Table 2 Characteristics of optimal and suboptimal network components
From: Discharging the complex patient - changing our focus to patients’ networks of care providers
Network of care components | |||
|---|---|---|---|
Family physician | Specialist | Personal supports | Personal capacities |
Optimal | Optimal | Strong | Independent |
Retains or further develops central figure/patient advocate and health care system navigator role Strategies for maintaining involvement in care of the medically complex patient: • Communicate with patient’s other physicians • Coordinate timely referrals • Offer personal line of contact with patient • Check in on them while in hospital • Set appointments soon after discharge • Advise them not to visit walk-in clinics and recommend avenues for after-hours care • Provide education materials • Enlist them in a paramedic home support program | Continuity over time Regular appointments Direct line of contact with patient Availability on relatively short notice Effective communication with patient’s other physicians May assume a Main Care Provider role for the period where they are being frequently seen Sees specialist(s) for health problem(s) that are of most relevance to them, or for health problems that are directly related to their recent hospitalization(s) or health decline | Has one or more people in the network who are actively involved/informed about all facets of their care One or more members can attend appointments/meet with clinical teams when hospitalized and as needed, advocate for patient Ideally have multiple layers; family members, friends, and/or neighbors When required, a coordinated effort involving multiple family members/friends takes place to offer support | Tends to comfortably advocate for themselves in hospital/health care settings Self-sufficient to a degree and able to adapt to changing circumstances, proactive Has a strong grasp of their issues/limitations and the type of support they require |
Suboptimal | Suboptimal | Weak | Dependent |
Does not play central health care figure role; may provide prescription renewal and offer episodic care for minor ailments Defers all decision making regarding major medical problems to other health care providers Does not appear to make effort to stay involved when specialists take on more central roles (e.g. heart failure or cancer care) Unable to offer timely appointments when health deteriorates or following transition home from hospital | Perceived investment in their health and well-being is minimal Lack of continuity over time (e.g. group practice where the same specialist is rarely seen) Intervals between appointments feel too long/rationale for intervals is not clear Unclear communication with patient regarding role in care Communication with patient’s other physicians perceived as poor Specialist no longer easily accessible or connected to network (e.g. works in a different city where the patient used to live) | Not present – participant does not have a strong individual or network of family/friends who can offer support when needed Not able – family/friends they do have cannot/will not invest the time and effort required to advocate for or support them meaningfully | Poor self-advocacy skills; may be related to social determinants of health including level of education Disengaged or disinterested in trying to improve health and well-being Denial about severity of health issues Impaired ability to self-advocate: mental health, substance use disorder, cognitive impairment |
No Rostered Family Physician | Playing a Minimal Role | Â | Â |
Increased reliance on other services: • Walk-in clinics • Emergency Department/Emergency Medical Services/Urgent Care • Homecare • Caregivers | Specialist not a relevant/contributing component of the patient’s network of care providers presently and in last two to three years Few specialist referrals in recent years, which were of little perceived value to the patient | ||