Continuity of Care Archives - Doc Rick Healthcare and Creative Writing

Continuity Frontstage and Backstage

Frontstage continuity 
Backstage continuity

Frontstage Continuity

Frontstage continuity is face to face care with the same person. In practice face to face involves a team, but the patient should have a co-ordinator who knows the patient over time. It is possible to provide frontstage continuity over time if one person is there for the crucial moments of care or able to step in when these arise. Other members of the team may handle acute minor illness. When a serious illness arises then the lead can take over.

Backstage continuity

Backstage continuity, is seamless access to the medical records and access to results. It is also a collective understanding and shared knowledge of the healthcare team looking after that person. Backstage continuity requires a commitment by all the team to provide full and up to date records of every consultation. This is underpinned by an IT system that integrates care and records.

Case study
Adam presents to his general practitioner with a tender abdomen on the right side. It has been present for a few weeks. He is seen as an emergency without any records and given advice about gastroenteritis.

He books with his usual GP because he still has symptoms. His GP knows Adam is rarely concerned about his health so is more careful to check. He recalls he diagnosed him with a skin problem in the past. He checks the records and confirms he had excision of a melanoma several years earlier. As a result of his past consultations with Adam (frontstage continuity) supported by the records (backstage continuity) he is able to rapidly diagnose the liver cancer and arrange earlier treatment.

All cases are aggregated and names fictional.

Continuity ICCA

Individualised
Continuity of care
As Advocates

General Practitioners can aspire to provide

ICCA Individualised Continuity of Care and act as Advocates

for their patients.

Individualised

Individualised means tailored to that particular person rather than applying the same approach that has been applied to every other person

Continuity of care

Continuity can be face to face (frontstage) or records (backstage)

As Advocates

Advocates hold the patients interests first and will speak on the behalf of their patient to promote their medical and social care

The Healthcare system should encourage these elements alongside the use of practical relevant clinical targets.

Continuity in Practice

Resource

Continuity helps care according to Isaac Barker et el in the BMJ Feb 2017. Higher continuity of care was associated with fewer admissions for ambulatory care sensitive conditions, particularly for the heaviest users of healthcare. 230 472 patients aged between 62 and 82 years and who experienced at least two contacts with a general practitioner between April 2011 and March 2013. The usual provider of care index, was defined as the proportion of contacts occurring that were with the most frequently seen general practitioner. Continuity of care has previously been associated with patient and practitioner satisfaction.

This can be read at: http://www.bmj.com/content/356/bmj.j84

Know the story
Build on from before
Use all sources of information

What are the fundamentals of continuity of care? Seeing the same person helps because it builds on a relationship and prior knowledge. There are situations where you cannot see the same person but steps can be taken to retain the advantages. Continuity of records, the nature of the records and how proactively they are handled by the person you are seeing are the key.

Know the story

Knowing the story provides the bedrock to start from. There are the current medical problems, past medical problems and how they were treated. This provides the essentials for good treatment but it is the social elements that make the difference between good care and high quality care. It is knowledge of the family, occupation and life events which allow a doctor to place the medical problems in context and deal with them more effectively. However, it is knowledge of the psychological elements that make the difference between high quality and excellent care. Knowing how a person relates to someone else and to illness tailors the diagnosis and management to that particular individual. This is the cutting edge of medical records which has not been effectively addressed. Myers Briggs personality scales are an example of how this might be recorded, but it is really only by seeing the same person again that his level of excellent care can be achieved.

Build on from before

Building on from where you were can only be done if you know all the story and background already. A ten minute consultation does not give enough time to get all the story to build on from. If the records (or your knowledge) give you the story in full then you can build on this point and really deal with the issues that present.

Use all sources of information

There are at least two minds working on the problem in every consultation and it helps to make the most of every mind in the room. People bring their own ideas and beliefs to the consultation. Often they have been thinking over the problem for a long time and have researched the cause with friends, relatives and the internet. It is crucial to identify these ideas because they can be a short cut to the diagnosis, provide a starting point for mutual understanding and allow time to address misunderstandings and false beliefs. Many times relatives, parents and patients have the correct diagnosis in their mind and doctors miss this at their peril.

