Objective. Little research has been done concerning continuity of care in the transition from hospital to community care and seldom have patients and informal caregivers been given the chance to express their views on continuity of care. In light of the trend in Canada to shorten hospital stays, the present research examined how different stakeholders define continuity, particularly as it relates to seniors as patients in this transition.

Setting & Methodology. In-depth interviews of patients (seniors), their informal caregivers, hospital nurses, community nurses, and case managers were conducted to find out how they defined continuity of care in the transition from hospital to home care. The content of the interviews were then analysed to identify the suggested elements of continuity. A quantitative measure was developed for each element and focus group discussions were used to assess the validity of the measures.

Results. The elements of continuity identified were: perception of good care, access to needs-based health services, stakeholder knowledge and communication, care provider attitudes and competency, consistency of care providers, uninterrupted delivery of care, and waiting time.

Patients and informal caregivers mentioned perception of good care, care provider attitudes and competency, and waiting time more frequently than the case mangers, community nurses, and hospital nurses.

Nurses and case managers mentioned knowledge and communication, consistency of care providers, and uninterrupted delivery of care more frequently than the patients and informal caregivers. Access to needs-based health services were mentioned often by all stakeholder groups.

Conclusions. Three main conclusions have been drawn. First, there are distinct differences between those in the formal care system and those in the informal care system in what they believe to be important elements of continuity of care. Second, patients and informal caregivers emphasized elements that were more subjective in nature, whereas stakeholders from the formal care system, not unexpectedly, identified system-related elements. Third, if a goal is to integrate formal and informal service providers and to maximize continuity, then information flow between and among those in the formal and informal care systems will be critical.

Keywords: Continuity of care, seniors, health services, community care

For more information, contact
Alan W. Salmoni or Raymond W. Pong.