Continuity in new models of care

Dear Colleagues,

This month marks the 60th anniversary of our College and the 20th anniversary of the Research and Education Foundation. It is interesting to think of a core group of family doctors meeting at the Palomar Supper Club in Vancouver, BC, on June 17, 1954, and deciding to create a professional home for GPs and FPs that would support better training, maintenance of competence, and high standards of practice.

Fast forward 60 years. We have the CanMEDS and CanMEDS–Family Medicine roles (a CanMEDS update will be released in 2015), and the Patient’s Medical Home. A colleague asked me recently what happened to the 4 principles, and whether they had been forgotten or engulfed in the other models. I was pleased to tell him that the 4 principles of family medicine are foundational, and continue to guide what we do as an organization. The 4 principles were initially conceptualized in the mid-1980s. The need to create them evolved from debates among passionate College members taking place at the curriculum committee level. Questions for discussion related to continuity of care, scopes of practice, and how much of residency should take place in family practice settings (personal communication with Dr Paul Rainsberry, former Director of Academic Family Medicine, 2014). Not very different from some of our current debates, really.

Continuity of care remains an important element defining our profession. Brown and colleagues identified 4 main factors influencing long-term attendance at a family practice teaching unit.¹ The first is the relationship context, which refers to the importance for patients of being known as persons; of sharing with their FPs meaningful life experiences such as birth, death, and critical health events; and of being aware of their doctors going the extra mile in caring for them. Relationships with members of the health care team, particularly receptionists and family practice nurses, were also considered important. The second factor is the team concept. Many participants understood the concept of a global relationship with the team, including the contribution of residents to their care, and that this provided an opportunity for “new ideas, up-to-date information, and thorough care.”¹ The third factor is professional responsibility and attitudes. Openness, honesty, and acknowledging uncertainty are considered key elements of this factor. The final factor is comprehensive and convenient care. The availability of 24-hour care, being able to connect with someone from the practice, and continuity across various settings are considered important elements of this factor.

How is continuity redefined in new models of care and practice? Important elements of the Patient’s Medical Home include the effective engagement of teams and improved continuity of care. There is specific evidence for the importance of involvement of team members who are not physicians in improving control in some chronic illnesses such as hypertension and diabetes.² Studies of teams reiterate the importance that patients place on having personal relationships with their FPs; that these relationships are most important for those experiencing chronic illnesses, the elderly, and the very young; that it is difficult to have a meaningful relationship with a group of providers (within a team or not); and that patients‘ opinions of care by members of the team are favourable if they get to know the members well, understand how these providers fit within the team, and sense good communication and coordination with their main providers.^2,3

So, yes, it is possible to have good experiences with continuity in new models of care. But we need to work at it, in terms of understanding the role of other providers and how they fit in; by having “morning huddles” as well as other, more formal opportunities to review care plans together; and by engaging ourselves and our patients in this process, which includes going the extra mile to connect with them—even if appointments have not been booked—if we are aware of meaningful events affecting them. This is not always easy to do in a busy practice, and yet it is so important to convey a sense of caring.

What about you? Do you have tips for certain gestures or strategies that you and your team have implemented that support continuity? Please send your comments to executive{at}cfpc.ca or comment on this article by visiting it at www.cfp.ca and clicking on Rapid Responses.

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