Enhance Care Continuity Post COVID-19

September 29, 2020

Although shortfalls in continuity were well described prior to coronavirus disease 2019 (COVID-19), the pandemic has created an opportunity to augment this critical component of care delivery, with the potential to improve patient-centered outcomes and enhance spending efficiency.

Am J Manag Care. 2021;27(4):In Press

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The coronavirus disease 2019 (COVID-19) pandemic has tested the pressure points of health care infrastructure, financing, and delivery. Fears of contracting COVID-19 coupled with clinic closures have impeded the ability of patients to consistently receive care from a clinician or care team with whom they have an established relationship. Although shortfalls in continuity were well described prior to COVID-19, the pandemic has created an opportunity to augment this critical component of care delivery, with the potential to improve patient-centered outcomes and enhance spending efficiency.

Continuity, defined as a relationship with a provider or providers over a continuum of time that extends beyond a single illness or disease episode, encompasses 3 essential elements: (1) informational content (including knowledge of patient preferences and values), (2) management plans (which are often complex and require adaptations to ever-changing circumstances), and (3) relational value (which enhances current and future care decisions).1,2 A robust literature demonstrates that continuity is associated with better compliance with care recommendations, higher patient and provider satisfaction scores, and a more trusting and satisfying experience for patient and clinician.3-5 In addition, patients with a regular clinician experience decreased emergency department visits, inpatient admissions, and lengths of stay for those admissions; in certain circumstances, these quality improvements translate to lower medical expenditures.2,5-7 There is an especially high impact for the medically complex.6,8 This positive finding is reinforced by the study by Rajan and colleagues in this issue of The American Journal of Managed Care®, concluding that veterans with diabetes who received less fragmented care experienced lower hospitalization rates.9

The identification of patient-level and systemic impediments to continuity preceded the pandemic, especially for patients with higher burdens of chronic disease, whose care crosses specialties and institutions.10,11 COVID-19 has further exacerbated barriers, which include:

  • closure of primary care practices;
  • a mismatched demand for and supply of clinicians able to take on the patient manager role—an unmet need that necessitates expanded panel sizes, which improve short-term access but may hinder access for existing patients12,13;
  • postponed appointments due to safety concerns, limitations in management created by closures of ancillary medical services, and needed clinician coverage of inpatient services;
  • a lack of interoperable communications among delivery systems, which has intensified as large independent delivery systems become the norm14; and
  • the successful launch of autonomous telemedicine services that are not connected to a patient’s usual clinician.

The near-overnight implementation of virtual care effectively absorbed some of this demand for in-person patient visits. Results of prepandemic studies show that telemedicine improves access, limits distance/transportation barriers, facilitates the expansion of nontraditional hours of clinical care delivery, decreases missed appointments, and is associated with high rates of patient satisfaction.15 When expansions in access are implemented thoughtfully, there is some evidence suggesting that they improve continuity.12 The pandemic motivated temporary expansions in insurance coverage that reimburse video- and audio-only visits at amounts equal to office visits, contributing to near-universal adoption and softening the negative financial impact of COVID-19 on medical practices. FAIR Health’s Telehealth Tracker estimated that claims for virtual visits increased more than 5000% nationally in May 2020 compared with May 2019.16 However, the impact of telehealth on continuity during the pandemic is unclear, especially for elderly and complex patients who may prefer face-to-face visits.

As care delivery is restructured following the pandemic, continuity should be encouraged, explicitly measured, and considered as a health system quality metric.6 Aligned incentives for providers and patients that augment continuity should become mainstream. Provider-facing elements include clinical payment bonuses, expanded roles of panel managers, and scheduling protocols that leverage the electronic health record to identify those with medical and behavioral complexity, psychosocial factors, and high health care utilization. Incentives for patients, such as lower cost sharing when seeing established providers—whether it be in person or with a virtual visit—are likely to add to their success. Interventions should prioritize medically complex patients who are likely to benefit most, clinically and financially. The potential for added revenues that result from quality bonuses and higher satisfaction scores could justify infrastructure investment and program monitoring.

The measuring stick of continuity—and care delivery as a whole—is the individual patient experience. Unexpected events such as COVID-19 and the resultant meteoric rise of telemedicine have created an opportunity to improve continuity of care, especially for our most vulnerable patients. Telehealth encounters—consisting of a medical record and a virtual patient history with no or limited physical exam—underscore the clinical nuance and intangible insights provided by an established patient-clinician relationship. As virtual visits become a permanent element of the “new normal,” continuity must be promoted, measured, and rewarded. Otherwise, the “continuity problem” will worsen, quality of care could suffer, and the proposed savings from fewer in-person visits will be diminished by duplicitous and potentially unnecessary care. Without this key element, patients will be less satisfied, and providers will be increasingly burdened with an unenviable and difficult task of providing safe, high-quality, and cost-effective care.

