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Advice to the Profession: Continuity of Care

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Advice to the Profession companion documents are intended to provide physicians with additional information and general advice in order to support their understanding and implementation of the expectations set out in policies. They may also identify some additional best practices regarding specific practice issues.

Continuity of care is an essential component of patient-centred care and is critical to patient safety. While it can be understood in a number of ways, central themes often include the importance of patient experiences with the health care system being connected and coordinated, and the importance of information exchange across different parts of the health-care system.

In order to set out expectations pertaining to continuity of care, the College has developed a set of inter-related policies addressing a range of issues. They are: Availability and Coverage, Managing Tests, Transitions in Care, and Walk-in Clinics. This document is intended to help physicians interpret their obligations as set out in these policies and to provide guidance around how these obligations may be effectively discharged. It also provides some background information on the scope of these policies and the role of patients, technology and the health-care system in facilitating continuity of care.

Facilitating Continuity of Care

The Role of Physicians and the College

Physicians hold a prominent and important role in the health-care system and in turn are key facilitators of continuity of care. However, the College recognizes that physicians are not solely responsible for ensuring that continuity of care is achieved as often there are health system- level factors that are beyond the control or influence of individual physicians that impact continuity of care.

The College’s approach to helping minimize breakdowns in continuity of care is to focus on the issues or elements of continuity of care that are within the control or influence of physicians.

The Importance of Patient Engagement and Technology

Patients have an important and growing role to play in facilitating continuity of care, as actions they take may contribute to or help prevent breakdowns in continuity of care. Engaging patients in their care and providing them with the information and tools they need to navigate the system may help minimize patients falling through the cracks.

Technology has an important role to play in facilitating continuity of care as well, and there are already many ways in which technological solutions can help. For example, there are technologies that may assist with test results management, facilitating access and/or coverage, facilitating information exchange between health-care providers, and improving transitions in care, especially as it pertains to handovers within health-care institutions, hospital discharges, and the referral and consultation process.

Both 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 also complement physicians’ efforts in this regard and together many potential breakdowns may be avoided.

An Evolving System

Preventing all breakdowns in continuity of care cannot be achieved through physician actions alone. The expectations set out in the continuity of care policies aim to help close some of the cracks in the system, but system level changes are also needed in order to complement, support, and enhance the expectations the College has set out.

Fortunately, continuity of care is an issue that is driving a lot of the change we are seeing in our system and many of our partners in the health-care system are also working to support a coordinated and connected health-care system.

While most physicians are using electronic medical records (EMRs), there is still work being done to ensure these different systems are talking with one another and eventually work together so that patients effectively have one record that follows them wherever they go. Significant strides have already been made on this front. Physicians looking to enhance their practice can register for a ONE ID account through the College’s Member’s Portal to access existing digital health services available from eHealth Ontario such as the clinical viewer and ONE Mail.1 ONE ID also enables access eConsult2 which seamlessly and securely connects, for example, family physicians with specialists in order to seek their opinion on specific patient issues in a direct and timely manner and, increasingly, directly through their EMR.

Similarly, patient portals are becoming more common, allowing patients 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 that occur and is an approach that is being adopted across Ontario.3 Further growth in terms of access to these emerging tools will help to support patients and facilitate continuity of care.

Additionally, changes in the way the system is resourced and how incentives for health-care providers are used all have the potential to bring positive change. For example: hospital fast track systems4 in emergency departments can help staff quickly treat patients; improved resources and changes to incentives may help support increased access to appropriate after-hours care or care during physician absences from practice; a centralized referral and consultation process may help reduce wait times and lost referrals; and enhancements to tools like Telehealth that help patients decide where and when to seek care. These are all examples of a system that is or can further evolve to better support patients and minimize breakdowns in continuity of care.

Availability and Coverage

Why has the College set out expectations relating to physician availability and making arrangements for care when physicians are not available?

Continuity of care does not mean that individual physicians need to personally be available at all times to provide on-demand care and continuous access to patients. Doing so would negatively impact the quality of care being provided and compromise physician health. However, in order to facilitate continuity of care and minimize risks to patient safety, the College has set out expectations for physicians, recognizing that their role in facilitating continuity of care includes being available and responsive to patients and health-care providers involved in their patients’ care and helping patients navigate the health care system and access appropriate care when their physicians are unavailable.

Why does the policy require physicians to be available by phone? Why not through other means of communication? How does this expectation apply to group practices, institutions or department based practices?

Good communication and collaboration are fundamental components of high quality care, but are not possible if patients and health-care providers are unable to contact physicians. While recognizing that physicians may offer a variety of ways to communicate with patients and other health-care providers, the policy sets out expectations about being available by phone and voicemail as this is still the default mode of communication for many and possibly the only mode of communication that some patients may have access to.

Physicians practising as part of a group practice or within an institutional or department-based environment may rely on a central and shared phone and voicemail to discharge this expectation.

