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Continuity and Comprehensiveness of Care. What is Continuity of Care?. Traditional Family Doctor: = single provider and single patient in a longitudinal, personal relationship Mental Health Worker: = coordination of many services over time. Common plans and goals.. many providers

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What is continuity of care l.jpg
What is Continuity of Care?

  • Traditional Family Doctor: = single provider and single patient in a longitudinal, personal relationship

  • Mental Health Worker: = coordination of many services over time. Common plans and goals.. many providers

  • Nurse: = smooth information transfer

  • Diabetic clinic: = “continuum of care”, multiple providers, protocol and result driven


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Can we define Continuity of Care in context of: …..

  • Doctor: ie “ Dr X always looks after all of my problems in a timely fashion”

  • Patient : ie “Patient X always has her problems looked after in a timely fashion by a group of providers”


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Doctor / patient relationship is key

  • BUT…. Are we

  • QUARTERBACKS

  • Or ORCHESTRA CONDUCTORS

  • What about PROVIDER / patient relationships in a multidisciplinary team model ?


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3 types of Continuity

  • Informational

  • Management

  • Relational


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Why revisit Continuity of Care?

  • Disease Complexity

  • Determinants of Health

  • Chronic Disease Burden

  • Increased focus on teaching

  • Increased focus on Multidisciplinary care

  • Access issues

  • How do we deliver 24/7

  • Marcus Whelby is dead


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Saint John CHC

  • Greater Saint John access:

  • 80 Family Doctors

  • 125,000 citizens

  • 140,000 ER visits p.a.

  • 140,000 FD/walk in visits

  • CHC catchment access

  • 12 Family doctors

  • 35,000 citizens


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CHC

  • 5 Family doctors,

  • 4 Nurse Practitioners

  • 3 LPN

  • 2 dieticians

  • 1 Social worker

  • And a……..


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CHC

  • OT , Domestic Violence Worker, Teen Resource workers

  • Numerous outreach workers and programs

  • Base patient number : 9000

  • Chronic Disease Clinics, Mental Health, Teen Clinic, Outreach to Sal Army, Soup Kitchens, Homeless etc etc

  • Medical services: Prenatal/Antenatal, Palliative Care ,Hospital Care , Shared Mental Health , Minor Surgeries , House calls etc, etc

  • Vital partnerships with community agencies


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How can you have Continuity of Care in such a model????

  • Information Technology (informational continuity of care)

  • Multidisciplinary Teams (managerial continuity)

  • Every patient has a primary provider and MD/NP team( relational continuity)


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Issues in development of new Continuity of care Models

  • Change Management

  • Government Expectations

  • Evaluation models….Audits …outcome based …..patient satisfaction…. Problem: What do we compare it to?

  • Marketing

  • Co location

  • Realistic numbers and expectations

  • “Don Quixote” syndrome

  • “say no to protect your yeses”


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Lessons Learned

  • Need Community Needs Assessment (not just practice needs assessment)

  • Triage

  • Navigation

  • Patients need to know about informational continuity

  • Marketing

  • Linked appointments

  • Time resource management

  • Some patients prefer old model .They should have options available


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