continuity of care lessons from two major research programs in uk and canada 1999-2006 george...
TRANSCRIPT
Continuity of Care Lessons
from two Major Research Programs in
UK and Canada 1999-2006George Freeman
Emeritus Professor of General Practice
research team
George Freeman, Maria Woloshynowych, Josip Car
– Imperial College London
Jeannie Haggerty – University of Sherbrooke, Quebec, Canada
Bruce Guthrie – University of Dundee
Richard Baker – University of Leicester
Mary Boulton – Oxford Brookes University
consultant
Ewan Ferlie - Royal Holloway, University of London
international expert advisers
USA
Dmitri Christakis Seattle
John Saultz Portland
Barbara Starfield Baltimore
Canada
Carol Adair Calgary
Norway
Per Hjortdahl Oslo
Netherlands
Henk Schers Nijmegen
why continuity?
1. top priority in SDO’s 1999 start up listening exercise
2. scoping study3. six major studies 2001-7
– all with strong user perspective
http://www.sdo.nihr.ac.uk/cpcontinuity.html
The Service Delivery and Organisation Programme is part of the National Institute for Health Research
UK - six long term projects
four diseasesdiabetes community
cancer hospital
stroke hospital
severe mental illnesscommunity
generalprimary care
community
organizational cross boundary study young people with learning disability communityolder people with a stroke community
what we did
• standardised data collection – site visits
– protocols, reports, presentations, publications
• draft report reviewed by– expert advisors
– project leaders
• common analytic framework– based on Canadian programme review - Haggerty
Canada - 34 projects
• wider variety of settings/methods
• findings match and extend UK programme
• intervention trials for severe mental illness
what is continuity?
two essential elements care of – an individual patient – delivered over time
three continuity types
Informational - timely appropriate information
Management – co-ordination between providers
Relationship - ongoing therapeutic relationship between a patient and one or more providers
lessons learned - 1
• all continuity types link with greater satisfaction
Our earliest experience of sickness is usually in a family context. We learn how
to be sick within the family
lessons learned - 2
• all continuity types link with greater satisfaction
• most users want more involvement & responsibility
• vulnerable minority need help
Our earliest experience of sickness is usually in a family context. We learn how
to be sick within the family
lessons learned - 3
• all continuity types link with greater satisfaction
• most users want more involvement & responsibility
• vulnerable minority need help
• the access trade-off
advanced medical home
all types of continuity offered
relationship continuity is key feature
- each patient has an ongoing relationship with
a personal physician
- continuous and comprehensive care
the access trade-off - how long to wait?
to see
• physician rather than nurse
• someone you know & trust
• someone with access to full medical history
how many extra days to wait?
vignette
minor new routineto see familiar uncertain check-up
doctor 1.0 3.5 3.5
known &trusted 0.9 2.4 4.2
full medicalhistory 1.6 3.9 7.8
primary care findings
patients
• are well aware of clash between access and relationship continuity
• have clear views on when they need relationship continuity
• expect good informational continuity
Sick elderly woman living alone
overall lessons
• patient-centred care is fundamental
– most users want more involvement
– more vulnerable need help
• which type of continuity?
– Relationship, Informational, Management
• give specific priority to relationship as well as
to informational and management
continuity of care when reorganising services
outstanding questions
Management and Informational continuity are almost self-evident goods
• how to deliver the goods?case for Relationship continuity is less clear• how to measure it and reward it?• more about trade-offs with
rapid accessspecialist expertise
• intervention trials needed
thank you for your attention!
questions?
primary care findings - 2
• patients value relationship continuity more
if they are older, iller or vulnerable
• some patients get less of what they want– non-white
– socially isolated or disadvantaged
– in full time work