Continuity of Care (Part II): Put it into practice in YOUR practice
Written by Liz Fischer
Here again 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.
Sounds good, right – now let’s look at the bolded items as a use as a checklist to see where your practice may be able to improve Continuity of Care:
Continuity of Care Checklist:
- Quality of care over time –
CHECK – no “treat ‘em and street ‘em” in DPC – you can get to know you patient well over time with unrushed appointments and availability when they need you
- Cooperatively involved in ongoing health care management –
CHECK – so easy to have share decision making without the metrics that drive physicians to push medications for chronic conditions
- Shared goal of high quality, cost-effective medical care –
CHECK – although the cost-effectiveness is for the benefit of the patient, not the 3rd party payer (unless the 3rd party payer is one of our self-funded small businesses and we love to help them spend their healthcare dollars wisely)
- Helps physicians gain their patients’ confidence –
CHECK – DPC physicians have time to earn the confidence of their patients and patients have the peace of mind that their DPC doctors work for patients and are not influenced by perverse financial incentives
- Enables family physician to be more effective patient advocates –
CHECK – you actually have time to call the specialist, send a thoughtful referral and fight (when necessary) with their insurance
- Facilitates the family physician’s role as a cost-effective patient advocate by making early recognition of problems possible –
CHECK – Here’s a specific example of a cost-effective way to recognize a problem early – – offer a $4 urinalysis with the annual physical. This is certainly cost effective and can help to identify an early problem but stopped being routinely covered by most insurance companies for physical labs.
- Long-term patient-physician partnership in which the physician knows the patient’s history from experience –
CHECK – When people say that DPC doctors are exacerbating the physician shortage – my question is – Just how many patients do you think one doctor can care well for? Or in this case, how many patients can you be in long-term partnership such that you know their history from experience? I would argue that you CANNOT know 2000-3000 patients well, but I have seen that you can know 700 well.
For example, Dr. Fischer’s side of an after-hours call that I might overhear since he started DPC typically goes something like this:
“Hi, Mrs. Smith, no you are not bothering me, what can I do for you?…
I’m sorry to hear you aren’t feeling well (followed by some specific questions of onset, severity, doctor questions, etc) …
the last time you had this I recall that (specific medication) worked well …
I’d be glad to call that in for you ..
oh you are at the beach – ok I will send it to the Morehead Dr. CVS now. Ok, call me back if you need me.”
I am always amazed that he rarely has to look anything up to handle after-hours calls including where their alternate pharmacy might be. Prior to DPC, when Dr. Fischer was on call for his group primary care practice, the after-hours calls were never patients that he knew well (sometimes even if he was technically their primary care doctor) and they rarely seemed productive. It seemed to me that he had little that he could confidently offer patients and often he was put in a position where he had to recommend the ER for medical/legal reasons based on what the patient said, even if he didn’t personally think an ER visit might be necessary.
Being on call before DPC was a pain and rarely left him or the patient feeling satisfied, but in DPC our members have benefitted greatly that they can not only get a doctor on the phone after hours, but that they get THEIR doctor who knows them well and can give them appropriate advice and often save them a trip to the ER. This continuity of care is a great hallmark of DPC and huge departure from what is possible in third party paid practices.
A familiarity of your patient’s medical history is essential to help make the next item on the list possible –
– The physician can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review –
CHECK – in DPC information integration is possible and as a patient this is one of the most valuable things that I want from my primary care physician. The ability to know me well and synthesize new information so that they can make the best recommendation for me. In his insurance centered previous practice, while seeing patients all day and often double-booked, Dr. Fischer was responsible for a mountains of clinical information that came from various sources and in various forms on the roughly 2500 patients for whom he was primary – specialists reports, notes from midlevels who saw his patients when he didn’t have room in his schedule, lab results, imaging reports, portal messages, requests for prior authorizations, helpful “care considerations” from insurance companies, call from patients who somehow had his cell phone, refill requests and there was no way process all of that information in a way that would be easily recalled without extensive review. Not to mention the billing driven note-bloat makes it nearly impossible to find what is clinically relevant in notes and reports. If you have lived or our currently living in that world, you should know that not being able to be on top of all of that information is not your fault or shortcoming. It is a fool’s errand that you were sent on by a broken system.
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.
Finally, AAFP confirms their support for the role of family physicians in providing continuity of care, but don’t beat yourself up, physician, if you are not in a structure that makes that easy to do. Continuity of care is valuable and valued by patients and physicians, but if you are trying to do it with 2000+ patients, then Like Lucille Ball in the wrapping department of the chocolate factory, you might say, “Ethel, I think we’re fighting a losing game”
