Continuity of Care

Although no references earlier than 1965 appear in a Medline search, in the last 20 years continuity of medical care has been increasingly acknowledged and advocated. Studies have sought to define the term and evaluate the benefits of continuity. Such studies have evaluated continuity, using a model based on the style of practice. Some of the earliest studies were reported in nursing and public health journals. Later efforts have sought to evaluate hospitalization emphasizing the patients' perception of care and outcomes. The multidimensional nature of these studies leaves most issues surrounding continuity unresolved, although remarkable progress has been achieved.

This entry reviews the past, considers the present, and explores the future for answers to the value of continuity. Humans have been described as pack or herd animals, showing a degree of cultural constancy and reliability, as opposed to loners. This craving isn't restricted to medicine or personal physicians. It pervades all aspects and facets of life: People like to use the same hairdresser or grocer, eat at the same restaurants, attend the same church, vote for the same political party, hire the same lawyer; many buy their automobile from the same dealer for years. This continuity represents brand loyalty, with its appreciation of a predictable product, dependable availability, and less effort expended in decisions. Thus humans may instinctively also seek continuity when selecting someone for advice on health issues, one of the most important aspects of life. This decision to choose continuity, like others, frequently occurs after experiencing an urgent need of such services.

Many reminisce about the “good old days” of medical practice, the romanticized Norman Rockwell model. That model still lives, in this era, with young, dedicated physicians caring and devoted to both patients and science. The tools for continuity have changed with the advent of new technology. The age of specialization, sometimes leading to fragmentation, created a drastic upheaval of our notions of continuity of medical care. Such concerns led Donald Berwick, M.D., referring to his wife's recent hospitalization, to comment, “Before, I was concerned; now, I have been radicalized.” In this chain of incidents, Berwick, a tireless health care reformer, witnessed firsthand the frailties of the system. Continuity, by definition, must include follow-through, monitoring, appropriate course adjustments, and [Page 102]outcome management—attributes Berwick found lacking in this health care crisis.

A face-to-face encounter, though valuable, is not required for continuity, but an in-depth, organized, longitudinal, integrated record is essential. In the United States, records are usually stored as bits and pieces of fragmented data. A laboratory bit or two here, a vital sign there, and historical information buried somewhere else, however, hardly constitute a continuum. The fragmented pieces of text today are often so voluminous that important facts may escape notice, buried deeply in a forest of data. Here competing needs collide, the needs for both information continuity and for privacy. Reconciling these concerns presents a challenge.

The team delivery system (TDS), a complementary restructure of our health care, has the potential to advance our continuity. Whereas teams gained early favor in Japanese manufacturing, the TDS had a slow start in medicine, and few outcome studies exist. In the manufacturing and service sectors, self-directed work teams are small groups of workers, with complementary skills, who share a common approach to basic purpose, performance goals, and mutual accountability. Such teams typically feature empowered members who learn and thrive in open, encouraging environments. Research in other industries has shown that self-directed work teams work effectively to improve results in quality and outcome.

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