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Continuity of care
Brief Reports This section will carry communications of work in progress, preliminary research reports, or interesting and unusual vignettes. Such reports will be considered for their practical clinical relevance or heuristic value.
Continuity
of Care
A Patient-Centered Model Stephen
B. Bernstein,
M.D.
Chief, Psychiatric Inpatient and Day Hospital Service and Family Institute, Tufts-New England Medical Center Hospital, and Associate Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts
Karen Zander, R.N., M.S.N. Nurse leader, Department of Psychiafy, and Organizational Developmenf Tufts-New England Medical Center Hospital, Boston, Massachusetts
Abstract: A patient-centered model for the delivery of mental healfh services to acufe psychiafric pafienfs is described. This model may also be applicable to more comprehensive delivery systems. Mental health systems usually are centered around separate staff and physical locations of various units. The psychiatric patient’s sensitivity to disruptions of the environment may respond favorably to a system of patientstaff continuity, which avoids fragmentation of care. The patient-centered care model allows the treatment staff fo follow patients throughout the entire course of their treatment program. lmpressions are that this model results in a marked decrease in acting out, suicide gestures, and other regressive manifestations at the time of transfer from one phase of the program to another. Specific issues of patient care accountability, patient follow-through, and compliance with treatment recommendations and cost-effectiveness are also discussed. In addition, staffsatisfaction andprofessionalgrowth are enhanced by the ability to follow patients andfamilies through all phases of their treatment. Decreased staff turnover and increased interdisciplinay communication can enhance staffgrowth as well as patient care. General Hospital Psychiatry 3, 5943, 1981 Q Elsevier North Holland, Inc., 1981 52 Vanderbilt Ave., New York, NY 10017
Specialist,
Department
of Nursing,
Current systems for the delivery of health care have generally accepted the limitations on total continuity of patient care imposed by geography, architecture, and staff specialization. Recent efforts to offer comprehensive care are, in part, attempts to overcome these limitations (l-5). Patients, however, often are subjected to fragmentation in their treatment as they are shifted to different staffs and buildings for service. Such discontinuous models of patient care must be examined in light of newer trends to (a) promote “deinstitutionalization,” (b) limit inpatient hospitalization in favor of more effective follow-up and aftercare programs, and (c) improve the quality and cost effectiveness of the delivery and use of services (6). Continuity of care usually has been defined in terms of an uninterrupted succession of services, if not by the same clinician at all times, then by others familiar with the patient’s condition and treatment 59 ISSN 0163-8343/81/010059-05/!$02.25
S. 8. Bernstein and K. Zander
program via the transmission of medical and clinical information regarding patient history and diagnostic and therapeutic data(7). Continuity of treatment staff, although seen as advantageous, has often been dismissed as impractical. While treatment of the medical patient may depend less on the interpersonal process, (i.e., renal failure treated by dialysis may be treated with some interruption of health providers), this is not acceptable in the case of the psychiatric patient because of frequent underlying extreme sensitivity to separation and loss. This dynamic issue differentiates the psychiatric patient from many primary medical patients and necessitates the examination of those models of continuity of care for the psychiatric patient which promote both interpersonal and information transferring continuity. Efforts to overcome barriers to continuity have focused primarily on the linkage or liaison between clinical an&or administrative staff of different services, located at different sites or at the same site but at some physical distance (such as discrete inpatient and aftercare units in the same hospital). It is the thesis of this paper that a patientcentered model of continuity of care appears to have certain advantages: (a) better access to the delivery of comprehensive services, (b) shorter and less repetitive inpatient evaluations, and (c) longer-term observation with more accurate diagnosis. In addition, the model contains feedback mechanisms which influence the assumption of responsibility and increases staff accountability. It also increases patient participation in planning for and complying with follow-up and aftercare measures.
