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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.5 Continuity of care

Our practice provides continuity of care for its patients.

Criterion 1.5.1

Continuity of comprehensive care and the therapeutic relationship

Our practice provides continuity of comprehensive care to patients.

Indicators

► A. Our staff can describe how patients can request their preferred GP when making an appointment or attending our practice.

► B. Our practice team can describe how we encourage continuity of comprehensive care.

Explanation

Key points

There are several types of continuity:

  • the sense of affiliation between the patient and their doctor (‘my doctor’ or ‘my patient’), sometimes called ‘relational continuity’
  • consistency of care by the various people involved in a patient’s care (ie. not working at ‘cross purposes’), sometimes called ‘management continuity’
  • continuity of information across healthcare events, particularly through documentation, handover and review of notes from previous consultations, sometimes called ‘informational continuity’.

Provider continuity and patient outcomes

A systematic review by van Walraven et al1 provides evidence that increased provider continuity is associated with improved patient outcomes and satisfaction. Research undertaken in the US2 found that discontinuity of primary care physician visits is associated with patients seeing more different specialists, which in turn is associated with higher costs, more procedures and more medications.

Continuity within general practice

By the RACGP’s definition, general practices provide patient centred, continuing, comprehensive, coordinated primary care to individuals, families and communities and it is important that patients have the opportunity to develop an ongoing relationship with the practice, GPs and staff members. One way to demonstrate continuity of care is through patient health records that show patients attending the practice over time.

Continuity is the degree to which a series of discrete healthcare events is experienced by the patient as coherent and connected and consistent with the patient’s medical needs and personal context. Continuity of care is distinguished from other attributes of care by two core elements: care over time and the focus on individual patients. This criterion focuses on those two elements: the attendance of individual patients, over time, at the general practice.

Doctor–patient relationship

Relational continuity is a sustained relationship between a single practitioner and a patient (or sometimes more than one practitioner and a patient) that extends beyond individual consultations or episodes of illness. This can be described as a sense of affiliation between a patient and their doctor (‘my doctor’ or ‘my patient’). It is often viewed as the basis for continuity of care. Many general practices now work with other health professionals such as practice nurses, mental health nurses, allied health professionals and Aboriginal health workers as part of the practice team. The principles in this criterion relating to the patient’s right to see their preferred GP also apply to appointments with other members of the clinical team.

System for supporting preferred relationships

It is acknowledged that some practices do not have formal, written appointment schedules by which patients are booked to see their preferred GP or another member of the clinical team. However, such practices need to be able to demonstrate that they have a system or a rationale for determining how patients may see the GP of their choice. It is noted that within Aboriginal medical services, continuity of comprehensive care may involve a wider set of relationships, extending from the patient to the GP, Aboriginal health workers and practice nurses.

Courtesy notifications

When a GP ceases to be a member of the practice team, it is courteous to notify the GP’s regular patients. Depending on the circumstances, it may be appropriate to advise patients how they can access their own health information if required.

Services providing care outside normal opening hours

The therapeutic relationship between the patient and the GP who usually provides their continuing comprehensive healthcare needs to be preserved. Indicator A is not applicable to services which provide care outside normal opening hours.

Standard 1.5 Continuity of care

Our practice provides continuity of care for its patients.

Criterion 1.5.1

Continuity of comprehensive care and the therapeutic relationship

Our practice provides continuity of comprehensive care to patients.

In a nutshell

Continuity of care refers to the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers. Such continuity is associated with improved patient health outcomes and satisfaction. There are three types of continuity in healthcare, each dealing with a different level at which health services provide ongoing care to patients:

  • 
the continuing relationship between patients and their doctors, known as relational continuity
  • 
the consistent way in which different health professionals provide healthcare to the one patient, known as management continuity
  • 
the continuity with which information about patients is communicated and documented by healthcare professionals, known as information continuity.

You could address all three types of continuity in your response to this criterion. Aspects of Criterion 1.4.1 Consistent evidence-based practice are also relevant here.

