Managing continuity of medical care.

Continuity is the assurance that knowledge of the details of one patient interaction is used in subsequent interactions. Interactions include visits in the office and the hospital, review of laboratory and x-ray data, and telephone calls. Continuity is frequently defined to mean repeated interactions with the same providers, but this is only one means of providing continuity. In this article, I refer primarily to the doctor-patient interaction, but the same principles apply for nurse practitioners, physician's assistants, midwives, social workers, and other health care providers.

Continuity is a multifaceted term that means different things to different people:

* A patient sees the same physician in an outpatient setting monthly over a span of years for chronic ambulatory medical problem. Knowledge of how the patient previously reacted to treatments helps the physician plan further treatment.

* An ICU patient with an illness that is critically unstable during the first day has one physician available inhouse for a 24-hour period. Knowledge of how the patient responded to treatment an hour ago helps the physician decide on the next step in treatment.

* A patient has a medical problem requiring long-term hospitalization, e.g., ventilator dependent pneumonia with failure to be weaned from a respirator. The primary physician sees the patient seven days a week to direct daily care. The patient does not suffer setbacks on the weekends, as could occur if a colleague had covered weekend rounds.

* An ambulatory patient with congestive heart failure and azotemia is precariously balanced by weekly visits and occasional furosemide injections. The same physician sees the patient for most of ambulatory visits and cares for the patient in the hospital 5-6 times a year for decompensation episodes. The physician's knowledge of the patient's reactions to medical pharmacotherapy helps in the ordering of appropriate dosages of medication in the hospital. The physician's ongoing relationship with the patient help in convincing the patient to accept dietary and other restrictions.

* A patient develops an adverse reaction to a drug a few hours after it has been prescribed. When the patient calls that evening for further advice, the prescribing physician handles the call. The physician tells the patient to stop the drug and, knowing the reason it was prescribed, is able to prescribe a replacement on the spot. The patient has trust in this advice, knowing that the physician who gave it is aware of overall care problems.

* A patient is scheduled for an appointment with a personal physician who is unavailable. That doctor's associate sees the patient with the benefit of records that clearly list problems, allergies, and current treatment modalities. The last note lists plans for the prevent visit. These plans are carried out.

* A patient is discharged from a tertiary referral center for ongoing care by the referring, primary care physician. The specialist speaks with the primary care physician and recommends further treatment and follow-up. The specialist follows up this conversation with a written summary. The patient sees the primary care physician shortly thereafter and the discharge plan is implemented.

The different types of physician continuity may be summarized as:

Hospital, hourly--physician available in house throughout the day.

Hospital, daily--physician available 24 hours per day.

Hospital, weekly--physician sees patient 5, or even 7, days per week. Or, the surgeon who operates on a patient is the same one who performs rounds and decides on discharge.

Hospital, recurrent--same physician handles each admission.

Hospital, ambulatory--hospital physician sees patient in clinic after discharge.

Ambulatory, hospital--regular clinic physician is called in to see patient in the hospital.

Ambulatory, recurrent--same physician sees patient at each outpatient visit.

Ambulatory, coverage--physician available 24 hours per day, 7 days per week, for follow-up on ambulatory care.

The list above may not be all inclusive. Other types of continuity may be important in nonphysician portions of the total delivery system. For example, in the multi-clinic/hospital medical group, such as a staff model HMO, pharmacy continuity may consist of shared drug and allergy profiles between and among clinics and hospitals. Or, computerized linkage of all ECG tracings from ambulatory, hospital, and home health settings may ensure use of previous data in the interpretation of new results. Nevertheless, it is valuable to break the concept of continuity into its components, whatever they may be for a particular system, because as a delivery system is designed, one type of continuity may be increased at the expense of another.

In a recent article in Medical Economics, [1] a doctor stated that, to be more available to his patients when they needed him, he had eliminated hospital work, referring all such cases to other doctors. Certainly his "ambulatory-recurrent" continuity was improved, but his "ambulatory-hospital" continuity was limited to the extent that he was in contact with hospitalizing physicians in his area. Subsequent "Letters to the Editor" [2] questioned whether this policy was good for his patients. Was this trade-off really in his patients' best interests? The answer to that question may not be clear, but the trade-off in types of continuity is obvious.

