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Background Providing access to pediatric healthcare services in British Columbia, Canada, presents unique challenges given low population densities spread across large geographic distances combined with a lack of availability of specialist providers in remote areas, leading to quality of care shortcomings and inequalities in care delivery. The study objective was to develop a framework that provides a common language and methodology for defining and planning child and youth healthcare services across the province. Methods The framework was developed in two phases. In Phase 1, a literature and jurisdictional review was completed using the following inclusion criteria: (i) description of a framework focusing on organizing service delivery systems (ii) that supports health service planning, (iii) includes specialty or subspecialty services and (iv) has been published since 2008. In Phase 2, a series of meetings with key provincial stakeholders were held to receive feedback on the developed Tiers of Service framework versions that were based on the literature and jurisdictional review and adjusted to the British Columbian health care context. The final version was endorsed by the Child Health BC Steering Committee. Results Ten medical articles and thirteen jurisdictional papers met the established selection criteria and were included in this study. Most frameworks were developed by the Australian national or state jurisdictions and published in jurisdictional papers (n = 8). Frameworks identified in the medical literature were mainly developed in Canada (n = 3) and the US (n = 3) and focused on maternity, neonatal, critical care and oncology services. Based on feedback received from the expert group, the framework was expanded to include community-based services, prevention and health determinants. The final version of the Tiers of Service framework describes the specific services to be delivered at each tier, which are categorized as Tier 1 (community services) through Tier 6 (sub-specialized services). Two consecutive steps were identified to effectively use the framework for operational and system planning: (i) development of a ‘module’ outlining the responsibilities and requirements to be delivered at each tier; and (ii) assessment of services provided at the health care facility against those described in the module, alignment to a specific tier, identification of gaps at the local, regional and provincial level, and implementation of quality improvement initiatives to effectively address the gaps. Conclusions The benefits of the Tiers of Service framework and accompanying modules for health service planning are being increasingly recognized. Planning and coordinating pediatric health services across the province will help to optimize flow and improve access to high-quality services for children living in British Columbia.

Background In the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients’ relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain). Methods We conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data. Results Patients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship. Conclusions Consistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists.

Background The rapid identification of deterioration in the pediatric population is complex, particularly in the emergency department (ED). A comprehensive multi-faceted Pediatric Early Warning System (PEWS) might maximize early recognition of clinical deterioration and provide a structured process for the reassessment and escalation of care. The objective of the study was to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS implemented in the ED of an urban public general hospital in British Columbia, Canada, and to guide provincial scale up. Methods We used a before-and-after design to evaluate the implementation fidelity, effectiveness, and utility of a 5-component PEWS (pediatric assessment flowsheet, PEWS score, situational awareness, escalation aid, and communication framework). Sources of data included patient medical records, surveys of direct care staff, and key-informant interviews. Data were analyzed using mixed-methods approaches. Results The majority of medical records had documented PEWS scores at triage (80%) and first bedside assessment (81%), indicating that the intervention was implemented with high fidelity. The intervention was effective in increasing vital signs documentation, both at first beside assessment (84% increase) and throughout the ED stay (> 100% increase), in improving staff’s self-perceived knowledge and confidence in providing pediatric care, and self-reported communication between staff. Satisfaction levels were high with the PEWS scoring system, flowsheet, escalation aid, and to a lesser extent with the situational awareness tool and communication framework. Reasons for dissatisfaction included increased paperwork and incidence of false-positives. Overall, the majority of providers indicated that implementation of PEWS and completing a PEWS score at triage alongside the Canadian Triage and Acuity Scale (CTAS) added value to pediatric care in the ED. Results also suggest that the intervention is aligned with current practice in the ED. Conclusion Our study shows that high-fidelity implementation of PEWS in the ED is feasible. We also show that a multi-component PEWS can be effective in improving pediatric care and be well-accepted by staff. Results and lessons learned from this pilot study are being used to scale up implementation of PEWS in ED settings across the province of British Columbia.

