Optimising personal continuity for older patients in general practice

BACKGROUND
Continuity of care denotes the connected and coherent care that is consistent with the health needs and personal circumstances of a patient. It is a widely accepted core principle of general practice. Continuity of care is a multidimensional concept, including personal continuity, team continuity, and cross-boundary continuity. This research project aims to optimise personal continuity for older patients in general practice.

The benefits of personal continuity have been studied extensively and include a better patient-provider relationship, increased patient and doctor satisfaction, improved uptake of preventive care, higher medication adherence, less overuse of medical procedures, higher quality of patients’ life, fewer hospital admissions, and less healthcare costs. Several studies also found personal continuity to be associated with lower mortality.

But society and healthcare have changed. Patients and doctors are increasingly mobile and solo practice is becoming rare. The number of patients with chronic diseases rises, and patients increasingly receive care from multiple professionals employed by different organisations. Most general practitioners work part-time and reorganize themselves into large group practices. Other healthcare workers such as the practice nurse have entered general practice.

All these changes potentially fragment care and reduce personal continuity. Especially older patients suffer the consequences of fragmentation and discontinuity of care, as they are likely to have multiple chronic conditions and benefit the most from personal continuity. Therefore, strategies to improve continuity of care in older patients are highly warranted, especially because global demographic trends suggest that the number of older persons will double in the next 35 years. If proven effective, such strategies will lead to higher patient-doctor satisfaction, higher quality of patients’ life, less overuse of medical procedures, reduced hospitalisation, less healthcare costs, and – on the longer term – lower mortality.

MAIN OBJECTIVE
The overall aim of this project is to develop and evaluate a multi-component intervention (‘toolkit’) designed to optimise personal continuity for older patients in Dutch general practice.

METHODS
For this research project, we adopted the UK Medical Research Council Complex Interventions framework. This framework provides an iterative phased approach to the development and evaluation of complex interventions, suggesting five phases:
During phase 0 (preclinical phase), we will perform a literature study to create the theoretical basis for development and implementation of the intervention.
During phase 1 (defining components of the intervention), we will perform surveys and focus groups to investigate patients’ and care providers’ views on personal continuity, and to define the components of the intervention. The intervention will consist of a toolkit to optimise personal continuity for older patients in general practice.
During phase 2 (defining trial and intervention design), we will perform a pilot study and test the acceptability and feasibility of the constructed toolkit. The results will be used to construct the final version of the toolkit.
During phase 3 (main trial), we will investigate the acceptability and feasibility of the constructed toolkit in a stepped wedge cluster randomised trial (N=30 general practices).
During phase 4 (implementation), we will use database registrations, practice observations, surveys, and semi-structured interviews to investigate the level of implementation.

The constructed toolkit will be an acceptable and feasible tool to improve personal continuity for older patients in general practice.

Year 1: development of the intervention (month 1-12);
Year 2: inclusion of patients, follow-up (month 13-24);
Year 3: follow-up, initial data analysis (month 25-36);
Year 4: data analysis, publication study results (month 37-48);
Year 5: data analysis, publication study results (month 49-60);
Year 6: publication study results, PhD thesis (month 61-72).

Tailored complex intervention, consisting of components to improve personal continuity.