Table 3 Summary of the communication patterns related to continuity of care

Communicate with Patient/Family

Communicating with the patient to examine the patient’s condition, share information, educate, and to develop a common understanding or plan.

• Patient visits with family physician.

• Home and Community Care nurse home visit with patient and family.

• Phone conversation from patient’s daughter with the on call family physician.

• Medication reconciliation by a pharmacist or nurse.

Request Historical Information (PMHx)¹

• Seeking additional information from a particular provider, care team, or organization.

• Specialist requests previous blood work from family physician.

• Hospice requests previous consult letters from Cancer Centre.

Provide Information

Ensuring other providers are aware of current findings and plans by sending information directly to named members of the Circle of Care.

• Follow up letter to family physician from Oncologist on change in chemotherapy.

• ER Physician note to GP after patient is seen in the Emergency.

• Home and Community Care Case Manager fax to the family physician to describe care plan.

Document in Shared Record(s)

Documenting findings/plans in a location that is accessible to others (who have access).

• Neurologist documenting in hospital chart.

• Family physician documenting in Mr. Hart’s long-term care paper chart.

• Laboratory placing a result into Hospital Information System.

Review Shared Record

Review information shared by other members of the Circle of Care to increase knowledge of patient’s condition.

• Family physician reviews long-term care paper record when rounding on patients.

• ER Physician reviews hospital information system prior to seeing patient in the ER.

• Oncologist reviews cancer records (electronic and paper) prior to follow up visit.

• Pharmacist reviews medication-dispensing history.

Request Advice

Request information and advice about options related to a patient case.

• Call to palliative care hotline to discuss medication options and conversion doses.

• Call to see what services might be available for particular type of patient.

• Discuss with radiologist what test is most appropriate for assessing symptom in a patient without disclosing patient name.

Request Assessment/Treatment

Contact another provider to request an action to assess and/or provide treatment recommendations to a patient based on their assessment.

• Family physician consults geriatrics for patient in nursing home to assess behavioural issues.

• Home and Community Care nurse sends referral to physiotherapy and occupational therapist to assess home safety.

• ER Physician calls neurology to assess stroke patient.

Order

Request specific activity be delegated to / performed by another provider

• Medication prescription from MD to pharmacist.

• Home and Community Care nurse delegated medication administration to Community Support Worker.

• Advance directive from patient.

Transfer Care

Handing off care responsibilities between care providers of a similar capability.

• Nurse handover at shift change.

• Family physician to family physician transfer when on call.

• ER physician transfer to family physician admission in hospital once patient is stabilized.

Coordinate as Care Team (i.e. all or part of the Circle of Care)

To review, in real time with more than two individuals, the status and plans for the patient from multiple viewpoints.

• Long-term care case conference.

• Breast cancer Oncology Rounds.

• Palliative Care Rounds.

• Ad hoc meetings between family physician, Home and Community Care nurse and family to discuss patient care or patient prognosis.