Continuity of Care and Retention Box Lunch Session

International Meeting on Inuit and Native American Child Health

April 30, 2005



Jim Lewis, MD

Bruce Martin, MD

James Jarvis, MD (Moderator)


The purpose of this session will be to define whether or not continuity of care makes a difference. The audience was encouraged to ask questions and engage in discussion, following brief presentations by the speakers:


·           Bruce Martin: Dr Martin is a family physician from Manitoba. He was first exposed to First Nations child health as a student and resident. During the past 2 decades, Dr Martin has worked in a number of First Nations communities in Manitoba.


·           Jim Lewis:  Dr Lewis is a pediatrician at the WW Hastings Indian Hospital at Tahlequah, OK. He trained at the University of Oklahoma and has been in Tahlequah since completing his training. His clinic is 80 miles away from the nearest medical center and Tahlequah is considered "rural." 


Defining Continuity of Care

The presenters began the session by presenting a framework for continuity of care, based on information from a 2003 article in the British Medical Journal (attached). It is important to define continuity in order to lay groundwork for how to reliably measure continuity when we look at some of the challenges associated with it. This article was published in Canada, with the principal authors coming from the US, England, and Canada. This study was funded by 3 high-level organizations in Canada (ie. Canadian Health Services Research Foundation, Canadian Institute of Health Information, and a group that advises on territorial, provincial, and federal ministers of health. This article was based on the methodology of literature review (over 2,400 articles) and a consensus conference.


There are 2 defining elements that are central to continuity. These include:

·           Care of an individual patient ? This refers to how the individual patient experiences integrated services and coordinated services. This is not an attribute of the provider, but rather the patient's experience.

·           Measure of care over time


There are 3 types of continuity:

·           Informational continuity ? common thread that links one provider to another and from one health care event of the patient to another. There is an informational component.

·           Management continuity ? includes 2 components

-         Consistency in the timely and complementary delivery of services ? providing a sense of predictability and security in care for both patient and providers.

-         Flexibility in management - ability to adapt care to changes in individual's need and individuals circumstances throughout the course of an illness or throughout the course of an individual's life. 

·           Relational continuity ? bridge from past/present care. . link to future care.  Consistent core of staff that provides patients with a sense of predictability and coherence. (this is what most people this of when they think of continuity or "continuous care clinician in a community".)


The presenters noted that the processes designed to improve continuity do not themselves equate to continuity; and that for continuity to exist, care must be experienced as connected and coherent.


In primary care literature, continuity is mainly viewed and defined as a relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. Continuity implies a sense of affiliation between patients and practitioners (ie. "my doctor," "my patient"). This is often expressed in terms of implicit contract of loyalty by the patient, and clinical responsibility by the provider. The affiliation can be sometimes referred to as longitudinal, relational, personal continuity and it fosters improved communication, trust, and sustained sense of responsibility. Primary care continuity is different than coordination of care, although better coordination of care follows from continuity.


Margaret Bay, a pediatrician in Montreal, suggested there may be another form of continuity, continuity of service period. She states that she and her husband left Northern Quebec because her husband no longer had employment. After she left, several other pediatricians left, and there is no longer any pediatric practice in the area. They have still been unable to recruit a pediatrician.


Continuity of Care for Native American Children (Indian Health Service)

Dr Lewis noted that the IHS has addressed informational and management continuity over a number of years. In terms of informational continuity, his service unit is in the process of switching over to an electronic health record (EHR). Because a patient may not see the same provider in a given service unit, one of the ways the IHS tries to ensure continuity is through the information system. The IHS has also done well in terms of management continuity. They utilize AAP clinical guidelines, as well as algorithms for the management of patients with chronic illnesses such as asthma and gastroenteritis. In addition, the EHR will incorporate Bright Futures guidelines to also help with management continuity.


While the IHS has historically done a good job with informational and management continuity, relational continuity could be improved upon. Relational continuity is something that is critical in the care of patients. 


