What are factors influencing coordination and continuity across care levels in the Catalan national health care system?

Introduction: The identification of factors influencing care coordination can offer valuable insights to healthcare managers and professionals on where to direct their efforts to improve health care service towards the provision of a smooth patient trajectory. Nevertheless, literature that comprehensively analyse influencing factors from the physician’s and patient’s perspective is scarce. Care coordination is the harmonious connection of the different services needed to provide care to a patient throughout the care continuum in order to achieve a common objective without producing conflicts. Continuity of care, in turn, is how patients experience care coordination. The objective is to explore factors influencing care coordination and continuity across care levels in different areas of the Catalan healthcare system (Spain) from the physician’s and patients’ perspective.

Methods: Descriptive-interpretative qualitative study. A three-stage theoretical sample was selected: (i) study contexts: healthcare areas in Catalonia with different services management models (selecting Baix Empordà, Girona and Ciutat Vella in Barcelona); (ii) GP and specialists (including different specialities providing outpatient, inpatient and emergency care) having been employed in the study areas for at least 1.5 years; (iii) users ≥ 18 years of age who were attended to at both care levels for the same condition. Data were collected by means of individual semi-structured interviews with GPs (26), specialists (24) and patients (49). Interviews were recorded and transcribed. Data were segmented by informant and study area. A thematic content analysis was carried out with a mixed generation of categories and triangulation of analysts.

Results: Physicians and patients of all study areas generally perceive the existence of coordination and continuity across care levels, especially referring to information transfer and consistency of treatments and tests. Only a few deficiencies in all the areas were perceived. Its (non-)existence was explained by a variety of influencing factors, of which only some related to organizations varied across the areas. 1) System-related factors: Physicians identified the rapid diagnostic circuit and the integrated electronic prescription system to be system-developed mechanisms that promoted timely access to secondary care and consistency across levels in treatment, respectively. However, lack of shared criteria and incentives for prescriptions emerged as barriers favouring frequent changes in treatments. In the patients’ discourse emerged the ‘clear distribution of roles’ between physicians, which was considered to favour consistency of care and accessibility across levels. 2) Organization-related factors: Different care coordination mechanisms were identified. The shared medical record system was identified by physicians and patients to be the main facilitator of information transfer. Physicians and to a lesser degree patients also identified mechanisms for informal communication (telephone and e-mail) and the expert system (joint meetings to discuss clinical cases in Girona and Baix Empordà, and e-consultations Baix Empordà and Ciutat Vella) which was used for rapidly solving doubts and facilitating access to secondary care. Physicians further mentioned the proximity of professionals (co-location in Ciutat Vella, small organization size in Baix Empordà and proximity in Girona and Baix Empordà) to promote mutual knowledge, which favours direct communication. Moreover, lack of time and insufficient resources were reported by both groups to be main barriers to achieve care coordination/continuity, leading to the insufficient use of mechanisms and an increase in waiting times to secondary care. Finally, GPs in Ciutat Vella and Girona reported that the change in the organization model, which perceived aim was to reduce secondary care activities, has resulted, in some cases, in a lack of provision of necessary secondary care. 3) Physician-related factors: Some specialists identified the limited training of GPs as a factor hindering adequate referrals to secondary care. On the contrary, patients highlighted that the GPs’ technical competence favoured referrals to the right care level when necessary. The attitude to collaborate and commitment to patient care, the latter only mentioned by patients, further emerged as enabling factors of consistency of care in all areas.

Discussion: Physicians and patients linked (dis)continuity to certain factors related to the system, organization and physicians. Some factors were identified commonly by both informant groups, such as a variety of coordination mechanisms, insufficient available resources, and the physician’s attitude towards collaboration. Other factors were specific to the information group: whilst physicians referred to a greater variety of coordination mechanisms and factors promoting personal proximity, patients identified the clear distribution of roles and the commitment to the patient care.

Conclusion: Physicians and users identify various factors that influence coordination and continuity across care levels which could be addressed when aiming to achieve integrated care delivery.