Author Affiliations: University of Michigan (NH, AMF), Ann Arbor, MI.

Source of Funding: None.

Author Disclosures: Dr Fendrick has been a consultant for AbbVie, Amgen, Centivo, Community Oncology Alliance, Covered California, EmblemHealth, Exact Sciences, Freedman Health, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, MedZed, Merck, Montana Health Cooperative, Penguin Pay, Risalto, Sempre Health, State of Minnesota, US Department of Defense, Virginia Center for Health Innovation, Wellth, Yale–New Haven Health System, and Zansors; has performed research for the Agency for Healthcare Research and Quality, Arnold Ventures, Boehringer Ingelheim, Gary and Mary West Health Policy Center, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, PhRMA, Robert Wood Johnson Foundation, and State of Michigan/CMS; and holds outside positions as co-editor-in-chief of The American Journal of Managed Care®, member of the Medicare Evidence Development & Coverage Advisory Committee, and partner in V-BID Health, LLC. Dr Hadeed reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (NH, AMF); drafting of the manuscript (NH, AMF); critical revision of the manuscript for important intellectual content (NH, AMF); and supervision (AMF).

Address Correspondence to: A. Mark Fendrick, MD, University of Michigan, 2800 Plymouth Rd, Bldg 16, Floor 4, 016-400S-25, Ann Arbor, MI 48109-2800. Email: amfen@med.umich.edu.

REFERENCES

1. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003;327(7425):1219-1221. doi:10.1136/bmj.327.7425.1219

2. Ahuja V, Alvarez CA, Staats BR. Maintaining continuity in service: an empirical examination of primary care physicians. Manuf Serv Oper Manag. 2020;22(5):1088-1106. doi:10.1287/msom.2019.0808

3. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2(5):445-451. doi:10.1370/afm.91

4. Barnett DR, Bass PF III, Griffith CH III, Caudill TS, Wilson JF. Determinants of resident satisfaction with patients in their continuity clinic. J Gen Intern Med. 2004;19(5, pt 1):456-459. doi:10.1111/j.1525-1497.2004.30125.x

5. Kao YH, Lin WT, Chen WH, Wu SC, Tseng TS. Continuity of outpatient care and avoidable hospitalization: a systematic review. Am J Manag Care. 2019;25(4):e126-e134.

6. Bazemore A, Petterson S, Peterson LE, Bruno R, Chung Y, Phillips RL Jr. Higher primary care physician continuity is associated with lower costs and hospitalization. Ann Fam Med. 2018;16(6):492-497. doi:10.1370/afm.2308

7. Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the costs for chronic disease. JAMA Intern Med. 2014;174(5):742-748. doi:10.1001/jamainternmed.2014.245

8. Frandsen BR, Joynt KE, Rebitzer JB, Jha AK. Care fragmentation, quality, and costs among chronically ill patients. Am J Manag Care. 2015;21(5):355-362.

9. Rajan M, Helmer D, Rowneki M, Fried D, Kern LM. Ambulatory care fragmentation and hospitalization among veterans with diabetes. Am J Manag Care. Published online September 29, 2020. doi:10.37765/ajmc.2021.88509

10. Waibel S, Vargas I, Aller MB, Coderch J, Farré J, Vázquez ML. Continuity of clinical management and information across care levels: perceptions of users of different healthcare areas in the Catalan national health system. BMJ Health Serv Res. 2016;16(1):466. doi:10.1186/s12913-016-1696-8

11. Tarrant C, Windridge K, Baker R, Freeman G, Boulton M. ‘Falling through gaps’: primary care patients’ accounts of breakdowns in experienced continuity of care. Fam Pract. 2015;32(1):82-87. doi:10.1093/fampra/cmu077

12. Rust G, Ye J, Baltrus P, Daniels E, Adesunloye B, Fryer GE. Practical barriers to timely primary care access: impact on adult use of emergency department services. Arch Intern Med. 2008;168(15):1705-1710. doi:10.1001/archinte.168.15.1705

13. Forrest CB, Starfield B. Entry into primary care and continuity: the effects of access. Am J Public Health. 1998;88(9):1330-1336. doi:10.2105/ajph.88.9.1330

14. Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-794. doi:10.1136/bmj.320.7237.791

15. Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. 2017;7(8):e016242. doi:10.1136/bmjopen-2017-016242

16. Monthly Telehealth Regional Tracker. FAIR Health. Accessed August 13, 2020. https://www.fairhealth.org/states-by-the-numbers/telehealth