MEASURING AND IMPROVING CONTINUITY IN RESIDENCY PRIMARY CARE PRACTICE
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* Steven R. Brown
* Gretchen Irwin

Continuity relationships with the patients that we serve are a cornerstone of Family Medicine. Physician-patient continuity has been shown to be valued by patients, decrease overuse of unnecessary tests, decrease overall cost of care, and improve patient outcomes.1 Frustration with a lack of continuity in residency practice along with poorly performing residency office-based practices can lead family medicine residents to choose practice settings after graduation that do not include continuity primary care. This deprives our health system of desperately needed family physicians.

The Accreditation Council of Graduate Medical Education requirements for family medicine mandate all family medicine residents to care for a panel of continuity patients. Further, The American Academy of Family Physicians Residency Program Solutions (RPS) Criteria for Excellence suggest that achieving benchmarks of continuity is one measure of a high performing residency program.2

To improve continuity, a residency program must first be able to measure it. The measurement of continuity can be complex. Metrics can be measured from the patient or the physician perspective and require physician attribution to a panel of patients.3 Measurement from the patient perspective reports what percentage of visits were to their assigned physician. The metric from the physician perspective measures the percentage of visits made up of patients assigned to the physician panel. One metric used is the Usual Provider Continuity (UPC) which measures the percentage of visits to the assigned clinician.4 Ideally, residency programs will query reports from their electronic medical record to automate the measurement of continuity. The RPS Criteria for Excellence suggest programs aim for a goal of 70% of routine patient visits with the patient’s family physician.2 A recent review shows mean UPC in residency program clinics of 56% with a range of 43% to 75%.5

Once a residency program has a reliable tool for measuring continuity, the program may implement efforts to improve. While improvement is challenging and complex, Gupta and Bodenheimer suggest the following ways to improve continuity: set goals and display results, increase the number of days each clinician is seeing patients in the office, improve same-day or next-day access for all clinicians, and enforce a practice.3 Policy on continuity and access including training of telephone and front desk personnel. Residency programs across the country have demonstrated that improvement can be made and sustained in a residency practice.4,6

The AFMRD, in our mission to inspire and empower family medicine residency program directors to achieve excellence in family medicine residency training, has embarked on a collaborative with the University of California San Francisco Center for Excellence in Primary Care (CEPC). In 2018–2019 we are connecting 18 family medicine residency programs with the CEPC to invigorate the current and future workforce in primary care through the building blocks model for high-performing teaching practices. We hope this collaborative will inspire improvement in these and other residency teaching practices. Our residency practices, our residents, our family medicine workforce, and our patients will benefit greatly from a focus on improving continuity.

*   © 2018 Annals of Family Medicine, Inc.

## References

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2.  American Academy of Family Physicians Residency Program Solutions. Criteria for Excellence. 9th Edition, 2015.
    
    

3.  Gupta R, Bodenheimer T. How primary care practices can improve continuity of care. JAMA Intern Med. 2013;173(20):1885–1886.
    
    

4.  Carney PA, Conry CM, Mitchell KB, et al. The importance of and the complexities associated with measuring continuity of care during resident training: possible solutions do exist. Fam Med. 2016;48(4):286–293.
    
    

5.  Walker J, Payne B, Clemans-Taylor BL, Snyder ED. Continuity of care in resident outpatient clinics: A scoping review of the literature. J Grad Med Educ. 2018;10(1):16–25.
    
    

6.  Weir SS, Page C, Newton WP. Continuity and access in an academic family medicine center. Fam Med. 2016;48(2):100–107.
    
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