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.
Continuity allows for improved patient care over time with a primary care provider, and for connection across healthcare events and all providers involved in a patient's 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.
Evidence shows that patients who consistently see the same physician use significantly fewer health care services, have better outcomes and lower costs. The higher the level of continuity between physician and patient, the better the clinical care, improved efficiency and patient and physician satisfaction. In addition, the value and essential role of the primary care team to continuity, of which physicians are members of, has been anecdotally and substantively demonstrated.