Continuity of Care for First Nations Children in Canada

Dr Michael Moffat outlined the model that was developed in Manitoba for pediatric continuity of care in isolated rural communities. He noted that this may not have a whole lot of application in the US for a couple of reasons: (1) pediatrics in Canada is not a primary care specialty, rather, it is at a secondary, subspecialty level, and (2) in some of their remote areas, primary care has been almost impossible to maintain on a continuous basis as they have huge turnover. (It was noted that primary care is most often provided by family physicians or nurses.) The strategy that they utilize involves individual pediatricians giving a lifetime commitment to a particular community or to several communities. Their program is built in such as way as to allow pediatricians to visit these communities on a very regular basis and interact with the primary care team in the villages. 


Dr Moffat noted that there are 3 communities that he visits at least twice/year. In the end, he becomes of the continuity for kids that have medical problems. Over 20 years or so, he has gotten to know all of the families of children with chronic conditions. He is also able to provide direct service to these children when they have to be hospitalized or referred to the tertiary care center, since he is located there.  He stated that this is one model that seems to work in Canada; but that this model is very provider dependent.


Is Relational Continuity Important?

As a whole, the audience felt strongly that relational continuity was important. Several points were raised:

·        Parents trust their most beloved keepsakes (ie. their children) to pediatricians. We need to honor this trust. Perhaps we could convince federal agencies that relational continuity is important by posing the question "What would you want for your child or for yourself?"

·        Michael Moffat, a pediatrician in Manitoba, stated that continuity does matter. He stated that fundamental human nature is developing relational attachments with people. However, he stated that the value of relational continuity has been very hard to define, and even harder to measure. There is no final proof of it's importance yet. He did note that there is some work going on using administrative data and other collected data from universal health care systems in Quebec; and there may be studies forthcoming.  Dr Moffat stated that he doesn't personally need more proof that continuity is important than having the experience when a family comes to Winnipeg from a remote community that he has been visiting, under the circumstances where their chronically ill child requires additional care or hospitalization. Parents absolutely brighten up when they see somebody that they actually know and that has seen their child previously.

·        Dr Lewis stated that the IHS system of care was modeled after the uniformed services. In 1987, a memo came out from the US Surgeon General that it was expected that 3-5 geographical transfers would take place within a 20 year career. While this model may work in the uniformed services because patients also change every 3-4 years; it is not as feasible in the IHS, since the patients do not change. We should consider this from the patient's perspective and consider asking the patient, "Do you want to see 3-5 providers from your child's birth to the time they are an adolescent?"

·        Bill Freeman, a family physician at Lummee for 13 years, stated that he learned something from community members when he left. The word that best describes his departure for him and the community was "divorce." He states that this is never a pleasant experience. This word should be used when we talk to Congress about the importance of continuity of care ("Senator, do you want a divorce from your doctor?"), because it reflects the severity of what happens when a doctor leaves.

·        Dr Martin emphasized the fact that although relational continuity is important, stability and continuity of methodology is also very important. He stated that when mixed messages are provided to parents from different levels of providers, it is easy to destroy a community's trust in all providers. He indicated that when examining an individual's lifelong commitment to a community, it is important to make sure that the commitment to the community is not only maintaining relational continuity, but also making sure there is integrity in management. It was noted that clinical guidelines and algorithms help with this issue.

·        Maria Garcia, a member of the Pascua Yacqui tribe in southern Arizona, stated that she never remembers going to the doctor as a child and therefore the lack of a relationship with a provider in an acute scenario doesn't impact her that much. She did note that as a provider, she has noticed that patients with chronic diseases are very frustrated when a provider leaves, because they have to go back in and tell a new provider all of their information.


Strategies to Improve Continuity of Care: Physician Retention

It was felt that physician retention is critical to improving relational continuity. Physician retention was identified as the cheapest form of recruitment.

