Experienced Continuity of Care When Patients See Multiple Clinicians: A Qualitative Metasummary

Jeannie L. Haggerty; Danièle Roberge; George K. Freeman; Christine Beaulieu

doi:10.1370/afm.1499

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Ensuring continuity of care according to patients' needs: a people-centred bottom-up approach
Sina Waibel

Published on: 09 August 2013
Management and informational continuity experienced by patients
Annette J. Berendsen

Published on: 16 July 2013
Experienced continuity of care when patients see multiple conditions
Martin Gulliford

Published on: 21 June 2013

Published on: (9 August 2013)

Ensuring continuity of care according to patients' needs: a people-centred bottom-up approach
Sina Waibel, Researcher
Other Contributors:
The qualitative meta-summary on continuity of care by Haggerty and colleagues provides relevant results on the patients' experiences with care received from various clinicians in a variety of contexts. Apart from their main finding that continuity is experienced as a sense of security and confidence rather than seamlessness, we would like to comment on two different but at least as relevant findings: the importance of fir...
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The qualitative meta-summary on continuity of care by Haggerty and colleagues provides relevant results on the patients' experiences with care received from various clinicians in a variety of contexts. Apart from their main finding that continuity is experienced as a sense of security and confidence rather than seamlessness, we would like to comment on two different but at least as relevant findings: the importance of first, ensuring patient autonomy and their contribution to achieving continuity of care, and second, promoting a relationship with a single trusted health professional.
In their article, Haggerty et al. conclude that clinicians need to build the capacity for patients to assume some agency in management through information sharing and partnership. This notion has found strong support in the literature in the last years, but also in the international health community with the re-emerging call of putting people at the centre, i.e. seeking a people-centred bottom-up approach (e.g. the Declaration of Alma Ata 1978 reflected in the new European health policy Health 2020). Nevertheless, caution should be taken that this notion of patient participation for achieving continuity of care is not misinterpreted by transferring the final responsibility to the patients, e.g. by giving them the task of information carriers or care administrators. Rather, patient autonomy should be promoted by providing them adequate information, by listening to them carefully and allowing them to make informed decisions. Furthermore, as highlighted by Haggerty and colleagues, patients are able to identify elements of discontinuity of care, e.g. insufficient communication between providers, and can provide helpful suggestions for improvement. Therefore, it is important to seek the patient's perspective when aiming at delivering people-centred care, as long as the final responsibility to find answers to and counteract discontinuity lies with the health providers.
According to Haggerty et al.'s results and our meta-synthesis (1), the patient's perspective underlines the need to have a single trusted physician who has developed a comprehensive knowledge and helps them navigating the system. Having a trustful relationship with one individual professional (most often the primary care physician) is considered to be necessary for ensuring that care is tailored to the patient's needs as well as consistent and coordinated.
Bibliography
Waibel S, Henao D, Aller MB, Vargas I, Vazquez ML. What do we know about patients' perceptions of continuity of care? A meta-synthesis of qualitative studies. Int. J. Qual. Health Care. 2012 Feb;24:39-48.
Competing interests: ?? None declared
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Competing Interests: None declared.
Published on: (16 July 2013)

