Research ArticleResearch

Toward a universal definition of provider-patient attachment in primary care

Monica Aggarwal and Richard H. Glazier
Canadian Family Physician October 2024; 70 (10) 634-641; DOI: https://doi.org/10.46747/cfp.7010634

Abstract

Objective To explore definitions of provider-patient attachment in primary care (PC) and help inform a universal definition of provider-patient attachment.

Data sources Comprehensive searches were conducted using the electronic databases MEDLINE (Ovid), PubMed, CINAHL (EBSCO), PsycInfo (Ovid), Social Sciences Abstracts (EBSCO), Cochrane Library, Scopus, Embase (Ovid), Google Scholar, and ResearchGate.

Study selection A scoping review was conducted. Articles focusing on PC setting, provider-patient attachment, and attachment approaches (enrolment, rostering, registration, empanelment) were included. All articles were from English-language publications and were available in full text in or after 2005. Of the 5955 unique titles, 97 peer-reviewed articles and 45 gray literature sources were included.

Synthesis The term attachment is sometimes used interchangeably with enrolment and empanelment. Provider-patient attachment is a confirmed affiliation between a patient and a regular primary care provider (PCP). This affiliation can be formal or informal. The goals are to deliver longitudinal care and establish a therapeutic relationship (relational continuity). Enrolment and empanelment are mechanisms that enable the affiliation of a patient with a PCP. Enrolment is a formal process of provider-patient affiliation, while empanelment is the assignment of a patient to a PCP.

Conclusion A universal definition of provider-patient attachment is provided: the confirmed and documented affiliation between a patient and a regular PCP (a clinician, ie, a family physician or nurse practitioner, etc), or a combination of clinician and care team or practice in which the PCP is responsible for providing longitudinal and continuous care to the patient via any delivery channel (ie, in person, remotely, or both), enabled by provider access to patient health information.

The continuous, longitudinal relationship between regular primary care providers (PCPs) and their patients is a key attribute of high-performing primary care (PC) systems.1,2 Patients with a regular family physician receive more preventive services and chronic disease management3-5; having a regular family physician reduces the use of walk-in clinics and emergency departments (EDs), decreases hospitalizations, and facilitates more cost-effective care.6-11 Continuity of care is associated with higher patient and clinician satisfaction and cost reductions.12-17 Globally, countries are facing a PC work force crisis,18,19 resulting in challenges with access to PC from PCPs.20-22 During the COVID-19 pandemic, virtual care became crucial for accessing care.23 Virtual care can improve patients’ access and attachment to PCPs, particularly in rural and underserved areas.24-27 However, virtual care through walk-in clinics can also worsen the problems of people seeking one-off, unconnected care,24,28-31 thereby reducing longitudinal and continuous care.24-27 In this context, virtual care has long-term implications for provider-patient attachment.32,33 The definition of attachment varies in the literature, introducing a substantial challenge to strengthening efforts to improve provider-patient attachment. The main purpose of this study is to explore the definition of provider-patient attachment to help inform a universal definition of attachment. Given the diverse range of literature on provider-patient attachment and the lack of a universally accepted definition, a scoping review offers a systematic approach with which to comprehensively map the existing literature, identify key concepts, and synthesize diverse perspectives, thus informing the development of a universal definition of attachment within the PC context.

METHODS

We followed the 5-stage methodology for scoping reviews by Arskey and O’Malley34 and Levac et al.35 The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines36 to enhance reporting quality (Appendix 1, available from CFPlus*). The review was conducted for articles published between January 1, 2005, and June 28, 2022.

Stage 1: identifying the research question

This review aims to explore definitions of attachment to inform a universal definition of provider-patient attachment. The research question is “What are the definitions of provider-patient attachment in the context of primary care?” We define primary care as “broadly [covering] the spectrum of first-contact health care models that focus on comprehensive, person-centered care sustained over time along with [primary care] initiatives that incorporate health promotion, community development, and addressing the social determinants of health.”37

Stage 2: identifying relevant studies

Peer-reviewed and gray literature was identified using a search strategy created and run by an information specialist and health sciences librarian. The search strategy was created and finalized in MEDLINE (Ovid) and translated to PubMed, CINAHL (EBSCO), PsycInfo (Ovid), Social Sciences Abstracts (EBSCO), Cochrane Library, Scopus, and Embase (Ovid) on June 28, 2022. Gray literature was searched in Google Scholar and ResearchGate (first 200 pages) using the same key words to identify relevant publications or reports.38

Stage 3: study selection

Search results were entered into the EndNote referencing system, de-duplicated,39 and inputted into the Covidence systematic review tool.40,41 Title and abstract screening was conducted by 2 research assistants (RAs) under the supervision of the primary investigator (PI) (M.A.). The RAs and the PI did the full-text review. All articles were screened in duplicate at both stages. The PI conducted a hand search to ensure comprehensiveness.

To be included in the review, articles were required to meet the following criteria: focus on PC settings, provider-patient attachment, and approaches to attachment (ie, enrolment, rostering, registration, empanelment); publication in English in or after 2005; and availability in full text. Articles were excluded if they were protocols, dissertations, or videos; or focused on non-PC settings. During the screening, conflicts were resolved through team discussions during meetings, with the PI having the final vote.

