Continuity of Care

What is continuity of care?

Continuity of care is about the ongoing relationship a patient has with a health care professional or team of health care professionals, and how smoothly the patient moves between different parts of the health service.

It can also be about the continuity of patient records and information. This can be about how we share information and how good communication is within the Practice team, as well as with other health care professionals outside the Practice.

Why is continuity of care important?

Where continuity of care is achieved, there is evidence of higher levels of patient satisfaction and also of better health outcomes.

What are we doing to encourage continuity of care?

We have taken a number of actions to try and encourage continuity of care at Frome Medical Practice:

• We have considered feedback about our telephone triage system, Patient Connect, and wrote a ‘You Said, We Did’ leaflet in relation to feedback that promotes continuity for patients
• Our new Patient Services Manager is overseeing the Care Navigator team and they are working together, for example through training and support, new IT software and working practices, to ensure Care Navigators are able to offer options to patients that promote continuity.
• We have improved how we support patients with access issues – for example, someone for whom English is not their first language or someone with a disability
• Our Care Coordination Hub helps us provide continuity for our most vulnerable patients
• We have coordinated a recruitment campaign to encourage more GPs and other clinicians to join the Practice, thus reducing our staff vacancies and reliance on locums
• We’ve also focused on the retention of staff, for example by increasing clinical training and providing new GPs with mentors

How will Frome Medical Practice continue to improve continuity of care?

There are a number of areas we will continue to focus on going forward. These include:

• Providing more information for our patients about continuity of care via this website
• Raising awareness with a Continuity of Care month in January 2020. The campaign will coincide with the full launch of our new website (soft launch in November 2019) and will take a whole team approach, ensuring every conversation we have promotes continuity of care.
• Promoting with patients how they can achieve continuity, via local press, social media and the Community Connections area in the Atrium.
• Promoting access arrangements in order to promote choice
• Inviting our patients and PPG to focus groups to further explore how we can better promote and achieve continuity
• Introducing care management plans for some frequent attenders
• Continuing the roll out of Group Consultations, which started in October 2019, further developing our in house skills to deliver these sessions
• Growing our patient education work, for example in areas such as diabetes, ‘escape pain’ and self management programmes
• Working with London South Bank University to improve our data analysis skills relating to continuity
• Establishing a Practice Lead for this area of work and champions within our teams so we remain focused on this issue
• Learning from other organisations and professional bodies as to how they have improved in this area and implementing this learning in the Practice