Learn how to measure the effectiveness of handoffs

Identify processes that affect continuity of care

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Continuity of patient care has many facets, such as availability of information, availability or constancy of a clinician, a usual source of care, and follow-up appointment keeping. It is driven by the goal of providing seamless patient transitions from one setting to another.

Among its many facets, continuity of patient information is essential; clinicians must have knowledge of or ready access to relevant facts about a patient at all times. Complete and pertinent information must be available to all caregivers. Effective information sharing must occur among the practitioners caring for a patient, whether in the same institution, between institutions, or between care settings. Information continuity depends on data being up-to-date, accurate, retrievable, understood, and used.

In transitions between settings of care, information is at risk of not being transferred, of being transferred but not read, of being read but misunderstood, or of being understood but discounted.

A variety of measures can be used to judge how well your hospital is doing at ensuring effective and efficient continuity for your patients. The measurement model — structure, process, and outcome — can be used to evaluate continuity of care. Structure in health care delivery refers to the way a health care entity organizes itself and sets up operations. Health care structures include elements such as the physical plant, configuration of management structure, and organizational linkages with other providers.

Process refers to specific interventions performed by health care professionals that result in an outcome. Outcome refers to the results of patient interactions with health care professionals and services. Measures of patient care continuity can encompass all of these components — structure, process, and outcome.

Structure measures look at the capacity of practitioners and providers to furnish seamless health care services. Measures of structure that relate to continuity of care generally focus on availability of services and the ability to communicate across the continuum. The following are some examples of structure measures that can be used to determine if continuity-of-care problems exist within a health care organization:

  • length of time between request for special services not provided within the organization and patient receipt of services;
  • percent of transferring facilities with whom your organization has a formal transfer agreement;
  • percent of staff who receive orientation and continuing education in continuity-of-care activities (for example, initial assessment, screening for high-risk patients, discharge planning);
  • percent of non-English-speaking patients for whom educational materials are available in their primary language.

To begin identifying structure measures for your organization, ask yourself: What organizational structures support, or should support, continuity of care in my organization? Rank the structures you list and focus your continuity-of-care structure measures accordingly.

Process measures should focus on activities that are critical to ensuring continuity of care. For example, patients being discharged from the hospital to their homes need detailed instructions about follow-up care, and family members or other caregivers may need training to provide care. Failure to teach them how to give drugs, implement treatment, and monitor recovery increases the likelihood of adverse outcomes and of hospital readmission. Process measures could evaluate provision of patient instructions for follow-up care and provision of necessary training for family members.

To begin identifying processes that affect the continuity of care in your organization, ask yourself: What tasks must be performed properly and what linkages must work well to achieve continuity-of-care goals in my organization? Focus your continuity-of-care process measures on these critical tasks and linkages. Here are some examples of the continuity-of-care questions your process measures could help answer:

  • How often does important information (for example, patient's cognitive and physical function, medical and social status, resuscitation status, drugs, drug allergies, family support) accompany patients when they are transferred to another facility?
  • What percent of patients are given adequate and complete follow-up instructions at the time of discharge?
  • How many patient records have a complete and up-to-date list of the patient's current medications and allergies?
  • What percent of inpatients have an adequate and timely assessment of their discharge needs?
  • How often are terminally ill patients offered appropriate guidance about advance care planning in the end-of-life experience?
  • What percent of patients receive appropriate referrals to community-support services?
  • How often are parents encouraged to play a part in the care coordination for their child?
  • What percent of patients with chronic conditions are assigned a case manager?
  • How often does everyone providing care to a patient use the same treatment plan?
  • How often does the nurse caring for a hospitalized patient talk with the nurse who will care for the patient after discharge?
  • What percent of the time is medication reconciliation done as required by hospital policy?

Outcome measures focus on the end result of health care processes. The patient, the environment, caregivers, and other factors can influence outcomes.

Therefore, selecting outcomes to measure that correlate directly with continuity-of-care tasks is difficult. It is most likely that the results of any outcome measures you choose will be affected by many factors, not just continuity-of-care tasks. That's why a family of structure, process, and outcome measures is needed to adequately evaluate the continuity-of-care function.

An outcome measure that may be directly tied to continuity of care is patient/family satisfaction. Targeted survey tools can be used to judge people's satisfaction with various aspects of health services such as:

  • adequacy of discharge plan explanations;
  • level of involvement of patients/families in decision making;
  • timeliness of response to questions and problems.

The chart below shows a survey instrument that could be used to gather satisfaction data from patients who have just been discharged from the hospital. The questions relate to various processes intended to improve continuity of care.

Inpatient Satisfaction Survey: Upon Discharge

The other survey instrument (see chart below) can be used to gather information from patients approximately one month after they have left the hospital.

Inpatient Satisfaction Survey: One Month Post-Discharge

To effectively manage the patient care continuum, case managers must help control the transitions or handoffs in the process of care.

The transitions may be between caregivers within the same setting, between services or departments within the same setting, or between caregivers in different settings. The effectiveness of these transitions is directly related to the design and operation of information linkages and handoffs within the continuum.

Examining the patient transitions in the care continuum in your organization provides you with a measure of the capability of your systems to support consistently safe, high-quality patient care.

Case managers should be at the forefront of identifying and resolving challenges that hamper the seamless delivery of patient care services.