Advice to the Profession: Continuity of Care

Continuity of care is an essential component of patient-centred care and is critical to patient safety. While it can be understood in a number of ways, central themes often include the importance of patient experiences with the health care system being connected and coordinated, and the importance of information exchange across different parts of the health-care system.

In order to set out expectations pertaining to continuity of care, the College has developed a set of inter-related policies addressing a range of issues. They are: Availability and Coverage, Managing Tests, Transitions in Care, and Walk-in Clinics. This document is intended to help physicians interpret their obligations as set out in these policies and to provide guidance around how these obligations may be effectively discharged. It also provides some background information on the scope of these policies and the role of patients, technology and the health-care system in facilitating continuity of care.

Facilitating Continuity of Care

The Role of Physicians and the College

Physicians hold a prominent and important role in the health-care system and in turn are key facilitators of continuity of care. However, the College recognizes that physicians are not solely responsible for ensuring that continuity of care is achieved as often there are health system- level factors that are beyond the control or influence of individual physicians that impact continuity of care.

The College’s approach to helping minimize breakdowns in continuity of care is to focus on the issues or elements of continuity of care that are within the control or influence of physicians.

The Importance of Patient Engagement and Technology

Patients have an important and growing role to play in facilitating continuity of care, as actions they take may contribute to or help prevent breakdowns in continuity of care. Engaging patients in their care and providing them with the information and tools they need to navigate the system may help minimize patients falling through the cracks.

Technology has an important role to play in facilitating continuity of care as well, and there are already many ways in which technological solutions can help. For example, there are technologies that may assist with test results management, facilitating access and/or coverage, facilitating information exchange between health-care providers, and improving transitions in care, especially as it pertains to handovers within health-care institutions, hospital discharges, and the referral and consultation process.

Both engaging patients in their health-care and adopting technological solutions where they are reasonably available have the potential to meaningfully facilitate continuity of care. Doing so will also complement physicians’ efforts in this regard and together many potential breakdowns may be avoided.

An Evolving System

Preventing all breakdowns in continuity of care cannot be achieved through physician actions alone. The expectations set out in the continuity of care policies aim to help close some of the cracks in the system, but system level changes are also needed in order to complement, support, and enhance the expectations the College has set out.

Fortunately, continuity of care is an issue that is driving a lot of the change we are seeing in our system and many of our partners in the health-care system are also working to support a coordinated and connected health-care system.

While most physicians are using electronic medical records (EMRs), there is still work being done to ensure these different systems are talking with one another and eventually work together so that patients effectively have one record that follows them wherever they go. Significant strides have already been made on this front. Physicians looking to enhance their practice can register for a ONE ID account through the College’s Member’s Portal to access existing digital health services available from eHealth Ontario such as the clinical viewer and ONE Mail.¹ ONE ID also enables access eConsult² which seamlessly and securely connects, for example, family physicians with specialists in order to seek their opinion on specific patient issues in a direct and timely manner and, increasingly, directly through their EMR.

Similarly, patient portals are becoming more common, allowing patients to access their test results directly and in some cases, view their entire health record. Changes in the way hospitals develop discharge summaries, with a focus on patient needs and comprehension also has the potential for better supporting transitions from hospital to home and minimizing breakdowns that occur and is an approach that is being adopted across Ontario.³ Further growth in terms of access to these emerging tools will help to support patients and facilitate continuity of care.

Additionally, changes in the way the system is resourced and how incentives for health-care providers are used all have the potential to bring positive change. For example: hospital fast track systems in emergency departments can help staff quickly treat patients; improved resources and changes to incentives may help support increased access to appropriate after-hours care or care during physician absences from practice; a centralized referral and consultation process may help reduce wait times and lost referrals; and enhancements to tools like Telehealth that help patients decide where and when to seek care. These are all examples of a system that is or can further evolve to better support patients and minimize breakdowns in continuity of care.

Availability and Coverage

Why has the College set out expectations relating to physician availability and making arrangements for care when physicians are not available?

Continuity of care does not mean that individual physicians need to personally be available at all times to provide on-demand care and continuous access to patients. Doing so would negatively impact the quality of care being provided and compromise physician health. However, in order to facilitate continuity of care and minimize risks to patient safety, the College has set out expectations for physicians, recognizing that their role in facilitating continuity of care includes being available and responsive to patients and health-care providers involved in their patients’ care and helping patients navigate the health care system and access appropriate care when their physicians are unavailable.

