Background
Continuity of care
Soft systems methodology
Circle of care: the patient’s healthcare system
Methods
Participants and recruitment
Data collection: interviews
Interview topic | Description/example questions |
---|---|
Participant Information | • What is your Profession or role in supporting end of life care? |
• How many years have you been in practice? | |
• Gender: M/F | |
• Please briefly describe your practice? | |
Persona Information |
Interviewer provides information about the patient case and then about each of the specific scenarios. This repeats for each of the two cases, with questions below being asked for each scenario.
|
Scenario Questions (For each scenario of each persona) | • Who would have engaged you in this patient’s care (e.g. another provider, patient themselves)? |
• How would they have communicated to you the need for your involvement? | |
• Where would you gather information about this patient (e.g. do you have a referral letter, chart, patient themselves)? | |
• What information do you often need that is missing for patients like this? | |
• Would you access information from another electronic record/electronic system? | |
• From your experience, who else would be engaged in < PERSONA NAME > 's care at this point? (Please describe the various provider roles you would expect to be involved) | |
Communication Questions | The questions below would be asked or each role described involved in the patients care above: |
• What role are they playing in the care of our patient at this point? | |
• How do you communicate with this provider? | |
• (Describe what you communicate) | |
• When does this happen? | |
• How do they communicate with you? | |
• (Describe what they communicate) | |
• Which methods of communication are most important to you to ensure Continuity of Care? | |
• If you do not communicate directly with this provider, should you? | |
○ If yes, please tell me why it would be important? | |
○ If No, please tell me why would it not be important? | |
• How can you improve Continuity of Care with this provider? | |
• How could the provider improve Continuity of Care with you? |
Debates/discussion groups
Data analysis
Results
Participants
Study interview summary data | |
---|---|
Number of Providers Interviewed | 32 |
Physician Participants | 13 |
Nurse Participants | 16 |
Pharmacist Participants | 3 |
Number of Clinical Roles | 39 |
Male Participants | 10 |
Female Participants | 22 |
Average Years Experience in Practice | 23.0 |
Average Years Experience in Community | 14.7 |
Information continuity
“Sometimes you get the lab and diagnostics [from the ER] and sometimes you have to go and track them down… I obviously prefer to get the information.” (V01)
“The difficulty is that if a person has [private] outpatient labs done, then the outpatient labs do not show up in the [public health authority].” (V06)
“If we had access to all the written information through one [system]… it would be beneficial for our clientele.” (D07)“There are gaps across the continuum about how those systems and how that information is going to follow a client or patient as they go from home to acute care and back home or to residential care.” (IMIT01)
“The secretary has to phone medical records at the cancer clinic-which she does, multiple time every day… and then you have to wait.” (V07)
Management continuity
“I don’t know how many times I have to make plans for people, first time I meet them. That frustrates me. I point out to the patients-why isn’t there a plan? Why are you directing traffic yourself?” (V13)
“There is a lot of overlap. You write plans in a lot of different places…and then you go back to the office and dictate a letter.” (V07)
Relationship continuity
“Once they are in hospice…I will go in periodically and see the patient, that’s more for morale support and leave the ordering to the hospice physician”; (V01)“I try to stay involved…I don’t want them to feel abandoned.”; and “I often just like to drop in to say hello. I’ve been involved throughout.” (V02)
“The patient is the loser. The person who really should be there is not there and this is part of this continuity issue. There is nobody in charge anymore.” (V13)
Provider connectedness
“There is the more social aspect of the continuity of care… speaking as a community family doc, in terms of cohesiveness… cohesiveness of the medical community.” (V03)
“I try to have a good relationship with them [the ER Physicians]… when I go to the hospital, I always go through Emergency…I just say hello to all the guys there, because when I call them, I know who they are. Most of them will call me back.” (V11)“I’ll just drop by [the GP’s office]…so that he knows me… You want the GP to know at least who you are. Understand that I’m not the home support worker.” (D09)
“We don’t know each other and so it becomes very impersonal. With this kind of work, there has to be a really high level of trust between professionals and it’s much harder to trust someone you don’t know than somebody you do know.” (V06)
Communication patterns related to continuity of care
Communication patterns | Description | Examples |
---|---|---|
Communicate with Patient/Family | Communicating with the patient to examine the patient’s condition, share information, educate, and to develop a common understanding or plan. | • Patient visits with family physician. |
• Home and Community Care nurse home visit with patient and family. | ||
• Phone conversation from patient’s daughter with the on call family physician. | ||
• Medication reconciliation by a pharmacist or nurse. | ||
Request Historical Information (PMHx)1
| • Seeking additional information from a particular provider, care team, or organization. | • Specialist requests previous blood work from family physician. |
• Hospice requests previous consult letters from Cancer Centre. | ||
Provide Information | Ensuring other providers are aware of current findings and plans by sending information directly to named members of the Circle of Care. | • Follow up letter to family physician from Oncologist on change in chemotherapy. |
• ER Physician note to GP after patient is seen in the Emergency. | ||
• Home and Community Care Case Manager fax to the family physician to describe care plan. | ||
Document in Shared Record(s) | Documenting findings/plans in a location that is accessible to others (who have access). | • Neurologist documenting in hospital chart. |
• Family physician documenting in Mr. Hart’s long-term care paper chart. | ||
• Laboratory placing a result into Hospital Information System. | ||
Review Shared Record | Review information shared by other members of the Circle of Care to increase knowledge of patient’s condition. | • Family physician reviews long-term care paper record when rounding on patients. |
• ER Physician reviews hospital information system prior to seeing patient in the ER. | ||
• Oncologist reviews cancer records (electronic and paper) prior to follow up visit. | ||
• Pharmacist reviews medication-dispensing history. | ||
Request Advice | Request information and advice about options related to a patient case. | • Call to palliative care hotline to discuss medication options and conversion doses. |
• Call to see what services might be available for particular type of patient. | ||
• Discuss with radiologist what test is most appropriate for assessing symptom in a patient without disclosing patient name. | ||
Request Assessment/Treatment | Contact another provider to request an action to assess and/or provide treatment recommendations to a patient based on their assessment. | • Family physician consults geriatrics for patient in nursing home to assess behavioural issues. |
• Home and Community Care nurse sends referral to physiotherapy and occupational therapist to assess home safety. | ||
• ER Physician calls neurology to assess stroke patient. | ||
Order | Request specific activity be delegated to / performed by another provider | • Medication prescription from MD to pharmacist. |
• Home and Community Care nurse delegated medication administration to Community Support Worker. | ||
• Advance directive from patient. | ||
Transfer Care | Handing off care responsibilities between care providers of a similar capability. | • Nurse handover at shift change. |
• Family physician to family physician transfer when on call. | ||
• ER physician transfer to family physician admission in hospital once patient is stabilized. | ||
Coordinate as Care Team (i.e. all or part of the Circle of Care) | To review, in real time with more than two individuals, the status and plans for the patient from multiple viewpoints. | • Long-term care case conference. |
• Breast cancer Oncology Rounds. | ||
• Palliative Care Rounds. | ||
• Ad hoc meetings between family physician, Home and Community Care nurse and family to discuss patient care or patient prognosis. |