Continuity Index

Resource

Isaac Barker et el in the BMJ Feb 2017 applied a usual provider of care index as a ratios with 1 as maximum continuity. It was defined as the proportion of contacts occurring that were with the most frequently seen general practitioner. This can be read at: http://www.bmj.com/content/356/bmj.j84

Number of times seen
Number of times seen by the same person
For that problem

If continuity of care contributes to quality of care we ought to consider what aspects are important and how we might measure them.

Measurement is not to reduce it to irrelevant components, but to allow research into whether continuity contributes to the quality of medical care and which elements of continuity contribute most.

There is increasing literature on this subject and a good summary is the Kings Fund report “Continuity of Care and the Patient Experience” by Professor George Freeman and Jane Hughes.

It is that proactive follow up of the presenting and incidental problems. Does that doctor actively cover all the issues, produce adequate records, note follow up arrangements, check any blood results and see through any planned actions.

On a very simplistic basis we could just consider:

Number of times seen for the same problem
Divided by
Number of times seen by the same general practitioner for that problem

A score of two or more might be better

A score of less than one might indicate a need to look at examples and if a change in approach is needed

Examples include the Usual Provider of Care index UPC (most frequent seen person) and the St Leonards Index of Continuity of Care SLICC (frequency named person seen).

This is an area of development and the proposals here are to encourage debate rather than as a definitive answer.

Continuity of Care – Being a Person

Personalised
Education
Responsive
Sympathetic
Overseeing
Networking

As a PERSON working in healthcare we should aim to provide Personalised Education, and be Responsive and Sympathetic whilst Overseeing and Networking for the patient.

Personalised

Personalised means tailored to the individual rather than handle every problem exactly the same way. What will work best for that person.

Education

Education is providing information about their illness and how to handle it so that they look after their problems better.

Responsive

Responsive indicates that you address the issues that arise in a Sympathetic way. You have empathy for that person and cover all their questions.

Overseeing

Overseeing and Networking is a crucial role. Rather just dealing with todays problem you are ensuring the whole episode of illness is handled smoothly by all people involved. You are a back stop if things go in the wrong direction and you refer and Network with the necessary people to keep things moving forward

Case example – being a PERSON

Its Monday morning and I am listening, again, to a catalogue of problems during my patients admission to hospital. From dirty floors, unfed patients to missed drugs and misunderstood instructions. Each, on their own, understandable and forgiveable, but as a whole dangerous and very frustrating. Potential Adverse Events. Each occuring as a result of care by multiple, well meaning healthcare workers focused on their immediate tasks, but missing the whole picture.

Care in the NHS can be fragmented, leading to failures in healthcare. What a healthcare system needs at its core is continuity. Technology, consumerism and a target driven culture have pushed aside continuity like an old friend left out in the cold by those busy in the midst of a party.

And the same pressures affect primary care. The drive to have immediate access is laudable, but results in additional steps that act as filters and unseen barriers. Triage nurses, duty doctors, urgent appointments with any doctor, conspire against seeing the same person over time.

Over the years the usual doctor gets a picture of their patient. An understanding of their preferred approach, their past life and medical problems and patterns in illness, which give early access to diagnosis and successful treatment. Mrs Antibe with her multiple aches whose arthritis has changed and now has the same polymyalgic symptoms as 5yrs ago. Mr Bellows whose rash has recurred which responds to anti depressants so well and is triggered by marital pressures at home. Simon whose concern about his normal epididymus is heightened by his father’s lymphoma.

All these are short cuts to diagnosis and treatment which an experienced doctor, familiar with their patient, can take, with due care and awareness. All these are scenarios, which could lead to over investigation, wasted resource and delayed treatment.

