Continuity of care, described as the connected and coordinated care that patients receive while moving between providers and through the healthcare system,1 is critical in delivering safe and effective patient care. Responsibility for maintaining continuity of care does not rest solely with physicians: patient engagement also helps strengthen this aspect of their medical care.
Professional obligations
All medical regulatory authorities (Colleges) have policies that outline expectations related to continuity of care, including physician availability and coverage, managing tests, transitions in care, and specific issues when working in walk-in clinics.2
While College expectations may vary, they generally focus on elements of care within physicians’ control. The Colleges recognize that multiple healthcare providers are typically involved in a patient’s care, and that continuity of care is affected by system factors.
As virtual care becomes a more accessible and common model of care in Canada, the Colleges continue to update their policies about providing care using different modalities.3 It is also widely accepted that updating technological infrastructure (e.g. province-wide electronic health records) facilitates the provision of care among multiple providers.
Case study: A lost referral
A 62-year-old woman is followed by her family doctor for chronic obstructive lung disease. She experiences a deterioration in her symptoms, and her family doctor writes a consultation note to a respirologist advising of the clinical changes. The respirologist orders a CT scan and pulmonary function tests. The results are unremarkable and show only a small deterioration in her pulmonary function tests (PFTs), and the patient is booked for a return visit in one year.
Less than six months after this first appointment with the respirologist, the patient’s symptoms progress significantly, and the family doctor prepares a referral to the respirologist. However, the referral becomes lost, and the family doctor does not follow up to confirm that the patient was seen by the respirologist.
At the scheduled one-year follow-up with the respirologist, a bronchoscopy is performed, at which point the patient is diagnosed with small cell lung cancer. She puts forward a complaint to the College about her family doctor.
After review, the College cautions the family doctor about inadequate medical record keeping and the failure to follow up on important referrals. While it is impossible to know whether the delay affected the patient’s long-term prognosis, the College concludes that the tumour might have been responsive to earlier treatment.
Managing tests and referrals
As the case study illustrates, a well-organized record-keeping system is crucial. Courts have found that when ordering a test, the physician must have a system that reasonably ensures referrals and results are received, and then communicated to patients in a timely manner.
Encouraging open dialogue with patients regarding tests—from ordering to tracking to follow-up—is important. This includes letting patients know why a test may be important, and encouraging patients to follow up if they are worried about a test. Since patients often think “no news is good news,” they should also be encouraged to follow up if they are not contacted by the referring physician’s office within an established period of time.
Transferring care
Patient care may need to be transferred to another physician at the end of a shift or when stepping away from a patient’s care, referring to a specialist, or discharging a patient from hospital. If not properly managed, these transitions in care can create breakdowns in continuity of care.
Communication is key when transferring care. Physicians should ensure patients are informed about who is involved in their care. Within a hospital or institution, it is also important to coordinate with other members of the patient’s care team, including confirming who has primary responsibility. When discharging a patient into the care of a primary care provider in the community for follow-up, physicians should take reasonable steps to confirm that the patient has a family physician or primary care provider.
Discharge summaries
For more information on discharge summaries, see the CMPA Good Practices section “Documentation and record keeping” (then go to “What to document – discharge summaries”).
For patients who have been hospitalized, timely completion and distribution of discharge summaries is important for communicating information about a patient’s care to providers involved in follow up and who are part of the circle of care. In a clinical or private office setting, there are potential hurdles when placing referrals for specialist opinions or transfers of care. Most Colleges have requirements for the minimum amount of information to be included in referrals and consult reports.4 Some Colleges also impose specified timeframes for responding to referrals5 and communicating appointment information directly to patients.6
Availability and coverage
Physicians have an obligation to ensure patients receive appropriate care when they are unavailable, though it is recognized that, in some areas, managing continuous coverage for patients can be challenging.