·        Jackie Nelson from Wind River suggested that physician retention could be improved by increasing or encouraging the careers of physicians. She stated that she initially went to Wind River to repay a debt to the state, but stayed there because it was the right type of practice for her with a very collegial medical community. Others also agreed that professional development was an important factor.

·        It was suggested that agencies begin to "think outside of the box" and decrease the restrictions that are placed on physicians. Currently, hospitals seem to want "all" or "nothing" if a physician chooses to move into the IHS or Provincial agencies. Perhaps if greater flexibility were given to physicians (ie. one week out of the month, they can go elsewhere, etc), this would improve physician satisfaction and retention. This individual felt it would be better to have a quality physician 90% of the time, than to have no physician or inconsistent locum tenens coverage. This individual felt that burn-out was a huge concern and more needs to be done to help physician maintain their sanity and not experience burn-out.

·        Dr Steve Holve indicated that the Navajo Area conducts exit interviews prior to the departure of a physician. He stated that reasons for departure were quite complex; and that many of the reasons were probably out of the control of the IHS (eg. remoteness, spouse's employment and lack of economic opportunities, educational issues for children). From his experience, one of the biggest factors in physician retention is collegial, supportive, and stable relationships. He stated that within the IHS, the places that do well in recruitment are places where the conditions are satisfactory, the physicians have access to support services, and where a nucleus of people stay. Having about 5-10 core people who stay for a long period of time makes a huge difference. 

·        Peter Talbot indicated that retention is also an issue in urban areas, such as the Seattle Indian Health Board. Their organization feels as though you have really got to want to work there and be willing to work for less pay. He stated that they had many qualified people come and receive training and then leave. He felt that a sensitized administration, an administration willing to talk with providers, was important.


Strategies to Improve Continuity of Care: Improved Recruitment

Dr Jarvis outlined the US experience related to recruitment. In early 1980's, US Health Resources and Services Administration, through Congressional funding, set up Centers for Excellence. These Centers are located in Universities that have a high proportion of Native students. The purpose of the Centers was to take what appeared to be deficits in these students that came out of their upbringing and cultural circumstances and turn them into assets. The Centers for Excellence have been proactive at identifying potentially promising students as early as secondary school, nurturing their experiences to get them to professional school, and once in professional school, supporting them through what can still be a daunting process. Centers of Excellence are able to gather very talented students in concentrated places, so they don't feel isolated. In addition, Centers for Excellence are able to gather groups of educators who have sensitivity to the cultural issues. It was guessed that about 2/3 of Aboriginal health care providers have been supported in one way or another by Centers of Excellence in the US.


Canada has a less successful record of training Aboriginal health care providers, as evidenced by the low proportion of Aboriginal health professionals in communities and in tertiary care. Dr Martin stated that part of the reason is related to the fact that many communities in Canada are extremely difficult to access and because these communities are marginalized. The challenge is developing access to literacy, access to good care, education about good parenting, etc. He indicated that programs that are geared toward engaging youth (ie. secondary students who have interest in math, science, health careers) have not been successful; and that likely it would be of greater benefit to devote resources to early literacy for 1-2 year olds. Therefore, it is really difficult in terms of looking at the timeline for a generation of health professionals who come from the communities of greatest need.


Strategies related to improved physician recruitment were identified:

·        Currently, there is not much funding set aside for recruitment. At this point, there is enough money to recruit between 20-25 physicians/year in the entire IHS. An investment up front would likely be offset by the cost of locums coverage later on.

·        It was noted that it would beneficial for Congress to allocate additional funds for scholarships. The ultimate objective would be to train Native professionals to go back to their communities and work there. Funding for these types of programs has been flat; despite the fact that the cost of education continues to increase.  As a result, fewer scholarships are offered now than in years past. 