The Patient-Centered Model Description The patient-centered model of continuity of care reorganizes the delivery of services around the patient’s needs for interpersonal continuity as opposed to models based on specialization of function and localization of service. The model is based on the premise that discharge from any part of a care system is a crisis for the patient, especially patients for whom separation and loss are experienced as rejection and abandonment. The basic element in the model is a combined inpatient, day hospital, and aftercare facility unified in philosophy, staffing, and programs and centralized in location. As such, it provides a constant 60
staff delivering a wide range of mental health services: case-finding (from community based facilities, medical consultation services, emergency room, and so on), emergency intervention, preadmission screening, inpatient and day hospitalization. It provides for family therapy and facilitates discharge planning with potential for aftercare treatment using individual, group, or family treatment, and/or medication monitoring. Linkages are maintained to other facilities when the hospitalization is taking place at a distance from a patient’s home or for specific services not otherwise available. Evaluation and treatment are carried out by continuous contact with the same “patientcentered” multidisciplinary team of professionals. Integral to the system is the use of an “overnight bed” for a short stay (one to three days) without formal rehospitalization of the patient at times of crisis, 24-hour phone access to the unit “on-call“ staff, home visits when necessary to assess the patient’s environment and to “re-engage” the patient or in efforts to support the patient’s family and social structure, and the ability to readmit the patient to the same inpatient service and staff if necessary.
Clinical Example A general hospital-based primary treatment facility of a medical school department of psychiatry will be used to elaborate the patient-centered model (although a larger and quite different facility will be discussed later). The unit is a short-term evaluation and treatment (three-week inpatient stay) facility with an integrated lo-bed inpatient service, 25patient day hospital, and fully integrated family evaluation and therapy service (family institute). The unit is considered to be a 35-bed unit with 25 patients leaving for eight hours at night. There is little differentiation between inpatients and day patients, who participate in the same group-oriented milieu program. The unit admits about 200 adult patients per year. Any patient able to be treated on an open general hospital unit is admitted. This includes a wide diversity of patients with psychiatric diagnoses including severe depression, borderline syndromes, acute psychotic episodes, and schizophrenia. Also admitted are patients with psychosomatic illnesses and those with psychiatric disorders related to serious medical illnesses referred by the medical and surgical services of the hospital. Five part-time psychiatric residents who staff the
Continuity
hospital psychiatric emergency room and the consultation/liaison service function as inpatient and day hospital patient evaluators and participate in the family treatment of all inpatient and day hospital patients. Under the guidance of the director of the psychiatric service and the chief resident, they are members of inpatient and day hospital teams, together with the patient’s primary nurse and family social worker. A full complement of staff nurses, who function as primary nurses, and four psychiatric social workers make up the rest of the regular staff. Teams of a resident/evaluator, primary nurse, and family worker participate in the evaluation and treatment of the 35 patients and the 110 family members who are enrolled in the integrated family institute. Specific staff members also function as liaison and referral links with community-based health and multiservice centers, the general hospital emergency room and consultation and liaison service, and other patient referral sources. This linkage function allows smooth entrance of patients into the system and helps in facilitating sustained return to the community when the patient is ready. In general, from the first patient contact at a referring agency or in the hospital emergency room, the consistent three or four person team carries out the admission, evaluation, short-term family treatment, and disposition planning for the patient. Although each team member has somewhat separate functions (i.e., evaluator, specific nursing roles, family contact), al1 are often seen as interchangeable and can “cover” for each other at times of absence. In addition, family meetings of the team with the patient and family are held to help deal with family dynamics which may promote the patient’s treatment and acceptance of aftercare, explain the course of the hospitalization, gather information, specify the evaluation results, and convey the recommended “prescription” of aftercare treatment for both patient and family. Such family work is seen as tending to increase the alliance of the patient and the family with the unit and to increase patient participation (“compliance”) with the “prescription” of aftercare treatment for both patients and family. Subsequent to inpatient hospitalization, most patients attend the day hospital for varying lengths of time and may continue in “alumni” or aftercare groups, individual psychotherapy, or medication follow-up with one of the existing team members. When the patient lives at a great distance from the unit, the patient may be “transitioned” to a facility nearer his home. In the transition to any other
of Care
facility, whether local or farther away, the new facility becomes a caregiver from the “outside” member of the unit “team,” attending meetings and conferences and beginning to meet with the patient on the unit. Thus, after establishing a relationship with the patient and being identified as a team member after a short time, the transition to the new treater and facility is accomplished with a sense of continuity and attempts to decrease the adverse effects of separation and abandonment.