Stage 4: charting the data

Data were extracted to identify definitions of provider-patient attachment and study results using an extraction form that an RA and the PI pilot-tested on 3 articles.35,42

Stage 5: collating, summarizing, and reporting

To describe the extent, range, and nature of literature, numerical summaries and tables were prepared.35,42 A thematic analysis of the charted data was conducted to explore the heterogeneity across studies to determine the core elements of the definition of provider-patient attachment and the approaches to attachment in PC.43,44 The PI and an RA conducted a line-by-line coding analysis on the abstracted data and noted similarities and differences between the data across studies through team meetings.45

RESULTS

Of the 5955 unique titles, 97 peer-reviewed articles and 45 gray literature sources were included. Most studies were conducted in North America (n=117/142, 82%). Table 1 (available from CFPlus*) shows the characteristics of included studies. Appendix 1 includes the supporting references for all key themes.*

Overview of findings

Attachment in the context of PC refers to the confirmed affiliation between a provider and a patient, characterized by the mutual agreement to engage in longitudinal care and establish a therapeutic relationship across the care trajectory. This definition encapsulates the key concepts identified through the synthesis of explicit and implicit definitions of attachment and aligns with the overarching goals of provider-patient attachment within PC settings. The scoping review identified 12 explicit definitions of attachment6,7,29,46-54 and 4 implicit definitions of provider-patient attachment.10,11,55,56 The term attachment is sometimes used interchangeably with enrolment (also known as registration,57,58 rostering, and empanelment51). Enrolment and empanelment are also sometimes used interchangeably. Explicit definitions of attachment indicate it consists of 6 elements in which 4 key concepts are most frequently identified (Table 2).6,7,29,46-53 The first key concept of attachment is that a patient has an affiliation with a regular PCP.6,7,29,46,47,50,51 This affiliation represents a commitment between the patient and the PCP to engage in ongoing, longitudinal care.29,46 Patients with a regular PCP benefit from continuity and consistency in health care delivery.46,54 The definitions of attachment are also tied to the goals of affiliation and include the delivery of longitudinal care7,29,47,49,50,52 (the second key concept) and the establishment of a long-term therapeutic relationship (relational continuity) between provider and patient (the third key concept).7,47-52 Attachment to a regular PCP is closely linked to the delivery of longitudinal care, which involves the patient’s repeated interactions with the provider over an extended period.7,29,47,49,50,52 Relational continuity refers to the ongoing and consistent therapeutic relationship between patient and provider over time.7 The fourth concept is tied to the notion that the affiliation is “confirmed.”7,48,49,50,51,53 This affiliation can be formal49,51-53 or informal.51,52 Formal confirmation might involve official registration or enrolment processes, where patient and provider explicitly agree to the formal relationship.58 Informal confirmation, on the other hand, might involve a mutual understanding or verbal agreement between the patient and the provider regarding their ongoing care relationship.58 In explicit and implicit definitions of attachment, most definitions identify the FP or GP as the regular PC provider.6,7,46

View this table:
Table 2.

Key elements of attachment definition

Definition of enrolment. Fifteen explicit definitions were reviewed for enrolment (or registration).1,52,54,57-68 Enrolment is a formal process during which a patient and provider enter into a reciprocal agreement whereby the provider agrees to be a patient’s regular provider, and the patient agrees to receive care exclusively from the provider.

In many jurisdictions, a physician or group must enroll patients to receive capitation-based payments.52,54,58,65,67,69 The PCP can be the FP or GP1,70 or the practice.62,71 Generally, the affiliation between patient and provider occurs through the mutual completion of an agreement developed by the government or payers and facilitates accountability.58 The confirmed affiliation can be recorded in information systems.54,57,65 The shift to patient enrolment in capitation-based models has improved coordination of care for older, chronically ill patients with multiple conditions; increased continuity of care; and facilitated cost savings.72-76 Fee-for-service group practices decreased provider-level continuity and coordination of specialist care and had little impact on reducing ED visits.66

Definition of empanelment. Twenty-three explicit definitions of empanelment were reviewed.2,77-98 Empanelment is the deliberate process of assigning78 or linking2,96 a patient to a provider. It assumes the provider will accept responsibility for the patient.81 It has 3 goals: longitudinal care,2 relational continuity,2 and population health management.90,94 Empanelment does not require formal agreements; the affiliation can be informally confirmed and optionally recorded in information systems.95 Much of the literature on empanelment focuses on the Patient’s Medical Home vision, in which a care team assumes responsibility for PC services. Panels can be assigned to an FP,99 a physician assistant,87 a nurse practitioner,81 a midwife,100,101 or the care team.90 Attachment is more common between the patient and the most responsible FP or GP and a care team of interprofessional providers. Informational continuity is important for supporting the team because information systems enable each provider to access the patient’s health information.92 Patients can be prospectively assigned to a PCP based on patient choice or be retroactively assigned to providers. There is considerable literature on panel sizes, approaches, and algorithms for assigning patients. In fee-for-service models, a patient is not formally tied to a PCP,86 which dilutes the power of linking payment to provider-patient affiliation and accurately assigning patients to providers.

