Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review

Elements of the patient-centered medical home associated with health outcomes among veterans: the role of primary care continuity, expanded access, and care coordination

Care continuity, access, and coordination are important features of the patient-centered medical home model and have been emphasized in the Veterans Health Administration patient-centered medical home implementation, called the Patient Aligned Care Team. Data from more than 4.3 million Veterans were used to assess the relationship between these attributes of Patient Aligned Care Team and Veterans Health Administration hospitalization and mortality. Controlling for demographics and comorbidity, we found that continuity with a primary care provider was associated with a lower likelihood of hospitalization and mortality among a large population of Veterans receiving VA primary care.

Effect of Named, Accountable GPs on Continuity of Care: Protocol for a Regression Discontinuity Study of a National Policy Change

Introduction:

Increasing continuity of care has been identified as a strategy to improve patient outcomes, but previous studies of integrated care have tended to focus on pilot areas, which limit their generalisability and the ability to determine in which contexts integrated care was most successful.

Objective:

This study protocol describes a quantitative evaluation of a reform in England that introduced named, accountable general practitioners for all National Health Service (NHS) patients aged 75 years or over. The national contract for general practice services required that named general practitioners offer longitudinal continuity of care within the general practice and be accountable for coordinating care to meet the patient’s healthcare needs.

Methods:

This study will apply a regression discontinuity design to pseudonymised electronic medical records from a sample of general practices in England. We will compare outcomes for patients aged just below and above the age of 75 to estimate the effect of named general practitioners and relate these estimated treatment effects to the characteristics of general practices. Outcomes will include a metric relating to continuity of care, namely the Usual Provider of Care Index, and numbers of general practitioner contacts, referrals to specialist care and diagnostic tests.

Discussion:

The study illustrates an approach to evaluate national changes aimed at more integrated care using electronic records, which will complement in-depth examination in pilot sites.

Patients' assessments of the continuity of primary care in Finland: a 15-year follow-up questionnaire survey

Background

Continuity of care is an essential aspect of quality in general practice. This study is the first systematic follow-up of Finnish primary care patients’ assessments with regard to personal continuity of care.

Aim

To ascertain whether patient-reported longitudinal personal continuity of care is related to patient characteristics and their consultation experiences, and how this had changed over the study period.

Design and setting

A 15-year follow-up questionnaire survey that took place at Tampere University Hospital catchment area, Finland.

Method

The survey was conducted among patients attending health centres in the Tampere University Hospital catchment area from 1998 until 2013. From a sample of 363 464 patients, a total of 157 549 responded. The responses of patients who had visited a doctor during the survey weeks (n = 97 468) were analysed. Continuity of care was assessed by asking the question: ‘When visiting the health centre, do you usually see the same doctor?’; patients could answer ‘yes’ or ‘no’.

Results

Approximately half of the responders had met the same doctor when visiting the healthcare centre. Personal continuity of care decreased by 15 percentage points (from 66% to 51%) during the study years. The sense of continuity was linked to several patients’ experiences of the consultation. The most prominent factor contributing to the sense of continuity of care was having a doctor who was specifically appointed (odds ratio 7.28, 95% confidence interval = 6.65 to 7.96).

Conclusion

Continuity of care was proven to enhance the experienced quality of primary care. Patients felt that continuity of care was best realised when they could consult a doctor who had been specifically appointed to them. Despite efforts of the authorities, over the past 15 years patient-reported continuity of care has declined in Finland.

Continuity of care in the cross-border context: insights from a survey of German patients treated abroad

BACKGROUND

Continuity of care is important for outcomes and patient satisfaction and includes additional considerations in the context of cross-border health care. Although this has been discussed in research and was picked up in the recently transposed Directive on patients' rights (2011/24/EU), there is limited evidence about related issues actually encountered by patients crossing borders.

METHODS

An anonymous postal survey was carried out by the Techniker Krankenkasse, one of the largest sickness funds in Germany. The questionnaire was sent to 45 189 individuals who had received treatment in EU/EEA countries and included items on relational, management and informational continuity.

RESULTS

The survey had a response rate of 41% (n = 17 543). Of those respondents who had travelled for care (n = 3307), ∼19% (n = 570) did so due to a relationship of trust with a given provider. Only 8% of all respondents required emergency follow-up services due to complications, the majority of which was obtained back in Germany. Twelve percentage of those who were prescribed medication abroad (n = 4208) reported problems, spanning unknown products, dispensation and reimbursement. Information exchange between providers across borders was rare and largely carried out by the patients themselves.

