Are continuity of care and teamwork incompatible?

Modern primary medical care is becoming more complex and challenging every day as the population ages and practices become more and more dominated by older patients who have an array of chronic conditions. Advances in prevention and illness care also have increased the demands on practices without associated changes in reimbursement. Wise commentators wonder whether primary care will survive. Major professional societies have proposed new models of primary care that call for transformed or redesigned practices able to provide better preventive care and care for the chronically ill in addition to innovative payment mechanisms that reward quality. These new practice models for primary care, based on the Medical Homeand the Chronic Care models, propose that 2 prominent features are enhanced continuity of care and the more effective use of teams. Because most view continuity as a sustained therapeutic relationship extending across care episodes with a single provider, the intensified involvement of the multiple members of a team in care raises the following questions: does greater involvement of other clinical staff in care diminish patients’ contentment with their primary care relationship? And how can the benefits that emerge from these long-term relationships be sustained when care is shared among team members? An important article in this issue of the journal examines patient perspectives on this question with a large group of enrollees of a multispecialty medical organization, each of whom had a designated primary care physician (PCP) that they had visited in the prior 6 months. The outcome measures were the subscales of the Ambulatory Care Experiences Survey (ACES), which are used to assess various aspects of primary care and practice organization. The ACES is now widely used to measure patient satisfaction and experience with care for research and increasingly for performance assessment and improvement. The independent variables included continuity measures derived from administrative data on primary care visits and the providers of record for those in addition to ACES survey measures of the visibility and “relationality” of the team as viewed through the patients’ eyes. The findings strongly confirm earlier evidence that patients value seeing the same primary care clinician over time when measured by a variety of indicators. In terms of continuity, this article provides fresh evidence as to why seeing the same physician over time is beneficial from the patient’s perspective. It may also help explain why continuity is associated with better health outcomes and costs of care and better patient satisfaction. When patients concentrate or sequence their care with the same provider over time, they perceive better communication, better accumulated knowledge of them, and better integration of their care over time. The article again reinforces the point that personal relationships in health care are valued and really do matter. A concern, however, is the observation that visits with another clinician appear to have a negative impact on patient experience, even when the visit is with a registered nurse (RN) or nurse practitioner (NP) that is a member of their doctor’s team. This observation may then substantiate the concern that clinical tasks rendered by someone other than the PCP detracts from the patient–physician relationship and the patient’s experience. Many PCPs seem to share this concern and use it as a rationale for not referring clinical tasks to members of their practice team. Unfortunately, these include