continuity and comprehensiveness of care
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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
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
can we define continuity of care in context of
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”
doctor patient relationship is key
Doctor / patient relationship is key
  • BUT…. Are we
  • QUARTERBACKS
  • Or ORCHESTRA CONDUCTORS
  • What about PROVIDER / patient relationships in a multidisciplinary team model ?
3 types of continuity
3 types of Continuity
  • Informational
  • Management
  • Relational
why revisit continuity of care
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
saint john chc
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
slide8
CHC
  • 5 Family doctors,
  • 4 Nurse Practitioners
  • 3 LPN
  • 2 dieticians
  • 1 Social worker
  • And a……..
slide10
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
how can you have continuity of care in such a model
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)
issues in development of new continuity of care models
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”
lessons learned
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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