Continuity of Care
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Continuity of care is one of those things we always talk about as being an important aspect of good patient care, and yet we seem to be moving farther away from it than ever as other priorities get in the way.
There are a lot of little nuances of a specific patient’s care that are known only to his/her primary care physician that are impossible to convey with any great detail to a covering physician. There are pertinent tests that have been done within the past year. There are certain complaints or problems that the patient and doctor have worked through already. There are little idiosyncrasies about each patient, knowledge of family relationships, unusual responses to particular medications, certain concerns that the physician may have had from time to time that may play a role in how a patient is treated. Not knowing some of these things may result in recurrent, duplicate testing, increasing lengths of stay during hospital care, or, even worse, may cause poor decisions to be made in patient care by those who are less familiar with the patient.
Loss of Continuity
Before the turn of the century, most primary care doctors followed their own patients in the hospital when they became ill enough to be admitted. Patients liked this; and there was good continuity of care since the doctor who knew the patient the best was the one taking care of him/her.
During and after that time however, the hospitalist movement swept over the country and essentially ended all that. Now when patients enter the hospital, they usually have a different doctor, whom they don’t know at all, talking to them about life threatening situations. The primary care physician whom the patient has come to trust over the years is nowhere to be found. The hospitalist must be able to overcome that barrier and win the patient’s confidence and trust in a very short period of time. Sometimes that works and sometimes it doesn’t.
The reasons why this occurred are mostly a matter of economics, convenience, need for a better lifestyle for overworked primary care physicians, lots of new hospitalists hungry for business, and somewhat because of growing discomfort among many PCPs of taking care of hospitalized patients who were becoming increasingly complicated and more difficult to care for. The latter reason is partly because hospital treatment regimens were becoming more complex and more difficult for doctors who were only occasional prescribers of these treatments, and because the level of acuity of hospitalized patients had gone up drastically over the past 10-20 years, mostly because insurance companies wouldn’t pay for patients with lesser illnesses to be hospitalized. The economics of the situation were such that there was no incentive for primary care doctors to spend an hour or more a day going to the hospital to see one patient for a Medicare payment of maybe $30. when he or she could spend that same hour in the office seeing four patients and collecting four times that amount. As a primary care doctor, when your reimbursement is limited by insurance and government regulations, and you have to see a certain large number of patients per day to just pay your overhead, you can’t afford the luxury of going to the hospital to see that one patient.
So, as a result of all the above, continuity of care lost out to more pressing priorities. I doubt if we can ever go back to the time when most doctors saw their own patients in the hospital, although some still do - sometimes because they enjoy hospital work and don’t want to stop and sometimes because they place a premium emphasis on continuity as an essential part of good patient care.
Another example of the loss of continuity of care include physician groups who rotate daily hospital rounding. In this case the patient sees a different doctor every day. This makes patient care very difficult for a number of reasons. The doctor never has the benefit of really getting a sense of what the patient looked like the day before. So it’s hard to tell if the person is better or worse or unchanged. You have to rely on what the patient tells you or what the nurse tells you. However, these days information from the nurse about what the patient looked like yesterday is nonexistent because the nurses also rotate, so that it’s rare for one nurse to have the same patient two days in a row. There’s absolutely no continuity of care in this situation. Sometimes in certain specialties, this may seem like the most efficient way to manage the workflow; however, it is always at the expense of continuity. Hopefully in those situations the loss of continuity of care by the specialists can be offset by good continuity from the the primary care physicians.
The details of the “handoffs” of patients from one physician to another are important in maintaining a least a semblence of continuity. The more detail the better, though this often leads to long checkouts which uses up precious time in a busy day. Still, it’s important to be as thorough as you can in your description of each patient.
The communication between hospitalists and outpatient primary care physicians is also critical to make sure important details needed for good follow-up are not lost. Sometimes these details make a big difference in helping to prevent problems after discharge and in preventing re-admissions which often can be correlated with poor transition of care and follow-up from the inpatient to the outpatient setting.
Even though we may never get back to continuity of care as it once was, I think we should always be mindful of it, try never to forget about it and always try to find ways to improve it as much as possible. Avoid the rotating rounds if at all feasible. Find ways to make patient “handoffs” and signouts detailed and efficient. Follow your patients in the hospital if only to make “social” rounds, or perhaps even by calling your patient on the phone while s/he’s there to let them know you’re concerned. Share any information you have with the attending physician that may clarify the patient’s diagnosis or treatment. Ask that s/he give you an update at least at the time of admission and at discharge if not in between.
We know continuity of care is important. We talk about how important it is all the time. Ideally, it really should be incorporated into our practices as much as possible. Patient care would definitely improve as a result.
This page was last updated on August 16, 2015.
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