CONCLUSIONS

Although relational continuity may be important to specific groups of patients travelling for care, it is primarily informational continuity and its interrelation with management continuity that need to be addressed in the cross-border context. Information exchange should be endorsed at European level. Additional focus is required on informing patients about documentation rights and requirements and providing health records that are comprehensive and comprehensible.

A qualitative study of integrated care from the perspectives of patients with chronic obstructive pulmonary disease and their relatives

Background

Disease management programmes have been developed for chronic obstructive pulmonary disease (COPD) to facilitate the integration of care across healthcare settings. The purpose of the present study was to examine the experiences of COPD patients and their relatives of integrated care after implementation of a COPD disease management programme.

Methods

Seven focus groups and five individual interviews were held with 34 patients with severe or very severe COPD and two focus groups were held with eight of their relatives. Data were analysed using inductive content analysis.

Results

Four main categories of experiences of integrated care emerged: 1) a flexible system that provides access to appropriate healthcare and social services and furthers patient involvement; 2) the responsibility of health professionals to both take the initiative and follow up; 3) communication and providing information to patients and relatives; 4) coordination and professional cooperation. Most patients were satisfied with their care and raised few criticisms. However, patients with more unstable and severe disease tended to experience more problems.

Conclusions

Participant suggestions for optimizing the integration of healthcare included assigning patients a care coordinator, telehealth solutions for housebound patients and better information technology to support interprofessional cooperation. Further studies are needed to explore these and other possible solutions to problems with integrated care among COPD patients. A future effort in this field should be informed by detailed knowledge of the extent and relative importance of the identified problems. It should also be designed to address variable levels of severity of COPD and relevant comorbidities and to deliver care in ways appropriate to the respective healthcare setting. Future studies should also take health professionals’ views into account so that interventions may be planned in the light of the experiences of all those involved in the treatment of COPD patients.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-471) contains supplementary material, which is available to authorized users.

The impact of the quality of communication from nephrologists to primary care practitioners: a literature review

OBJECTIVE

This review of the literature aims to explore two research questions: (1) what is the evidence that patients benefit from sound communication between primary care practitioners (PCPs) and nephrologists; and (2) what information is required in primary care to meet the needs of patients who have attended a renal unit?

RESEARCH DESIGN AND METHODS

Fifty-seven citations were independently reviewed by four authors. The inclusion criteria were: (1) the article focused on information flow from nephrologists and/or specialists to general practitioners; (2) it includes the involvement of PCPs in nephrology, including registrars and PCPs with special interests or specialists in any medical field; (3) it was published from 1990 onwards (inclusive) and (4) the study was conducted in the United Kingdom, Canada, The Netherlands, Australia, United States or New Zealand. Selected articles were then reviewed by the fifth author as a measure of inter-rater reliability.

RESULTS

Eighteen papers in four categories were identified: six audits or observational studies, one meta-analysis; one randomized controlled trial; six qualitative studies; and four position statements or quality improvement tools. Published audits involving feedback to clinicians using validated tools demonstrate the scope for substantial improvement in the amount of information relayed to PCPs. Specialists may not prioritize the letter to the PCP but there is some evidence of a direct impact from limited or inadequate communication on patient outcomes. Only two studies focused on patients attending nephrology clinics.

CONCLUSIONS

There is some evidence that improving the quality of letters from specialists to PCPs may benefit patient care. This review suggests a need for research on communication from nephrologists about patients who have received care at a renal unit regardless of whether or not the patient continues to attend.

Nurses’ Experiences of Providing Care to Dementia Patients Through Home Health Care

Most Western countries aim to enable dementia sufferers to live at home for as long as possible. Person centeredness, continuity of care, and competence level are all important for the quality of home health care (HHC). The aim of this qualitative study is to describe staff’s experiences of providing care to home-dwelling dementia clients through HHC services. The study used a phenomenological-hermeneutic interpretation of focus group interviews. This study supports the value of continuous interpersonal relationships in HHC services. The findings show that specialized teams facilitate continuity and person-centered care, and that after training, staff become more holistically oriented, involve clients in daily care, and experience greater job confidence.

Poor longitudinal continuity of care is associated with an increased mortality rate among patients with mental disorders: results from the French National Health Insurance Reimbursement Database

BACKGROUND

Research on the impact of the continuity of care (COC) on health outcomes in patients with mental illness is limited. This observational study examined whether the longitudinal COC is associated with a decreased likelihood of death among patients with mental disorders in the French general population.