Does the policy require physicians to arrange for after-hours coverage?

No. The policy requires physicians to inform patients about appropriate access points to the health care system when in need of after-hours care. This may include any arrangements they have made with other providers or it may mean directing patients to, for example, Telehealth or the emergency department where it would be appropriate and reasonable to do so. It’s important to note that depending on the nature of a physician’s practice, the legal concept of duty of care may require taking additional steps to help patients access the right kind of care (e.g., post-operative follow-up, obstetrical care, etc.). What this means will depend on the physician’s practice type, and so physicians may wish to seek legal advice for further clarity.

The policy requires physicians who are going to be unavailable during temporary absences from practice to take reasonable steps to make coverage arrangements for patient care. What are reasonable steps?

As the policy notes, what is reasonable will depend on a variety of factors. In general, longer absences increase the risk to patients and will require additional effort on the physician’s part to make sure patients have access to appropriate care. In some cases it may be quite difficult to make coverage arrangements with another physician of the same specialty and whose practice is within a reasonable distance. As such, the policy recognizes that other options might be appropriate, including informing patients about appropriate access points such as the emergency department, where no other options are reasonably available.

Additional expectations are set out for managing test results, referrals, and information sharing during temporary absences from practice as these issues can be managed differently than providing direct care and pose additional risks to patient safety that are otherwise difficult to mitigate without coverage.

How can physicians support patients in accessing the right kind of care and supporting continuity of care when they are not available?

Patients have a role to play in managing their care. In particular, it’s important for patients to understand the value of seeing physicians with whom they have a sustained relationship and how this contributes to continuity of care. Physicians can help patients understand that, notwithstanding the convenience of going to a walk-in clinic or emergency department, if they are able to wait to see their own physicians, they may contribute to a more continuous care experience.

Physicians can also help encourage patients to develop a list of their medications and health conditions so that when they go to an emergency room, walk-in clinic, or other health-care provider providing coverage, they can share that information and support the provision of the best possible care.

Managing Tests

Should primary care providers be copied on test requisitions?

Where an ordering physician is not a patient’s primary care provider, it is generally good practice to copy the patient’s primary care provider on the requisition form so that they are kept in the loop regarding tests that are being ordered and the results that come in. Under the Personal Health Information Protection Act, 2004, physicians can generally assume that they have consent to share relevant information with the patient’s primary care provider unless the patient has expressly withdrawn consent.

That said, there may be instances where patients would not want a particular test result shared with their primary care provider and so it will be important for the ordering physician to consider whether express consent should be obtained. This is particularly true for physicians ordering tests in the context of a walk-in clinic and specific expectations regarding information sharing are set out in the Walk-in Clinics policy.

What is a critical test result?

A critical test result is one where the nature of the result is such that immediate patient management decisions may be required. The Ontario Association of Medical Laboratories’ Guideline for Reporting Laboratory Test Results sets out the criteria for how labs define a critical lab result and the necessary steps labs must take in response. The guidelines state that a ‘critical’ value is one that “shows a marked deviation from reference ranges, with no clear indication to the laboratory that these are expected deviations. Results of this nature may indicate a significant risk of a life-threatening event.” If in receipt of a critical result, the labs will call clinicians 24 hours a day, 7 days a week to report the result to facilitate prompt medical intervention if required.

The Canadian Association of Radiologists also sets out standards in their Communication of Diagnostic Imaging Findings. This standard provides guidance on when verbal or other direct communication with the referring or ordering physician is needed, including the detection of:

  • Conditions carrying the risk of acute morbidity and/or mortality which may require immediate case management decisions.
  • Disease sufficiently serious that it may require prompt notification of the patient, clinical evaluation, or initiation of treatment.
  • Life or limb threatening abnormalities which might not have been anticipated by the referring physician.

What does the Canadian Medical Protective Association (CMPA) say about managing tests, and specifically about what a physician should do if a test result is received in error?

The CMPA is a national organization and provides broad advice about a number of medico-legal issues. For Ontario-specific information, physicians are advised to look at the CPSO policy and advice document regarding managing test results. However, physicians may find this CMPA article helpful.

Transitions in Care

When should physicians have a discussion with the patient and/or those assisting in their care about being discharged from hospital?

Transitions from hospital to home present a number of challenges, and breakdowns in continuity of care may occur. A comprehensive discussion in advance of the patient’s discharge can help the patient or their caregiver understand how to manage the transition and any post-discharge care. Where possible, it’s helpful for this discussion to happen in advance of the discharge rather than waiting until just before the discharge. The more time patients and caregivers have, the more likely they are to process the information, ask questions, and prepare for the discharge. Waiting until just before the discharge to share important information may increase stress and anxiety for patients and caregivers.

Does the policy require discharge summaries to be transcribed and distributed within 48 hours? What are best practices for dictating discharge information and completing the discharge summary?

