Peter Brock, a Geriatrics specialist trainee working in the North East and Secretary of the Association for Elderly Medicine Education (AEME) blogs about why continuity of care is important for junior doctors.

Continuity of care is about the patient having a co-ordinated and managed transition through the healthcare system. The transition [PDF] from hospital back in to the community can be particularly significant and junior doctors play a pivotal role in making this a success.

Junior doctors are expected to have a thorough knowledge of each patient’s inpatient journey, to ensure that every professional who wishes to follow the patient up has made arrangements to do so. They need to be good communicators, both in their written communication with General Practioners (GP’s) and face to face with patients and their carers in order to explain the follow up plans. Finally, they need to co-ordinate between the multiple health professionals involved in the patient’s care to ensure that everything is prepared for the day of discharge. When an elderly patient with multiple, complex conditions leaves hospital, fulfilling these roles can be challenging.

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“Continuity of care is not just about the movement of a patient from hospital to the community. It is a vast undertaking involving every interaction the patient has with the NHS. This is particularly true for elderly patients – each new medication started or changed can interact with others, a worsening of one condition can have consequences for another.”

4 top tips for junior doctors on good continuity of care

  • Ensure the patient and their carers understand the follow up plan. This will reduce their anxiety, empower them to be partners in their own health care and increase their likelihood of attending appointments.
  • Provide accurate and comprehensive information in discharge summaries . This is a critical component of continuity of care that helps to ensure that the patient’s GP is aware of new diagnoses and any changes to medications, including the justifications for these.
  • Liaise with the specialities planning to follow-up a patient to ensure appointments are made. Ideally include times and dates of these in the discharge summary so the patient and the GP have a record.
  • Communicate with each member of the multi-disciplinary team to ensure timely discharge. As the member of the medical team who is most commonly on the ward, you are in the ideal position to co-ordinate between the different professionals involved.

An example of the complexity junior doctors can face

Consider the following hypothetical case. An elderly female patient is admitted to hospital after a fall. She sustained a fractured arm as, like 71% of females over 75 [PDF], she has a chronic underlying condition that puts her at risk of complications. In this case it was osteoporosis – a condition where the bones are more likely to break if injured . She had the fracture successfully repaired and requires follow up with the orthopaedic team once she leaves hospital so they can monitor movement and how the wound is healing.

After her surgery she suffered a complication – a pulmonary embolism (a blood clot in the pulmonary artery ) was diagnosed after she became short of breath. This was managed with medication. When she leaves hospital she will require a district nurse to administer this medication in the form of an injection and a review by in an outpatient elderly care clinic to decide on the length and route of treatment. In patients over 80 having surgery, 20-50% will go on to have a complication.

The patient was transferred onto an elderly care rehabilitation ward to help improve her mobility prior to discharge. Here she was noted to be exhibiting slower movements, rigidity and tremor and was diagnosed with Parkinson’s disease. New medications were started and she will require follow up with a Parkinson’s disease nurse specialist to ensure her symptoms are managed appropriately.

She was discharged to a nursing home, where she will have a new GP to look after her in the community.

Importance of continuity of care to this patient

This case is a simplified version of a real patient’s journey . I have deliberately highlighted the areas of care that need to transition from the hospital to the community. Done well and the patient will benefit from care that optimises their health and keeps them informed and involved in the follow-up plan. Done poorly and the patient is more likely to require readmission to hospital, suffer from side effects of medications and adverse effects of chronic conditions.
Continuity of care is not just about the movement of a patient from hospital to the community. It is a vast undertaking involving every interaction the patient has with the NHS. This is particularly true for elderly patients – each new medication started or changed can interact with others, a worsening of one condition can have consequences for another.

A micro and a macro challenge

Take the macro-view of continuity of care, and you see how it is the result of the local and national systems which make up the NHS. The challenges that these systems present to good continuity of care for elderly patients, and how they can be improved, are discussed in this King’s Fund report [PDF].

Take the micro-view, looking at each individual patient’s journey and you realise that every patient will interact with these systems differently and that each individual involved in their care has a role in ensuring continuity of care. Therefore, as the GMC’s Good Medical Practice makes clear,  each of us has the opportunity and responsibility [paragraphs 44-45] to make a positive difference.

Have you got any experiences of continuity of care? Share your views and let us know what you think in the comments below.

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Find resources, guidance and more relating to continuity of care for older patients

Peter Brock, a Geriatrics specialist trainee working in the North East and Secretary of the Association for Elderly Medicine Education (AEME) 

 

 

 

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