METHOD

Data were derived from the French National Health Insurance (NHI) reimbursement database. Patients with any mental disorder who visited a psychiatrist at least twice within 6 months were included. The primary endpoint was death by all causes. We measured longitudinal COC with a psychiatrist twice a year between 2007 and 2010, using the COC index developed by Bice and Boxerman. The COC index was analysed as a time-dependent variable in a survival analysis after adjustments for age, gender and stratifying on comorbidities and social status.

RESULTS

Among 14,515 patients visiting a psychiatrist at least twice in 6 months and tracked over 3 years, likelihood of death was significantly lower in patients with higher continuity of care (hazard ratio for an increase in 0.1 of continuity, adjusted for age, sex, and stratified on comorbidities and social status: 0.83 [0.83-0.83]), particularly in those with bipolar disorder, major depressive disorder and schizophrenia.

CONCLUSION

Improving longitudinal continuity of care in mental health care may contribute to substantially decrease mortality.

Concordance between continuity of care reported by patients and measured from administrative data

Continuity of care can be measured using patient survey or administrative data, though the degree of concordance between continuity of care reported by patients and measured from their actual utilization is not well understood. A cross-sectional analysis of the 2010 Medicare Current Beneficiary Survey and linked 2009-2010 Medicare Carrier and outpatient claims data measured the concentration of ambulatory care visit patterns according to two commonly used metrics of continuity of care. Continuity of care measured from claims data did not align with patient reports of having a usual care provider. However, high levels of continuity for patients with a usual care provider were associated with a longer patient-provider relationship, greater patient-perceived provider knowledge of the patient's medical condition and history, and more confidence in the provider. Inferences about a patient's continuity of care must be placed in the context of the data source with which continuity is measured.

Measuring interpersonal continuity in high-frequency home healthcare services

AIM

To provide a method for assessing the degree of interpersonal continuity adapted to context and to measure and assess the degree of interpersonal continuity for long-term recipients dependent on daily home health care.

BACKGROUND

Interpersonal continuity is important to the quality of care for long-term dependents. In high-frequency home healthcare services where patients receive daily care from many nurses or other health personnel over time, interpersonal continuity may be difficult to attain.

DESIGN

A cross-sectional study with a descriptive design.

METHODS

Information concerning 79 patients receiving long-term frequent care was collected during four weeks in a maximum variation sample of Norwegian municipalities, from January 2009-May 2010. We measured interpersonal continuity objectively using indices of dispersion and the next-day sequence of health personnel. For each measure, we computed the highest feasible level of continuity that could be attained in this home healthcare context given a standard shift plan. This level was then used as benchmark against which the actual level of continuity was assessed.

RESULTS

Patients received on average 51 visits from a mean of 17 different carers during four weeks. The results revealed a low degree of interpersonal continuity in practice, far below what was feasible according to the benchmarks.

CONCLUSION

High-frequency home health care was characterized by interpersonal discontinuity, but with potential for improvement. Objective measures of interpersonal continuity, when the benchmark is adapted to the context, are useful tools for planning and surveying continuity of care.

Barriers to information exchange during older patients' transfer: nurses' experiences

AIMS AND OBJECTIVES

To describe nurses' experiences of barriers that influence their information exchange during the transfer of older patients between hospital and home care.

BACKGROUND

The successful transfer of an older patient across health organisations requires good communication and coordination between providers. Despite an increased focus on the need for cooperation among providers across healthcare organisations, researchers still report problems in the exchange of information between the hospitals and the healthcare systems in the municipalities.

DESIGN

A qualitative study using focus group methodology.

METHODS

Three focus group interviews using topic guides were conducted and interpreted. The study included registered nurses (n = 14) from hospital and home care. The data were analysed through content analysis.

RESULTS

Three main themes were identified: barriers associated with the nurse, barriers associated with interpersonal processes and barriers associated with the organisation. These themes included several subthemes.

CONCLUSIONS

The findings highlight the challenges that nurses encounter in ensuring a successful information exchange during older patients' transfer through the healthcare system. The barriers negatively influence the nurses' information exchange and may put the patients in a vulnerable and exposed situation. In order for nurses to conduct a successful exchange of information, it is critical that hospital and home care systems facilitate this through adequate resources, clear missions and responsibilities, and understandable policies.

