians will extend themselves to be available to their patients at particularly meaningful times birth and death being two examples. This extension of themselves illustrates clearly the commitment, the sense of responsibility and the idea that physicians are not replaceable parts of a machine. Modeling continuity of care for patients to our residents involves much more than providing them the opportunity to care for patients over a period of time. We must model care to patients in a variety of settings (office, home, emergency department, in hospital) and through a variety of illnesses; we must instill in them the concept that the consultant advises and the family physician follows through on the recommendations of the consultant. We must instill in the residents the understanding that, for the family doctor providing continuous care is a major aspect of professionalism. Goals and Objectives for Continuity of Care The resident will: 1. Build a panel of patients within their Family Practice for whom they will provide care over a two year period. 2. Demonstrate the sense of responsibility for their patients by: a. seeing the same patient in a variety of settings b. seeing the same patient over time c. developing relationships with families of patients d. caring for several members of the same family e. ensuring that care is available for their patients when the resident is not personally available f. following up on problems that arise outside of specific office visits g. communicating effectively with consultants and allied health professionals who are involved in the care of their patients h. participating in a defined activity which clearly demonstrates continuity of care. This will generally be half-day backs or another structured and monitored activity as approved by the Post-graduate Committee. Page 2 of 5
In order to foster this sense of responsibility for patients among residents the following conditions are outlined: Faculty Faculty are responsible for modeling and talking to residents about the sense of responsibility in the informal day to day clinical teaching. Formal teaching around continuity of care must occur. Faculty must emphasize this principle to each resident at the beginning of every family medicine rotation. They must convey to the resident the message that they are responsible for the care of the patients they see during their rotation. They must follow up to ensure that the resident is experiencing continuity as outlined above. Faculty must remind and enforce the principle of continuity for residents with reception and nursing staff. Faculty must organize their offices so continuity for residents is achievable. Faculty advisors should discuss continuity with the residents for whom they are responsible. Faculty must ensure their residents participate in a structured activity that demonstrates proactive efforts to remain in contact with patients from their Family Practice throughout first year and while on core Family Medicine in second year. This will normally be through the use of halfdays back. Nurses Nurses must ensure they direct questions regarding a patient to the resident who has seen the patient. Residents who are not present should be paged about patient concerns. Residents Residents should always ask patients to book follow up visits with them. They should always have their pagers turned on during work hours. Residents should visit any of their patients who are admitted to hospital whenever possible. If there are complex or difficult issues with any of their patients residents should ensure that these issues are communicated to the on call team. Site Directors Each site director should: Review the implementation of this policy with all teaching practices. Implement a variety of strategies from the menu (Appendix 1) to ensure residents experience continuity. Page 3 of 5
Report to the Residency Training Committee on a regular basis to review the strategies and experience of continuity for the residents. Enthusiastically promote the importance of continuity of care in teaching. Program Director Review continuity at all site visits. Assist site directors to overcome barriers to implementation. Appendix 1 Strategies to Foster Continuity of Care Provide a half-day back to the resident s home practice in first year. If half-days back are not used they must be replaced by a defined and evaluated activity that provides the resident with the opportunity to experience continuity of care and contribute toward building a panel of patients. This activity must be approved by the Residency Training Committee. The alternate activity must be evaluated in terms of the goals of this document and outcomes reported to the Residency Training Committee. In addition sites are expected to implement strategies that are appropriate for their educational and clinical setting. Not all strategies are appropriate for each site. The Residency Training Committee will approve the menu of strategies that each site chooses Residents are expected to return to the same practice for their second year core family medicine block Receptionist must ensure that they ask patients which resident they have seen and book patients to see the same resident. Receptionists should book family members of patients the resident has seen with that same resident. Receptionists should direct phone calls and prescription renewals for patients to the resident who has seen them Nurses must ensure they direct questions regarding a patient to the resident who has seen the patient. Flag all charts for the individual Resident to ensure that a Resident s panel of patients is created within their preceptor s practice. Hold yearly meetings with the receptionist and nurses on each practice team prior to the beginning of the academic year to ensure staff is well aware of the need to create a panel of patients for the Resident and how to accomplish this goal. Page 4 of 5
Make booking cards available in each examining room for the Residents to provide to the patients they are seeing to ensure that they are able to return on the day that the Resident will next be within the practice. During their Family Medicine rotations ask all residents to ensure all discharged hospital patients are set up to see them on their half-day back. These hospital patients should all be added to the Residents panel of patients. The Site Director will review with all Residents two weeks into each Family Medicine rotation all continuity strategies to ensure they have been addressed. A form letter will be sent to all preceptors one week prior to receiving new Residents with strategies listed to ensure they are reminded just prior to having a new Resident into their practice. References 1 Newbery, P. Time to rethink continuity. CFP 2000; 46:1248-1249. 2 McIsaac WJ, Fuller-Thompson E, Talbot Y Does having regular care by a family physician improve preventive care? CFP; 2001 47: 70-76 Page 5 of 5