The policy does not require that the discharge summary be transcribed and distributed within 48 hours, as transcription and distribution processes are often beyond the control of individual physicians. Rather, the policy requires the most responsible physician to complete their component of the discharge summary within 48 hours of discharge. This aligns with the OHIP billing requirements and means, for example, that the physician has completed their dictation within 48 hours. While the policy requires that this be done within 48 hours of discharge, it’s generally considered best practice for physicians to complete their dictation at the time of discharge as doing so will contribute to the timely completion and distribution of the discharge summary.

Are there best practices that referring physicians can keep in mind to help reduce delays?

Even in the absence of a comprehensive database of all specialists, their respective speciality or sub-specialty, and information about whether a consultant physician is accepting patients, physicians can turn their minds to these issues prior to making a referral. Giving consideration to whether the patient’s condition(s) is (are) within the scope of practice of the consultant physician and whether that consultant is accepting patients will help minimize delays in the process. Similarly, when making referrals it can be helpful to give some consideration to whether the consultant physician’s practice will be accessible to the patient (e.g., the location of the practice, physical accessibility, etc.)

The policy requires that physicians track referrals that are urgently needed. What about other referrals?

While the policy requires consultant physicians to acknowledge referrals within 14 days from the date of receipt and urgently if necessary, referring physicians have a role to play in this process as well and can track to make sure the referral is received and acknowledged. While the policy sets our expectations for tracking urgent referrals, in the course of their practice physicians may identify non-urgent referrals that warrant a bit more attention as well. Generally speaking, best practice could involve a plan to do referral reconciliations every week or so, as a status check on any outstanding referrals.

The policy requires consultant physicians to acknowledge a referral in a timely manner, urgently if necessary, but no later than 14 days. What does the policy mean by “acknowledge”?

An acknowledgment lets the referring health care provider know whether the referral is going to be accepted and if so, what an estimated or actual appointment date is. There is no requirement to see the patient within 14 days, just a requirement to review the referral and close the loop. This allows the referring physician to make alternative arrangements if needed.

When referrals aren’t acknowledged, care can be significantly delayed. This is especially true when the referral is for an issue that is out of scope for the consultant physician. Acknowledging these quickly and getting a response to the referring physician will allow them to make alternative arrangements, rather than waiting days or weeks only to hear that they have to start the process again with another provider. It also has the benefit of allowing consultants to focus their attention on those referrals that are in scope rather than letting out of scope referrals pile up.

Do consultant physicians have any obligation to suggest another provider if they’re unable to take on the referral?

No. However, specialists may have more information about their colleagues than referring physicians do and so to the extent that they are able to provide assistance in re-directing the referral, it would be helpful to do so and would contribute to positive collegiality within the profession. This is especially true in instances where the referral is urgent or for particularly niche issues.

Walk-in Clinics

When and why does the policy require physicians practising in a walk-in clinic to send a record of the encounter to the patient’s primary care provider?

Patients seek care from walk-in clinics for a variety of reasons, but breakdowns in care can happen and physicians practising in walk-in clinics can take steps to help avoid these breakdowns. In particular, because there is not always coordination between the care provided in walk-in clinics and other parts of the health-care system, the policy requires physicians practising in walk-in clinics to provide the patient’s primary care provider with a record of the encounter when the patient asks or when it’s warranted from a patient safety perspective and consent has been obtained. This will help to make sure that the patient’s primary care provider can provide future care that is informed by this experience. Of course, physicians are also free to send a record of the encounter in other instances where there might be some benefit in doing so and the patient provides consent.

Notably, the policy recognizes that it will not always be easy to send information to the primary care provider and so allows for information to flow through the patient where it’s not possible to send the information directly because, for example, there is uncertainty about who the primary care provider is or incomplete contact information.

Does the policy set out expectations for physicians practising in walk-in clinics who are providing care to patients without a primary care provider?

No. Walk-in clinics are not intended to be a substitute or replacement for a sustained relationship between a primary care provider and a patient. Rather, they are intended to provide episodic care where there is no expectation of a sustained relationship beyond any follow-up care that is required to address the presenting concern(s). That said, there are some patients who have real difficulty finding a primary care provider and routinely visit the same walk-in clinic for care. To the extent that physicians can, these patients would benefit greatly from additional care beyond the usual walk-in clinic experience. While there are limits to what can be done, even working together with other physicians in the practice to help these patients, for example, monitor and manage basic elements of a chronic condition or provide annual physicals, would benefit them greatly.

Endnotes

1. See eHealth Ontario for more information on ONE ID.

2. See OntarioMD (https://www.ontariomd.ca/pages/overview-of-econsult.aspx) or the Ontario Telemedicine Network (https://otn.ca/patients/econsult/) for more information.

3. See the University of Health Network’s OpenLab work on Patient Oriented Discharge Summaries, which are now being adopted by hospitals across Ontario.

4. See for example St. Joseph’s Health Care Toronto’s “SuperTrack” program.