The following is a more complex example of such trade-offs. The internal medicine department of an HMO consisted of one internist from each of five centers. Call was rotated every fifth night and weekend and included answering floor calls after 5 p.m., checking all admissions for the day, and performing rounds for all patients on weekends. Admissions were turned over the next day to the internist of the patient's medical center. Thus, "ambulatory-hospital" continuity was good. Except for the night of the admission, patients saw the internist of their own medical center. "Hospital-ambulatory" continuity was good as long as the internist referred the patient back to himself and not to the general and family practitioners in the medical centers. "Hospital-hourly" continuity was mediocre. Nurses called the internist of record at his or her center if problems arose after rounds, but the physician was not available in house unless clinic appointments were canceled, and, after 5 p.m., nurses got only the on-call internist. On weekends, one internist performed rounds and fielded all floor calls for 48 hours; approximately, "hospital-hourly" and "hospital-daily" continuity were better on weekends during the week. "Hospital-daily" continuity was poor on weeknights, especially if good sign-out was not the rule. "Hospital-weekly" continuity was poor for any given doctor's patients during 4 out of 5 weekends, as rounds were covered by another physician after fairly thorough sign-out. "Ambulatory-recurrent" continuity was good because each internist was in clinic daily; "ambulatory-coverage" continuity was weak, as one internist covered call not just for the other four internists but for all GPs and FP as well. Physicians spent a lot of time driving from clinic to hospital, and it was hard for clinic nurses to adapt to physicians' hospital schedules, for they were often in clinic for five- to six-hour blocks, not the usual four-or eight-hour blocks.

As the HMO grew and entered the Medicare risk capitation market, several things changed. The internal medicine department doubled in size; call was less frequent but more intense; there was more than one internist at several centers; and the work load at centers with large Medicare case loads was disproportionately high, so transferring care of all of the center's patients to these doctors would have created an unfair work load distribution. A patient's attending physician was assigned on the basis of day of admission rather than of the patient's medical center. Rarely was a patient transferred to an internist at his or her own center who knew the patient best. Because calls to clinic physicians were becoming more frequent and were disruptive of the clinic schedule, and because more patients had critical illnesses requiring attendance in intensive care units, one of the internists (called the O.D.) was assigned to remain in the hospital for twelve-hour day shifts. Nurses no longer called the physician of record in the afternoon; they called the O.D. Twenty-four-hour on -call shifts became too exhausting so they were cut to 12 hours, and the night physicians remained in-house.

Physicians were more available on an hourly basis in the hospital, but with 12 physicians sharing call, the on-call doctor was less likely to know any individual patient. Thus "hospital, 24-hour" continuity decreased. On weekends, two physicians now performed rounds and split call duty, so niether knew all the patients while on call, and the 48-hour weekend continuity mentioned above was therefore lost. As the department moved from a 5-person group, with each knowing the other's small group of patients, to a 10- to 12-person group with less consistent sign-out and less knowledge of all the patients, "hospital, weekly" continuity decreased. After staying in the hospital at night, physicians needed the next day off. They now had daytime hospital shifts, so they were less available in clinic. These changes reduced "ambulatory, recurrent" continuity.

Though 24-hour in-house coverage had improved care in some ways, patients were losing several types of continuity. Once again, the HMO's management reassessed the entire rounds and call system, while also considering goals not related to continuity: reducing driving time for physicians (reduced trips from hospital to clinic) to improve productivity and adopting more standard clinic blocks to allow consistent nursing schedules.

Management and the internal medicine department changed the system to three teams of doctors with 2-week hospital blocks, including 2 weekends and rotating night call, followed by six-week clinic blocks. This led to good daytime "hospital, hourly" continuity and "hospital, weekly" continuity because, for most hospital admissions (those lasting less than two weeks and not near a change in rotation), the same doctor was available in the hospital all day, every day, including weekends. This occurred at the expense of "hospital, recurrent" continuity; the chances of the same physician being on a hospital rotation the next time a patient was admitted was only one in three. "Ambulatory, recurrent" continuity was worsened by each internists' absence from the clinic for 2-week blocks. On the ambulatory side, however, continuity was aided by formation of 4-internist teams. Although one of the four would be in the hospital and one might be on vacation or on educational leave, the 2 or 3 in clinic would cover for the absent members' patients, including phone messages, laboratory results, and follow-up visits. Biweekly sign out included both hospital and ambulatory work in progress. Patients were given printed cards with all four physician's names as well as the name of the nursing team leader (who acted as a continuity focus for ambulatory care). In some cases, nonhospitalizing physicians, nurse practitioners, and physician's assistants were also part of the teams. Thus team continuity replaced individual continuity.

In-hospital continuity improved with this system, it allowed clinic nurses to staff 9-hour days coinciding with physician staffing, and the patient flow in clinic was less interrupted with hospital duties. However, the team system did not work as planned to ensure "ambulatory, recurrent" continuity. Turnover of nursing and physician staff and transfers to expansion clinics became very disruptive to the team concept. The HMO is now contemplating a split into full-time hospital and full-time ambulatory internists.

