Compliance with Continuity of Care: Let’s Make Changes

Morgan Hrynyk Messenger, Trevor's Take On 7 Comments

Two years in a row, over the Christmas break, we’ve randomly phoned about a hundred offices after hours to learn what messages were left on answering machines and, specifically, whether a patient who called after hours would be able to speak with a covering physician. Was there a physician on-call? Recognizing that a telephone message is only a surrogate and that the methodology in 2015 was a little different from Christmas 2014, the results are very similar: only about one-fifth of offices clearly have a physician available after-hours, and another one-quarter perhaps are compliant. (Specifically, we called 296 offices with a functional phone number; of that number, sixty-six had a clearly identified physician on call – 22%. Another sixty-three we classified as possibly adherent – as the message referred callers either to Health Link or to a specific ER – about 21% – but we’re being generous in suggesting possible adherence as very few clinics have a formal arrangement with an emergency department outside rural areas or with Health Link).

When we surveyed the profession on this topic last spring, the results were more encouraging; about 60% of physicians self-reported being compliant with the College’s Continuity of Care Standard of Practice. I’m disappointed, therefore, that the objective results haven’t appreciably changed from a year ago.

This result is simply unacceptable.

This year we kept a log of the offices we called. Every one of these offices will receive follow-up by us. We will commend those physicians and practices who are clearly compliant; we will query those who may have an acceptable arrangement in place (e.g. they’ve indicated that patients should attend the local ER; in a rural setting there is a good possibility that the physicians have agreed that after hours calls should be handled in the local ER by the on-call physician); and for those where the message indicates non-compliance (e.g. “call 911” or “go to the nearest emergency department”), we are going to ask for assurance that proper after hours arrangements have been made, and we’ll follow up to ensure that occurs.

Please understand that after hours availability for patients and for critical test results is not optional. It’s not just ‘nice to do’. It’s necessary, and, as your College, we’re going to keep at this until we’re satisfied that the membership has coverage in place.

Some may argue that other Standards of Practice are just as important. I agree. Ensuring compliance with Continuity of Care is only a start as tracking compliance with this standard is relatively easy to do. But it is just a start.

There is much to be done to improve medical practice in Alberta. If every member practiced in adherence to the Standards of Practice, we’d make big inroads into a number of problems. While we have plans to ensure all practices are aware of and adhere to the Standards of Practice, we’re starting with Continuity of Care. For those who are already practicing good medicine in compliance with our standards, I applaud you. For the rest, it’s past time to start.

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On the same topic, we have an article in this issue about the role of radiologists helping patients – and their referring physicians – move more efficiently through the diagnostic maze by, when appropriate, proceeding with (or arranging) the next diagnostic imaging test.

The Health Quality Council of Alberta is reviewing its November 2013 Continuity of Care recommendations. Following recent discussions, we were asked to reiterate the College’s position about the role of the radiologist in helping the referring physician and the patient get the next test done, when doing so is clearly the right thing to do.

I emphasize that the radiologist should always attempt to connect first with the referring physician, to explain the situation and findings, to learn whether the referring physician has other information that would alter a decision about next steps, and to ensure coordination for the patient. I recognize that such efforts will not always be successful, but the attempt must be made. In all situations, the radiologist must document attempts to consult with the referring physician and the discussion with the patient.

Some radiologists are concerned that helping arrange (or doing) the next test without an explicit request might be seen as self-referral, a conflict of interest. As long as the radiologist is clearly acting in the patient’s best interest, those concerns should be allayed. Acting in the patient’s best interest will always be viewed positively by this College.

As always, I welcome your comments below or email me at trevor.theman@cpsa.ab.ca

Trevor Theman

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I live in a small town served by one clinic staffed with about 10 doctors. These doctors also serve on rotation at the local hospital. My wife and I both have the same family doctor and when she’s gone for her regular two to three month break, one of the other doctors is assigned to us. Not knowing our complex needs, and by our experience, showing no interest in learning them, I find it hard to believe that we are receiving any definition of “continuity” in our medical care. As both of have been through one crisis after another with… Read more »

Emmanuel Osegbue

For continuity of care , are specialists like surgeons, psychiatrist and internist expected to keep their clinic or phones opened after hours for non-urgent or non emergencies consultation with patients as family physicians are expected. If this is not the case, please why not as I have patients who will like to see the surgeons and internists after hours periods.

Trevor Theman

I appreciate all the comments. PCNs offer an ideal opportunity to create a formal after-hours mechanism for patients as Dr. Alabaster explains. The Standard applies to ALL physicians. We are not targeting any group or specialty. As someone who practised general surgery for 18 years, I recognize the importance of being available to my practice population. I believed I was responsible for the post-operative care and complications. Dr. Schuld raises important points. To some extent we can only judge the care or decisions made retrospectively. As stated in the article, the ideal is for the radiologist to connect and consult… Read more »

Mark M

The issue of after hour access is critical. But I hope these corrective efforts are not solely directed at Family Physicians. Patient access to specialists and surgeons for follow up care is laughably poor. Patients are (in almost every single case) told to see their family doctor or go to ER for post operative complications. This then puts stress on the acute care system, and encourages use of walk in clinics, and worsens continuity of care. Family physicians and ER physicians dealing with those patients are often stonewalled by the on-call consultants, especially if they were not the ones who… Read more »

Richard Schuld

As long as the radiologist is CLEARLY acting in the patients best interest? Clear to whom? And who is in charge of knowing that the radiologist has clinical medical knowledge of the patient whose best interests he/she is is acting upon?

Fraser Armstrong

Very important issue, well stated. We absolutely need, as a profession to take this issue on. Thanks for your care, concern and work on this. PCNs could prove to be useful agents in this cause.

Jane Alabaster

I am part of a PCN and patients in my practice have access to our out of hours emergency/ urgent care clinic. This clinic is staffed by members of the PCN and a letter is sent to the home clinic of visiting patients to inform the primary physician of their visit and any pending tests and need for follow up. I think it is an excellent system and I believe addresses very well the concerns the CPSA rightly has about continuity of care.