Results of the Patient-Centered Model Results, which follow, are based on observations on the same unit before and after integration of all services and the establishment of the patientcentered model. Observations are also based on cases in which continuity failed or was not possible for various internal or external reasons.
The Psychiufrisf us Primary Care Physician In the patient-centered model, the psychiatric director and psychiatric residents closely observe the longitudinal course of the patient’s total treatment, thereby functioning at times as primary care physicians in diagnosing medical problems and implementing treatment suggestions proposed by medical and surgical consultants(8,9). The psychiatric staff appear more sensitized to their primary roles as physicians, or, in the case of nonmedical staff, to the physical problems that can arise with psychiatric patients. Effect of
the Model on Patient Cure
The continuity-based focus of the unit provides smooth patient flow from one part of the evaluation and treatment to the next. In the past, the transition in treaters and treatment modalities led, at best, to noncompliance with dispositions and, at worst, to regression, acting out, and serious suicide attempts. These events became understood as complications of noncontinuous transition and markedly decreased with the implementation of the new model. Also, there is less secondary gain in maintaining a hospitalized status since hospitalization is no longer a criterion for continuing with valued treaters. In addition, the team’s greater knowledge of patients who use the mechanism of splitting and the team’s own understanding of reactions to such disruptive defenses, facilitate communication, efforts at behavioral change, and integration of new 61
S. 8. Bernstein and K. Zander
behavior. Another benefit accrues: follow-through with aftercare recommendations over extended periods of time. Long-term contact with the patient provides greater opportunity for observation of fluctuations in the patient’s mental status, physical condition, and response to medication. Use of overnight beds can often prevent readmission. A well-functioning patient-centered team reduces the number of people necessary to make important decisions, fixing patient responsibility and accountability with a smaller group of professionals. Patients appear to reflect a sense of security at an early stage of their hospitalization by hearing about the continuity of care and the staff’s commitment to them over time.
Effects of the Model on the Staff The unified theoretical basis allows the staff to see their roles as significant and, in fact, more important than the physical or geographic location of the unit. Staff tend to have a sense of internal control and mutual support. Team members with different specific functions (evaluator, primary nurse, family worker) have opportunities to clarify their own professional roles and to teach new skills to each other. Intrateam colleagial education develops new skills and an interest in the team group process. Learning, which appears to occur in team functioning, seems to increase the staff morale, participation, productivity, and accountability. To this enhanced morale and the staff’s gratification from their work is,attributed a markedly decreased staff turnover on the unit. Stability of staff complement can promote maturity, deepening of experience, and superior training. The resident/evaluators may function as family workers, just as nurses or social workers may function as evaluators in the process of mutual education and growth; in this working relationship, “turf” issues assume less importance. Hazards of the model may derive from disruptive group processes resulting from continuous involvement of staff members who work poorly together. Furthermore, it is sometimes possible that prolonged familiarity with certain patients may heighten staff-patient comfort with concomitant difficulty in permitting the patient to disengage from the unit; excessive dependency upon the system may result. Finally, staff may occasionally develop excessively high expectations of their patients as well as themselves. Skilled supervision must constantly be brought to bear on these pitfalls as goals and treatment limitations are clearly defined. 62
Discussion Efforts to achieve continuity of care are not new. Such attempts have (a) utilized the team as a treatment entity, (b) provided interagency links, and (c) treated psychiatric patients on a long-term basis. Indeed, these are widely practiced elements of psychiatric care. The patient-centered model is herein emphasized as a foundation upon which to structure and to build, refine, and reorganize treatment systems. The value of continuity in staff-patient relationships, though well accepted, appears to suffer limitations in the transition points between a sequence of services or clinics. Several centers have implemented programs which approximate the patient-centered model. Applications of this concept have ranged from “multipurpose, multiservice” geriatric centers providing longitudinal care to the reorganization of a psychiatric ward as a “mini-mental health center”(l0). To combat the limitations of discontinuous systems, Johnson et al.(lO) organized a large general psychiatric ward to provide comprehensive services with continuity. In contrast to the smaller unit described above, Johnson’s program involved a larger more chronic population; inpatient census decreased from 196 to 30 after a shift to increased day hospital and outpatient services and good compliance with recommendations for aftercare. Further studies are indicated to decrease the personal and social burdens of extensive inpatient hospitalization, through increasingly effective treatment modalities and their delivery to patients in psychiatric care systems(l1). Increased utilization of aftercare treatment is considered both beneficial to the patient and cost-effective. It is our belief that development of new strategies of care delivery which stress continuity may provide shorter inpatient stays, fewer complications during transition between treatment modalities, less frequent and extensive rehospitalizations, and greater compliance with needed long-term aftercare programs.
