What is the purpose?
The purpose of the Relational Continuity Change Package is to assist primary care clinics in optimizing processes for relational continuity.
What is the aim statement?
By a specific date, the clinic team will have improved average physician relational continuity by a specific percentage.
What do I need to do before proceeding?
This is the foundational change package that should be reviewed:
Panel Processes Change Package SummaryHigh Impact Changes
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Recognize the value
1.1 Potentially Better Practice
Plan regular team meetings to review the benefits and importance of relational continuity between patients and primary care physicians and to begin planning around how to apply to your clinic context.
Process Measures
Team meetings are scheduled regularly.Tools
Relational Continuity Guideline
1.2 Potentially Better Practice
Develop a plan to work as a team to create processes to strengthen relational continuity, with the recognition that it is the foundational building block for achieving management and informational continuity.
Tools
HQCA Primary Healthcare Panel Reports
1.3 Potentially Better Practice
Identify elderly patients, vulnerable populations, and those with complex needs or multiple chronic conditions who may benefit most from improved continuity.
Tools
Evidence Summary: The Benefits of Relational Continuity
1.4 Potentially Better Practice
Apply knowledge into practice that recognizes that all patients benefit from relational continuity.
Tools
An Albertan Perspective - IHE Innovation Forum Video -
Foster patient and provider team relationships
2.1 Potentially Better Practice
Make explicit agreement with the patient that the identified primary care physician will provide and/or coordinate their healthcare needs.
Tools
Guide to Panel Identification
2.2 Potentially Better Practice
Partner with patients for shared decision-making and explore their values and preferences.
Tools
Setting Effective Patient-Centred Goals Guide
2.3 Potentially Better Practice
Develop modes of communication and care plans where all primary care team members respect and honour patients and families as team members in shared decision-making.
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Advise and advocate continuity
3.1 Potentially Better Practice
Promote and advocate the value of continuity to all patients and within the health system.
- Within practice, within the community
- Advocate within the health system by communicating and raising awareness of the value.
- Educate and empower patients, families and caregivers to resolve discontinuity.
Tools
Continuity Posters Continuity Advocacy Tool -
Identify and manage your panel
4.1 Potentially Better Practice
Take steps to identify your panel of unique patients (those with whom you have a trusting, ongoing therapeutic relationship).
- Develop processes for panel identification and ongoing verification and maintenance.
- Ask your patients at every opportunity, document consistently, review your list.
Tools
Guide to Panel Identification STEP Checklist STEP Toolkit STEP Workbook
4.2 Potentially Better Practice
Review and actively manage your panel size.
4.3 Potentially Better Practice
Identify and focus on sub-populations that may benefit most from continuity (e.g., elderly patients, vulnerable populations, and those with complex needs or multiple chronic conditions).
- Develop processes to identify patient lists of clinical need.
- Routinely review patient lists (whether patients still belong there or not).
Tools
CII/CPAR EMR Guide for PMH EMR Resources -
Enable continuity via office processes
5.1 Potentially Better Practice
Test and adopt office processes to improve continuity with a goal where your patients visit their own primary care physician >80% of the time.
- Test and apply the hierarchy of booking processes to maintain continuity when patients cannot see their own primary care physician.
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Balance demand for care with capacity (supply)
6.1 Potentially Better Practice
Apply the following principles and strategies for access improvement:
- Match appointment demand to supply available.
- Optimize the care team to enhance and maximize capacity.
- Address scheduling complexities to maximize use of appointment time.
- Utilize contingency planning for both scheduled and unscheduled time away.
Tools
Improving Access to Primary Care Strategies document in progress.
Strategies to Reduce Demand -
Measure baseline continuity and track progress
7.1 Potentially Better Practice
Obtain data to know your current rate of continuity and identify a baseline from which to improve.
Tools
HQCA Primary Healthcare Panel Reports
7.2 Potentially Better Practice
Develop, as a team, a goal (aim statement) that focuses on improving continuity.
7.3 Potentially Better Practice
Continue to measure, share and display your progress toward a goal of >80% continuity.
7.4 Potentially Better Practice
The following measure of continuity can be accessed via HQCA Primary Healthcare Panel Reports:
- Physician Continuity – the number of patients' visits to primary care physician divided by the total number of all family physician visits
- Average physician continuity – the sum of all individual patients' physician continuity divided by the total number of patients in the physician panel
- Facility continuity – the number of family physician visits to a primary care facility divided by the total number of all facility visits
7.5 Potentially Better Practice
General practitioner sensitive condition visits – average number of general practitioner visits to the emergency department (ED) by a specific patient population
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Optimize the patient care team to improve and support continuity
8.1 Potentially Better Practice
Develop processes to engage with patients as a member of their own care team.
Tools
Cambridge Health Alliance Team-Based Care Toolkit
8.2 Potentially Better Practice
Create processes to support team-based care (e.g., algorithms, shared EMR, interdisciplinary huddles, regular meetings to discuss care and care coordination).
8.3 Potentially Better Practice
Develop roles and responsibilities where the skills, knowledge and training of all team members is optimized.
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Optimize all potential improvements in all contexts
9.1 Potentially Better Practice
Follow the above recommendations, particularly around access improvement to exercise all possible strategies to improve continuity.
Tools
HQCA Primary Healthcare Panel Reports
9.2 Potentially Better Practice
Understand that relational continuity still holds value in all contexts and may require more innovative strategies, including engagement with other groups to creatively problem-solve together.
9.3 Potentially Better Practice
Recognize that improving continuity is a multifactorial pursuit that optimally requires effort in all areas of recommendations, and despite challenges, some levels of improvement can be achieved in all contexts.
9.4 Potentially Better Practice
Address each recommendation based on context and capacity with the support of Alberta resources, including the Continuity Change Package, PCN, and other provincial support.
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