Question

What are som challenge continuity of care may face for which age group

Answer 1

Continuity of care is concerned with the quality of care over time. There are two important perspectives on this. Traditionally, continuity of care is idealized in the patient's experience of a 'continuous caring relationship' with an identified health care professional. For providers in vertically integrated systems of care, the contrasting ideal is the delivery of a 'seamless service' through integration, coordination and the sharing of information between different providers. As patients' health care needs can now only rarely be met by a single professional, multidimensional models of continuity have had to be developed to accommodate the possibility of achieving both ideals simultaneously. Continuity of care may, therefore, be viewed from the perspective of either patient or provider.

Continuity in the experience of care relates conceptually to patients' satisfaction with both the interpersonal aspects of care and the coordination of that care. Experienced continuity may be valued in its own right. In contrast, continuity in the delivery of care cannot be evaluated solely through patients' experiences, and is related to important aspects of services such as 'case-management' and 'multidisciplinary team working'. From a provider perspective, the focus is on new models of service delivery and improved patient outcomes. A full consideration of continuity of care should therefore cover both of these distinct perspectives, exploring how these come together to enhance the patient-centredness of care.

Children with complex chronic conditions (CCC) are those with a health condition expected to last greater than a year (unless death occurs) that involves one or more organ systems, and requires care from specialty providers and likely hospitalization in a tertiary care center. The complexity and severity of these patients’ health conditions necessitate frequent interactions with the healthcare system, and coordination of care to ensure the effective and efficient transfer of information among a potentially large team of providers.

Parents of children with CCC consistently report a desire for continuity of care for their child across the care continuum. They value the individualized care that familiar providers deliver, and they have confidence in the quality of care provided by those who know their child best. The care these parents are seeking is a relational continuity, or the development over time of trusting relationships between patients/families and individual care providers.

Continuity of care is a particular concern for older people. Older people are particularly likely to have several practitioners (each specializing in one organ system or problem) and thus to move from one care setting to another (called transition of care). They may receive care in several private practitioner offices, in a hospital, in a rehabilitation facility, and/or in a long-term facility.

Many practitioners
Having several practitioners may disrupt the continuity of an older person's health care. For example, one health care practitioner may not have up-to-date, accurate information about the care provided or recommended by other practitioners. That practitioner may not know the names of the other practitioners involved or may not think to contact them. Information about care may be miscommunicated or misunderstood, particularly when older people have disorders affecting speech, vision, or mental function (cognition) that make it more difficult for them to communicate effectively. Older people may mention an important detail to one practitioner and forget to mention it to the others.

To ensure that care is continuous (and optimal), all practitioners involved must have complete, up-to-date, and accurate information about what other practitioners have done, particularly about tests done and drugs prescribed. When this information is missing or miscommunicated, the following can result:

• Diagnostic tests may be needlessly repeated.
• Inappropriate drugs or other treatments may be prescribed.
• Preventive measures may not be taken because each practitioner assumes someone else has provided them.

Different practitioners may have different opinions about a person's health care. For example, practitioners in a hospital may disagree with a person's primary care practitioner about whether surgery is required or about whether the person should go to a nursing home after being discharged. The person and family members may be overwhelmed and confused by differences of opinion among the various practitioners.

People taking many prescription drugs, as is common with older people, may fill their prescriptions at different pharmacies (for example, the one nearest each specialist's office). When different pharmacies are involved, each pharmacist may not know all the drugs people are taking and thus will not know when a newly prescribed drug might interact negatively with a current one.

Many settings
Moving from one care setting to another (transition of care), such as going from a hospital to a skilled nursing facility, increases the chance that errors in care may occur. New drugs may be prescribed in the hospital, and they may duplicate or interact negatively with the person’s other drugs. Sometimes old, needed drugs may be unintentionally omitted. Even when changes in people's drugs are appropriate, the changes may not be communicated to all involved health care practitioners, such as the primary care practitioner.

To prevent such problems, current regulations in the United States require health care organizations to do drug reconciliation whenever the care setting is changed and whenever new drugs are ordered or existing orders are rewritten. Drug reconciliation involves comparing people's drug orders to all the drugs they were previously taking and thus make sure no drugs are duplicated or omitted. When changing care settings, older people or their caregiver should ask practitioners whether drug reconciliation was done.

If people are not in a health care facility, they and/or their caregivers should do their own drug reconciliation. People should keep a list of their current drugs as well as a list of drugs they used to take (and why they were stopped). Then, after people see a new practitioner or enter or leave a hospital or other care facility, they should check whether any newly prescribed drugs are on these lists. If people see any of the following, they should speak to the practitioner right away.

• A duplicate prescription for a drug that they are already taking
• A prescription for a drug that they previously needed to stop taking
• A missing drug—one that they were taking but that is not on the facility's list of their current drugs

Making an appointment with the primary care practitioner soon after discharge from the hospital or other care facility (such as a rehabilitation center or skilled nursing facility) is always a good idea. The practitioner can then review all of the drugs and instructions recommended at the time of discharge.

Many rules
The health care system has many rules that affect continuity of care. The rules may be made by the government, insurance companies, or professional organizations for health care practitioners. For example, some insurance companies limit which hospital people can go to. The person’s primary care practitioner, if not on staff at that hospital, may be unable to provide care there. Also, many primary care practitioners no longer provide care in hospitals or rehabilitation centers. As a result, a person in such settings may be cared for by new practitioners who are not familiar with the person's medical history. It is important for the person or the person's caregiver to make sure that all pertinent information is provided to the new practitioner.

Lack of access to care
Continuity of care may be disrupted when people do not have access to health care. For example, older people may miss a follow-up appointment because they do not have transportation to a practitioner's office. They may not see a practitioner because they do not have insurance and cannot afford to pay for health care themselves.

Other problems
People may forget or be unaware that they have an appointment with a health care practitioner.