Strategies to Improve Continuity of Care: General Strategies

·        Janet Aguilar, a community pediatrician who currently works at Kaiser stated that they have implemented a strategy to improve continuity of care for their patients. Children are all assigned to a personal physician, if they have not identified one. This way, all children and families at least have a name. They also put up billboards that include photos of the physicians, and have developed a Web site that includes credentials of the physicians. Patients and families were then given more opportunities to make an informed choice. She stated that as a result of this effort, they have seen physicians developing more ownership for the patients that are assigned to them (ie. their "panel" of patients) and they have developed greater concern for the overall health of their panel. It was unclear whether or not this has had a measureable impact on the quality of care. It was felt that it would be beneficial to obtain data on measures such as improved compliance with care, decreased ER visits and hospitalizations, decreased appointment times, etc.

·        Kent Saylor, pediatrician in Canada, stated that in his experience, in order for continuity to work in the Canadian model, there must be continuity in the primary care providers in the villages, as well as in the consultant pediatricians. When there's a breakdown in one of these areas, he's seen a breakdown in continuity. This has resulted in increased referrals to the tertiary care centers in his experience.

·        Jim Carson, pediatrician in Canada, stated that they will probably never have strong relational continuity in Canada, and they will likely need to look for continuity solutions within the community. This could be accomplished by training local people to provide services to a certain level (eg. community health representative training for maternal child health, public health, etc). Pediatricians can provide support through telephone or tertiary services. This may be another strategy for ensuring continuity, especially in remote areas. A similar model for providing care was also described in Alaska; where care is provided mostly through Native women in remote villages who are certified, but not licensed, working with their primary care referral person over the phone. These individuals are trained and go back to minister to their people. The benefit of this approach is the sensitive perspective to the cultural priorities of the people that the provider possesses. Typically, these people work in their community and stay for longer periods of time.

·        Heather Anyetta, a pediatrician who worked in Eastern Canada on the Labrador Coast for 6 years, felt that nurse practitioners will be the core for continuity and that there is a need to support and respect what nurse practitioners are doing. She also stated that there was great value in having strong interaction with the community.

·        Peter Talbot, physician in the Seattle Indian Health Board, stated that over the years, the thing that worked best for them was to try to finesse both a "walk-in" mentality, as well as a "continuity" mentality. One way that they tried to accomplish this was by making sure health promotion bases were covered, even when the patient comes in for a sick visit. They have utilized practitioner meetings to ensure consistency between visits, so that charts would be standardized and more quickly reviewed. In a sense, systems continuity became a substitute for relational continuity. They have found that this works best in well-developed models, such as their diabetes program. 

·        In some places, relational continuity may never exist. In these instances, emphasis should be placed on a team approach to providing continuity and also on the management of information. It was suggested that significant money and thought be invested into management continuity and on measuring it's benefits, in the hopes that this will help overcome health and human resource challenges. Bill Green stated that he currently works as a locum tenens physician, and feels much more confident when he is in an IHS site where he knows he will at least have some information about the patient available. He stated that the IHS records system is a very important part of the quality of care in the Indian Health system.


Dr Jarvis compared the patient ? provider relationship to the interaction between healer and an individual seeking healing. In a tradition view, there is an interrelationship where there is an exchange of trust, as well as a level of intimacy. Superficially, this interaction means we involve ourselves with aspects of people's lives that they don't necessarily share with other people; but this also means that we are always trying to reach the places where people are most vulnerable, frightened, and most in need of being comforted. It takes an extraordinary sense of self both on the part of the healer and on the part of the family of the person seeking healing to really make that relationship work. Dr Jarvis stated that his intuition is that there would be something horribly disconnected if the person seeking healing feels or knows that the healer is going to be gone in 2 years. 


In summary, it was noted that physicians touch people like no one else does. Physicians did not go into medicine to make money, but rather because they care. Physicians need encouragement to keep going. The physician-patient relationship works only because the patient and the family have mutual trust. It is unclear if we can truly measure the benefit of relational continuity; but it is clear that the cost of not having it is immeasureable. One way or another, it will be important to find a better and more stable system of health care for Aboriginal people in North America.