This is not to say GPs and healthcare workers need to return to the 120hr weeks and the day and night on call. Rather it is to say that the system should encourage continuity over time. Encourage responsibility for one person to oversee care and tie up loose ends. To act as an advocate on behalf of the patient as they negotiate the healthcare system.

All cases are aggregated and names fictional.

Summary

General Practitioners need to provide Individualised Continuity of Care and act as Advocates for their patients. ICCA. The Healthcare system should encourage these elements alongside the use of practical relevant clinical targets.

Continuity exists in two main forms. Frontstage, which is face to face with the same person, and backstage, which is the medical records and access to results. In practice face to face involves a team, but it requires a co-ordinator who knows the patient over time. Backstage continuity requires a commitment by all the team to provide full and up to date records of every consultation underpinned by an IT system that integrates care and records.

A patient within the hospital setting also requires a PERSON to help them navigate the different elements of the NHS. That PERSON provides Personalised Education, is Responsive and Sympathetic whilst Overseeing and Networking for the patient. Personalised means considering an individuals medical and social history, educating them about the system and their own illness. Responsive and sympathetic is about being aware of the patients current issues and addressing these. Overseeing and Networking relates to ensuring all healthcare comes together as part of a whole. Seeing where the gaps in care are occurring, linking with the key people to co-ordinate care and link between different parts of the healthcare system.

GPs often act as a PERSON alongside a patient over many years. Stepping in and out of the role as needed. However a GP is separated from that episode of care in a hospital so a PERSON is also needed during a period of hospital care. This can be any healthcare worker but preferable someone with healthcare experience and already involved in part of a patients care such as a nurse or doctor. Someone who oversees care as a whole.

In conclusion, think about acting as an ICCA or PERSON for your patients.

As an ICCA try to give Individualised Continuity of Care and be an Advocate for your patients over the years.

For each episode of illness consider if you or someone else is best placed to act as a PERSON. Providing that Personalised Education, being Responsive and Sympathetic and also Overseeing and Networking on behalf of that patient.

Continuity of Care Webinar Tips

Why increase continuity
How to increase continuity
Checking continuity has increased

Checking continuity has increased

The Health foundation two year Continuity Programme which started in 2019, is supported by the Royal College of General Practitioners. There are five sites in the UK that are looking at ways to introduce greater continuity of care for their patients. This covers half a million people.

Can continuity be increased?

The emerging answer is: Yes continuity of care can be increased alongside access, and this is in the real life setting of a busy NHS. Continuity of Healthcare Counts.

Why increase continuity

See the webinar number one with Professor Sir Denis Peira-Gray from St Leonards GP Practice in Exeter
https://www.rcgp.org.uk/clinical-and-research/our-programmes/innovation/continuity-of-care/continuity-of-care-resources.aspx

Continuity of care saves lives, reduces illness, saves time and saves resources. The weight of qualitative evidence and the evidence for the association of continuity of care with improved health is strongly positive and outweighs any disadvantages.

How to increase continuity

See the webinar number two with Jo Knight from South Cumbria.
https://www.rcgp.org.uk/clinical-and-research/our-programmes/innovation/continuity-of-care/continuity-of-care-resources.aspx

Practical interventions have been shown to increase continuity whilst maintaining access. An enhanced toolkit is being developed. Messages include tailor your approach to your GP practice, and collect feedback on how you are doing.

Checking continuity has increased

See the webinar number three with Professor Phil Evans from St Leonards GP Practice in Exeter.
https://www.rcgp.org.uk/clinical-and-research/our-programmes/innovation/continuity-of-care/continuity-of-care-resources.aspx

Dashboards are being developed that GP practices can use to look at continuity. These can let a practice monitor patients who circulate around different doctors and are at risk. The dashboard also gives feedback on how much continuity is provided and how it compares to other practices. The Usual Provider of Care index (most frequent seen person) and a modified St Leonards Index of Continuity of Care (frequency named person seen) are provided.