A few studies show that patient empanelment using the Patient’s Medical Home vision positively affected continuity and quality of care81,102 and reduced rates of ED use.102

DISCUSSION

The increased prevalence of virtual care by not-for-profit and for-profit organizations, especially during the COVID-19 pandemic, raised important questions about how provider-patient attachment is defined. Without a clear definition of provider-patient attachment, PC reform policies might not adequately address the evolving needs and expectations of patients and providers in an increasingly digital health care environment. A universal definition of attachment is essential for developing future PC reform policies in the context of virtual care. This synthesis suggests the definition of provider-patient attachment consists of 4 key concepts. It is the confirmed affiliation between a provider and a patient. This affiliation can be formal or informal, but the goal is to deliver longitudinal care and establish a therapeutic relationship across the care trajectory. We propose that a universal definition of attachment be aligned with existing definitions and be focused on the clinician with whom a patient builds this relationship.

The definition of provider-patient attachment should consider health care systems’ desired goals and future state, encompassing continuity of care, accountability, coordination, cost-effectiveness, access to care, comprehensiveness, and support for providers and patients. Additionally, it must acknowledge the importance of the care team in delivering patient care.37,103-105 Attachment to a clinician and the care team allows patients to access care from a team, which might result in less disruption in their care when their clinician is unavailable. Research indicates that team-based care models enhance accessibility and quality of care while also fostering collaboration among health care professionals.106,107 In the context of chronic disease management108 or mental health care,107-110 where patients might benefit from input from multiple specialists and allied health professionals, attachment to a team can facilitate integrated and holistic care delivery. However, the patient must be attached to a provider (not just the team) to ensure one team member is their quarterback. The definition should also include patient affiliation to a practice or a team that includes the most responsible clinician. To allow for virtual care to patients, the definition should include informational continuity since it is necessary for team members to access health information and provide ongoing care. In some jurisdictions, the confirmed affiliation involves accountabilities and establishing PCPs as health stewards for a defined population through patient enrolment.76,111-114 In other jurisdictions, the confirmed affiliation is documented but does not require formal agreements.115,116 Given the diversity of approaches to generating patient lists and team-based care, the terms confirmed and documented with regard to affiliation should be in the definition.

Thus, we propose the following universal definition for provider-patient attachment in the context of PC and virtual care:

Provider-patient attachment is the confirmed and documented affiliation between a patient and a regular primary care provider (clinician—ie, family physician or nurse practitioner, etc—or a combination of clinician and care team or practice) in which the primary care provider is responsible for providing longitudinal and continuous care to the patient via any delivery channel (ie, in person or remotely or both), enabled by provider access to patient health information.

Longitudinal care includes delivering a range of services by a clinician, practice, or team over a patient’s lifetime. The proposed universal definition attempts to balance the goals of provider-patient attachment; considers the local context; and provides flexibility to implement diverse approaches. Finally, it acknowledges the key role of virtual care, information systems, and teams.

Limitations

Only published English-language articles were included, excluding definitions that might exist in other languages. Moreover, some relevant articles might have been missed, particularly from non–English-language sources or publications outside the specified time frame, given the lack of consistent conceptualization of provider-patient attachment. The review focused on published literature, which might introduce publication bias as studies with statistically significant findings are more likely to be published. This bias might lead to an overrepresentation of certain perspectives or definitions of attachment, potentially limiting the generalizability of the findings. Most included studies were conducted in North America, which might limit the generalizability of the findings to other regions with different health care systems and cultural contexts.

Conclusion

The proposed definition of provider-patient attachment will advance policy making and facilitate the development of health systems in which a patient is attached to a PCP and receives longitudinal and relational care. With a confirmed and documented affiliation, clinicians can proactively provide care to their patient population and participate in quality improvement and performance measurement. At the systems level, it enables data collection for stewardship, work force planning, and resource allocation. Finally, it acknowledges the important role of virtual and team-based care in the attachment of patients to providers.

Acknowledgment

We acknowledge Lynda Gamble for guiding the search strategy for this study and Susannah Taylor and Raghda El Hassanein for abstract screening and full-text review. We thank Benjamin Diepeveen, Elizabeth Toller, and the Federal, Provincial, and Territorial Virtual Care/Digital Table for supporting this project.

Footnotes

  • ↵* Appendix 1 and Table 1 are available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

  • Contributors

    Dr Monica Aggarwal contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to writing the manuscript for submission. Dr Richard H. Glazier contributed to interpreting the data and editing the manuscript.

  • Competing interests

    The project is sponsored by Health Canada. Dr Monica Aggarwal was partially compensated for her time on this project by the sponsor.

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

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Toward a universal definition of provider-patient attachment in primary care
Monica Aggarwal, Richard H. Glazier
Canadian Family Physician Oct 2024, 70 (10) 634-641; DOI: 10.46747/cfp.7010634
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