Background
The lack of integration of health services is considered to be one of the key causes of poor quality of care [
1,
2]. Fragmented care, or care that is insufficiently coordinated between providers, might be harmful to patients due to the duplication of diagnostic tests, inappropriate poly-pharmacy and conflicting care plans [
1]. Especially patients suffering from multi-morbidities and chronic conditions tend to receive care from several professionals of different disciplines in various settings and institutions, thus meeting their healthcare needs through seamless care over extended periods of time is particularly challenging [
3,
4].
The analysis of integrated care should take into account intermediate outcomes (access to healthcare, care coordination and continuity of care) and final outcomes (equity of access, efficiency and quality of care), as well as the factors influencing it, from different perspectives, including those of the key actors [
5]. Analysing continuity of care from the patient’s perspective endows one main benefit: they can provide a global picture of the care provided since they experience services along the continuum of care [
6] and first-hand from multiple providers [
7]; hence seeking patients’ perceptions and experiences provides an excellent opportunity to better understand this phenomenon [
8,
9].
The concept of continuity of care has been garnering more attention in recent years in line with the publication of several meta-syntheses that aim to improve the conceptual framework [
10-
14] and clarify the conceptual boundaries of related terms, such as care coordination or integration [
15]. Although conceptual discussions are ongoing, an increasing number of qualitative and quantitative studies, for example those of Cowie et al. [
16], Aller et al. [
17,
18] or Uijen et al. [
19], have adopted Reid et al.’s framework [
4,
9]. They define continuity of care as one patient experiencing care over time as connected and coherent with his or her health needs and personal circumstances [
20]. In other words, continuity of care can be understood as the result of care coordination as experienced by an individual patient [
20]. Their model classifies continuity according to three types [
4,
9]:
continuity of clinical management, which is the patient’s perception that they receive the different services in a coherent way that is responsive to their changing needs;
continuity of information, which is the patient’s perception that information on past events and personal circumstances is shared and used by the different providers; and
relational continuity, which is the patient’s perception of an ongoing therapeutic relationship of the patient with one or more providers. Continuity of clinical management and continuity of information can be analysed across levels of care (primary and secondary care interface) and will thus be the focus of this article.
Recent literature reviews [
6,
12] confirm that a number of qualitative studies have analysed patients’ experiences and perceptions of continuity of care. These studies, mainly conducted in the NHS of the United Kingdom and Canada [
6,
12], concentrated on relational continuity, whereas continuity of clinical management and information were studied only in a limited way [
12]. Furthermore, most studies focused on chronic conditions, especially diabetes [
6,
12], cancer [
6], and mental health problems [
6,
12]. Therefore, perceptions of patients with acute health problems or different conditions receiving care from both care levels have been analysed to a lesser extend, which would allow for identifying context-specific shortcomings concerning smooth transitions.
The analysis of the association between the perception of continuity of care and factors which could influence (i.e., facilitate or hinder) continuity of clinical management and continuity of information from the patients’ perspective focused on individual factors using quantitative methods. Results suggested differences related to age and educational level – the elderly population is more likely to perceive higher levels of continuity of clinical management and information [
7,
18,
21], whilst higher education was significantly associated with lower ratings [
21] – but the influence of socioeconomic level, health status or sex on the continuity types is inconclusive [
7,
18,
21]. The analysis of factors related to health services organizations and health professionals was targeted in two quantitative studies; one conducted in Catalonia, Spain [
17] and the other in Quebec, Canada [
22]. Results showed that healthcare areas (which differed in the management model of primary and secondary care) [
17] and operational agreements with other healthcare establishments (mostly shared-care protocols and mechanisms for facilitated referrals and information sharing) were associated with all three continuity types [
17,
22]. In qualitative research, influencing factors predominantly emerged as a by-product of the study results, i.e., their identification was not the study objective, with a few exceptions [
11,
13,
23,
24], or seemed to be entangled with the elements that defined continuity. Moreover, it is not clear to what extent the factors were actually mentioned by patients or whether they were inferred in the interpretation of the researchers.
Scant evidence exists on the possible consequences or outcomes of (dis)continuity of care [
11]. According to a meta-analysis, the association of continuity of clinical management and information with reduced health services utilization (including hospitalization and emergency visits) and patient satisfaction is uncertain [
25]. Qualitative research suggests that coordination breakdowns lead in particular to the transfer of responsibilities to patients, for example, the patients having to act as a mechanism of coordination to maintain the continuity of clinical information [
24] (“patients as the information broker” [
23]) and keep all agencies abreast of changes [
26]. From the professionals’ point of view, this could produce significant medical errors [
27]. Thus, although continuity of care is already purported to be a critical feature of high quality services, more documentation is needed to better explain the relationship between continuity and its potential outcomes [
28].
Achieving integrated care has also become a priority of the Spanish NHS, which is financed by taxes and decentralized into regional health services. At the time of the study, it offered universal coverage and free access at point of delivery [
29]. Healthcare provision is organized into levels of complexity: primary care is the gatekeeper and is responsible for coordinating the patient’s care along the care continuum [
30] and secondary or specialist care acts as a consultant for primary care and is responsible for more complex care [
29,
31]. In the autonomous community of Catalonia, the healthcare system is characterised by a split of the financing and provision functions. The provision of services is the responsibility of a number of contracted providers; mainly the Catalan Health Institute (
Institut Català de la Salut), but also consortia, municipal foundations and private foundations (largely non-profit but also for profit), which make up the Integrated Healthcare System for Public Use (
Sistema sanitari integral d’utilització pública de Catalunya) [
32]. This diversity of providers has originated various management models for the joint management of primary and secondary care, such as integrated healthcare networks [
33]. In Catalonia, empirical evidence on the three continuity types is scant, except for a population survey using the CCAENA© questionnaire [
17,
18] and a qualitative multiple case study with COPD patients attended to at different integrated healthcare networks [
34]. Other surveys of the Catalan NHS – the CatSalut Satisfaction Survey Plan (PLAENSA©) [
35] and the Health Survey of Barcelona [
36] – seek the citizens’ perception in terms of quality and satisfaction and thus include only specific items related to continuity of care, for instance information transfer across levels or waiting times for a secondary care visit. Results suggest that transitions between primary and secondary care were mostly reported by patients to be connected and consistent; however some noteworthy elements of discontinuity were identified, for example long waiting times for secondary care after a referral [
17,
34] or gaps in the information transfer across levels [
17]. The need for an in-depth analysis to explore the rationales that could explain these results and thus to understand the full complexity of the phenomenon has been postulated [
17].
The aim of this study is to analyse perceptions of continuity of clinical management and information across care levels and the factors influencing it, from the viewpoint of users of the Catalan NHS. This article forms part of a wider study that analyses the relationship between coordination and continuity across care levels by seeking the health care services’ [
37] and users’ perspectives (here presented).
Acknowledgements
The authors wish to thank all informants for their thoughtful and open participation in the study. Furthermore, we gratefully acknowledge the kind collaboration and support of the staff of participating organizations (Isabel Serra, Josep Maria Lisbona, Maria Escartín Vas, Elena Martínez Prats). We highly appreciate the contributions of the following individuals who form part of the GAIA group (Grup d’Avaluació de la Integració Assistencial): Sebastià Calero (Instituto Catalán de la Salud), Francesc Cots (Parc de Salut Mar), Mercè Abizanda (PAMEM) and Lluís Colomés (Grupo SAGESSA). This article was produced within the framework of the Doctorate in Paediatrics, Obstetrics and Gynaecology, Preventive Medicine and Public Health of the Universitat Autònoma de Barcelona.