References Washburn W, Smith Elaine J: Continuum of Mental Health Service. Hosp Commun Psychiatry 22:48-50, 1971 Shorr GI, Nutting PA: A population-based assessment of the continuity of ambulatory care. Med Care 15:455-464, 1977 Johns CJ. et. al.: A minirecord: An aid to continuity of care. Johns Hopkins Med J 140:277-284, 1977
Continuity
4. Hansen MF: Continuity of care in family practice. Part 3: Measurement and evaluation of continuity of care. J Family Practice 2439-444, 1975 5. Shortell SM: Continuity of medical care: Conceptualization and measurement. Med Care 14:377-391, 1976 6. May PR: Adopting new models for continuity of care: What are the needs. Hosp Commun Psychiatry 26:599-601, 1975 7. McGuire HD: Better continuity needed. JAMA 50:9197, 1976 8. Rashkis HA: General psychiatry, primary care and medical primacy. Gen Hosp Psychiatry 1:270-275, 1979 9. Sandifer G: Psychiatry, the medical model and primary care. Psychosomatics 21:187-188, 1980
of Care
10. Johnson E et. al.: Adopting new models for continuity of care: The ward as mini-mental-health -center. Hosp Commun Psychiatry 26601~604,1975 11. Tessler R, Mason H: Continuity of care in the delivery of mental health services. Am J Psychiatry 136:12971301, 1979
Direct reprint requeststo: Stephen B. Bernstein, M.D. Department of Psychiatry New England Medical Center 171 Harrison Avenue Boston, MA 02111
63
Continuity
of Care
A Patient-Centered Model Stephen
B. Bernstein,
M.D.
Chief, Psychiatric Inpatient and Day Hospital Service and Family Institute, Tufts-New England Medical Center Hospital, and Associate Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts
Karen Zander, R.N., M.S.N. Nurse leader, Department of Psychiafy, and Organizational Developmenf Tufts-New England Medical Center Hospital, Boston, Massachusetts
Abstract: A patient-centered model for the delivery of mental healfh services to acufe psychiafric pafienfs is described. This model may also be applicable to more comprehensive delivery systems. Mental health systems usually are centered around separate staff and physical locations of various units. The psychiatric patient’s sensitivity to disruptions of the environment may respond favorably to a system of patientstaff continuity, which avoids fragmentation of care. The patient-centered care model allows the treatment staff fo follow patients throughout the entire course of their treatment program. lmpressions are that this model results in a marked decrease in acting out, suicide gestures, and other regressive manifestations at the time of transfer from one phase of the program to another. Specific issues of patient care accountability, patient follow-through, and compliance with treatment recommendations and cost-effectiveness are also discussed. In addition, staffsatisfaction andprofessionalgrowth are enhanced by the ability to follow patients andfamilies through all phases of their treatment. Decreased staff turnover and increased interdisciplinay communication can enhance staffgrowth as well as patient care. General Hospital Psychiatry 3, 5943, 1981 Q Elsevier North Holland, Inc., 1981 52 Vanderbilt Ave., New York, NY 10017
Specialist,
Department
of Nursing,
Current systems for the delivery of health care have generally accepted the limitations on total continuity of patient care imposed by geography, architecture, and staff specialization. Recent efforts to offer comprehensive care are, in part, attempts to overcome these limitations (l-5). Patients, however, often are subjected to fragmentation in their treatment as they are shifted to different staffs and buildings for service. Such discontinuous models of patient care must be examined in light of newer trends to (a) promote “deinstitutionalization,” (b) limit inpatient hospitalization in favor of more effective follow-up and aftercare programs, and (c) improve the quality and cost effectiveness of the delivery and use of services (6). Continuity of care usually has been defined in terms of an uninterrupted succession of services, if not by the same clinician at all times, then by others familiar with the patient’s condition and treatment 59 ISSN 0163-8343/81/010059-05/!$02.25