Key team members

  • Health service manager
  • All clinical staff
  • Administrative staff

Key organisational functions

  • Policies and processes for the appointment system
  • Rotation and rostering system for availability of GPs and clinical staff
  • Patient information management system
  • Policy and processes for access to patient information
  • Patient consent policy
  • Patient communication policy and processes
  • Patient confidentiality and privacy policies
  • Electronic communications policies

Indicators and what they mean

Table 1.9 explains each of the indicators for this criterion. Refer to Criterion 1.5.1 Continuity of comprehensive care and the therapeutic relationship of the Standards for general practices for explanations of some of the concepts referred to in this criterion. 

Table 1.9 Criterion 1.5.1 Continuity of comprehensive care and the therapeutic relationship
IndicatorWhat this means and handy hints
▶ A. Our staff can describe how patients can request their preferred GP when making an appointment or attending our practice. Your patients have choices when they request an appointment with their preferred GP. These choices are reflected in your health service’s:
  • processes to ensure that, as often as possible, patients can see the doctor they ask to see
  • appointment system, with an appropriate rostering and rotation system for GPs
  • appointment system, which endeavours to allow patients’ choice of GP and times they can see them.
You can further assist patient choice by prominently displaying easily understandable information notices about GPs and their availability, and offering advice that, for practical reasons, it won’t always be possible to meet patients’ requests to see a preferred GP.
▶ B. Our practice team can describe how we encourage continuity of comprehensive care. Continuity of comprehensive care means that your health service has systems in place for three different types of continuity:
  • relational continuity, where your service offers information and choice to patients about the GPs they could ask to visit. This can include an appointment system and information about GPs in the reception and waiting rooms. Relational continuity can extend to other clinical staff – for example, nurses and Aboriginal health workers
  • management continuity, where your service has protocols and policies in place that ensure consistency of care between different clinical staff members. This can be demonstrated through strategies such as:
    •  regular clinical-team meetings that discuss individual patient care
    •  up-to-date record keeping and case notes on patient records
    •  alert systems, communications systems and protocols that enable effective communication between clinical staff members about patient care
  • informational continuity, where your service has handover and review protocols between healthcare providers. Your clinical staff are also required to keep up-to-date consultation notes in patient health records. Also helpful in multidisciplinary health services that provide out-of-hours care are policies and protocols that set out how patient information is to be recorded and by whom. Regular clinical-team meetings can also encourage informational continuity for complex case patients.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure appropriate continuity of care for its patients and community. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The service recognises that an essential element for its patients is the relationship they have with their GP and other health service providers. It also acknowledges that trusting relationships take time to be established and need to be respected. The service therefore does whatever it can to make sure all patients get to see the GP or health providers that they have this good relationship with.

Reception staff understand the importance of relationships in maintaining continuity of care. They also behave in a friendly, respectful way to every patient, and try to establish relationships of trust that reinforce those developed by patients with their health providers. Sometimes reception staff offer to make appointments for patients with the external health providers to whom they have been referred, because they know some patients find doing this themselves to be difficult.

GPs and other health staff members have individual appointment books and there is a rotating roster for GPs on walk-in appointment mornings; this is to facilitate patient requests for appointments with a preferred GP. An audit of patient health records will show that most active patients generally see the same GP, clinical staff member or health worker.

The service’s staff actively use the recall and reminder system in the patient management and clinical software, and pop-up reminders alert health staff about scheduled events for individual patients.

An audit of patient health records will show that patients with complex or chronic health needs have active management plans in place. These are managed by a care coordinator, who is employed by the service.

Notices are put in the waiting room listing when visiting doctors or allied health staff are due to visit.

Showing how you meet Criterion 1.5.1

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Have individual appointment books for GPs, nurses, allied health and Aboriginal health workers.
  • Rotate GPs on walk-in sessions.
  • Ensure health records show ongoing care provided by a particular GP where possible.
  • Have notices in the waiting room if a GP is on leave, including details of when that GP is due back.
  • Ensure that health records for ongoing or long-term patients show that they have been coming to the service for more than 2 years, demonstrating their preference for the health service.
  • Maintain minutes of clinical-team meetings.
  • Run a recall and reminder system.
  • Keep a communications book.
  • Document management plans in patient health files, especially for those with complex or chronic health problems.
  • Maintain a clinical handover system.
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