RELEVANCE TO CLINICAL PRACTICE

Recognition of the barriers that affect nurses' exchange of information is important to ensure patient safety and successful transitions. The barriers described here should help both nurses in practice and their leaders to be more attentive to the prerequisites needed to achieve a satisfactory nursing information exchange and enhance informational continuity.

Predictors of relational continuity in primary care: patient, provider and practice factors

BACKGROUND

Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care.

METHODS

This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient's perspective.

RESULTS

Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics.

CONCLUSIONS

Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that 'bigger is not always necessarily better'.

Service users' and caregivers' perspectives on continuity of care in out-of-hours primary care

Modernization policies in primary care, such as the introduction of out-of-hours general practice cooperatives, signify a marked departure from many service users' traditional experiences of continuity of care. We report on a case study of accounts of service users with chronic conditions and their caregivers of continuity of care in an out-of-hours general practice cooperative in Ireland. Using Strauss and colleagues' Chronic Illness Trajectory Framework, we explored users' and caregivers' experiences of continuity in this context. Whereas those dealing with "routine trajectories" were largely satisfied with their experiences, those dealing with "problematic trajectories" (characterized by the presence of, for example, multimorbidity and complex care regimes) had considerable concerns about continuity of experiences in this service. Results highlight that modernization policies that have given rise to out-of-hours cooperatives have had a differential impact on service users with chronic conditions and their caregivers, with serious consequences for those who have "problematic" trajectories.

Nurses' information exchange during older patient transfer: prevalence and associations with patient and transfer characteristics

Introduction

To ensure continuity of care, it is important to effectively communicate the health status of older patients who are transferred between health care organizations. The objectives of this study were to: (1) evaluate the prevalence of nursing transfer documents, and (2) identify patient and transfer characteristics associated with the presence of nursing transfer documents for older patients transferred from home care to hospital and back to home care again after hospitalization.

Methods

Nursing documents were reviewed from a total of 102 records of older inpatients admitted from home care to medical wards at a local hospital in central Norway and later discharged home. Frequencies were used to describe patient and transfer characteristics, and the prevalence of transfer documents. Pearson’s χ² test and logistic regression were used to identify possible associations between patient and transfer characteristics and the presence of nursing transfer documents.

Results

While nursing admission notes were present in 1% of the patient transfers from home care to the hospital, 69% of patient discharges from the hospital to home care were accompanied by nursing discharge notes. Patient and transfer characteristics associated with the presence of a nursing discharge note were age, gender, medical department facility, and length of hospital stay.

Conclusions

The low prevalence of nursing transfer documents constitutes a challenge to the continuity of care for hospitalized home care patients. Patient and transfer characteristics may impact the nurses’ propensity to exchange patient information. These findings emphasize the need for nurses and managers to improve the exchange of written information. While nurses must strive to transfer accurate patient information at the right place and at the right time, the managers must facilitate this by providing appropriate guidelines and standards, as well as adequate personnel and resources.

Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences

PURPOSE

Our study described patient and caregiver experiences with care transitions following hospital discharge to home for patients with mobility impairments receiving physical and occupational therapy.

METHODS

The study was a qualitative longitudinal interview study. Interviews were conducted at 2 weeks, 1 month, and 2 months post discharge. Participants were men, Caucasian, between 70 and 88 years old, and had either a medical or surgical diagnosis.

RESULTS

Breakdowns in communication in four domains impacted continuity of care and patient recovery: (a) Poor communication between patients and providers regarding ongoing care at home, (b) Whom to contact post discharge, (c) Provider response to phone calls following discharge, and (d) Provider-provider communication.

DISCUSSION AND CONCLUSIONS

Improved systems are needed to address patient concerns after discharge from the hospital, specifically for patients with mobility impairments. Better communication between patients, hospital providers, and home care providers is needed to improve care coordination, facilitate recovery at home, and prevent potential adverse outcomes.

The association between continuity of care in the community and health outcomes: a population-based study

BACKGROUND

The study goal was to assess indices of continuity of care in the primary care setting and their association with health outcomes and healthcare services utilization, given the reported importance of continuity regarding quality of care and healthcare utilization.

METHODS

The study included a random sample of enrollees from Clalit Health Services 19 years-of-age or older who visited their primary care clinic at least three times in 2009. Indices of continuity of care were computed, including the Usual Provider Index (UPC), Modified Modified Continuity Index (MMCI), Continuity of Care Index (COC), and Sequential Continuity (SECON). Quality measures of preventive medicine and healthcare services utilization and their costs were assessed as outcomes.

