Can We Conceptualize and Measure Continuity of Care in Individual Episodes? The Case of Mental Health Services in Puerto Rico

Abstract

While continuity of care becomes a more pressing issue given changes in the locus of medical care under reform initiatives, our ability to understand how socio-medical factors shape the continued use of medical care services is limited by current conceptual and measurement tools. In this paper, we reconsider the possibility of measuring continuity of care for individuals during the course of an episode of illness. We recognize the inherent heterogeneity in the notion of "continuity" and suggest that different scenarios produce breaks in the use and delivery of services. We lay out two crucial distinctions. The first targets the type of breaks in continuous care, distinguishing among provider, sector and system continuity. Second, we examine the source of provider continuity, separating breaks in health service use that result from the client's failure to remain in treatment and the health care system's failure to provide for continuous care. We suspect that these scenarios represent different social processes and may be related to varying social, medical and organization factors. We argue that attempts to measure continuity of care must be tailored to both a longitudinal account of an illness episode and the specific nature of health problems. Here, we describe one way to gather data and we present an interview-based module focused on contact with formal practitioners consulted for selfreported mental health problems. Using data from the second wave of the ongoing, longitudinal study, Mental Health Care Utilization Among Puerto Ricans Study (1993-1994, N -3,263), we provide preliminary analyses of the extent and nature of continuity of care among individuals who live in low income areas of the island. We find that this approach is not only possible but feasible given the availability of computer-based algorithms. Just over one third (35.1 percent) of individuals meet criteria for our definition of continuity of care. Most breaks in service use are client-initiated (85.2 percent). We conclude by discussing the role of social scientists in reformulating theories of health care contacts that capture the experience of illness in an era characterized by community-based, managed care.Please address all communications to the first or second authors. We acknowledge support from the National Institute of Mental Health (Research Grants ROI MH42655, R24 MH51669; Research Scientist Development Awards KOl MH00849 and K02 MH012989 to the second author). We would like to thank Marisol Pena and Jose Calderon for their programming aeeietance, and Paul Cleary, Donald Steinwachs and Daniel Freeman for their advice and comments on various versions of this project.

Service Users’ and Caregivers’ Perspectives on Continuity of Care in Out-of-Hours Primary Care

“…Participants in this study perceived the cooperative to be an extension of and replacement for their regular inhours GP service, and they appeared to view consultations in the cooperative through a "temporal window" (Alegria et al, 1997) in their overall care trajectories. Frequently, the symptoms they presented with at the cooperative were described as illness episodes, not stand-alone incidents, and cooperative consultations were perceived as "trajectory sequence points" (Strauss et al, 1985) in users' trajectories.…”

“…It is important to connect details of these users’ and caregivers’ experiences with their expectations of the out-of-hours services, because we know there is a documented relationship between expectations and patient satisfaction with out-of-hours services generally (McKinley et al, 2002). Participants in this study perceived the cooperative to be an extension of and replacement for their regular in-hours GP service, and they appeared to view consultations in the cooperative through a “temporal window” (Alegria et al, 1997) in their overall care trajectories. Frequently, the symptoms they presented with at the cooperative were described as illness episodes, not stand-alone incidents, and cooperative consultations were perceived as “trajectory sequence points” (Strauss et al, 1985) in users’ trajectories.…”

“…In theoretical terms, consultations in the cooperative were perceived by participants as “sequence points” (Strauss et al, 1985) or “episodes of care” (Alegria et al, 1997) in an ongoing illness trajectory. In turn, this had implications for participants’ expectations of continuity of care.…”

“…With some exceptions (e.g., Alegria, Pescosolido, Santos, & Vera, 1997; Allen, Griffiths, & Lyne, 2004; Low, 2004), the vast majority of qualitative studies about continuity of care have been atheoretical, even though the need for social science theory in conceptualizing about experiences of continuity in chronic illness has been highlighted (Diederiks & Bal, 1997; Freeman et al, 2001). Therefore, we employed a medico-sociological model, the Chronic Illness Trajectory Framework (CITF; Strauss, Fagerhaugh, Suczek, & Wiener, 1985) in this study.…”

Contradicciones en Salud Mental: Estigma, Alfabetización en Salud Mental y Revelación (o no) del Diagnóstico de un Desorden Mental.

“…Con esta investigación inicia Pescosolido una larga carrera de investigaciones sobre cómo el estigma asociado a las dolencias mentales media en la percepción que tenemos sobre ellas, pero también en las campañas diseñadas, como veremos, para paliarlo. En años sucesivos publica con otros investigadores artículos y capítulos de libros apoyando esta afirmación (Alegría, Pescosolido, Santos, & Vera, 1997;Pescosolido, 1992bPescosolido, , 1993Pescosolido, , 1996Pescosolido & Boyer, 1999;Pescosolido, Figert, & Lubell, 1996;Pescosolido, Gardner, & Lubell, 1998a;Pescosolido & Kronenfeld, 1995;Pescosolido, Wright, & Sullivan, 1995). Resumimos brevemente las principales aportaciones de este esfuerzo.…”