S. 8. Bernstein and K. Zander
program via the transmission of medical and clinical information regarding patient history and diagnostic and therapeutic data(7). Continuity of treatment staff, although seen as advantageous, has often been dismissed as impractical. While treatment of the medical patient may depend less on the interpersonal process, (i.e., renal failure treated by dialysis may be treated with some interruption of health providers), this is not acceptable in the case of the psychiatric patient because of frequent underlying extreme sensitivity to separation and loss. This dynamic issue differentiates the psychiatric patient from many primary medical patients and necessitates the examination of those models of continuity of care for the psychiatric patient which promote both interpersonal and information transferring continuity. Efforts to overcome barriers to continuity have focused primarily on the linkage or liaison between clinical an&or administrative staff of different services, located at different sites or at the same site but at some physical distance (such as discrete inpatient and aftercare units in the same hospital). It is the thesis of this paper that a patientcentered model of continuity of care appears to have certain advantages: (a) better access to the delivery of comprehensive services, (b) shorter and less repetitive inpatient evaluations, and (c) longer-term observation with more accurate diagnosis. In addition, the model contains feedback mechanisms which influence the assumption of responsibility and increases staff accountability. It also increases patient participation in planning for and complying with follow-up and aftercare measures.
The Patient-Centered Model Description The patient-centered model of continuity of care reorganizes the delivery of services around the patient’s needs for interpersonal continuity as opposed to models based on specialization of function and localization of service. The model is based on the premise that discharge from any part of a care system is a crisis for the patient, especially patients for whom separation and loss are experienced as rejection and abandonment. The basic element in the model is a combined inpatient, day hospital, and aftercare facility unified in philosophy, staffing, and programs and centralized in location. As such, it provides a constant 60
staff delivering a wide range of mental health services: case-finding (from community based facilities, medical consultation services, emergency room, and so on), emergency intervention, preadmission screening, inpatient and day hospitalization. It provides for family therapy and facilitates discharge planning with potential for aftercare treatment using individual, group, or family treatment, and/or medication monitoring. Linkages are maintained to other facilities when the hospitalization is taking place at a distance from a patient’s home or for specific services not otherwise available. Evaluation and treatment are carried out by continuous contact with the same “patientcentered” multidisciplinary team of professionals. Integral to the system is the use of an “overnight bed” for a short stay (one to three days) without formal rehospitalization of the patient at times of crisis, 24-hour phone access to the unit “on-call“ staff, home visits when necessary to assess the patient’s environment and to “re-engage” the patient or in efforts to support the patient’s family and social structure, and the ability to readmit the patient to the same inpatient service and staff if necessary.
