What is inpatient continuity of care?

Inpatient continuity of care is the continuous succession of visits to a patient by the same provider over an extended period of time. For example, a hospitalist might see the same patient two days in a row or even months later if the patient is re-admitted. While valued by most hospitals and demonstrated to have a positive impact on outcomes (including patient satisfaction), inpatient continuity of care is difficult to achieve because of the need to provide care 24 hours a day, 7 days a week and rotating shifts by providers.

The Research About Primary Care Is Clear: Continuity of Care Leads to Better Outcomes, Improved Patient and Physician Satisfaction, and Lower Costs

Continued care has traditionally considered one of the core principles of family medicine. Studies have consistently shown that interpersonal continuity between primary physicians and patients has been associated with improved delivery of preventive services and lower rates of hospitalization. Higher levels of continuity have also resulted in lower rates of emergency department visits, lower complication rates and lower episode costs. And the reverse is true. An increasing number of primary or specialty care providers has been linked to poorer outcomes.

Is the same true for acute care?

The continuous caring relationship in an inpatient environment faces a different set of challenges compared to a primary physician environment. For example, acute care is non-stop –24 hours a day, 7 days a week. This requires constant monitoring and evaluation from a number of different providers. As a result, continuity is difficult to establish and then maintain. Patients are also sicker, resulting in more care and more providers involved.

The reality is — hospitalized patients are experiencing less integrated care than 10 years ago.

Discontinuity, Length of Stay (LOS) and Future Hospitalizations

Discontinuity of care affects hospitals in a number of ways.

For example, in one study, researchers looked at what impact the fragmentation of care for patients suffering from pneumonia and heart failure. Their results demonstrated that the length of stay (LOS) patients increased significantly as a result of the fragmentation.

In another study, the reverse was true. Researchers in that study found that increased weekend continuity of care was associated with reduced length of stays.

A third study involving the Delaware Medicaid program, researchers found that continuity with a clinician reduces a patient’s likelihood of future hospitalization.

Inpatient Continuity of Care and Patient Satisfaction

Another area where inpatient care coordination can have a dramatic impact revolves around patient satisfaction. For example, the results in one study pointed to the importance of the experiences shared between patients and physicians and the value patients place on continuity with their regular physician. In fact, other research suggests that patients who have medical problems requiring substantial intervention on the part of the physician are more likely to exhibit a desire for continuity.

The same circumstances apply to nurses as well.

In one study, discontinuity in acute care nurse assignments was high and negatively impacted patient clinical conditions. In fact, the researchers concluded that improved continuity of provider-patient assignments should be advocated to improve patient outcomes in acute care.

Can Inpatient Continuity of Care Be Achieved?

On a consistent and long-term basis, the simple answer has been no. One reason is the manual assignment process in place at most hospitals.

From back-to-back days, continuity and care management can be handled through a manual process. The person or group in charge of assignments for the morning rounds scans the census and identifies those patients who were in the hospital the previous day and assign the same physician to them.

But what happens if a patient is sent to ICU and then returned to hospital medicine? In most cases, that patient is assigned another hospitalist, since the person assigning patients doesn’t have a way to keep track of previous assignments.

The same is true for re-admissions or “bouncebacks.” It’s just too difficult and complex to keep a rolling list of patients over an extended period of time. As a result, while providers may have the best of intentions, continuity of care cannot be sustained.

What If There Was Better Way?

What if software algorithms were used keep track of all patients so that they were automatically assigned to a physician they have had in the past, regardless of whether the time frame was one day, one week, a month or even a year?

Furthermore, what if “rules” could be built into the software so that assignments were made based on a variety of other factors, such as a patient’s condition or location?

ASSIGN for Physicians | ASSIGN for Nurses

MedAptus has built technology that specifically addresses and solves the problem of discontinuity in acute care environments.

ASSIGN for Physicians and ASSIGN for Nurses are software programs that automatically and intelligently match the right provider with the right patient based on customizable “rules.” For example, the software can determine if a physician or nurse was assigned a patient during previous visits and then automatically assign them to that same physician again, thereby assuring better continuity of care.

The software also intelligently balances workloads so that multiple factors are taken into account when a provider is assigned a patient. This ensures a safer work environment since it prevents providers from getting overloaded in their assignments and cause medical errors.

Inpatient Continuity of Care is Possible

Inpatient continuity of care can be done, but it requires technological assistance. ASSIGN for Physicians and ASSIGN for Nurses provide just the right combination of intelligence and automation to accomplish the task for hospital medicine.

