Continuity of Care Tools
Continuity of Care Checklists
Family Medicine Checklists
Social Worker Checklists
ARE YOU CONCERNED ABOUT CONTINUITY OF CARE?
With the support of national and provincial funding and numerous health care decision makers, providers, and patients, our group developed several tools to help better assess and address problems in continuity of care.
Continuity of care refers to coherent care with seamless transitions over time, between settings and providers, through consistent communication and coordination. It is associated with:
Fewer gaps and errors in care - PATIENT SAFETY
Decreased patient anxiety - PATIENT-CENTERED CARE
Reduced stress for health care providers - IMPROVED WORK ENVIRONMENT
Improved efficiency and lower health care costs- EFFICIENCY & COSTS
WOULD YOU LIKE TO BE ABLE TO IDENTIFY PROBLEMS IN CONTINUITY OF CARE?
The Patient Continuity of Care Questionnaire (PCCQ) is a reliable, valid, and sensitive questionnaire designed to help identify difficulties patients experience in continuity of care. It is given to patients/caregivers two to four weeks after discharge or transfer from hospital (e.g., either through follow-up phone interviews, in person interviews, or mail).
Patients are the best sources of information since this is their health care experience.
If patients rate care poorly, you can be sure there is a problem.
The questionnaire can identify areas of concern and direct you to areas that need improvement.
It can also be used to assess whether initiatives to improve continuity of care work.
The PCCQ consists of 41 items. However, we found that 25 items (i.e., PCCQ-short) were applicable to most patients with different health problems and group into the following subscales:
Transfer of important information to patient
Relationships with providers involved in care
Relationships with providers taking over care
Organization of follow-up care
Communication among providers across the continuum
Completion and transfer of forms
WOULD YOU LIKE TO HELP PATIENTS BECOME ACTIVELY INVOLVED IN ENSURING THEIR CARE IS CONTINUOUS?
Patients are often overlooked as having an important role to play in continuity of care. Instead, we tend to focus on what providers can do to improve the coordination and communication among providers. We developed a very brief brochure that can be given to patients in hospital before discharge, that helps them be actively involved in ensuring their care is continuous.
Over 78% of patients who received these materials felt that they were very beneficial to them, either telling them new information that they had not thought of, or reminding them of important things they should know or do to assist with their care.
Over 96% of providers (nurses and coordinators) positively evaluated the brochures. They felt that the brochures had a friendly format that saved them time by:
Reminding patients/caregivers to ask and prepare questions, and
Encouraging patients/caregivers to advocate for their health.
WOULD YOU LIKE TO BE CERTAIN YOU CAN ADDRESS CONTINUITY OF CARE IN PRACTICE?
Our group worked with a national panel of experts to develop a Continuity of Care Checklist that lists: 1) central information that needs to be transferred to patients and providers; 2) core elements of relationships that impact continuity of care; and 3) essential management processes that impact continuity of care.
How can the Checklist be used?
The Checklist can be used by providers to review whether they have done everything they need to do to ensure continuity of care before an individual patient is discharged or transferred to other providers.
Decision makers can use the Checklist as a review or audit tool for examining current practice surrounding continuity of care.
Educators can use the checklist to train new providers in ensuring continuity of care.
What do providers say about the Checklist?
Providers who used the Checklist feel that it is a good reminder of what needs to be done to ensure continuity of care, identifies barriers to continuity of care that otherwise might be overlooked, encourages multidisciplinary communication, and ensures transfer of valuable information to patients.
Are there challenges to using the Checklist?
Time and 'buy in' are the greatest challenges. If you use the Checklist, you will need to adapt it to your unit (i.e., determine who will complete it, with which patients, where the Checklist will be placed, and at what point in time it will be completed).
What benefits have been found using the Checklist?
When providers used the Checklist with Family Medicine patients, the Checklist was associated with improved patient perceptions of a number of aspects of care, including:
being informed of ongoing treatment that may be required after discharge;
sharing of necessary information with informal caregivers;
the perception that different health care providers in hospital communicated well with those in the community; and
the belief that necessary forms were sent to all appropriate places/providers.
Among Orthopaedic patients, there was an even greater impact when the Checklist was used with patients. Orthopaedic patients had more positive perceptions of many aspects of their care, including information provision, quality of relationships with providers, and coordination of care after discharge.
ARE THESE TOOLS GENERALIZABLE?
Forty-two respondents from across Canada reviewed our work on a narrated PowerPoint presentation on the web.
An overwhelming majority of respondents believed that the Checklist would improve continuity of care (96.8%).
Almost three-quarters of respondents (74.1%) indicated they would use the Checklist in their work.
Most respondents (88.9%) believed that it would be helpful to have the Continuity of Care Questionnaire administered to clients in their setting in order to understand continuity of care issues specific to their work setting.
Most respondents (88.5%) also reported that they would find it helpful to use the patient materials in their work setting.
WHERE CAN YOU FIND THE TOOLS?
All tools are available on the web for use. Dr. Hadjistavropoulos only asks that you keep her informed of how you are using the tools.
This research was made possible in part by grants from the Canadian Institutes of Health Research, Canada Health Services Research Foundation, and Saskatchewan Learning. In-kind, funds were also provided by the Saskatchewan Health Authority.