Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders
Published in: Journal of the American Geriatrics Society, v. 55, no. S2, Oct. 2007, p. S285-S292
Posted on RAND.org on January 01, 2007
Continuity and coordination of care are attributes of medical care that influence its quality. Donabedian described coordination of care as the process by which the elements and relationships of medical care during any one sequence of care are fitted together in an overall design. Continuity means lack of interruption in needed care, and the maintenance of the relatedness between successive sequences of medical care. According to the Institute of Medicine, continuity is care over time by a single individual or team of healthcare professionals including effective and timely communication of healthcare information. Continuity and coordination of care are particularly important for older patients, because they are apt to have multiple medical problems treated by several clinicians. These aspects of care involve the spectrum of healthcare providers and staff and their systems in a wide variety of venues, because the work of continuity and coordination includes roles that physicians often do not perform, such as scheduling, communication, and reminders. Continuity and coordination of care have several components, including a longitudinal relationship with a single identifiable provider and cooperation between providers and between venues of care. Coordination involves the availability of information about prior problems and services and the recognition of that information as it bears on the needs for current care. Continuity and coordination depend largely on the system of healthcare delivery, but the Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs) focus on how the system affects what happens to the patient. Thus, these quality-of-care indicators focus on the following domains of continuity and coordination: continuity of care from the perspective of the patient, information continuity and coordination across and within providers, and continuity and coordination between venues of care. Continuity of care is often equated with having a primary care physician. Several studies demonstrated associations between physician-patient continuity and satisfaction, reduced utilization, increased efficiency, and better preventive care. A structured literature review that evaluated 22 studies, including four clinical trials, found that interpersonal continuity was related to greater satisfaction, lower utilization, and generally higher care quality, although one study found interpersonal continuity to be associated with higher pharmacy and referral costs. Nonphysicians, such as case managers, or multidimensional interventions sometimes provide continuity and coordination. Most, although not all, interventions to enhance continuity and coordination reduce utilization, but these interventions have multiple components that cannot easily be disentangled and often are not tested outside research settings. Structural factors, including disease registries and formal sign-out systems, also can improve continuity and coordination of care, but these structures are not easily measured at the patient level using clinical information. Therefore, this set of QIs focuses on general components of continuity and coordination at the physician level. QIs for condition-specific continuity and coordination of care (e.g., follow-up for newly treated depression and laboratory testing after starting specific medications) are contained in the condition-specific monographs. METHODS: A total of 1,994 articles were considered in this review: five identified using a Web search and 1,989 through the ACOVE-3 literature searches. RESULTS: Of the 17 potential QIs, the expert panel process judged 16 to be valid, and one was rejected. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.