Background Concordance refers to shared characteristics between a clinician and patient, such as ethnicity or language. The purpose of this study was to examine whether patient-clinician concordance is associated with patient-reported continuity of care (relational, informational and management) and patient-reported impacts of care (quality and empowerment). Methods This is a secondary analysis of cross-sectional patient surveys that were administered across British Columbia, Manitoba and Quebec using random digit dialling. Participants were adults who spoke English, French, Mandarin, Cantonese or Punjabi and who had visited a primary care clinician in the previous 12 months (n = 3156). Patients self-identified as being of European, Chinese, South Asian and Indigenous descent. Outcome measures included patients' perceptions of continuity, quality and empowerment. Adjusted logistic regression models and odds ratio were generated. Results More than 64% of non-Indigenous respondents reported ethnocultural concordance. Ethnocultural concordance was associated with higher odds of relational and management continuity. This same pattern held when there was both ethnocultural and language concordance. No association was found between language concordance and any outcome measure. Chinese participants reported lower quality (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.48), as did South Asian participants (OR 0.17, 95% CI 0.09-0.31) than did participants of European descent. Interpretation Higher relational and management continuity is more likely with the presence of patient-clinician ethnocultural and language concordance. Lower continuity and quality reported by Chinese and South Asian particpants could indicate important health care disparities.

Objective: To compare immigrants’ and natives’ perceptions of relational, managerial and informational continuity of care and to explore the influence of the length of stay on immigrants’ perceptions of continuity. Methods: Cross-sectional study based on a survey of a random sample of 1,500 patients, of which 22% (331) were immigrants. The study area was made up by three healthcare areas of the Catalan healthcare system. To collect data, the CCAENA questionnaire was applied. Multivariate logistic regression models were conducted. Results: Like natives, immigrants perceive high levels of managerial continuity (88.5%) and relational continuity with primary and secondary care physicians (86.7 and 81.8%), and lower levels of informational continuity (59.1%). There were no statistically significant differences in managerial and informational continuity between immigrants and natives. However, immigrants perceive a worse relational continuity with primary care physicians in terms of trust, communication and clinical responsibility. Conversely, immigrants perceive higher relational continuity with secondary care physicians in terms of effective communication and clinical responsibility. Discussion: Similar managerial and informational continuity perceptions seem to point towards a similar treatment of patients, regardless of their immigrant status. However, differences in relational continuity highlight the need for improvements in professionals’ skills in treating immigrants’ patients.

Objective. To determine the patients’ perceived degree of continuity of care between primary and secondary care and to identify contextual and individual factors that influence patients’ perceptions of continuity of care. Design. Cross-sectional study by means of a survey of patients attended to in primary and secondary care. Setting. Three health-care areas of the Catalonian public health-care system. Participants. A random sample of 1500 patients. Main Outcome Measures. Relational, informational and managerial continuity of care measured by means of Likert scales, using the CCAENA questionnaire. Results. Overall, 93.8 and 83.8% of patients perceived an ongoing relationship with primary and secondary care physicians, respectively (relational continuity), 71.2% perceived high levels of information transfer (informational continuity) and 90.7% perceived high levels of consistency of care (managerial continuity). Patients from health-care areas where primary and secondary care were managed by a single organization and the elderly tended to perceive higher levels of all three types of continuity. Foreign-born patients were less likely to perceive relational continuity with primary care physicians; those with higher educational levels were less likely to perceive high levels of informational continuity and patients with worse health status were less likely to report high levels of managerial and relational continuity with secondary care physicians. Conclusions. Study results suggest high levels of perceived continuity of care, especially for relational and managerial continuity. The adopted comprehensive approach proves to be useful to properly understand the phenomenon because perceptions and associated factors vary according to the type of continuity.

Background The integration of health care has become a priority in most health systems, as patients increasingly receive care from several professionals in various different settings and institutions, particularly those with chronic conditions and multi-morbidities. Continuity of care is defined as one patient experiencing care over time as connected and coherent with his or her health needs and personal circumstances. The objective is to analyse perceptions of continuity of clinical management and information across care levels and the factors influencing it, from the viewpoint of users of the Catalan national health system. Methods A descriptive-interpretative qualitative study was conducted using a phenomenological approach. A two-stage theoretical sample was selected: (i) the study contexts: healthcare areas in Catalonia with different services management models; (ii) users ≥ 18 years of age who were attended to at both care levels for the same health problem. Data were collected by means of individual semi-structured interviews with patients (n = 49). All interviews were recorded and transcribed. A thematic content analysis was conducted segmented by study area, with a mixed generation of categories and triangulation of analysts. Results Patients in all three areas generally perceived that continuity of clinical management across levels existed, on referring to consistent care (same diagnosis and treatment by doctors of both care levels, no incompatibilities of prescribed medications, referrals across levels when needed) and accessibility across levels (timeliness of appointments). In terms of continuity of information, patients in most areas mentioned the existence of information sharing via computer and its adequate usage. Only a few discontinuity elements were reported such as long waiting times for specific tests performed in secondary care or insufficient use of electronic medical records by locum doctors. Different factors influencing continuity were identified by patients, relating to the health system itself (clear distribution of roles between primary and secondary care), health services organizations (care coordination mechanisms, co-location, insufficient resources) and physicians (willingness to collaborate, commitment to patient care, the primary care physician’s technical competence). Conclusions Care continuity across care levels is experienced by patients in the areas studied, with certain exceptions that highlight where there is room for improvement. Influencing factors offer valuable insights on where to direct coordination efforts. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1696-8) contains supplementary material, which is available to authorized users.

