Continuity of Care (Part 1): How Continuity of Care is Defined and Practical Ways We Prioritize Continuity

Written by Liz Fischer

“The continuing relationship between the general practitioner and the patient allows the doctor to build up a picture piece by piece over the years”  

Continuity of Care and Quality of Care – Inseparable Twins

A lot is written these days about the importance of Continuity of Care in medicine but the fragmented, insurance-driven and siloed way that most Americans access healthcare makes continuity a nearly impossible goal to achieve.  Being able to provide continuity is not so much based on the will of the doctor, but the structure they are working in.  For starters, most doctors have very little control over how they work both in terms of how their time is allocated and what they must prioritize within that time.  Autonomy through DPC uniquely enables physicians to offer high continuity of care and the benefits are tremendous, to both the doctor and the patient.  

Here is the definition of Continuity of Care by the AAFP  (bold emphasis is mine) 

Continuity of care is concerned with quality of care over time. It is the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high quality, cost-effective medical care.

Continuity of care is a hallmark and primary objective of family medicine and is consistent with quality patient care provided through a medical home. The continuity of care inherent in family medicine helps family physicians gain their patients’ confidence and enables family physicians to be more effective patient advocates. It also facilitates the family physician’s role as a cost-effective coordinator of the patient’s health services by making early recognition of problems possible. Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review.

Continuity of care is facilitated by a physician-led, team-based approach to health care. It reduces fragmentation of care and thus improves patient safety and quality of care. Thus, the American Academy of Family Physicians supports the role of family physicians in providing continuity of care to their patients in all settings, both directly and by coordination of care with other health care professionals.

As I read that definition as a practice manager, I think about how hard that would be to accomplish in an insurance-centered practice, and how the structure of DPC makes continuity of care possible.  Patients value the continuity of care and whether you are a solo  doctor or part of a multi-physician/multi-location DPC clinic,  you can prioritize continuity of care in how you set up your practice.    

As a multi-physician DPC clinic, there are specific ways that we have set up Fischer Clinic to support continuity of care and I’ve shared some of those recommendations below. 

Continuity of care inside our office:

• Same day availability – Each physician tries to keep some time open every day for acute issues and we work people in when we need to depending on their issue – like this one.  
• Personal panel – All scheduled appointments are made with your own patients and your partners only see your patients for acute issues when you are out.  As Dr. Lapinskes’ says, he considers it a privilege to be able to be selfish with his patients and wants the be the one who cares for them.  
• Teamwork makes the dream work – Each physician has their own panel of patients that are managed by a team of two, i.e. the “Office of Ben Fischer” within Fischer Clinic is Ben Fischer, MD and Brittany Upchurch, RMA with their own dedicated phone and fax number.  
• Streamlined communications – Brittany is the main point of contact for all emails and faxes related to Fischer patients which reduces message hand-offs in the clinic.  She controls his schedule and manages communications during clinic hours so he can focus on the person in front of him and the phone rolls to his cell phone after hours.  Patients just need to remember one number for their doctor – day or night.
• Team Coverage – One member of Team Fischer, Team Lapinskes or Team Eberly is always there – – we strive to never have the physician and their clinical support staff gone at the same time.  That way, when a member calls, they are talking to someone who knows them, even if their doctor is out.  This arrangement also benefits the doctor who is out because their team member knows the patients well and can usually work with the covering doctor to resolve acute issues.  

Continuity of care outside of our office:

• Close the loop – Have a process in place where you track referrals and “close the loop”.  Like a good general contractor, in DPC you should have the time to make sure that your “subs” are doing right by your patients and that your patients are not slipping through the cracks.  There is the myth that electronic records make care coordination and sharing of information easier, but sometimes you just need to reach out to a person on behalf of your patient. 
• Build community among local physicians – Related to the above, work hard to make and keep good relationships with specialists in your area.  Don’t cut yourself off from medical professionals in your area.  One way we do this is to throw a “doctor party” twice a year where we invite physicians, we share patients with (or just docs that we like to have a Trophy beer with) – it’s really fun and doctors rarely get to go to medical gatherings that don’t have an industry sponsor or administrative agenda.  
• Meaningful Medical Meetings – Host “Morning Rounds” and invite community doctors that you want to know better.  Pick a particularly interesting case that has involved the greater medical community and invite those doctors to present the case with you.  Good coffee, breakfast snacks – great event!  
• Creative Collaboration – We have collaborated with the Triangle YMCA for over 10 years to host a wellness program every Fall and Spring where we go WITH our patients to a group workout exclusively for Fischer Clinic patients.  We have converted a few couch potatoes to workout warriors and created a great community of people who enjoy pursing health together.  For many of our aging patients, this program has given them a new connections to a place that they can go anytime for a class or social stimulation.  It’s a great cure for loneliness, among other benefits!  We love the Y and Dr. Fischer refers to it often in his exam room calling it, “the most important health facility in town.”  
• Inpatient care – Thanks to Dr. Lapinskes’ who never stopped following his own patients in the hospital, Fischer Clinic has admitting privileges at WakeMed, a Level I trauma center.  Each physician can admit and follow their own patients in the hospital and they do so, except on weekends when they have a rotating schedule among 5 physicians.  Not all DPC practices can offer this level of continuity, in part because it takes two to tango and many hospitals are not open to such an arrangement.  We are grateful for our partnership with WakeMed and see this admitting privilege as a true privilege – a way to advocate for and shepherd our patients in their time of greatest need.  Sometimes, when Dr. Fischer’s alarm goes off to round on a hospitalized patient before clinic he might rather stay in bed, but, like exercise, he rarely looks back with regret at the decision to go.  

In Continuity of Care Part II we will use the definition above to make a checklist for your current or future DPC practice to see if there are areas where you can improve structure your practice to support continuity.   If you have an insurance-based practice, as they say in the south, Bless Your Heart, because it’s going to be hard to honestly check off any of the items.