Continuity as a multi-dimensional concept

As efforts to define continuity in health care progressed, the dichotomy that had emerged in the conceptual models of continuity of care during the eighties created growing confusion rather than a synthesis of opinion. Ideas of multi-dimensional models of continuity that brought together aspects of timeliness, communication and the development of trust were already in circulation. In the mid-seventies Hennen had described four dimensions of continuity in family practice: “chronological, geographical,

interdisciplinary, and interpersonal”. (Hennen, 1975) While Mary-Anne Test’s multi-

dimensional model for continuity in mental health care incorporated a further, cross- sectional, element:

“At any given time-point in a chronically mentally ill person’s treatment, the person must be involved in a system of care that is comprehensive and integrated”

(Test, 1979)

In 1980, Rogers and Curtis acknowledged the lack of consensus in the emerging conceptual frameworks by publishing a review of the many different phenomena in the care process to which the term “continuity” had been applied. (Rogers and Curtis, 1980) They acknowledged that the term continuity was being used in different ways by different researchers and called for “the establishment and agreement of a definition”. However, their re-examination of the issues did not solve the problem, and this may be the reason why their paper is less frequently cited than the editorial by Barbara

Starfield that appeared in response to it. (Starfield, 1980) “Continuous Confusion”, pleaded for a standardisation of terms, and for clarity in their use and application when describing the concept of continuity. In particular she argued for the distinction

between “continuity” and “longitudinality” that had been made by Rogers and Curtis in their paper. Longitudinality, Starfield proposed was:

“…a phenomenon involving both the availability of a regular source of care (place or professional) and a decision, by the patient, to seek care from that source whenever care is needed.”

(Starfield, 1980)

In this definition, longitudinality implies the establishment of a long-term relationship that is independent of a specific health problem; achievement and maintaining longitudinality is under the control of the patient. Continuity is thus separated from longitudinality and characterised as a structural element of care, largely controlled by the care provider, which provides “a mechanism to ensure that problems are

adequately followed up from one visit to the next”. Starfield’s proposals were aimed at

clarifying the focus of research in order to move things forward and, although based on the nature of family practice, they do attempt to draw in wider provision beyond the primary care sector by specifying that continuity should extend to “those aspects of

secondary and tertiary care that involve management of an illness”.

Leona Bachrach’s conceptual analysis of continuity in relation to care for chronic mental health patients did not separate longitudinality and continuity in the way in which Starfield had proposed. (Bachrach, 1981) It did, however, continue the theme of continuity as a multi-dimensional concept and included a longitudinal aspect as one of its elements. Her paper, published in 1981, has become one of the seminal “continuity of care” papers. In it she proposed a seven dimensional model based on a systematic observation of records of admissions to psychiatric services in one area of the USA over a period of several years. By summarising and explaining how basic elements of continuity could be defined with specific reference to chronic mental services, she too hoped to reduce the confusion that had been described by Starfield (and Rogers and Curtis) a year earlier. The seven dimensions proposed by Bachrach were the temporal dimension (longitudinal continuity), individuality; comprehensiveness; flexibility;

relationships; accessibility and communication. However, whether the extra

dimensions of continuity led to greater clarity is debateable, and her actual definition of continuity was in essence very similar to that of Stephen Shortell (Page 29).

“Continuity of care may be understood as a process involving the orderly, uninterrupted movement of patients among the diverse elements of the service delivery system”.

Further conceptual reviews appeared in the eighties but without any emergent

consensual agreement, and this trend continued throughout the nineties bringing with it a plethora of definitions. Many of these were operationalisations of existing concepts in relation to measurement and, while there was commonality in their terminology, there was considerable divergence in the various aspects of care to which the terms were applied. Needless to say, no real progress towards developing a consensus in the understanding of continuity in health care was achieved despite the plea for clarity that Starfield’s earlier editorial had made.

At the end of the 20th _{century, the NCCSDO scoping exercise sought to synthesise all} the existing ideas and concepts by conducting a full review of the evidence. The output of this work was the Freeman model of continuity, a multi-axial definition which draws to a large extent on the multi-dimensional models of Hennen and Bachrach. (Hennen, 1975, Bachrach, 1981) It is reproduced here, (in Figure 1.a below), as it was

presented in the final report to the NHS NCCSDO. (Freeman, 2000)

Figure 1.a The Freeman model of continuity of care

Scoping Definition of the elements of continuity of care

At a minimum a definition of continuity of care should include the following elements. 1 The experience of a co-ordinated and smooth progression of care from the

patient’s point of view (experienced continuity). To achieve this central element the service needs:

2 excellent information transfer following the patient (continuity of information) 3 effective communication between professionals and services

(cross-boundary and team continuity)

4 to be flexible and adjust to the needs of the individual over time (flexible

continuity)

5 care from as few professionals as possible consistent with other needs

(longitudinal continuity)

6 to provide one or more named individual professionals with whom the patient can establish and maintain a therapeutic relationship (relational or personal

continuity).”

The ongoing debate about continuity of care gathered momentum and, shortly after the publication of the Freeman report, the Canadian Health Services Research Foundation (CHSRF) Workshop provided another forum for discussion. The product of this

exercise was the CHSRF report which further synthesised the ideas that had emerged from the SDO scoping exercise. The successor to the Freeman report emulated Starfield’s plea to reduce the confusion that was still apparent in the conceptual framework of continuity in healthcare. The workshop resulted in a proposal for a new model of continuity of care which comprised three types of continuity (see Figure 1 b below) with two core elements: that it is received and experienced by an individual, and that care is provided over time. (Reid, 2002)

Figure 1.b The CHSRF model of continuity of care

Informational Continuity: the transfer and use of information, and accumulated knowledge

Managerial Continuity: the provision of timely, complementary and responsive services

Relational Continuity: the maintenance of patient-provider relationships and consistency of personnel

A number of smaller reviews have been published since 2001 which have built on the CHSRF conceptual model, some have focused on one particular aspect of continuity of care. Krogstad et al. for example based their 2002 definition on the informational dimension of continuity and the way it is integrated within the structure and process of care:

“Continuity behind the scenes is based on shared information and

responsibility, and it is structurally supported by implementation of routines such as shift reports, written guidelines and regular meetings.”

(Krogstad et al., 2002)

Saultz took the theme of interpersonal (relational) continuity as a basis for his review, and offered a hierarchical definition based on three levels of continuity of care: Informational; longitudinal and interpersonal. (Saultz, 2003) These were intrinsically the same as the three types of continuity that had been proposed in the CHSRF report. However, he attested the importance of interpersonal continuity as fundamental to his model, based in family medicine, as this he argued was the means by which the other aspects of continuity were achieved. However, other researchers have questioned whether models of continuity based on interpersonal relationships are sustainable in

modern general practice. The emergence of larger group practices, flexible work patterns and more GP specialisation for example all contribute to a shared model of care in which the maintenance of relational continuity becomes harder to achieve.