Here’s where you can learn more about the software:

Studies: Continuity of Care

The impact of fragmentation of hospitalist care on length of stay.

Blecker S1, Shine D2, Park N3, Goldfeld K3, Scott Braithwaite R1, Radford MJ2, Gourevitch MN3.

Int J Qual Health Care. 2014 Oct;26(5):530-7. doi: 10.1093/intqhc/mzu065. Epub 2014 Jul 3.

CONCLUSION: Increased weekend continuity of care is associated with reduced length of stay. Improvement in weekend cross-coverage and patient handoffs may be useful to improve clinical outcomes.

The effect of hospitalist discontinuity on adverse events.

O’Leary KJ, Turner J, Christensen N, Ma M, Lee J, Williams MV, Hansen LO.

J Hosp Med. 2015 Mar;10(3):147-51. doi: 10.1002/jhm.2308. Epub 2014 Dec 19.

CONCLUSION: Hospitalist physician continuity does not appear to be associated with the incidence of AEs. Because hospital care is provided by teams of clinicians, future research should evaluate the impact of team complexity and dynamics on patient outcomes.

The impact of hospitalist discontinuity on hospital cost, readmissions, and patient satisfaction.

Turner J, Hansen L, Hinami K, Christensen N, Peng J, Lee J, Williams MV, O’Leary KJ.

J Gen Intern Med. 2014 Jul;29(7):1004-8. doi: 10.1007/s11606-013-2754-0. Epub 2014 Jan 17.

CONCLUSION: Hospital physician discontinuity appears to be associated with modestly increased hospital costs. Hospital physicians may revise plans as they take over patient care responsibility from their colleagues.

Association of weekend continuity of care with hospital length of stay.

Blecker S1, Shine D2, Park N3, Goldfeld K3, Scott Braithwaite R1, Radford MJ2, Gourevitch MN3.

Int J Qual Health Care. 2014 Oct;26(5):530-7. doi: 10.1093/intqhc/mzu065. Epub 2014 Jul 3.

CONCLUSION: Increased weekend continuity of care is associated with reduced length of stay. Improvement in weekend cross-coverage and patient handoffs may be useful to improve clinical outcomes.

Impact of continuity of care on mortality and health care costs: a nationwide cohort study in Korea.

Shin DW1, Cho J1, Yang HK1, Park JH1, Lee H1, Kim H1, Oh J1, Hwang S1, Cho B2, GuallarE3.

Ann Fam Med. 2014 Nov-Dec;12(6):534-41. doi: 10.1370/afm.1685.

CONCLUSION: Lower indices of continuity of care in patients with newly diagnosed hypertension, diabetes, and hypercholesterolemia were associated with higher all-cause and cardiovascular mortality, cardiovascular events, and health care costs. Health care systems should be designed to support long-term trusting relationships between patients and physicians.

Continuity and the costs of care for chronic disease.

Hussey PS1, Schneider EC2, Rudin RS1, Fox DS1, Lai J1, Pollack CE3.

JAMA Intern Med. 2014 May;174(5):742-8. doi: 10.1001/jamainternmed.2014.245.

CONCLUSION: Modest differences in care continuity for Medicare beneficiaries are associated with sizable differences in costs, use, and complications.

Patient-physician shared experiences and value patients place on continuity of care.

Arch G. Mainous III, PhD1, Meredith A. Goodwin, PhD2 and Kurt C. Stange, MD, PhD2

J Fam Pract. 1990 Jul;31(1):69-73.

CONCLUSION: The results of this study point to the importance of the experiences shared between patients and physicians and the value that patients place on continuity with their regular physician.

The Importance of Continuity of Care in the Likelihood of Future Hospitalization: Is Site of Care Equivalent to a Primary Clinician?

Arch G. Mainous III, PhD, James M. Gill, MD, MPH

AM J Public Health. 1998;88:1539-1541

CONCLUSION: A location providing health care without clinician continuity may not be sufficient to ensure cost-effective care.

Continuity of care in a family practice residency program. Impact on physician satisfaction.

Blankfield RP1, Kelly RB, Alemagno SA, King CM.

J Fam Pract. 1990 Jul;31(1):69-73.

CONCLUSION: The data support the hypothesis that continuity of care with patients is an important determinant of resident and faculty physician satisfaction with their outpatient experience.