Why does the policy require physicians to be available by phone? Why not through other means of communication? How does this expectation apply to group practices, institutions or department based practices?

Good communication and collaboration are fundamental components of high quality care, but are not possible if patients and health-care providers are unable to contact physicians. While recognizing that physicians may offer a variety of ways to communicate with patients and other health-care providers, the policy sets out expectations about being available by phone and voicemail as this is still the default mode of communication for many and possibly the only mode of communication that some patients may have access to.

Physicians practising as part of a group practice or within an institutional or department-based environment may rely on a central and shared phone and voicemail to discharge this expectation.

Does the policy require physicians to arrange for after-hours coverage?

No. The policy requires physicians to inform patients about appropriate access points to the health care system when in need of after-hours care. This may include any arrangements they have made with other providers or it may mean directing patients to, for example, Telehealth or the emergency department where it would be appropriate and reasonable to do so. It’s important to note that depending on the nature of a physician’s practice, the legal concept of duty of care may require taking additional steps to help patients access the right kind of care (e.g., post-operative follow-up, obstetrical care, etc.). What this means will depend on the physician’s practice type, and so physicians may wish to seek legal advice for further clarity.

The policy requires physicians who are going to be unavailable during temporary absences from practice to take reasonable steps to make coverage arrangements for patient care. What are reasonable steps?

As the policy notes, what is reasonable will depend on a variety of factors. In general, longer absences increase the risk to patients and will require additional effort on the physician’s part to make sure patients have access to appropriate care. In some cases it may be quite difficult to make coverage arrangements with another physician of the same specialty and whose practice is within a reasonable distance. As such, the policy recognizes that other options might be appropriate, including informing patients about appropriate access points such as the emergency department, where no other options are reasonably available.

Additional expectations are set out for managing test results, referrals, and information sharing during temporary absences from practice as these issues can be managed differently than providing direct care and pose additional risks to patient safety that are otherwise difficult to mitigate without coverage.

How can physicians support patients in accessing the right kind of care and supporting continuity of care when they are not available?

Patients have a role to play in managing their care. In particular, it’s important for patients to understand the value of seeing physicians with whom they have a sustained relationship and how this contributes to continuity of care. Physicians can help patients understand that, notwithstanding the convenience of going to a walk-in clinic or emergency department, if they are able to wait to see their own physicians, they may contribute to a more continuous care experience.

Physicians can also help encourage patients to develop a list of their medications and health conditions so that when they go to an emergency room, walk-in clinic, or other health-care provider providing coverage, they can share that information and support the provision of the best possible care.

Managing Tests

Who is responsible for ordering tests and tracking results for referred patients?

Generally, any physician who determines that a test is needed is responsible for ordering that test, tracking the results, and managing any follow-up stemming from that test. By ordering tests that they themselves have deemed necessary, physicians ensure that patient care is not unnecessarily delayed, and that their colleagues are not required to receive results or manage care that falls outside their scope of practice.

Sometimes, physicians in a patient’s circle of care may be able to accept responsibility (i.e., tracking and/or follow-up) for a test ordered by another physician, but the receiving physician has to agree to accept responsibility for the test.

Is it sometimes appropriate for a specialist to refer patients back to their family physician for follow-up care, including additional testing following a consultation?

Yes. If, during the course of an assessment, a specialist makes an incidental finding unrelated to the consultation (including abnormal lab or imaging tests), they will need to use their professional judgment to determine what is appropriate, taking into account the clinical significance of the finding and the timeliness of the required follow-up.

For example, if a test result needs to be urgently managed, then specialists need to communicate the results to the patient and take steps to arrange timely follow-up for the patient. If, however, the result is not urgent and not typically within the scope of the specialist to investigate or manage, they will need to inform the patient of the finding and advise the patient to follow-up with their family physician.

What is the responsibility of physicians who provide e-consult services for ordering tests?

Physicians who provide e-consult services may not assess patients directly but might recommend that a test be ordered. In these cases, the physician seeking advice from the e-consultant physician would order the test and follow-up on the results.

Who is responsible for ordering and tracking tests in the context of urgent episodic care?

In some situations, physicians might provide urgent or emergent episodic care, such as in an emergency department. Any recommendations for additional non-urgent investigations that fall outside of the acute care being provided are not generally the responsibility of the physician providing the urgent or emergent care.

