Managing medicines-related continuity of care: the views of a range of prescribers in New Zealand general practice
C. Julie Wells 1 2 * , Lynn McBain 1 , Lesley Gray
1
1
2
Abstract
Continuity of care is considered vital to achieving high-quality health care. Traditionally, general practitioners have played a key role in managing continuity of care and have largely been accountable for prescribing decision-making in primary care. Following prescribing legislation changes, a range of health disciplines make decisions regarding medicines in the general practice setting. To date, few studies have investigated how different prescribing disciplines view the management of medicines-related continuity of care. Understanding the views of these clinicians is important to achieving safe, effective and equitable outcomes from medicines.
The purpose of this study was to explore the views of general practitioners, nurse prescribers and pharmacist prescribers about their role in managing medicines-related continuity of care.
Qualitative, semi-structured in-depth interviews were undertaken with 16 prescribers based in eight North Island (New Zealand) general practices. Interviews were transcribed verbatim and analysed thematically using an inductive approach.
Three key themes were identified from data analysis: a patient-focused approach; interdisciplinary teamwork; and optimising the medicine regimen.
Prescribers in this study identify the important connection between continuity of care and achieving good outcomes from medicines. Good patient–prescriber relationships and ongoing interdisciplinary relationships across all health settings are considered essential to medicines-related continuity of care. Prescribers experience challenges associated with increasing multimorbidity, medicines complexities and fragmentation of clinical records.
Keywords: continuity of care, general practitioners, non-medical prescriber, nursing roles, pharmacy services, prescriber, prescription medications, primary health care.
| WHAT GAP THIS FILLS |
| What is already known: Continuity of care facilitates high-quality care and good patient health outcomes. Prescribing legislation changes in New Zealand (NZ) have resulted in medical and non-medical prescribers prescribing medicines for patients with chronic disease. Previous research has established a correlation between multiple prescribers’ involvement in a single patient’s care, discontinuity and medicines-related risks. |
| What this study adds: Clinical complexities associated with the medicines management of patients with multimorbidity and the current service delivery model are challenging NZ general practice prescribers’ ability to manage continuity of care. There is a need for heightened awareness of the significance of medicines-related continuity of care, so prescribers within and across all health settings are supported to prescribe collaboratively and safely. |
Introduction
Continuity of care, often considered to be the responsibility of general practice teams, is fundamental to high-quality health care.1 Although the literature includes a variety of definitions of the term ‘continuity of care’,2–4 this paper will use the definition suggested by Haggerty et al.5 (p. 1221): ‘the degree to which a series of discrete healthcare events is experienced as coherent and connected and consistent with the patient’s needs and personal context’. This definition recognises three dimensions of continuity of care (relational, informational and management), as shown in Fig. 1. In light of an ageing population, increasing multimorbidity and on-going disconcerting health disparities, it is difficult to ignore the importance of understanding how continuity of care from a medicines perspective is managed and maintained.6
In the past, general practitioners (GPs) were largely responsible for medicines-related decision-making in primary care. The last two decades have seen New Zealand (NZ) align with other countries with various prescribing legislative changes.7–9 This has resulted in non-medical prescribers such as nurses and pharmacists prescribing medicines alongside the GP in the general practice setting. Variations exist between these prescribers in scopes of practice, medicines they are authorised to prescribe, and the educational requirements required to gain prescribing rights.10 The benefits of medicine combinations as a medical intervention for chronic disease prevention and management is well known.6,11,12 Yet, there is an urgent need to address avoidable medicines-related harm associated with errors, inappropriate medicine combinations, fragmentation of care and unsafe systems and processes.6,11 A significant challenge for primary care prescribers is to collaboratively support patients to achieve safe and beneficial outcomes from medicines.13,14
The literature acknowledges the importance of continuity of care in patients with multimorbidity.15–17 There is growing concern that these patients are at increased risk of experiencing medicines-related harm because they generally receive care from multiple prescribers, within and across health settings, over time.18–21 Furthermore, there is limited guidance to support prescribers to prescribe medicines safely and appropriately for this patient group.19,22,23
To date, there has been little empirical research on continuity of care as it relates to medicines. Also, there have been relatively few studies since prescribing rights were extended to include non-medical prescribers. The aim of this study was to explore how prescribers based in NZ general practice settings view their role in managing medicines-related continuity of care.
