Continuity of Care
Extended consultation leads to substantial changes to all four inter-related policies
We asked. You responded. We listened.
The result is four inter-related continuity of care policies that better reflect the realities of practice, while retaining important requirements of the profession that further our goal of ensuring patient safety. As the burden on the health-care system increases, the information exchange across different parts of the health- care system becomes increasingly important.
The discussions generated by our extended six month consultation – in which we heard from individual practising physicians, a patient advisory group, physician leaders, key stakeholder organizations representing physicians, service providers, and individual members of the public – led us to make substantial changes to all four of the continuity of care policies.
The changes found favour with Council, who approved the policies at its September meeting. “These policies have been a long time in the making – work began in June 2016 — but its been worth every minute of effort,” said Dr. Brenda Copps, a Hamilton family physician and Chair of the policy working group. “The stakes were high, so we did not want to end up with policies that were rushed through. We needed to look at our expectations, and have others look at our expectations, from every conceivable angle. We did that and as a result we have policies that are workable, reasonable and very much in the public interest,” she said.
While elements of the draft policies received support from many respondents, concern that the expectations would unduly burden individual physicians, requiring them to provide solutions to broader system level issues emerged as a general theme in the feedback.
The College recognized from the outset that physicians can not be solely responsible for ensuring that continuity of care is achieved; health system-level factors that are beyond the control or influence of individual physicians also impact continuity of care. Our consultation process helped us identify those limits.
“During the consultation, respondents often offered more moderate steps that physicians could take to address continuity of care issues and we thought many of these steps seemed reasonable, while still retaining a focus on patient safety,” said Dr. Copps.
In addition to the external consultation, which garnered nearly 700 responses, the College also worked closely with stakeholders to find common ground and expand upon areas of agreement.
“At the heart of all our conversations was a shared understanding that continuity of care is an essential component of patient-centred care and is critical to patient safety,” said Dr. Peeter Poldre, President of the College and a member of the policy working group. “And we all understood the importance of information exchange across different parts of the health-care system. So it was never a discussion of “why do we need to do this?” but rather an exploration of how best to do this,” he said.
Below is a description of some of the changes made to the approved policies as a result of the consultation. The list is not exhaustive and physicians are advised to go online to read all of the expectations.
Availability and Coverage
The revised Availability and Coverage policy retains the spirit and intention of the draft policy but has been updated to ensure the policy better reflects the realities of practice while still setting an appropriate minimum standard.
Phone and voicemail
The policy requires physicians to have an office phone that is answered and/or allows voice mails to be left during regular office hours.
In response to feedback regarding the risks and potential burden associated with requiring physicians to allow voicemail messages to be left outside of operating hours, the revised policy has been narrowed to only require their use during business hours.
The draft policy included a requirement that physicians have a plan in place to coordinate patient care after-hours in order to minimize unnecessary visits to walk-in clinics or the ER. In response to feedback that this would unduly burden individual physicians and would be akin to requiring continuous access to care, the expectation has been revised to focus on informing patients about when and where to access appropriate care outside office hours.
Temporary Absences from Practice
The draft policy requirement that physicians make coverage arrangements for patient care during temporary absences has been refined to require physicians to take “reasonable steps” (what is reasonable depends on a variety of factors) to make coverage arrangements and to notify patients of appropriate access points to care if no arrangements can be made. This change was made in response to feedback that there are some instances where it simply will not be possible to arrange coverage.
Coverage for Critical Test Results
Physicians must ensure that critical test results can be received and reviewed at all times, including outside of regular office hours and during temporary absences from practice. The expectation was updated to clarify that the expectation only applies to critical test results and that the intent is to enable appropriate communication to the patient when immediate emergency intervention is needed; not to provide patient care directly.
The Managing Tests policy was revised to better focus on the most essential elements of test results management.
‘No News is Good News’
Recognizing the need to strike a balance between practice management issues and patient access to their test results, use of “No News is Good News” practices has been retained in the final policy. A small amendment was made to clarify that patients can also book an appointment to receive the results rather than call in.
The final policy states that ordering physicians must ensure that appropriate follow-up on test results received occurs. This means communicating the test result to the patient in an appropriate manner and taking appropriate clinical action in response to the test result.
In certain health-care environments, the ordering physician may not be the same physician who receives the test result (e.g., in an emergency department or a walk-in clinic). In these situations, ordering physicians must either delegate, assign or otherwise ensure that there is another person that is responsible for coordinating the follow-up or that there is a system in place to do so.
Transitions in Care
While the core expectations of the draft have been retained, a number of updates were made in response to practical challenges raised in the feedback.
Given strong support for the requirement that discharge summaries be completed in a timely manner, and calls to adopt a 48-hour (or shorter) timeline, the policy was amended to include a 48-hour completion requirement.
The final policy retains a requirement that consultant physicians acknowledge a referral within 14 days. The expectation, in general, received broad support from stakeholders. A minor revision was made to manage vacations, acknowledging that the ‘clock starts’ when physicians return from a temporary absence.
The core expectation of this policy – that physicians practising in a walk-in clinic must meet the standard of practice of the profession — is unchanged. This expectation applies regardless of whether care is being provided in a sustained or episodic manner. For example, physicians practising in a walk-in clinic must conduct any assessments, tests, or investigations that are required in order for them to appropriately provide treatment and must provide or arrange for appropriate follow-up care.
The draft policy included a requirement that physicians practising in a walk-in clinic send a record of each encounter to the patient’s primary care provider (and others, as appropriate). Feedback received identified practical limitations and consequences to operationalizing this requirement (e.g., administrative burden, incomplete information, increased ‘noise’, privacy concerns). In response, the policy no longer requires that information sharing be done as a matter of course, but rather only where the patient has requested that this be done or where it is a matter of patient safety. The policy acknowledges that the record may need to be shared through the patient, rather than directly to the provider.
System level changes will support, enhance College expectations
The expectations set out in the Continuity of Care policies aim to help close some of the gaps in the system, but system level changes are also needed in order to complement, support, and enhance the expectations the College has set out.
For example, we believe that breaks in continuity of care may be minimized by engaging patients in their care and providing them with the information and tools they need to navigate the system. And emerging technologies can help strengthen patient engagement. With patient portals becoming more common, patients will have greater opportunity to access their test results directly and in some cases, view their entire health record.
Changes in the way hospitals develop discharge summaries, with a focus on patient needs and comprehension, also has the potential for better supporting transitions from hospital to home and minimizing breakdowns. Further growth in terms of access to these emerging tools will help to support patients and facilitate continuity of care.
Engaging patients in their health- care and adopting technological solutions where they are reasonably available have the potential to meaningfully facilitate continuity of care. Doing so will complement physicians’ efforts in this regard and together many potential breakdowns may be avoided.