Your health is dynamic. Events happen, diseases wax and wane, and none of us can escape the process of aging. Your health is also complex. The human body has many systems, all of which interact with one another. Diagnosis and treatment is rarely straightforward. Tests are ordered, treatments are tried, and specialists get involved. It is most often an iterative process of trial and error.
This requires coordination, documentation, and follow-through by someone that knows you well. This is continuity of care. It is at the heart of primary care medicine, and the reason why all patients need a primary care doctor.
Components of Continuity of Care
Continuity of care can be broken down into three components:
Relationship continuity - This is having the same doctor over time - from phone call to phone call, visit to visit, and year to year. With time, this doctor begins to accumulate knowledge about you - your values, your passions, and your fears. Knowledge difficult to record in a chart, yet key to making good medical decisions.
Information continuity - This is the maintenance and distribution of your medical records. Medical care produces a mountain of information. Your health records need to be collected and accessible in a central location. Only with full access to complete information can your doctors make good medical decisions.
Management continuity - The complexity and dynamic nature of your health requires coordination. A single entity needs to assume accountability. An entity with infrastructure to monitor tests, treatments, chronic conditions, specialty consultations, and ensure follow-through.
From observational studies, patients with good continuity of care have better health outcomes. These outcomes include: greater patient satisfaction, increased adherence to medication, fewer ER visits, reduced hospital use, and even reduced mortality.
Poor continuity of care
Poor continuity of care, on the other hand, leads to fragmented care involving multiple providers. They have limited access to your records and unfamiliar with your case. A major criticism of current medical practice is poor continuity of care. It is widespread. Let me illustrate some examples of poor continuity of care:
The lost test result - A doctor orders a mammogram. A suspicious lesion is found and the report is faxed to the office. However, it does not make its way to the doctor's desk. The patient assumes the result is negative, not hearing back from the office. The office does not have a system in place that ensure follow-through of tests and test results.
The after-hours call - David has a long history of chest pain, extensively tested, and thought to be caused by anxiety. Over the weekend, he an episode and is only able to speak with the on-call doctor. Unfamiliar with his history, and unable to access to his chart, they don't want the risk, and advise him to go to the ER. The ER doctor, also unwilling to take the risk, admits David for further testing. This situation could have been easily avoided if David had spoken with his regular doctor initially.
The Executive Physical - The Executive Physical is a thorough yearly examination, frequently conducted in a city other than your own. (During my Internal Medicine residency at Mayo Clinic and Cleveland Clinic, I was involved in numerous such evaluations.) Many individuals rely on their Executive Physical physician as a replacement for their primary care doctor at home. This leads to poor continuity of care, as a different doctor is often assigned for each executive physical, and they are unavailable when you become ill between these check-ups.
Causes of poor continuity of care
There are several causes of poor continuity of care:
Unclear accountability - Continuity of care is shared between primary care doctors and specialists, it’s often unclear who is responsible.
Inappropriate incentives - Both primary care doctors and specialists are not incentivized to ensure continuity of care - it is not directly reimbursed. Instead, they are reimbursed for more offices visits, more tests, and more procedures. It's better to pass the responsibility back or forward to the other doctors in the case.
Inadequate Resources - Most primary care doctors do not have adequate time or personnel to ensure continuity of care.
Poor patient accessibility - Patients often are aware of poor continuity of care but are left powerless due to their lack of access to the practice. Often, they can't even get a callback.
Concierge Medicine and Continuity of Care
The Concierge Model of medicine is the ideal practice model for optimal continuity of care. My practice does not suffer from any of the above causes of poor continuity of care.
Clear accountability - In my practice accountability for continuity of care is clear. I am in charge of your case, and I always assume accountability.
Appropriate incentives - The Concierge Model incentivizes me to ensure you are in good health. Good continuity of care is an essential part of your health.
Ample resources - With far fewer patients than a typical practice, my staff and I are never overwhelmed and can take on even the most complex cases.
Direct access - Patients are encouraged to assist with continuity of care. They can reach me directly via cell phone and my staff via phone. We have no answering machine and someone always picks up.
With this my practice excels in all three components of continuity of care:
Relationship continuity - I do not delegate your care to subordinates. I take care of you directly. Knowing you and your values and preferences allows me to help you make better medical decisions. I am always there to bridge the gap between you and the rest of the medical world.
Informational continuity - My staff and I have ample time to retrieve, collate, and share your health records. Old records are retrieved from prior doctors. Current records are retrieved from specialists and facilities. All are stored and maintained in your electronic medical record. Outside facilities requiring records are handled expediently.
Management continuity - With direct access to me, you and I will ensure follow-through with tests, treatments, and specialty referrals. To assist us, I use automated features of the electronic medical records, such as automated reminders and drug interaction checkers.
Instead of fragmented care involving multiple providers with limited access to your records and unfamiliar with your case, my Concierge practice ensure a smooth continuity of care with a central accessible provider taking charge and ensuring follow-through.
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