Should primary care providers be copied on test requisitions?

It is generally good practice to copy the patient’s primary care provider on a test requisition so they are aware of the tests ordered and the results; however, they would have no additional responsibilities in regard to the tests or results, unless there is reason to believe that a clinically significant test result has not been followed-up on.

Physicians can generally assume that they have consent to share relevant information with the patient’s primary care provider unless the patient has expressly withdrawn consent. However, there may be instances where patients would not want a particular test result shared with their primary care provider, and so it will be important for the ordering physician to consider whether express consent should be obtained.⁴

What is a critical test result?

A critical test result is one where the result is of such a serious nature that physicians may be required to make immediate patient management decisions. The Ontario Association of Medical Laboratories’ Guideline for Reporting Laboratory Test Results sets out the criteria for how labs define a critical lab result and the necessary steps labs must take in response. If in receipt of a critical result, the labs will call clinicians 24 hours a day, 7 days a week to report the result to facilitate prompt medical intervention if required.

The Canadian Association of Radiologists also sets out standards in their Communication of Diagnostic Imaging Findings. This standard provides guidance on when verbal or other direct communication with the referring or ordering physician is needed, including the detection of:

• Conditions carrying the risk of acute morbidity and/or mortality which may require immediate case management decisions.
• Disease sufficiently serious that it may require prompt notification of the patient, clinical evaluation, or initiation of treatment.
• Life or limb threatening abnormalities which might not have been anticipated by the referring physician.

What does the Canadian Medical Protective Association (CMPA) say about managing and following-up on test results?

The following articles may be helpful to physicians:

• CMPA article on test follow-up and the family-based physician

Transitions in Care

Working Together: Family Physicians and Specialists

All physicians are facing significant challenges as clinical and administrative workload increases and as pressure on the health system continues to rise. It is more important than ever that physicians work together to deliver quality care to Ontario patients.

How can referring physicians and consultant physicians support each other, reduce delays, and provide quality patient care?

Referring physicians and consultant physicians share responsibility for ensuring patients can access the care they need.

It is important for referring physicians to consider whether a patient’s condition is within the consultant’s scope of practice, whether the consultant is accepting patients, and whether the consultant’s practice is accessible to the patient.

Consultant physicians can support referring physicians by accepting consultation requests, where possible, even if there are minor issues with the requests (e.g., incorrect or outdated referral forms). Similarly, it is important that consultant physicians who use e-referral platforms also provide an alternative option for physicians who are unable to access this platform. This will allow referring physicians to complete their consultation requests in a timely manner and will help ensure patient care is not unnecessarily delayed.

Consultant physicians will need to provide appropriate follow-up care and handle any administrative work stemming from this care. Referring physicians may not have the expertise or resources needed to manage a patient’s specialised care.

The policy requires that physicians acknowledge referrals in a timely manner, urgently if necessary, but no later than 14 days. What does the policy mean by “acknowledge”?

Acknowledging a referral simply means informing the referring physician whether the referral will be accepted. If it is accepted, consultant physicians can indicate the estimated or actual appointment date. There is no requirement to see the patient within 14 days, just a requirement to review the referral and close the loop.

If a patient requires urgent care, it may be appropriate for referring physicians to speak directly with consultant physicians to ensure the patient can be seen as soon as possible. However, any verbal consultation request must be followed up with a written request from the referring physician.

Can consultant physicians decline a referral based on incomplete information?

Referring physicians must include all the information necessary for the consultant physician to understand the patient’s condition and address the questions or concerns they are being asked to consider. Referring physicians will need to have conducted an appropriate assessment before referring a patient to a consultant physician. While the policy sets out the type of information that could be included in a referral request, referring physicians can determine what is appropriate in the circumstances.

Consultant physicians can decline referrals that do not provide sufficient information, but they must communicate their reasons to the referring physician. Rather than having the referring physician make a new referral, there may be opportunities for the consultant physician to work with the referring physician to clarify any outstanding questions.

Do consultant physicians have an obligation to suggest another provider if they’re unable to accept the referral?

No. However, consultant physicians may have more information about their colleagues than referring physicians do. If they are able to assist the referring physician in re-directing the referral, it would be helpful to do so, especially where the referral is for urgent or unique issues.

Who is responsible for referring patients to subspecialists?

