Key Success Factors
and Pitfalls

Continuity & Comprehensiveness of Care

Factors to Ensure Success

Linking Family Physicians & Other Physicians, Providers and Patients

Linking family physicians appropriately with other family physicians, as well as other medical specialists, other primary care providers and with patients themselves, is key to continuity and comprehensiveness of care.

Between Family Physicians

With the increasing mobility of patients as well as providers, (e.g. transient or locum family physicians), it is important to ensure appropriate linkages between all family physicians providing care to the patients of family practice or primary care groups. Communications is vital. In many settings, continuity and comprehensiveness between family physicians is maintained by using after and during hours call groups for 24/7 coverage. The lead physician for the group or an appointed non-physician administrator may take the initiative to organize these groups. Most medical associations have adopted guidelines for reasonable on-call, (e.g. one day in five), and these guidelines should be reviewed in arranging on-call schedules. It is further recommended that schedules be created for at least a one-month period, preferably longer, and that they be distributed with at least three months' advance notice to physicians before finalizing, allowing time for physicians to negotiate changes before releasing externally to local agencies or institutions.

Between Family Physicians and Other Specialists

Extra importance should be given to the inter-dependence of family physicians with other medical specialists in the provision of continuous, comprehensive care, including specialists practicing in hospital or other institutional settings. Appropriate IM/IT systems will improve communications as well as the seamlessness and continuity of care across a variety of specialists and settings. In some communities, family physicians have looked to the development of "shared care " systems between themselves and other specialists, (e.g. shared mental healthcare). In these models, two requirements are met. One is the assurance of timely referral and the ability to communicate need for patients being sent to other specialists. And the other, perhaps the most important of the two, is the increase in the capacity of the primary medical care system to deliver collaborative care. Meeting these requirements is important because it is clear that many medical specialties in Canada are suffering from insufficient human resources, similar to family medicine. As a result of shortages, family physicians are often required to manage the numerous complexities of a vast range of conditions, especially chronic conditions that now encompass a significant portion of the family physician's workload. Since the referral of complex patients has become progressively more difficult, shared care projects should be encouraged and indeed, funded by imaginative incentives provided through negotiations with government.

Between Family Physicians and Nurses

Family practice nurses are one of the most important health human resources in primary care and should be available to all family physicians in practice. Trusting relationships are experienced and demonstrated by numerous family physicians in the provision of care with shared and delegated responsibilities given to the nurse. In the evolution of primary care interdisciplinary collaboration, the family practice nurse should be nurtured and maintained as a key and essential member of the team.

Other nursing roles are increasingly contributing to the value of collaboration between family physicians and nurses in the provision of primary care. These include nurse practitioners, advanced practice nurses, and nurses with specialized roles such as those associated with public health and certain aspects of newborn or well women care.

With the importance being given to telephone nursing services, telehealth is becoming an increasingly accepted way to deal with patient problems after-hours. As with other forms of primary care, communication by telehealth personnel with the patient's family physician, the on-call family physician, or the family physician's office, either immediately or within 24-48 hours, is essential for good continuity of care.

Between Family Physicians and Patients

Linkages between family physicians and patients may take many forms. As may be necessary for their defined patient populations, family physicians in established practices should be capable of providing better and more informed care to their patients using formal linkages with local:

  • Public health
  • School, housing and justice systems
  • Social service agencies
  • Private industries
  • Governments and municipalities

Individual patient linkages may also be accomplished through formal enrollments within certain primary care models where the expectations of both parties (patients and providers) are clearly outlined. Enrollment is a way to register patients who are attached to a family practice or primary care group/team and is seen as a method of ensuring every patient has a local primary care group to which he or she belongs. The goal of federal/provincial/territorial government leaders to provide a target percentage of the population with 24/7 primary care by 2010 has driven enrollment in many locations.

Enrollment encourages continuity and comprehensiveness of care by defining the practice population for which all aspects of care will be provided. Given that patients in most jurisdictions sign up with a specific family physician, enrollment may strengthen the relationship between the patient and his/her own family physician while discouraging the use of health care services outside of the enrolled practice population. One of the disadvantages of enrollment is the extra time required for providers to explain what enrollment means and to seek patients' signed consent. A disadvantage for patients may be the perceived obligation to restrict primary care services to the provider(s) with whom the patient is enrolled.

Finally and ultimately most important, linkages and mutually rewarding partnerships between patients and their family physicians are best exemplified by the development and nurturing of patient self-management strategies that offer excellent opportunities to improve patient satisfaction, health outcomes, and physician job satisfaction.