These examples are presented to communicate some basic elements of continuity of care:

* Continuity is a multifaceted concept.

* Any delivery system has trade-offs in the proportion of each facet that it can accommodate.

* The continuity mix is within the control of the medical manager.

* It is the medical manager's responsibility to optimize the continuity mix, along with quality, productivity, and cost-effectiveness, in the design of the delivery system.

Any system that allows physicians time off leaves gaps in continuity that must be filled. And if a physician works in more than one setting--such as a hospital, a clinic, and a nursing home--there is the likelihood of discontinuity occurring in at least one of those settings. The way those gaps are filled determines whether one of the types of continuity identified earlier in this article is sacrificed for another.

A physician who is available to his patients 24 hours per day, 7 days a week, 52 weeks a year does optimize the various types of continuity in the provision of medical care, but this work schedule has its own disadvantages. It often leads to burnout, antagonism toward patients, and fatigue-induced errors. It leaves no time for educational leave, which could lead to obsolescence, obviously not in the long-range best interest of patients. And, practically, few physicians are willing to accept that life-style.

What is important in continuity of medical care is information transfer. A good sign-out system, complete and legible chart notes, and well-thought-out cross-coverage systems improve information transfer and thus continuity. Because not all medical knowledge is conscious and what is not conscious cannot be communicated, there is sometimes no substitute for repeated interactions with the same provider. The more explicit a physician is in his or her assessments, however, the easier and more accurate is the information transfer.

Any system has some discontinuity in physician services. A system is needed to ensure continuity when patients receive special care or when the physician is ill, has a personal emergency, takes vacation, or has weekends or nights off. Information transfer must be accepted as a legitimate means of continuity. It must be planned and optimized.

Discontinuity is not always bad. For a practicing chief of medicine, covering for physicians on weekends may be the best means of performing concurrent quality review, especially when sign-out is inadequate and he or she is forced to make assessments. Retrospective quality assurance, relying on chart documentation, does not allow reviewers to check on the accuracy of a history or physical exam or on patient perception of competence or compassion. It does not allow correction of the quality problem before it has an adverse outcome. There are methods of concurrent quality assurance using nurse screeners and clinical indicators, but in their absence or as a supplement, discontinuity systems can detect quality problems. Indeed, physicians who assume the care of other physician's patients can be a primary case-finding group generating quality assurance referrals.

Planned discontinuity may actually improve quality by a sentinel effect: Knowing another physician will have the opportunity to check his or her work may improve the quality of a physician's documentation and thought processes in clinical decisions.

Even if there are no blatant quality findings, a fresh evaluation may lead to an improved diagnosis or treatment plan. A physicin who has been caring for a patient for two weeks may examine only one organ for deterioration or improvement; a new physician may discover a new problem. A patient followed as an outpatient for months or years frequently obtains a new diagnosis at the time of hospitalization by another physician. Sometimes the "new" diagnosis may be wrong (the cost of discontinuity), and sometimes it may be right (the benefit). Perhaps a system that has a balance between physician continuity, information exchange, and fresh looks by other physicians will lead to the best care.

How does a physician executive design a delivery system with the optimal mix of the different facets of continuity? There are no data to support the choice of any one rounds/call system. One could look at outcome measures, such as patient satisfaction with continuity, physician satisfaction, readmissions, or patient days, or at process measures, such as wasted visits, repeated long appointments, or extra tests, before and after a change in a system. All of these indicators are so multifactorial in a growing, evolving, complex delivery system that even if a significant difference were found, attributing the difference to a continuity-specific variable would be presumptuous. It would be even more presumptuous to extrapolate that conclusion to another system with a different patient mix, provider mix, and geographic distribution. However, I can present some guidelines from my own observations of different systems.

"Hospital, hourly" continuity is most important in the intensive care setting. Some institutions provide this continuity by providing a team of intensivists. This frees primary care physicians for other kinds of continuity. Scheduling physicians to work at the hospital all day, as opposed to performing rounds for an hour or two and then disappearing to other tasks, is the basic requirement for this type of continuity.

"Hospital, daily" is generally most important in the first hospital day and for the sickest patients. It is very difficult to achieve for more than one day, as physician fatigue ensues. Good daily sign-out of a patient's history or team meetings among the physicians who share night call can supplement weaknesses in this type of continuity generated by the call system.

