Defusing the Confusion: Concepts and Measures of Continuity of Healthcare

by Robert Reid, Jeannie Haggerty, Rachael McKendry | Mar 01, 2002

Main Messages

Continuity of care is how one patient experiences care over time as coherent and linked; this is the result of good information flow, good interpersonal skills, and good coordination of care.

Continuity of care occurs when separate and discrete elements of care are connected and when those elements of care that endure over time are maintained and supported.

Definitions of continuity are often presumed rather than stated, and it is not possible to measure what is not clearly defined.

Continuity of care means different things to different types of caregivers, but all recognize three types: continuity of information, of personal relationships and of clinical management. The type of continuity should be agreed to before discussions or planning begin.

Informational continuity means that information on prior events is used to give care that is appropriate to the patient's current circumstance.

Relational continuity recognizes the importance of knowledge of the patient as a person; an ongoing relationship between patients and providers is the undergirding that connects care over time and bridges discontinuous events.

Management continuity ensures that care received from different providers is connected in a coherent way. Management continuity is usually focused on specific, often chronic, health problems.

Multiple measures are needed to capture all aspects of continuity; no single measure is able to reflect the whole concept. Some measures are more useful in some contexts than others.

More emphasis is needed on the development and application of direct measures of continuity from the patient’s perspective and to measure continuity across organizational boundaries.

Measures based on patterns of health service use should be used with caution as indicators of continuity until researchers have tested implicit assumptions that they reflect informational, relational, and/or management continuity.

Executive Summary

When patients receive care from a variety of sources, connecting that care into a smooth trajectory becomes increasingly difficult. Policy reports worldwide urge a concerted effort to avoid fragmentation and enhance continuity of care. But efforts to describe the problem or formulate solutions are hampered because continuity has been defined and measured in myriad ways.

This report was commissioned by the Canadian Health Services Research Foundation, the Canadian Institute for Health Information and the Conference of Deputy Ministers of Health’s Federal/Provincial/ Territorial Advisory Committee on Health Services. The mandate was to survey how continuity has been used and measured in order to develop a common understanding of the concept and to recommend measures for health system monitoring. We did a systematic survey of how the phrase “continuity of care” was used in the literature, and then presented the results to 59 researchers and decision-makers in a discussion paper and two-day workshop in June 2001.

Concepts of Continuity

Continuity of care is conceived differently in primary care, mental-health care, nursing, and condition-specific literature but its meaning is more often presumed than defined. However, there are two core elements and three types of continuity that bridge the domains of health care.

The experience of care by a single patient with his or her provider(s) is the first core element of continuity; the second is that the care continues over time (which is sometimes referred to as longitudinal or chronological continuity). Both elements must be present for continuity to exist, but their presence alone does not constitute continuity.

There are three types of continuity: informational continuity; relational continuity; and management continuity. These are closely related attributes that vary in importance depending on providers or the process of care. Every discipline has recognized all of these features, and all are important in ensuring high quality care. Continuity can be viewed from either a person-focused or disease-focused perspective.

Informational continuity is the use of information on prior events and circumstances to make current care appropriate for the individual and his or her condition. Information is the common thread that links care from one provider to another and from one health event to another. Information transfer has been most emphasized in nursing literature. Documented information tends to focus on specifics of the health condition, but knowledge about the patient's values, preferences, and social context developed through a stable provider-patient relationship, is equally important and has been most emphasized in primary care and mental-health care.

Relational continuity refers to an ongoing therapeutic relationship between a patient and one or more providers. It not only bridges past and current care, it provides a link to future care. An ongoing patient-provider relationship is highly valued in primary care, where it translates into an implicit contract of patient loyalty to the provider and ongoing provider responsibility to the patient. Even where there is little expectation of establishing relationships with caregivers, such as homecare and in-hospital care, a consistent core of personnel can give patients a sense of predictability and coherence in their care. In mental health care, sometimes providers take responsibility to maintain contact with patients to ensure relational and management continuity.

Management continuity refers to the provision of timely and complementary services within a shared management plan. Disease-specific literature emphasizes the content of care plans to ensure consistency. Nursing and mental-health literature goes further, emphasizing the importance of consistent implementation, especially when patients cross-organizational boundaries. However, flexibility in adapting to changes in an individual's needs is equally important, especially in mental-health care.

Measures of Continuity

Just as the literature is replete with different concepts of continuity, so it is with ways of measuring them. Most measures were developed with a single aspect of continuity in mind, which means few examine continuity across care settings or professional domains and until recently, little attention has been paid to the patient’s perspective.

The vast majority of measures examine the chronology of a patient's contact with healthcare providers over time. Continuity is inferred from the duration of patient-provider affiliation and from the concentration and sequence of care among different providers. The assumption is that enduring contact with a single provider is linked with stronger relationships, better information transfer and uptake, and more consistent management. However, there is remarkably little evidence for these assumptions. Formal testing of these assumptions should be a research priority before chronological measures can be used as indicators of continuity care.

Measures of informational continuity relate to the availability of documentation, the completeness of information transfer between providers, and to the extent to which existing information is acknowledged or used by a provider or patient.

Relational continuity is usually measured by using either the affiliation between patient and provider, or how long their relationship has lasted as a proxy for continuity. There is a growing impetus to evaluate ongoing relationships by asking patients and providers directly how strong their ties are.

Measures of management continuity focus on the delivery of one aspect of care in the continuum of the management plan, most commonly whether follow-up visits are made when care crosses organizational boundaries. Measures of compliance with management protocols blur the boundary between assessment of continuity and quality of medical care.

Clearly no single measure captures the whole concept of continuity. The choice of one or more measures will depend on the types of continuity that are pertinent in a given context. Existing measures that focus on chronology need to be validated against direct measures from the patient or provider. New measures are needed for continuity across organizational and disciplinary boundaries, in particular for informational and management continuity.

Conclusions

Continuity is the result of a combination of adequate access to care for patients, good interpersonal skills, good information flow and uptake between providers and organizations, and good care coordination between providers to maintain consistency. For patients, it is the experience of care as connected and coherent over time. For providers, it is the experience of having sufficient information and knowledge about a patient to best apply their professional competence and the confidence that their care is recognized and pursued by other providers.

There are substantial gaps in the range of instruments to measure continuity. This is particularly true of instruments that measure the transfer and use of information (whether medical or contextual) by providers in most care contexts as well as those that measure consistency of care among providers and across organizational boundaries. Many measures have focused on mechanisms thought to foster continuity rather on the direct experience of patients and providers. There was general consensus at the June 2001 workshop that it is premature to recommend any measures for use as wide-scale performance indicators.