RESULTS

1,713 randomly sampled patients were included in the study (mean age: 48.9 ± 19.2, 42% males). Continuity of care indices were: UPC: 0.75; MMCI: 0.81; COC: 0.67; SECON: 0.70. After controlling for patient characteristics in a multivariate analysis, a statistically significant association was found between higher values of UPC, COC, and SECON and a decrease in the number and cost of ED visits. Higher MMCI values were associated with a greater number and higher costs of medical consultation visits. Continuity of care indices were associated with BMI measurements, and inversely associated with blood pressure measurements. No association was found with other quality indicators, e.g., screening tests for cancer.

CONCLUSIONS

Several continuity of care indices were associated with decreased number and costs of ED visits. There were both positive and negative associations of continuity of care indices with different aspects of healthcare utilization. The relatively small effects of continuity might be due to the consistently high levels of continuity in Clalit Health Services.

What do we know about patients' perceptions of continuity of care? A meta-synthesis of qualitative studies

OBJECTIVE

The increasing complexity in healthcare delivery might impede the achievement of continuity of care, being defined as 'one patient experiencing care over time as coherent and linked'. This article aims to improve the knowledge on patients' perceptions of relational (RC), informational (IC) and management continuity (MC) across care levels.

DESIGN

A descriptive, qualitative meta-synthesis was conducted based on a literature search in various electronic databases using the subject heading 'continuity of care' and linked key terms. We scanned retrieved articles for adherence to inclusion criteria: (i) relevance to research topic, (ii) original study adopting a qualitative design and (iii) investigating the patient's perspective. Content analysis was conducted by identification of themes and aggregation of findings.

RESULTS

The selected 25 studies most frequently investigated RC. Being attended to regularly and over time by one physician (RC) was valued by chronic ill patients, but balanced with convenient access by young patients (MC). Communication and information transfer across care settings as well as the gathering of holistic information about the patient were perceived to foster IC. Critical features for achieving MC were accessibility between care levels, individualized care and a smooth discharge process including the receipt of support. Patients further considered that their personal involvement was one facilitating element of continuity of care.

CONCLUSIONS

Patients identified elements that enhance or distract from continuity of care across boundaries. Variations in perceived importance seem to depend on both individual and contextual factors which should be taken into account during healthcare provision.

Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases

The dramatic scale-up of HIV services in lower-income countries has led to the development of service delivery models reflecting the specific characteristics of HIV and its treatment as well as local contexts and cultures. Given the shared barriers and challenges faced by health programmes in lower-income countries, many of the implementation approaches developed for HIV programmes have the potential to contribute to the continuity care framework needed to address non-communicable diseases (NCDs) in resource-limited settings. HIV programmes are, in fact, the first large-scale chronic disease programmes in many countries, offering local and effective tools, models and approaches that can be replicated, adapted and expanded. As such, they might be used to 'jumpstart' the development of initiatives to provide prevention, care and treatment services for NCDs and other chronic conditions.

RN Continuity in Home Health: Does It Make a Difference?

Continuity of care in home health is valued but poorly understood. This article is about the delivery of nursing care to elderly home health patients and to determine if visits provided by the same RN improve selected “Outcome and Assessment Information Set” outcomes. Functional status, psychological status, and use of emergent care were examined. Cases selected represented individuals aged 65 years and older, with at least one chronic illness and a good prognosis. Patients received four or more visits from the same RN.The clinical and administrative billing records from an initial 60-day period yielded a convenience sample of 887 discharged cases from a suburban, U.S. hospital-based home health agency. Higher levels of RN continuity were associated with a decreased likelihood of neuro/emotional/behavioral issues for patients at discharge. The findings showed no relationship of RN continuity of care to functional status and use of emergent care for the period examined.

The breadth of primary care: a systematic literature review of its core dimensions

Background

Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level.

Methods

A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit.

Results

Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health.

Conclusions

A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.