Clinical Example A general hospital-based primary treatment facility of a medical school department of psychiatry will be used to elaborate the patient-centered model (although a larger and quite different facility will be discussed later). The unit is a short-term evaluation and treatment (three-week inpatient stay) facility with an integrated lo-bed inpatient service, 25patient day hospital, and fully integrated family evaluation and therapy service (family institute). The unit is considered to be a 35-bed unit with 25 patients leaving for eight hours at night. There is little differentiation between inpatients and day patients, who participate in the same group-oriented milieu program. The unit admits about 200 adult patients per year. Any patient able to be treated on an open general hospital unit is admitted. This includes a wide diversity of patients with psychiatric diagnoses including severe depression, borderline syndromes, acute psychotic episodes, and schizophrenia. Also admitted are patients with psychosomatic illnesses and those with psychiatric disorders related to serious medical illnesses referred by the medical and surgical services of the hospital. Five part-time psychiatric residents who staff the
Continuity
hospital psychiatric emergency room and the consultation/liaison service function as inpatient and day hospital patient evaluators and participate in the family treatment of all inpatient and day hospital patients. Under the guidance of the director of the psychiatric service and the chief resident, they are members of inpatient and day hospital teams, together with the patient’s primary nurse and family social worker. A full complement of staff nurses, who function as primary nurses, and four psychiatric social workers make up the rest of the regular staff. Teams of a resident/evaluator, primary nurse, and family worker participate in the evaluation and treatment of the 35 patients and the 110 family members who are enrolled in the integrated family institute. Specific staff members also function as liaison and referral links with community-based health and multiservice centers, the general hospital emergency room and consultation and liaison service, and other patient referral sources. This linkage function allows smooth entrance of patients into the system and helps in facilitating sustained return to the community when the patient is ready. In general, from the first patient contact at a referring agency or in the hospital emergency room, the consistent three or four person team carries out the admission, evaluation, short-term family treatment, and disposition planning for the patient. Although each team member has somewhat separate functions (i.e., evaluator, specific nursing roles, family contact), al1 are often seen as interchangeable and can “cover” for each other at times of absence. In addition, family meetings of the team with the patient and family are held to help deal with family dynamics which may promote the patient’s treatment and acceptance of aftercare, explain the course of the hospitalization, gather information, specify the evaluation results, and convey the recommended “prescription” of aftercare treatment for both patient and family. Such family work is seen as tending to increase the alliance of the patient and the family with the unit and to increase patient participation (“compliance”) with the “prescription” of aftercare treatment for both patients and family. Subsequent to inpatient hospitalization, most patients attend the day hospital for varying lengths of time and may continue in “alumni” or aftercare groups, individual psychotherapy, or medication follow-up with one of the existing team members. When the patient lives at a great distance from the unit, the patient may be “transitioned” to a facility nearer his home. In the transition to any other
of Care
facility, whether local or farther away, the new facility becomes a caregiver from the “outside” member of the unit “team,” attending meetings and conferences and beginning to meet with the patient on the unit. Thus, after establishing a relationship with the patient and being identified as a team member after a short time, the transition to the new treater and facility is accomplished with a sense of continuity and attempts to decrease the adverse effects of separation and abandonment.
Results of the Patient-Centered Model Results, which follow, are based on observations on the same unit before and after integration of all services and the establishment of the patientcentered model. Observations are also based on cases in which continuity failed or was not possible for various internal or external reasons.
The Psychiufrisf us Primary Care Physician In the patient-centered model, the psychiatric director and psychiatric residents closely observe the longitudinal course of the patient’s total treatment, thereby functioning at times as primary care physicians in diagnosing medical problems and implementing treatment suggestions proposed by medical and surgical consultants(8,9). The psychiatric staff appear more sensitized to their primary roles as physicians, or, in the case of nonmedical staff, to the physical problems that can arise with psychiatric patients. Effect of
the Model on Patient Cure
The continuity-based focus of the unit provides smooth patient flow from one part of the evaluation and treatment to the next. In the past, the transition in treaters and treatment modalities led, at best, to noncompliance with dispositions and, at worst, to regression, acting out, and serious suicide attempts. These events became understood as complications of noncontinuous transition and markedly decreased with the implementation of the new model. Also, there is less secondary gain in maintaining a hospitalized status since hospitalization is no longer a criterion for continuing with valued treaters. In addition, the team’s greater knowledge of patients who use the mechanism of splitting and the team’s own understanding of reactions to such disruptive defenses, facilitate communication, efforts at behavioral change, and integration of new 61
S. 8. Bernstein and K. Zander
behavior. Another benefit accrues: follow-through with aftercare recommendations over extended periods of time. Long-term contact with the patient provides greater opportunity for observation of fluctuations in the patient’s mental status, physical condition, and response to medication. Use of overnight beds can often prevent readmission. A well-functioning patient-centered team reduces the number of people necessary to make important decisions, fixing patient responsibility and accountability with a smaller group of professionals. Patients appear to reflect a sense of security at an early stage of their hospitalization by hearing about the continuity of care and the staff’s commitment to them over time.
