Continuity and Comprehensiveness of Care

1. Continuity and Comprehensiveness of Care

2. What is Continuity of Care? • Traditional Family Doctor: = single provider and single patient in a longitudinal, personal relationship • Mental Health Worker: = coordination of many services over time. Common plans and goals.. many providers • Nurse: = smooth information transfer • Diabetic clinic: = “continuum of care”, multiple providers, protocol and result driven

3. Can we define Continuity of Care in context of: ….. • Doctor: ie “ Dr X always looks after all of my problems in a timely fashion” • Patient : ie “Patient X always has her problems looked after in a timely fashion by a group of providers”

4. Doctor / patient relationship is key • BUT…. Are we • QUARTERBACKS • Or ORCHESTRA CONDUCTORS • What about PROVIDER / patient relationships in a multidisciplinary team model ?

5. 3 types of Continuity • Informational • Management • Relational

6. Why revisit Continuity of Care? • Disease Complexity • Determinants of Health • Chronic Disease Burden • Increased focus on teaching • Increased focus on Multidisciplinary care • Access issues • How do we deliver 24/7 • Marcus Whelby is dead

7. Saint John CHC • Greater Saint John access: • 80 Family Doctors • 125,000 citizens • 140,000 ER visits p.a. • 140,000 FD/walk in visits • CHC catchment access • 12 Family doctors • 35,000 citizens

8. CHC • 5 Family doctors, • 4 Nurse Practitioners • 3 LPN • 2 dieticians • 1 Social worker • And a……..

10. CHC • OT , Domestic Violence Worker, Teen Resource workers • Numerous outreach workers and programs • Base patient number : 9000 • Chronic Disease Clinics, Mental Health, Teen Clinic, Outreach to Sal Army, Soup Kitchens, Homeless etc etc • Medical services: Prenatal/Antenatal, Palliative Care ,Hospital Care , Shared Mental Health , Minor Surgeries , House calls etc, etc • Vital partnerships with community agencies

11. How can you have Continuity of Care in such a model???? • Information Technology (informational continuity of care) • Multidisciplinary Teams (managerial continuity) • Every patient has a primary provider and MD/NP team( relational continuity)

12. Issues in development of new Continuity of care Models • Change Management • Government Expectations • Evaluation models….Audits …outcome based …..patient satisfaction…. Problem: What do we compare it to? • Marketing • Co location • Realistic numbers and expectations • “Don Quixote” syndrome • “say no to protect your yeses”

13. Lessons Learned • Need Community Needs Assessment (not just practice needs assessment) • Triage • Navigation • Patients need to know about informational continuity • Marketing • Linked appointments • Time resource management • Some patients prefer old model .They should have options available