Abstract and Introduction
Abstract
Objective The increasing complexity in healthcare delivery might impede the achievement of continuity of care, being defined as 'one patient experiencing care over time as coherent and linked'. This article aims to improve the knowledge on patients' perceptions of relational (RC), informational (IC) and management continuity (MC) across care levels.
Design A descriptive, qualitative meta-synthesis was conducted based on a literature search in various electronic databases using the subject heading 'continuity of care' and linked key terms. We scanned retrieved articles for adherence to inclusion criteria: (i) relevance to research topic, (ii) original study adopting a qualitative design and (iii) investigating the patient's perspective. Content analysis was conducted by identification of themes and aggregation of findings.
Results The selected 25 studies most frequently investigated RC. Being attended to regularly and over time by one physician (RC) was valued by chronic ill patients, but balanced with convenient access by young patients (MC). Communication and information transfer across care settings as well as the gathering of holistic information about the patient were perceived to foster IC. Critical features for achieving MC were accessibility between care levels, individualized care and a smooth discharge process including the receipt of support. Patients further considered that their personal involvement was one facilitating element of continuity of care.
Conclusions Patients identified elements that enhance or distract from continuity of care across boundaries. Variations in perceived importance seem to depend on both individual and contextual factors which should be taken into account during healthcare provision.
Introduction
Rapid advances, new treatments, high specialization and shifts in care from institutional to outpatient and home settings mean that patients see an ever-expanding array of different types of providers in a variety of places. That is particularly the case in patients with chronic diseases or pluripathologies who receive care from multiple disciplines. Policy-makers and healthcare providers increasingly express concerns about that fragmentation of care. Connecting the care components into a smooth trajectory can be challenging. Continuity of care is purported to be a critical feature in delivering healthcare services. Literature on continuity of care suggests better outcomes when present in healthcare provision, e.g. higher patient satisfaction with medical care, improved delivery of preventive services and lower hospitalization rates.
Due to the tendency of segmenting care delivery, the concept of continuity of care has been garnering more attention in the last few years. This has been accompanied by a discussion on clarifying its conceptual boundaries, most lately in Parker et al. and Freeman and Hughes. Maybe the widest accepted conceptual framework is that of Reid et al., who define continuity of care as one patient experiencing care over time as coherent and linked; similar to Freeman et al.'s description: the experience of a smooth and coordinated progression of care from the patients' point of view. Continuity of care embraces two core elements: first, care provided over time and secondly experienced by a single patient. Borders to related concepts may be blurred, e.g. the term 'coordination of care' is sometimes used synonymously, however, reflects the provider's perception and refers to the agreement of all healthcare services in order to achieve a common goal without producing conflicts, and independently on where it takes place. Care is conceived to be integrated when the maximum level of coordination has been reached.
In their conceptual framework, Reid et al. classify three types of continuity of care: relational continuity (RC), informational continuity (IC) and management continuity (MC). Each of those can be characterized by several dimensions (Table 1). RC (often used synonymously with personal continuity) refers to the patient's opinion on an ongoing therapeutic relationship with one or more providers that connects care over time. IC is defined as the patient's perception of the availability and use of information on past events and personal circumstances by the physician, whereas MC refers to the patient's view about the provision of separate types of health care in ways that they complement each other and are connected in a coherent way for a smooth progression of the patient through the system. Those three types are closely related and may vary in importance depending on patients' characteristics, or the process of care, however, an effective healthcare organization has to embody all of them.
So far, mostly quantitative meta-analyses focusing on the impact of continuity of care and reviews of qualitative and quantitative studies have been carried out. Qualitative investigation has an important role in evidence-based medicine, in that it represents the human dimensions and experiences of healthcare users. The aim of the paper was to contribute to improving the knowledge on continuity of care based on the review of qualitative studies, trying to respond to the following research questions: what are patient's views on RC, IC and MC across care levels? What is their attributed relevance? What are the causes and consequences of perceived discontinuity?