Participants

     A total of 248 patients (seniors), informal caregivers, hospital nurses, community nurses, and case managers were interviewed. All participants signed an informed consent or consented verbally before participating. Patients (N=50) ranged in age from 65 to 89 years (Mean=72.70 , SD=5.44) and consisted of 23 males and 27 females. Informal caregivers (N=50) ranged in age from 35 to 84 years (Mean=62.54, SD=11.14) and consisted of 16 males and 34 females. Hospital nurses (N=57), case managers (N=51), and community nurses (N=40) also participated. All participants were within the same health district.

Procedure

     Hospital nurses on the floor asked patients whether they would be willing to speak with someone about participation in a research project. If the patient agreed, a nurse-researcher visited the patient, explained the study, and asked if they would participate once discharged from the hospital. Patients were deemed eligible to participate if they were 65 years of age or older, had been in the hospital for no more than 10 days, and did not reside in a nursing home prior to admission or upon discharge. To insure a cross section of medical problems, patients were recruited from as many different areas of the hospital as possible. Patients who had volunteered were contacted 5 days after their discharge to set up an interview.

     Informal caregivers were recruited by asking the patients whether they had someone who helped care for them and if that individual would be interested in participating. The named individual was then contacted by phone to arrange a meeting time/place for an interview.

     Hospital nurses from different floors (i.e., vascular, medical, psychiatric) were initially approached by a clinical leader to ask whether they would be willing to participate. The interviewer then scheduled a time and place for the interview (usually during work time). Case managers and community nurses were sent a memorandum through their place of employment explaining the study and asking for their participation. Most were interviewed during work hours at their places of work (i.e., both groups reported regularly to a central-office).

     Once the elements of continuity were identified (using content analysis of the interviews) the literature was scanned to see whether quantitative measures existed for the identified elements. If no measure could be found, a measure was created. Several measures were created/found for each element. A series of focus groups with different stakeholder groups were then conducted to review the feasibility and clarity of the suggested measures. Based on the feedback obtained, measures of continuity for each element were suggested (see Measures of Continuity section).

Interview

     It was deemed important to develop an interview protocol that did not define continuity a priori for the participants being interviewed. After extensive pilot testing, it was decided that the best interview protocol was to present a picture to the interviewee which set the context for the discussion. The picture consisted of four scenes connected by arrows depicting the following text at the top of each scene: ‘Entered the hospital’, ‘Cared for in hospital’, ‘Discharged and sent home to continue recovery’ and ‘Cared for at home’. A recursive interview process was employed during which participants were repeatedly asked to clarify their statements and they were regularly prompted to insure that they had no new ideas concerning the question posed.

     First, participants were referred to the picture and asked how they would define continuity of care in this context. If the picture was insufficient, participants were prompted using parts of the definition used by Shortell who suggested that continuity of care is the extent to which medical care services are received as a coordinated and uninterrupted succession of events consistent with the medical care needs of the patient. Less than 5% of the participants needed this additional prompting.

     Next, participants were asked to identify the important elements of continuity, as they had defined it. Following this, participants were asked to suggest (personal) actions they could take to ensure or facilitate continuity (as they had defined it). Finally, participants were questioned about the problems or barriers they felt could make it difficult for them to complete the personal actions they had suggested. As a conclusion to the interview, the participants were asked once again for a definition of continuity and then thanked for their participation.

     The majority of participants were interviewed in-person, however, four patients and their caregivers were interviewed on the phone. The length of interview ranged from 8 to 45 minutes, with a mean interview length of 16 minutes (SD=8 minutes).