Background 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 relates to how patients experience coordination. The objective is to compare doctors’ perceptions of coordination and patients’ perceptions of continuity across care levels …

Background 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 is related to how patients experience the coordination of services. The objective is to identify factors influencing care coordination and continuity across care levels …

Background: Integrated health care networks (IHN) are promoted in numerous countries as a response to fragmented care delivery by providing a coordinated continuum of services to a defined population. However, evidence on their effectiveness and outcome is scarce, particularly considering continuity across levels of care; that is the patient's experience of connected and coherent care received from professionals of the different care levels over time. The objective was to analyse the chronic obstructive pulmonary disease (COPD) patients’ perceptions of continuity of clinical management and information across care levels and continuity of relation in IHN of the public health care system of Catalonia.Methods: A qualitative multiple case study was conducted, where the cases are COPD patients. A theoretical sample was selected in two stages: (1) study contexts: IHN and (2) study cases consisting of COPD patients. Data were collected by means of individual, semi-structured interviews to the patients, their general practitioners and pulmonologists and review of records. A thematic content analysis segmented by IHN and cases with a triangulation of sources and analysists was carried out.Results: COPD patients of all networks perceived that continuity of clinical management was existent due to clear distribution of roles for COPD care across levels, rapid access to care during exacerbations and referrals to secondary care when needed; nevertheless, patients of some networks highlighted too long waiting times to non-urgent secondary care. Physicians generally agreed with patients, however, also indicated unclear distribution of roles, some inadequate referrals and long waiting times to primary care in some networks. Concerning continuity of information, patients across networks considered that their clinical information was transferred across levels via computer and that physicians also used informal communication mechanisms (e-mail, telephone); whereas physicians highlighted numerous problems of the information system, thus the need to use informal communication channels. Finally, regarding continuity of relation, patients of some networks pointed out high turnover of personnel - being frequently seen by locum doctors or assigned to new physicians - which hindered the development of a trusting relationship.Conclusion: Study findings suggest a generally perceived adequate performance of IHN in continuity of care but also the existence of a series of difficulties related to all continuity types. Results can provide opportunities to improving the care process of COPD patients but also of patients with other conditions who receive care across the primary and secondary care level.