Continuity of nursing and the time of sickness

This paper explores the relationship between temporal continuity in nursing and temporal features of sickness. It is based on phenomenological and hermeneutical philosophy, empirical studies of sickness time, and the nursing theories of Nightingale, of Benner and of Benner and Wrubel. In the first part, temporal continuity is defined as distinct from interpersonal continuity. Tensions between temporal continuity and discontinuity are discussed in the contexts of care management, of conceptualisations of disease and of time itself. Temporal limitations to the methodological concept of situation are discussed. The main part of this paper explores nurses' possibilities to relate to their patients' time, and how temporal features of sickness may warrant temporal continuity of nursing. Three temporal characteristics of sickness are discussed: the immediacy of patients' suffering, the basic continuity of life through sickness and health care, and the indeterminism and precariousness of sickness. The timing of nursing acts is discussed. The paper explores how sickness is both part of the continuity of life, and threatens this continuity. It concludes that this tension is implicitly recognised in the temporal continuity of nursing, which allows for discontinuous and continuous aspects of sickness time. Nurses accordingly perceive the sick person's time at several levels of temporality, and distinguish highly complex temporal processes in their patients' trajectory. Temporal continuity provides the time, flexibility, and closeness for nurses to perceive and act into time dimensions of individual sickness. The paper shows that temporal continuity of nursing is grounded in temporal characteristics of severe sickness. It suggests that temporal continuity is an important theoretical concept in nursing.

A case study of a Canadian homelessness intervention programme for elderly people

The aims of this study were to describe: (1) how the Homelessness Intervention Programme addressed the needs of elderly people who were homeless or at risk of homelessness; and (2) the factors that influenced the ability of the programme to address client needs. The programme was offered by a multi-service non-profit agency serving low-income families and individuals in an urban neighbourhood in Ontario, Canada. Using a case study approach, we conducted 10 individual interviews and three focus groups with programme clients, programme providers, other service providers and programme funders. Programme providers completed intake forms, monthly follow-up forms and exit/housing change forms for each of the 129 clients served by the programme over a 28-month period. Approximately equal proportions of clients were between 54 years old and 65 years old (47%) and over 65 years (53%). There were equal proportions of women and men. In addition to being homeless or marginally housed, clients lived with multiple and complex issues including chronic illness, mental illness and substance abuse. Through the facilitation of continuity of care, the programme was able to meet the needs of this vulnerable group of elderly people. Three types of continuity of care were facilitated: relational, informational and management continuity. The study confirmed the value of a continuous caring relationship with an identified provider and the delivery of a seamless service through coordination, integration and information sharing between different providers. Study findings also highlighted the broader systemic factors that acted as barriers to the programme and its ability to meet the needs of elderly people. These factors included limited housing options available; limited income supports; and lack of coordinated, accessible community health and support services. The central findings stress the importance of continuity of care as a guiding concept for intervention programmes for homeless and marginally housed elderly people.

Definition of information technology architectures for continuous data management and medical device integration in diabetes

The growing availability of continuous data from medical devices in diabetes management makes it crucial to define novel information technology architectures for efficient data storage, data transmission, and data visualization. The new paradigm of care demands the sharing of information in interoperable systems as the only way to support patient care in a continuum of care scenario. The technological platforms should support all the services required by the actors involved in the care process, located in different scenarios and managing diverse information for different purposes. This article presents basic criteria for defining flexible and adaptive architectures that are capable of interoperating with external systems, and integrating medical devices and decision support tools to extract all the relevant knowledge to support diabetes care.

Discharge planning, transitional care, coordination of care, and continuity of care: clarifying concepts and terms from the hospital perspective

Hospital discharge planning is a key element of continuity of care for persons leaving the hospital. Yet many important questions regarding processes and effects of discharge planning have not been addressed, in part because the multiple terms associated with discharge planning have not been consistently defined or used. Failure to clearly name, define, and consistently use terms creates a barrier that inhibits scientific progress and best practice. This article reviews the use of terms and definitions and compares concepts associated with hospital discharge planning across key documents frequently referenced by hospitals. A conceptual model is proposed to facilitate consistent use of these concepts.

Infrastructural arrangements for integrated care: implementing an electronic nursing plan in a psychogeriatric ward

PURPOSE

The paper contributes to the conceptualisation of "integrated care" in heterogeneous work practices. A dynamic perspective is developed, emphasising how integrated care is malleable, open, and achieved in practice. Furthermore, we explore the role of nursing plans in integrated care practices, underscoring the inherent difficulties of building one common infrastructural system for integrated care.

METHODS

Empirically, we studied the implementation of an electronic nursing plan in a psychiatric ward at the University Hospital of North Norway. We conducted 80 hours of participant observation and 15 interviews.

RESULTS

While the nursing plan was successful as a formal tool among the nurses, it was of limited use in practice where integrated care was carried out. In some instances, the use of the nursing plan even undermined integrated care.

CONCLUSION

Integrated care is not a constant entity, but is much more situated and temporal in character. A new infrastructural system for integrated care should not be envisioned as replacing most of the existing information sources, but rather seen as an extension to the heterogeneous ensemble of existing ones.