Physicians should know the expectations of their College regarding availability and on-call coverage. While some Colleges require physicians to directly provide or arrange for continuous care outside of regular office hours,7 others limit the expectation to informing patients about when and where they can access appropriate care outside of regular office hours.8
The bottom line
- Be aware of your College’s expectations for continuity of care.
- Engage patients in their care and communicate openly with other healthcare providers to reduce the potential for breakdowns in continuity of care.
- Develop and implement robust procedural systems that facilitate coordination among care providers, notably for managing tests and referrals, patient transfers, and availability and coverage.
References
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College of Physicians and Surgeons of Ontario, and Citizen Advisory Group. Continuity of Care: Guide for Patients and Caregivers [cited 2021 May]. Available from: https://www.cpso.on.ca/admin/CPSO/media/Documents/public/public-information/coc-guide/coc-guide-patients-caregivers.pdf
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College of Physicians and Surgeons of Ontario. Continuity of Care – Approved Policies [cited 2021 May]. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Continuity;
College of Physicians and Surgeons of Newfoundland and Labrador. Standard of Practice: Continuity of Care 2021 [cited 2021 May]. Available from: https://www.cpsnl.ca/web/files/2021-03-17%20-%20Continuity%20of%20Care%20(2021)%20-%20SoP.pdf;
College of Physicians and Surgeons of Saskatchewan. Policy - Medical Practice Coverage [cited 2021 May]. Available from: https://www.cps.sk.ca/imis/CPSS/Legislation__ByLaws__Policies_and_Guidelines/Legislation_Content/Policies_and_Guidelines_Content/Medical_Practice_Coverage.aspx;
College of Physicians and Surgeons of British Columbia. Practice Standard: Care Coverage Outside Regular Office Hours [revised 2021 Feb 25; cited 2021 May]. Available from: https://www.cpsbc.ca/files/pdf/PSG-Care-Coverage-Outside-Regular-Office-Hours.pdf
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Canadian Medical Association. Report of the Virtual Care Task Force [2020 Feb; cited 2021 May]. Available from: https://www.cma.ca/sites/default/files/pdf/virtual-care/ReportoftheVirtualCareTaskForce.pdf
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For example, College of Physicians and Surgeons of Newfoundland and Labrador. Standard of Practice: Continuity of Care 2021 [cited 2021 May]. Available from: https://www.cpsnl.ca/web/files/2021-03-17%20-%20Continuity%20of%20Care%20(2021)%20-%20SoP.pdf.
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For example, College of Physicians and Surgeons of Ontario. Policy: Transitions in Care [2019 Sept; cited 2021 May]. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Transitions-in-Care
College of Physicians and Surgeons of Alberta. Standard of Practice: Referral Consultation [updated 2017 Jan; cited 2021 May]. Available from: https://cpsa.ca/physicians/standards-of-practice/referral-consultation/
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College of Physicians and Surgeons of Ontario. Policy: Transitions in Care [2019 Sept; cited 2021 May]. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Transitions-in-Care
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For example, College of Physicians and Surgeons of Saskatchewan. Policy – Medical Practice Coverage [cited 2021 May]. Available from: https://www.cps.sk.ca/imis/CPSS/Legislation__ByLaws__Policies_and_Guidelines/Legislation_Content/Policies_and_Guidelines_Content/Medical_Practice_Coverage.aspx;
College of Physicians and Surgeons of British Columbia. Practice Standard: Care Coverage Outside Regular Office Hours [revised 2021 Feb 25; cited 2021 May]. Available from: https://www.cpsbc.ca/files/pdf/PSG-Care-Coverage-Outside-Regular-Office-Hours.pdf;
College of Physicians and Surgeons of Alberta. Standard of Practice: Continuity of Care [updated 2015 Jun 11; cited 2021 May]. Available from: https://cpsa.ca/physicians/standards-of-practice/continuity-of-care/
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For example, College of Physicians and Surgeons of Ontario. Policy: Availability and Coverage [2019 Sept; cited 2021 May]. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Availability-and-Coverage
