Three types of continuity of care have been identified in a review of the relevant literature, these are information continuity, management continuity and relational continuity (Haggerty et al., 2003). The LoTS care manual emphasises ‘management continuity’, which is defined as: ‘a consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing need’
(Haggerty et al., 2003). The system of care aimed to promote ‘continuity of care’
through a process of assessment, care planning, monitoring and review. These were the implementation activities expected in the delivery of the system of care’s components. The assessment booklet included the care plan, which was expected to link the problems identified with appropriate service responses, as stakeholder 1 commented:
Stakeholder 1: If all you ever do is do an assessment then you’re not
making a difference to the patient. So you’ve got to link the assessment with an action plan or goals that you negotiate with the patient that mean you’re going to change something for the patient, or help the patient change things for themselves. So they’re two sides to it really. There’s the assessment and then what does that trigger’.
The conclusion of the comprehensive and systematic assessment was the documentation of a care plan that described what the service user wanted to achieve (their goal) and what the Coordinator and patient intended to do in order to achieve this goal (actions). Continuity of care would be promoted through the use of the care plan that would record the monitoring processes (follow-up of actions and review of goals) and the number of reviews (repeated assessment) performed over the period of one year (the LoTS care trial’s duration). The study protocol, stated that ‘the Stroke Care Coordinator will undertake a primary assessment of patients (and carers
if appropriate) and instigate service responses, with additional follow-up and monitoring visits as considered appropriate to the needs of individual patients,’ Monitoring was to be provided ‘as needed’, however it was anticipated that this would involve at least two/three visits, which was also stated in the project protocol. The importance of monitoring the care plan was established during earlier studies performed at the AUECR (Murray et al., 2006, Dowswell et al., 1997), stakeholder 1 commented:
Stakeholder 1: What [the qualitative study] showed was, and I think this is
quite good really, if you take an average group of stroke patients and you see them at six months they have a range of different problems and you intervene and you help them hopefully to solve their problems, if you go back and see them at nine months you found that you have ameliorated some of the problems but now there are some new problems that have emerged,[…] You may be solving one problem, for example, you may be able to get a stroke patient to be more active socially going off to a local day centre but then that raises their expectations and they may have a higher horizon for doing something new and different. So I think that’s why we need to do a review and almost be working with them and really try and promote their recovery over quite a long period.
Previous empirical work demonstrated that addressing the needs of stroke survivors required a ‘long-term perspective’ as their needs changed over time (Dowswell et al., 1997). The feasibility study of the system of care supported these findings although for a different reason. This study surveyed participants’ three-months after their assessment to identify unmet needs (Murray et al., 2006). The survey indicated that some problems, which had been identified by the Coordinator, persisted. The research team established that the Coordinator had identified and addressed the problem by referring to an appropriate service. However, the Coordinator had not clarified whether the service user had subsequently received that service, stakeholder 2 commented: ‘if no-one is chasing these things [referrals] up then no one is tying up the loose ends in the system and problems are not being addressed, I think the process of care has to be a series of circles.’ The stakeholder emphasises that in order for a problem to be addressed through the system of care
an iterative process of monitoring and review needs to be performed. A follow-up telephone call was built in to the system of care during the feasibility study to address this gap in service provision.
During the LoTS care trial, the recruitment process clarified that the services visited individuals more than once, as stakeholder 4 clarified: ‘were not saying they have to see the patients at six months and a year. It’s when they would normally do a follow up anyway but before they are recruited to the trial we make sure that there isn’t just a one off assessment and that’s it.’ Therefore, there was an assumption that some follow-up processes would be performed as part of the Coordinators’ standard practice. Further to this, the twelve points advocated at the LoTS care training days included three points that promoted contact with service users over an extended period of time, these were
• Follow-up should be conducted on actions that have been referred out. • Review goals that have been made with the patient.
• Timing/duration of intervention in line with RCP Clinical Guidelines for Stroke & National Stroke Strategy.
Although not stipulated, the duration of the intervention was also expected to reflect national guidelines. The most recent guidelines were in the National Stroke Strategy, which recommended that a review take place at six weeks, six months and annually thereafter. Five ‘contacts’ (assessment structure and care plan documentation) were provided in one LoTS care assessment booklet. These contacts would facilitate the implementation of reviews where new problems could be identified, as stakeholder 4 commented: ‘it would be useful for them [the Coordinators] to do the whole assessment so they could review any new problems that had come up since the last visit, particularly if the first visit was quite soon after going home as the patient may not have realised some problems.’ Although reviews and monitoring were described as important components of the system, there were no strategies employed to ensure these processes were performed. The assumption was that the Coordinators would incorporate the follow-up processes necessary to
ensure that the problems identified were addressed i.e. achieving the system of care’s aim.