Quality Indicators for Continuity and Coordination of Care inVulnerable Elders

Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders

Neil S. Wenger, MD, MPH, and Roy T. Young, MD

Key words: continuity of patient care; quality ofhealth care; interinstitutional relations; care coordination

Continuity and coordination of care are attributes ofmedical care that influence its quality. Donabedian de-scribed coordination of care as the ‘‘process by which theelements and relationships of medical care during any onesequence of care are fitted together in an overall design.Continuity means lack of interruption in needed care, andthe maintenance of the relatedness between successive se-quences of medicalcare.’’1According to the Institute ofMedicine, continuity is ‘‘care over time by a single individ-ual or team of healthcare professionals’’ including‘‘effective and timely communication of healthcare infor-mation.’’2Continuity and coordination of care are partic-ularly important for older patients, because they are apt tohave multiple medical problems treated by several clini-cians. These aspects of care involve the spectrum of health-care providers and staff and their systems in a wide varietyof venues, because the work of continuity and coordinationincludes roles that physicians often do not perform, such asscheduling, communication, and reminders.Continuity and coordination of care have several com-ponents, including a longitudinal relationship with a singleidentifiable provider and cooperation between providersand between venues of care.3Coordination involves the‘‘availability of information about prior problems and ser-vices and the recognition of that information as it bears onthe needs for current care.’’4Continuity and coordinationdepend largely on the system of healthcare delivery, but theAssessing Care of Vulnerable Elders (ACOVE) quality in-dicators (QIs) focus on how the system affects what hap-pens to the patient. Thus, these quality-of-care indicatorsfocus on the following domains of continuity and coordi-nation:5continuity of care from the perspective of the pa-tient, information continuity and coordination across andwithin providers, and continuity and coordination betweenvenues of care.Continuity of care is often equated with having aprimary care physician. Several studies demonstrated asso-ciations between physician–patient continuity and satisfac-tion, reduced utilization, increased efficiency, and betterpreventive care.6,7A structured literature review that eval-uated 22 studies, including four clinical trials, found that‘‘interpersonal continuity’’ was related to greater satisfac-tion, lower utilization, and generally higher care quality,8,9although one study found interpersonal continuity to beassociated with higher pharmacy and referral costs.10Nonphysicians, such as case managers, or multidimen-sional interventions sometimes provide continuity andcoordination. Most, although not all,11,12interventionsto enhance continuity and coordination reduce utiliza-tion,13–18but these interventions have multiple compo-nents19that cannot easily be disentangled20and often arenot tested outside research settings. Structural factors, in-cluding disease registries and formal sign-out systems,21also can improve continuity and coordination of care,22butthese structures are not easily measured at the patient levelusing clinical information. Therefore, this set of QIs focuseson general components of continuity and coordination atthe physician level.23QIs for condition-specific continuityand coordination of care (e.g., follow-up for newly treateddepression and laboratory testing after starting specificmedications) are contained in the condition-specific mono-graphs.METHODSA total of 1,994 articles were considered in this review: fiveidentified using a Web search and 1,989 through theACOVE-3 literature searches.RESULTSOf the 17 potential QIs, the expert panel process judged 16to be valid (see the QIs on pages S464–S487 of this sup-plement), and one was rejected. The literature summariesthat support each of the indicators judged to be valid in theexpert panel process are described.

Address correspondence to Neil S. Wenger, MD, UCLA Division of GeneralInternal Medicine and Health Services Research, 911 Broxton Plaza, LosAngeles, CA 90024, E-mail: nwenger@mednet.ucla.edu

DOI: 10.1111/j.1532-5415.2007.01334.x

From the Division of General Internal Medicine and Health ServicesResearch, University of California at Los Angeles, Los Angeles, California.

JAGS 55:S285–S292, 2007r

2007, Copyright the AuthorsJournal compilation r 2007, The American Geriatrics Society

http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2007.01334.x/epdf