Assessment of a System for Managing Continuity of Care

Key Implications for Decision Makers

At the request of local authorities, our research team conducted an assessment of the implementation and effects of a system for managing continuity of prenatal care. The continuity management system essentially is based on a system of inter-institutional referrals and a pregnancy logbook designed by developers of the system.

Findings on the intervention.

  • The intervention implemented is a continuity management system consisting of four potential components: active participation by mothers; a comprehensive approach; synergy of tools; and co-operation among workers. The choice of these components reflects a comprehensive, creative approach with potential for general application. The strength of this approach lies in the fact that the intervention considers the essential aspects such as client needs, relations between professionals, and organizational structures.

Findings on the implementation

  • This type of system can only be implemented in fertile ground, where trust and co-operation among workers are well-established and nurtured by leadership shared among organizations and by access to settings for professional dialogue and socialization.
  • Some implementation problems were related to a lack of consensus, especially on active client participation, the concept of psychosocial risk, the comprehensive nature of the approach, and the ultimate purpose of the information tools. Serious differences were noted in these areas between professionals in the organizations (hospitals, CLSCs1, private practices) and between disciplines (physicians/nurses).

Findings on the effects

  • Despite the implementation difficulties, positive effects from the system were noted in comparisons between the region where the system was implemented and a control region:
    • greater integration of physicians in private practice (GPs and specialists) into the network through formalization of information exchanges;
    • more early prenatal referrals by physicians for clients at psychosocial risk;
    • greater continuity of information between institutions and greater consistency in information given to mothers;
    • greater satisfaction among mothers with services received in physicians' offices and in hospital; and
    • greater empowerment of mothers in decision-making and better preparation for delivery.
  • Women in their first pregnancy benefited more from the system than those in subsequent pregnancies by making greater use of continuity tools.

The work invested by developers ensured that the continuity management system achieved several of its intended objectives. Professionals in the region adopted an integrated network approach in which new practices developed related to continuity of care. This system has the potential to become an effective means of changing practices provided that professionals achieve consensus (especially on client participation and the concept of psychosocial risk for the medical profession). However, this type of continuity management system can only survive through the ongoing injection of human and financial resources to ensure its stability.

1 CLSC: Local community services centres

Executive Summary

This research project addresses the theme of managing continuity of care, specifically systems for managing continuity of care in the subregional context of a networked operating structure for delivering perinatal care and services. At the request of local authorities with which we had previously co-operated, our team conducted an assessment of the implementation and effects of the prenatal component of a system for managing continuity of perinatal care based essentially on inter-institutional referrals and a pregnancy logbook managed by each pregnant woman. Developers of the system sought the following objectives: 1) promote identification and early referral of pregnant women presenting biopsychosocial risks; and 2) ensure continuity of information among the various healthcare partners.

Using data gathered from October 2003 to August 2004, the study consists of two parts, one qualitative and the other quantitative. The first part entailed a case study to describe the intervention and determine the influence of the environmental and organizational context on implementation of the intervention and on the effects observed. The analysis of the intervention was based on semi-structured interviews with 20 professionals, managers, and workers from various organizations (14 interviews were conducted in the southern subregion, where the intervention was developed and implemented, and six were conducted in the northern subregion, used as a comparison group).

The purpose of the second part was to 1) document the intervention from the perspective of mothers in terms of use and assessment of the information tools, especially the pregnancy logbook designed by developers; and 2) determine the effects of the intervention on services received, appropriation by mothers of their pregnancy, preparation for delivery, health of the mother and newborn, and assessment of services. To achieve this, an epidemiological study was conducted at two times, one month and three months after delivery. In the first survey, 324 mothers in the southern subregion and 327 in the northern subregion completed an initial telephone interview, for a response rate of 54.5 percent in the south and 70.9 percent in the north. In the second survey, the response rates were 84.3 and 92.7 percent respectively.

The analysis of the data gathered in each part was conducted in parallel and the findings were subsequently integrated. In the south, the prenatal continuity management system emerged at the initiative of a group of managers and professionals from the hospital and the two CLSCs in the territory, as part of a networked operating structure in which interprofessional and interorganizational co-operation in postnatal care were already well-established. The system has four potential components: active participation by mothers; a comprehensive approach; synergy of tools; and co-operation among workers. Various information tools were created by developers of the system. For inter-institutional referrals, there is the history of perinatal care (a selfadministered questionnaire filled out by mothers at the time of their first prenatal medical appointment) and the prenatal referral form (from the physician to the CLSC). This is augmented by the pregnancy logbook Between Sky and Earth given to mothers at their first appointment with their birthing physician. The logbook serves two purposes: 1) to inform and enhance the awareness of mothers about pregnancy, delivery, and their return home; and 2) to foster the exchange of information among professionals. Mothers can record general information in the logbook (appointments and important telephone numbers) as well as personal medical information, their delivery plan, and their intention to breast feed their child.

The system's first component, active participation by mothers, is based on greater accountability of mothers for their health. They therefore hold a central place in the system as players and assessors. Nine mothers in 10 were given the pregnancy logbook and the vast majority (90 percent) made written entries in the book. Women in their first pregnancy made greater use of the book and found the information they recorded proved useful for professionals. We are forced to note, however, that the anticipated degree of participation by mothers and the usefulness of the pregnancy logbook as a tool for exchanging information by no means enjoy a consensus among professionals.

The comprehensive nature of the approach translates into consideration of medical and psychosocial risk factors. These factors are likely to influence the progress and outcome of the pregnancy; through identification at the start of the pregnancy, mothers at risk can be directed at an early stage to appropriate resources. The system did in fact promote a more comprehensive approach to clients at risk, especially among medical specialists who consider the history of perinatal care a tool that facilitates consideration of psychosocial problems. However, there continues to be a lack of consensus among some physicians and workers in CLSCs on the risk factors that justify a prenatal referral (such as tobacco use and financial difficulties).

Although the various information tools in the system fostered greater integration of physicians, especially for early referral of clients at risk, we note a lack of consensus on the ultimate purpose of the tools, linked in large part to the professional values of individuals. Some professionals view the pregnancy logbook as a personal tool in which mothers can record what they wish, and these professionals doubt the ability of mothers to manage an instrument which is partly intended to circulate information among professionals. These differences of opinion reduce the synergetic potential of information tools.

Positive effects of the system include better co-operation between CLSCs and community organizations, networking between CLSCs and private practices, a significant increase in the number of mothers in prenatal care referred to CLSCs, greater appropriation by mothers of their pregnancy, due partly to the fact that mothers who made optimum use of their pregnancy logbook felt they had a say in the decisions made about them by professionals during their pregnancy, better preparation for delivery by writing a delivery plan, a feeling by mothers that the pregnancy logbook is effective in conveying information to workers without always having to repeat the same information, greater satisfaction among mothers with the services received in physicians' offices and in hospital, and the feeling that physicians gave more consideration to their needs.

A steering committee was formed for operational implementation of the system. The key factors for successful implementation of the system are presence of a liaison nurse dedicated to the project; personalization of the approach with physicians; and constant monitoring of annual feedback on the indicators of system outcomes. Although the system was implemented in fertile ground in which a solid relationship of trust and co-operation had already been established, efforts must be made in future to make community organizations full-fledged partners and to maintain the motivation of professionals to participate in the system. We therefore find that this type of continuity management system essentially based on the adoption of new practices cannot survive without the allocation of human and financial resources to ensure its stability.