Management and informational continuity experienced by patients
Annette J. Berendsen, MD, PhD
Jeannie Haggerty et al. outline in their well performed metasummary the hypotheses generated in single studies on problems patients encounter receiving care of multiple clinicians. They state that coordination may be assumed by patients and not observed.
The assessment of management continuity from patients' perspective is difficult. Patient perceptions of inter-professional communication are affected by the appr...
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Jeannie Haggerty et al. outline in their well performed metasummary the hypotheses generated in single studies on problems patients encounter receiving care of multiple clinicians. They state that coordination may be assumed by patients and not observed.
The assessment of management continuity from patients' perspective is difficult. Patient perceptions of inter-professional communication are affected by the appreciation of the communicative skills of the doctors.(1) Several instruments were developed measuring continuity of care but most instruments have problems with either the number or quality of its assessed measurement properties.(2) Possibly, one of the reasons why it is difficult to develop these instruments is that each patient- doctor contact is a combination of communication and medical content. From patients' perspective discrimination between these two aspects is not possible.(1) Haggerty et al. make a valid observation that management continuity is best assessed indirectly by patients through reporting failures and gaps (discontinuity) and informational continuity directly through patients' experience. Improvement of informational continuity is necessary especially when patients are discharged from hospital care as studies from the USA (3) as well as Europe (4) showed. Of the patients from the USA 74% wanted more information. They found that communication was inadequate concerning follow-up, sources of information and to whom questions should be directed.(3) In the Netherlands patients thought it important to receive sufficient information upon discharge from the hospital, but only 84% received sufficient information.(5) All patients treated by more than one specialist felt it is important that specialists keep each other well informed. However, patients experienced this fully in only 55% of cases, in 28% to some extent and not at all in 17%. Above all patients do not want contradictory information from multiple specialists though 19% of them reported having received contradictory information.(5)
1. Berendsen AJ, de Jong GM, Meyboom-de Jong B, Dekker JH, Schuling J. Transition of care: experiences and preferences of patients across the primary / secondary interface - a qualitative study. BMC Health Serv Res. 2009; 9:62.
2. Uijen AA, Heinst CW, Schellevis FG, van den Bosch WJ, van de Laar FA, Terwee CB, Schers HJ. Measurement properties of questionnaires measuring continuity of care: a systematic review. PLoS One. 2012;7(7):e42256.
3. Holland DE, Mistiaen P, Bowles KH. Problems and unmet needs of patients discharged "home to self-care". Prof Case Manag. 2011; 16:240-250.
4. Hesselink G, Flink M, Olsson M, Barach P, Dudzik-Urbaniak E, Orrego C, Toccafondi G, Kalkman C, Johnson JK, Schoonhoven L, Vernooij-Dassen M, Wollersheim H; European HANDOVER Research Collaborative. Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Qual Saf. 2012;21 Suppl 1:i39-49.
5. Berendsen AJ, de Jong GM, Schuling J, Bosveld HE, de Waal MW, Mitchell GK, van der MK, Meyboom-de JB. Patient's need for choice and information across the interface between primary and secondary care: A survey. Patient Educ Couns. 2010; 79:100-105.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (21 June 2013)

Experienced continuity of care when patients see multiple conditions
Martin Gulliford, Professor of Public Health
Jeannie Haggerty and colleagues provide a valuable synthesis of research concerning patients' experiences of continuity of care, when care is provided by multiple clinicians.
The concept of continuity is of growing importance. Multi-morbidity, the co-existence of several long-term conditions, is now the rule rather than the exception among older adults. This has the consequence that individual patient's care ma...
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Jeannie Haggerty and colleagues provide a valuable synthesis of research concerning patients' experiences of continuity of care, when care is provided by multiple clinicians.
The concept of continuity is of growing importance. Multi-morbidity, the co-existence of several long-term conditions, is now the rule rather than the exception among older adults. This has the consequence that individual patient's care may be delivered by a range of clinicians, including both family physicians and specialists, as well as the wider members of clinical and social care teams. Haggerty et al. identify 'continuity' as an experience of 'security and confidence'. This is relevant because research shows that errors in care, and problems of patient safety, may arise when continuity is lacking, either at transitions in care, or when there are relational difficulties, or if there are problems of communication and information transfer.(1) Greater focus on interpersonal and organisational issues that promote continuity of care might enhance patient safety. Generic measures of the patient experience of continuity of care may be utilized in patients with multiple long-term conditions in order to promote safer and more acceptable care. Such measures are now being described,(2) with content that is broadly consistent with the elements outlined in the synthesis of Haggerty et al.
References
1: Burgess C, Cowie L, Gulliford M. Patients' perceptions of error in long-term illness care: qualitative study. J Health Serv Res Policy. 2012 Jul;17(3):181-7. doi: 10.1258/jhsrp.2012.011122. PubMed PMID: 22807556.
2: Gulliford M, Cowie L, Morgan M. Relational and management continuity survey in patients with multiple long-term conditions. J Health Serv Res Policy. 2011 Apr;16(2):67-74. doi: 10.1258/jhsrp.2010.010015. Epub 2010 Jun 30. PubMed PMID: 20592048.
Competing interests: None declared
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Competing Interests: None declared.