Effects of the Model on the Staff The unified theoretical basis allows the staff to see their roles as significant and, in fact, more important than the physical or geographic location of the unit. Staff tend to have a sense of internal control and mutual support. Team members with different specific functions (evaluator, primary nurse, family worker) have opportunities to clarify their own professional roles and to teach new skills to each other. Intrateam colleagial education develops new skills and an interest in the team group process. Learning, which appears to occur in team functioning, seems to increase the staff morale, participation, productivity, and accountability. To this enhanced morale and the staff’s gratification from their work is,attributed a markedly decreased staff turnover on the unit. Stability of staff complement can promote maturity, deepening of experience, and superior training. The resident/evaluators may function as family workers, just as nurses or social workers may function as evaluators in the process of mutual education and growth; in this working relationship, “turf” issues assume less importance. Hazards of the model may derive from disruptive group processes resulting from continuous involvement of staff members who work poorly together. Furthermore, it is sometimes possible that prolonged familiarity with certain patients may heighten staff-patient comfort with concomitant difficulty in permitting the patient to disengage from the unit; excessive dependency upon the system may result. Finally, staff may occasionally develop excessively high expectations of their patients as well as themselves. Skilled supervision must constantly be brought to bear on these pitfalls as goals and treatment limitations are clearly defined. 62
Discussion Efforts to achieve continuity of care are not new. Such attempts have (a) utilized the team as a treatment entity, (b) provided interagency links, and (c) treated psychiatric patients on a long-term basis. Indeed, these are widely practiced elements of psychiatric care. The patient-centered model is herein emphasized as a foundation upon which to structure and to build, refine, and reorganize treatment systems. The value of continuity in staff-patient relationships, though well accepted, appears to suffer limitations in the transition points between a sequence of services or clinics. Several centers have implemented programs which approximate the patient-centered model. Applications of this concept have ranged from “multipurpose, multiservice” geriatric centers providing longitudinal care to the reorganization of a psychiatric ward as a “mini-mental health center”(l0). To combat the limitations of discontinuous systems, Johnson et al.(lO) organized a large general psychiatric ward to provide comprehensive services with continuity. In contrast to the smaller unit described above, Johnson’s program involved a larger more chronic population; inpatient census decreased from 196 to 30 after a shift to increased day hospital and outpatient services and good compliance with recommendations for aftercare. Further studies are indicated to decrease the personal and social burdens of extensive inpatient hospitalization, through increasingly effective treatment modalities and their delivery to patients in psychiatric care systems(l1). Increased utilization of aftercare treatment is considered both beneficial to the patient and cost-effective. It is our belief that development of new strategies of care delivery which stress continuity may provide shorter inpatient stays, fewer complications during transition between treatment modalities, less frequent and extensive rehospitalizations, and greater compliance with needed long-term aftercare programs.
References Washburn W, Smith Elaine J: Continuum of Mental Health Service. Hosp Commun Psychiatry 22:48-50, 1971 Shorr GI, Nutting PA: A population-based assessment of the continuity of ambulatory care. Med Care 15:455-464, 1977 Johns CJ. et. al.: A minirecord: An aid to continuity of care. Johns Hopkins Med J 140:277-284, 1977
Continuity
4. Hansen MF: Continuity of care in family practice. Part 3: Measurement and evaluation of continuity of care. J Family Practice 2439-444, 1975 5. Shortell SM: Continuity of medical care: Conceptualization and measurement. Med Care 14:377-391, 1976 6. May PR: Adopting new models for continuity of care: What are the needs. Hosp Commun Psychiatry 26:599-601, 1975 7. McGuire HD: Better continuity needed. JAMA 50:9197, 1976 8. Rashkis HA: General psychiatry, primary care and medical primacy. Gen Hosp Psychiatry 1:270-275, 1979 9. Sandifer G: Psychiatry, the medical model and primary care. Psychosomatics 21:187-188, 1980
of Care
10. Johnson E et. al.: Adopting new models for continuity of care: The ward as mini-mental-health -center. Hosp Commun Psychiatry 26601~604,1975 11. Tessler R, Mason H: Continuity of care in the delivery of mental health services. Am J Psychiatry 136:12971301, 1979
Direct reprint requeststo: Stephen B. Bernstein, M.D. Department of Psychiatry New England Medical Center 171 Harrison Avenue Boston, MA 02111
63