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Table 2 Extended continuity of care model [15]

From: Through the professional’s eyes: transfers of care during pregnancy, childbirth and the postpartum period

Elements

Description

Original model of continuity by Haggerty and Reid [16]

1. Client and family

The perceived coordination of care for a single client over time.

2. Information continuity

The capacity of information belonging to a client, between providers and over time, to facilitate continuity of care experience [27].

3. Management continuity

The extent to which services delivered by different healthcare professionals are timely and complementary such that care is experienced as continuous [28].

4. Relationship continuity

A sustained relationship between a patient and a specific healthcare professional [29].

Extended features of model of continuity by Price and Lau [15]

1. Circle of care

An individual client’s healthcare system. The circle of care is a soft system that consists of the client, providers, other agents, and the information repositories (paper and electronic) related to that client. It is self-organizing, can span organizations, and changes based on the needs of the client and availability of resources [15].

2. Environmental influences

Factors outside the circle of care that can influence continuity of care – factors that are not related to the client, professionals, or information repositories.

3. Provider connectedness

Cohesiveness of the relationships between professionals in a circle of care.

4. Communication patterns

Transfer care

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

Provide current information

Ensuring that other professionals are aware of current findings and plans by sending information directly to named members of the circle of care.

Encounter with client and family

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

Request historical information

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

Document in shared record

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

Review shared record

Review information shared by other members of the circle of care to increase knowledge of a client’s condition.

Request generic advice

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

Request assessment and treatment

Contact another professional to request an action to assess and provide treatment recommendations to a client, based on their assessment.

Orders

Request that specific activity be delegated to or performed by another professional.

Case conference

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