Introduction : Care coordination has become a priority in most health systems, as patients increasingly receive care from several professionals in different settings, particularly those with chronic conditions and multi-morbidities. Fragmented care produces difficulties in access to care, poor technical quality, discontinuity of care and inefficiency. 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. Perceptions of physicians and user have rarely been analyzed in a comprehensive manner. The objective is to analyze comparatively physicians’ perceptions of coordination and patients’ perceptions of continuity across care levels in different areas of the Catalan national health system. 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 Emporda, 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 in all study areas perceived the existence of coordination and continuity across levels, especially referring to information transfer and consistency of medical indications, treatments and tests. Nevertheless, limitations were also identified, some of which varied between healthcare areas and informant groups. Main differences of perceptions of physicians of the different study areas related to referrals and accessibility across care levels. First, concerning coordination/continuity of information, both informant groups perceived its existence, described by the transfer of information across care levels via a shared medical history system and its uptake. Physicians across the areas pointed out that, as a result of information sharing, the care provision across levels was consistent and follow-up at the other care level facilitated. For its part, patients indicated that they were spared from carrying test results and commenting on antecedents or preceding visits. However, physicians also reported some limitations of information transfer, e.g. missing reason for referrals or recommendations for follow-up. Whilst GPs indicated insufficient uptake of information by some specialists, patients highlighted limited use by emergency and locum doctors. Second, concerning consistency of care, both informant groups perceived that physicians generally provided the same diagnosis and treatment to the patient and that incompatibilities of medications were rare. Moreover, few test duplications were reported by physicians and patients. According to physicians, consistency was achieved particularly through the coordination of information across levels and direct communication to respond to questions about diagnosis and treatment and to reach consensus. In addition, physicians reported that care is generally provided at the appropriate care level and according to patient needs, which was similar to patients’ accounts indicating the receipt of care at right level and when necessary. Nevertheless, some specialists reported that referrals to their care level were inadequate and some GPs of Ciutat Vella and Girona highlighted that in some occasions necessary secondary care was not provided (too early emergency and impatient discharge and referral rejections). A few patients of all healthcare areas expressed absent referral resulting in the patient seeking private care and a perceived loss of time and resources. Finally, concerning accessibility across levels, both informant groups perceived adequate waiting times for urgent specialized care. However, according to some GPs, waiting times were too long for non-urgent secondary care after a referral and in Girona for some specific tests, resulting in diagnostic and therapeutic delays. Occasionally, some patients reported interruptions in the diagnostic process and treatment due to long waiting times for non-urgent secondary care. Discussion : Physicians and patients generally perceived that coordination and continuity across care levels existed in the study areas. However, some interruptions were also identified, such as the insufficient uptake of information or long waiting times for non-urgent secondary care. Results further suggest similar perceptions in all areas, as well as congruent reports by physicians and patient, with a few specific differences in highlighted problems. Conclusion : Coordination and continuity across care levels appears to exist in the areas studied, with certain exceptions that highlight where there is room for improvement.

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 Emporda, 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 Emporda, and e-consultations Baix Emporda 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 Emporda and proximity in Girona and Baix Emporda) 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.

Background Achieving continuity of care across care levels has become a priority in many health care systems that experience specialization and fragmentation of care; since continuity should contribute to the delivery of high quality care and the adequate use of resources. Continuity of care is defined as one patient experiencing the provision of care over time as coherent and interlinked. Three types can be distinguished: informational, managerial and relational continuity. The objective is to explore …

Objective: To analyze patient's reported elements of relational, informational and managerial (dis)continuity between primary and outpatient secondary care and to identify associated factors. Methods: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care for the same condition. The study settings consisted of three health areas of the Catalan health system. Data were collected in 2010 using the CCAENA© questionnaire, which identifies patients' experiences of continuity of care. Descriptive analyses and multivariable logistic regression models were carried out. Results: Elements of continuity of care were experienced by most patients. However, elements of discontinuity were also identified: 20% and 15% were seen by more than one primary or secondary care physician, respectively. Their secondary care physician or both professionals were identified as responsible for their care by 40% and 45% of users, respectively. Approximately 20% reported a lack of information transfer. Finally, 72% of secondary care consultations were due to primary care referral, whilst only 36% reported a referral back to primary care. Associated factors were healthcare setting, age, sex, perceived health status and disease duration. Conclusion: Users generally reported continuity of care, although elements of discontinuity were also identified, which can be partially explained by the healthcare setting and some individual factors. Elements of discontinuity should be addressed to better adapt care to patients' needs.

Objective. The increasing complexity in healthcare delivery might impede the achievement of continuity of care, being defined as ‘one patient experiencing care over time as coherent and linked’. This article aims to improve the knowledge on patients’ perceptions of relational (RC), informational (IC) and management continuity (MC) across care levels. Design. A descriptive, qualitative meta-synthesis was conducted based on a literature search in various electronic databases using the subject heading ‘continuity of care’ and linked key terms. We scanned retrieved articles for adherence to inclusion criteria: (i) relevance to research topic, (ii) original study adopting a qualitative design and (iii) investigating the patient’s perspective. Content analysis was conducted by identification of themes and aggregation of findings. Results. The selected 25 studies most frequently investigated RC. Being attended to regularly and over time by one physician (RC) was valued by chronic ill patients, but balanced with convenient access by young patients (MC). Communication and information transfer across care settings as well as the gathering of holistic information about the patient were perceived to foster IC. Critical features for achieving MC were accessibility between care levels, individualized care and a smooth discharge process including the receipt of support. Patients further considered that their personal involvement was one facilitating element of continuity of care. Conclusions. Patients identified elements that enhance or distract from continuity of care across boundaries. Variations in perceived importance seem to depend on both individual and contextual factors which should be taken into account during healthcare provision.