The Quality-Cost Connection: How’s your outpatient continuity of care’?

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

Evaluating the continuity of patient care in ambulatory health care services is challenging. Continuity of care implies the progression of a predetermined plan for health care services without disruption of the plan. However, the ambulatory care client, unlike the hospitalized patient, is not as easily controlled, monitored, or guided through health care processes. For this reason, the client of ambulatory care must be a more active player in the health care process if it is to be successful. Traditional continuity measures have included counts of the number of:

  • missed appointments that are not further reviewed or evaluated for trends;
  • scheduled laboratory tests or imaging procedures that never occur;
  • results of testing services that never find their way into the medical record or at least are not posted in a timely manner;
  • lack of documentation of clinical findings in the medical record, including not signing and dating the entry by the physician or other clinicians.

Three other quality monitors also may effectively evaluate continuity of care in the ambulatory care program, depending on the nature of the care required or offered and the setting of the program. These are monitors of:

  • referral for consultation by a specialist without adequate documentation of clinical findings and test results;
  • referral for surgery or hospitalization without the aforementioned documentation;
  • inadequate medical record documentation where there is a multiphysician staff rotation or where medical residents rotate through the ambulatory care program every several weeks.

As health care networks expand to encompass a variety of settings, the concept of continuity of care also should expand. In integrated delivery systems, evaluating continuity requires quality management systems that extend from outpatient services to the inpatient environment, if necessary.

Departments that provide outpatient care must constantly monitor the flow of the patient and communications about that patient’s care in an effort to avoid interruptions in the care process. Many ambulatory units telephone patients the day before their scheduled appointment to remind them of the appointment and then contact them again the day after the treatment to inquire about the outcomes of treatment. Staff should contact patients who miss scheduled appointments to determine why the appointment was missed and arrange for rescheduling. Ambulatory care units also can evaluate wait times between the arrival of the client and the initiation of treatment intervention or the start of therapy. Such data can be used to identify and eliminate events that cause clients to leave prior to treatment.

Appropriateness reviews of prescribed treatments, tests, or referrals can be used to identify quality of care concerns as well as continuity of care problems. High on the quality evaluation list should be the measurement of client satisfaction as an important aspect of continuity of care. If clients are not satisfied, they are likely to seek care from another provider or discontinue treatment entirely.

Many measures of continuity are applicable to any setting or service; however, departments also should focus evaluations on issues of particular importance to their unit and the clients served. For example, the durable medical equipment (DME) service provides in-home care and services including IV infusion therapy, oxygen therapy, and all types of medical equipment support (wheelchairs, walkers, hospital beds, etc). To evaluate continuity of care, the DME service can measure client satisfaction with continuity of care issues, e.g., Was the equipment timely in arriving? Were instructions adequate? Was service unnecessarily interrupted for any reason? If questions arose after the initial installation, did the client receive timely and appropriate responses? Was there adequate medical intervention when the DME service needs of the client changed? Were equipment vendors responsive to the medical and emotional needs of the client? Early identification of quality problems in these potentially problematic areas can reduce or eliminate continuity of care concerns.

Ambulatory care departments such as outpatient physical and occupational therapy can monitor clients’ utilization of services as a measure of continuity of care. By evaluating such issues as client/therapist ratios, rehabilitative services can identify potential overcrowding problems that may cause clients to seek services elsewhere. Home care services also can evaluate over- and underutilization as a measure of continuity of care. Clients should be accepted for home care only if needed services are available. If the services needed for appropriate continuity of care are not available through the home care department, then an alternative care program must be found to assure that care is not interrupted. Home care personnel should visit clients within 24 hours of receiving a referral. Evaluating compliance with this standard is a measure of continuity of care.

The outpatient oncology service can evaluate patient care continuity by monitoring patient treatment plans and goals, e.g., Is the care plan complete and up-to-date? Is goal accomplishment realistic? To ensure continuity, the oncology staff constantly must evaluate the efficiency of communication between inpatient providers and their outpatient counterparts. There are times when interruptions in the treatment process are unavoidable. However, each case should be reviewed independently with the department’s performance standards in mind. Staff in oncology services also must be sensitive to the patient’s clinical and emotional needs. Through early identification of treatment interference problems, staff can encourage the patient to keep returning for care until the designated plan of treatment is completed. An important measure of quality is patient/staff communication. Patients and families must know what their responsibilities are in the treatment process. Is the treatment active or passive? Do they need constant supervision, or can they continue the treatment with minimal help, once instructed? If these matters are not addressed proactively, continuity of care and health care problem resolution can be adversely affected.

Outpatient labs play a vital role in preserving continuity of care. For example, patients receiving chemotherapy or radiation can be adversely affected by poor quality lab services. The length of time between blood draws and reporting of the test results to the respective physician are important performance measures for the laboratory. Tests results must be available quickly to assure that doses of chemotherapy or radiation are accurate to the patient’s needs. The outpatient labs can evaluate the quality of the specimen collection process through periodic assessments of the behavior of collection personnel, compliance with patient identification procedures, appropriateness of specimen choice in relation to the test ordered, and specimen rejection rates. These performance measures provide important data about the quality of laboratory services and help to identify issues that can affect continuity of care.

Continuity of patient care is an important component of effective performance in ambulatory services. Outpatient providers should measure important aspects of care to identify issues that can create undesirable lapses in health care services. Managers of departments that provide care to outpatients should ensure that mechanisms are established to maintain continuity of care as patients enter or leave the department. Patients must be provided with pertinent information as they move through the health care delivery system. Care must be coordinated among health care professionals through effective sharing of important information as the patient receives services in different levels of care.