In most cases, the consultant physician rather than the referring physician is responsible for making the referral if they determine after an assessment that subspecialist care is needed.

If a consultant declines a referral on the basis that a subspecialist is needed, the referring physician would be responsible for initiating another referral to an appropriate subspecialist.

How can consultation reports support referring physicians?

It is important for consultation reports to be clear and include a summary of the information necessary for the referring physician to understand the patient’s needs and follow-up care. Depending on the circumstances, they may be short, or they may require more comprehensive and detailed notes.

How do the billing changes for virtual care impact the referral and consultation process?

Changes to virtual care billing came into effect December 2022. As a result of these changes, consultant physicians who provide virtual care will need to preserve their physician-patient relationships in order to bill for the comprehensive virtual care they provide.

Referring physicians may need to reissue referrals every 24 months where ongoing virtual care is needed. While referring physicians need to determine what information to include in these referrals, they can be straightforward and meet the expectations of the Transitions in Care policy if they include the patient’s name, the referring physician’s name, and a statement indicating that the patient should continue to receive comprehensive virtual care from the consultant physician, along with any changes in the patient’s condition.

Practice Issues: Hospital Discharges

When should physicians have a discussion with the patient and/or those assisting in their care about being discharged from hospital?

A comprehensive discussion in advance of the patient’s discharge can help the patient or their caregiver understand how to manage the transition and any post-discharge care. Where possible, it is helpful for this discussion to happen in advance of the discharge. The more time patients and caregivers have, the more likely they are to process the information, ask questions, and prepare for the discharge. This will reduce the potential for breakdowns in continuity of care.

Does the policy require discharge summaries to be transcribed and distributed within 48 hours? What are best practices for dictating discharge information and completing the discharge summary?

No. The policy does not require that the discharge summary be transcribed and distributed within 48 hours. Rather, the policy requires the most responsible physician to complete their component of the discharge summary within 48 hours of discharge (for example, completing dictation). While the policy requires that this be done within 48 hours of discharge, it’s considered best practice for physicians to complete their dictation at the time of discharge as doing so will contribute to the timely completion and distribution of the discharge summary.

Walk-in Clinics

When and why does the policy require physicians practising in a walk-in clinic to send a record of the encounter to the patient’s primary care provider?

Patients seek care from walk-in clinics for a variety of reasons, but breakdowns in care can happen and physicians practising in walk-in clinics can take steps to help avoid these breakdowns. In particular, because there is not always coordination between the care provided in walk-in clinics and other parts of the health-care system, the policy requires physicians practising in walk-in clinics to provide the patient’s primary care provider with a record of the encounter when the patient asks or when it’s warranted from a patient safety perspective and consent has been obtained. This will help to make sure that the patient’s primary care provider can provide future care that is informed by this experience. Of course, physicians are also free to send a record of the encounter in other instances where there might be some benefit in doing so and the patient provides consent.

Notably, the policy recognizes that it will not always be easy to send information to the primary care provider and so allows for information to flow through the patient where it’s not possible to send the information directly because, for example, there is uncertainty about who the primary care provider is or incomplete contact information.

Does the policy set out expectations for physicians practising in walk-in clinics who are providing care to patients without a primary care provider?

No. Walk-in clinics are not intended to be a substitute or replacement for a sustained relationship between a primary care provider and a patient. Rather, they are intended to provide episodic care where there is no expectation of a sustained relationship beyond any follow-up care that is required to address the presenting concern(s). That said, there are some patients who have real difficulty finding a primary care provider and routinely visit the same walk-in clinic for care. To the extent that physicians can, these patients would benefit greatly from additional care beyond the usual walk-in clinic experience. While there are limits to what can be done, even working together with other physicians in the practice to help these patients, for example, monitor and manage basic elements of a chronic condition or provide annual physicals, would benefit them greatly.

Endnotes

^1. See eHealth Ontario for more information on ONE ID.

^2. See OntarioMD (https://www.ontariomd.ca/pages/overview-of-econsult.aspx) or the Ontario Telemedicine Network (https://otn.ca/patients/econsult/) for more information.

^3. See the University of Health Network’s OpenLab work on Patient Oriented Discharge Summaries, which are now being adopted by hospitals across Ontario.

^4. This is particularly true for physicians ordering tests in the context of a walk-in clinic, and specific expectations regarding information sharing are set out in the Walk-in Clinics policy.