The relationship between patients, their physicians and the practice team is at the heart, and a critical goal of the Patient's Medical Home (PMH). Continuity of care is how a patient's experiences of care over time are coherent and linked; this is the result of good information flow, good interpersonal skills, and good coordination of care.
While continuity of care can occur in traditional primary care practice delivery, within the PMH there are conscious efforts to maintain and improve continuity through standardized practices and processes.
The first step to improving continuity is directly linked to identifying and maintaining your panel of unique unduplicated patients. A physician or team should be able to generate a patient panel, or roster, that lists the unique patients who have an established relationship with that physician. There is an explicit agreement that the identified physician will provide primary care services. Relational continuity (an ongoing relationship between a physician and a patient) is a key objective of establishing panel identification processes.
The Health Quality Council of Alberta provides physicians with individualized reports about their patients and is a valuable resource to begin with and can be requested here: HQCA Panel Report Request.
Other tools and resources related to improving panel and continuity can be found using the links below.