"Hospital, weekly" is the most important to good utilization of hospital days, so that patients continue to make progress over the weekends and holidays and are discharged expeditiously. If the average length of stay of most hospital patients is short, less than six or seven days, this type of continuity is achievable by having physicians perform rounds at least 12 days in a row, preferably 14, before they have a day off. This will occur at the cost of other facets of continuity, as physicians will likely agree to this only if compensated with time off during some other part of the rounds/call/clinic schedule.

"Hospital, recurrent" continuity is of prime importance in a system with a significant population of seriously and chronically ill patients, or when there is wide variation in patient response to a given therapy. Examples include patients with cardiac output; cancer patients receiving recurrent chemotherapy; and patients with asthma, chronic obstructive pulmonary disease, or chronic psychiatric illness. Good hospital charting also helps here, especially thorough discharge summaries.

"Hospital, ambulatory" continuity is vital when hospital stays are too short to resolve patients' problems thoroughly and follow-up visits are the time to finish out hospital stays. Continuity may well prevent readmissions and other quality problems. It can generally be accomplished by a paper message system. Discharge summaries are generally inadequate for that purpose, too often coming late. A brief summary written by the physician at the time of discharge, with copies given to the patient and to the office record, is helpful.

"Ambulatory, hospital." Using ambulatory data in diagnostic and treatment decisions in the hospital will often save ancillary service utilization, and a good automatic chart transfer system can accomplish the information transfer. To many patients, the whole point behind having regular clinic physicians is to have someone they know and trust see them when they are most vulnerable--in the hospital. This becomes a service issue.

"Ambulatory, recurrent." Patients who are generally healthy and use health care for acute, self-limited illnesses will benefit less from this type of continuity than those with chronic illness. A series of acute illnesses may itself be a diagnostic clue, but a nursing team leader can be the continuous link that notices such patterns. In some cases, computerized appointment systems can be designed for the continuity link. When physicians see patients they know, they are more productive in the ambulatory setting and may use fewer tests.

"Ambulatory, coverage." Except in the case of the solo practitioner who takes his own calls each night, this type of continuity is very difficult to achieve. Good patient instructions, warnings, educational materials, and protocols can minimize the need for designing this facet into the continuity mix. Computerized record systems available to an on-call professional may fill this need.

This article was written to encourage health system planners to look at continuity not as a "holy grail" but as a means to attain the highest quality care. This entails an evaluation process:

* Define your own patient mix. Do you have mostly young and healthy patients, for many chronically ill and recurrently hospitalized patients? What is your average length of stay? Do your patient satisfaction surveys reveal that your patients care about seeing the same doctor in the ambulatory setting? Sometimes surveys show that significant numbers do not.

* Assess your physician resources. Are all of your physicians competent in the hospital? Are your physicians willing to be limited to one practice setting? How flexible are they in their life- and practice styles? In the specialty in question, do you need to perform certain procedures frequently to remain competent?

* Determine the most important types of continuity for a given patient population. Consider the limitations that your physician factors place on you, and build them into your system.

* Recognize the trade-offs made to achieve the important types of continuity. Address the potential for discontinuity in the other types. This might entail developing a team system, whereby patient assignment methodologies are modified to ensure physician continuity for certain high-risk patients, improved sign-out or charting requirements, new forms, regular team meetings, the use of case managers or nursing team leaders, or some original mechanism that will work in your particular delivery system.

Physicians want continuity for several reasons. One is to optimize quality of patient care. Another is to attain one of the rewards of medicine--seeing tangible evidence of their efforts by following their patient's outcomes. These reasons are valid and in the long run will affect quality. If we design a system that diminishes individual physician continuity and thereby gives physicians less feedback on individual cases, we also need to design a means to replace that loss. Sharing physician practice profiles that include outcome data, sponsoring team meetings that discuss patient outcomes, and providing regular and frequent feedback from quality assurance systems can all partially compensate for that loss.

Nonphysician managers, in my experience, often have difficulty with the concept of continuity. They want to design an effective production-line operation, and the concept of continuity may seem an obstacle to them. They may intuitively understand how they themselves would want continuity in certain instances, but the idea is often muddied when used in different contexts. It is up to physicians, and especially physician executives, to explain the concept so that it can be incorporated as much as possible into health care delivery systems.

Jonathan Harding, MD, FACPE, is Medical Director, FHP, Inc., Cerritos, Calif.

References

[1] Sheppard, S. "If You're Better Than HMOs, Say So." Medical Economics 65(20):71-3, Oct. 17, 1988.

[2] Farnsworth, D., and Solomon, G. "It's Not Enough Simply to Say You're Better (Letter)." Medical Economics 66(4):22, Feb. 20, 1989.