Understanding how clinician-patient relationships and relational continuity of care affect recovery from serious mental illness: STARS study results

Recent recommendations for improving the delivery of health care include suggestions for substantive collaboration between patients and clinicians, increased patient empowerment and activation, and greater continuity of care, including seeing the same clinician over time (relational continuity) (Hibbard, Stockard, Mahoney, & Tusler, 2004; Institute of Medicine et al., 2006; Institute of Medicine & Committee on Quality Health Care in America, 2001; Reid, Haggerty, & McKendry, 2002; US Department of Health and Human Services, 1999; World Health Organization, 2006). Although these factors are generally addressed as independent indicators of care quality, that conceptualization may not accurately reflect real-world care delivery, for these practices and behaviors occur within the context of clinician-patient relationships, and good relationships are a likely prerequisite for producing the kind of collaboration and activated patients envisioned in these recommendations. Thus, these quality-of-care indicators may be more appropriately conceptualized as interrelated indicators of the quality of clinician-patient relationships. Berwick makes this point eloquently, arguing that “health care tends to regard human interactions more as a toll or price than as a goal or product,” and proceeds as though interactions between clinicians and patients are the “burden it must bear so that it can deliver the care,” (pp. 50–51) when, in reality, interactions themselves are the care, and “To perfect care, we must perfect interactions” (p. 52) (Berwick, 2002). For these reasons, improved “continuity of care,” in and of itself, may not directly improve the results of mental health or other care. For example, some continuity of care indicators measure whether or not an individual has had a visit with any clinician over a particular period of time, while others measure whether outpatient care was received after a hospitalization, or whether an individual’s care was received within the same clinic over a specific time period, irrespective of the number of clinicians that person visited within the clinic (Adair et al., 2003; Freeman & Sheppert, 2000; Johnson, Prosser, Bindman, & Szmukler, 1997; Reid et al., 2002). While it is clear that these forms of continuity have an important place in understanding how care is delivered, none addresses the human relationships and interactions inherent in good care, or the knowledge that is, or is not, brought to bear when relational continuity is present or absent. For example, when coordination between clinicians is lacking or minimal, “continuous” care may be provided, but with little information passed from one clinician to the next. In such situations, patients and family members must tell their stories over and over, and little “real” continuity exists (see Wyden’s [Wyden, 1998] powerful account of how he often provided the only continuity in his son’s long-term treatment for schizophrenia). Given the large differences in current continuity measures, and the complexities of the interactions and processes they are attempting to assess, it is not surprising that research evaluating the effects of “continuity of care” has produced inconsistent results (Adair et al., 2003; Adair et al., 2005; Freeman & Sheppert, 2000). In addition, most studies of care continuity have followed people for relatively short periods (12 months or less) (Adair et al., 2005), yet the kinds of clinician-patient relationships necessary for improving care may take significant time and experience to develop. Thus, what we have come to call “continuity of care” could more realistically be viewed as a group of somewhat-related measures that serve as proxies for a more complex set of interrelationships that include: (a) coordination of care between clinicians working simultaneously with one patient, (b) smooth transitions in care from one clinician or service setting to another, c) clinician-patient interaction patterns, d) learning, education, and information exchange on the part of clinicians and patients, and, perhaps most importantly, e) the construction of a shared history of illness and recovery and the development of important interpersonal ties (Chien, Steinwachs, Lehman, Fahey, & Skodol-Wilson, 2000; Donaldson, 2001; Freeman & Sheppert, 2000; Johnson et al., 1997). For these reasons, to truly understand the effects of different forms of continuity of care, we must focus on the processes by which particular types of continuity affect specific outcomes. To date, few studies have addressed such process-related questions among individuals with serious mental health problems (Johnson et al., 1997), even though such individuals are likely to have greater need for continuity of care because of symptoms, memory problems, and cognitive deficits that may interfere with their ability to provide information about their treatment history. Moreover, despite recent recognition of the importance of including patient perspectives in research (Corrigan & Ralph, 2005), studies of continuity of care have rarely included patient or consumer experiences, or assessed their preferences (Crawford, de Jonge, Freeman, & Weaver, 2004; Joyce et al., 2004). An exception to these criticisms is work by Ware et al. (Ware, Tugenberg, Dickey, & McHorney, 1999) who interviewed and observed a small number of clinicians (n = 16) and patients (n = 16), carefully detailing processes by which clinicians and other staff worked to improve various types of continuity. They found that clinicians a) stepped outside of prescribed roles to meet patient needs, b) anticipated potential trouble spots and took action to prevent problems, c) worked to smooth transitions by creating service or provider overlap or by delaying some transitions to reduce the impact of others, d) tried to be flexible about access to care, and e) prodded the system to improve response times. When clinicians had shared clinical histories with clients, they were able to situate current circumstances or behavior in relation to prior circumstances or behavior, often helping to redefine current struggles as improvements over prior difficulties. Yet, though these processes occurred in the context of relationships between clinicians and clients, Ware et al.’s descriptions focused primarily on clinician activities and processes, and did not directly address clinician-patient relationships. More recently, Ware and her team examined the perspectives of low-income consumers on their relationships with clinicians (Ware, Tugenberg, & Dickey, 2004), reporting that consumers appreciated receiving “extra things”–things normally outside the constrained clinician-client relationship, that consumers wanted to feel that they had some form of common ground with their clinicians, such as race or religion, and valued feeling known by their clinician. The opportunity to talk in a context of acceptance and warmth, and without fear, was also important, as was being treated as an individual and having the opportunity to provide input into treatment. Finally, consumers identified practitioner availability and flexibility for scheduling appointments as important aspects of these relationships. These later analyses, however, did not examine the connection between relational continuity of care, as explored in the former work, and these clinician-patient relationships. Our work addresses this gap in the literature by extending Ware et al.’s work. We use triangulated qualitative and quantitative data to examine clinician-patient relationships in the context of relational continuity. We also examine the associations between relational continuity, clinician-patient relationships, quality of life, and recovery. We report results from the STARS Study (Study of Transitions and Recovery Strategies), an exploratory, longitudinal, mixed-methods study of recovery from serious mental illness.