Methods
General practices and prescribers across NZ were approached and provided with information pertaining to this study. All respondents were included in the study. Participants, all from the North Island, were purposefully selected to include a range of professional disciplines with prescribing rights. A qualitative approach using semi-structured in-depth interviews (in-person and via Zoom™ videoconferencing technology), conducted by the lead author, was used. Three broad topic areas were covered: role as a prescriber; medicines-related continuity of care experiences; and views on strategies to improve continuity of care. Interviews were audio-recorded with consent and transcribed by the lead author prior to undertaking a preliminary analysis using an inductive thematic analysis approach.24 The initial themes identified were discussed and final themes were agreed upon by all authors.
This study was approved by the University of Otago Human Ethics Committee (Reference Number H19/133). Research consultation with Māori took place through the University of Otago Ngāi Tahu research consultation committee.
Results
Participants
Eight general practices located across four geographical regions in the North Island NZ agreed to participate, as shown in Table 1 below. Sixteen participants from within these practices were recruited and included seven general practitioners (GPs), four pharmacist prescribers (PPs), and five nurse prescribers (NPrs), which includes four nurse practitioners and one registered nurse with prescribing rights.A Table 2 presents the professional discipline and the number of years of prescribing experience for participants.
| Location (region) | Rural/urban classification | Enrolled population size | ||||
|---|---|---|---|---|---|---|
| Bay of Plenty | 1 | Rural | 2 | <5000 | 1 | |
| Waikato | 1 | Urban | 6 | 5000–10,000 | 2 | |
| Manawatu/Whanganui | 5 | 10,000–20,000 | 3 | |||
| Wellington | 1 | >20,000 | 2 | |||
| Professional discipline A | Prescribing experience (years) | |||
|---|---|---|---|---|
| General practitioner (GP) | 7 | <5 | 4 | |
| Nurse prescriber (NPr) | 5 | 5–10 | 4 | |
| Pharmacist prescriber (PP) | 4 | 11–20 | 1 | |
| 21–30 | 2 | |||
| 31–40 | 3 | |||
| 41–50 | 1 | |||
| Not provided | 1 | |||
Participants included in the study had a range of age, gender and prescribing experience, shown in Table 2 and Table 3.
Themes
Three main themes were identified from analysis of the data: patient-focused approach; interdisciplinary teamwork; and optimising the patient’s medicine regime. Table 4 provides an overview of the sub-themes associated with each main theme. These are described in more detail below, with illustrative quotations.
| Theme one: patient-focussed approach | Theme two: interdisciplinary teamwork | Theme three: optimising the patient’s medicine regimen | |
|---|---|---|---|
| Knowing and understanding the patient’s needs | Model of care | The patient’s clinical record | |
| Engaging and supporting the patient to understand their medicines | Building relationships between prescribers and combining knowledge and expertise | Medicines-related care over time | |
| Co-ordination of clinical care | Verbal communication between prescribers | Responsibility for decisions relating to medicines |
A patient-focused approach was a strong theme among participants, ranging from knowing and understanding the patient’s needs, engaging with, and supporting patients’ understanding of their medicines, to co-ordination of the patient’s clinical care. Various problems associated with chronic disease medicines management were described. Many participants acknowledged that patients, particularly from vulnerable populations, frequently experience more than one health condition, which complicates clinical decision-making.
Long-term conditions now come in a packet…very rarely, especially in high-needs population [would you find only one condition]. (NPr4)
Concerns were expressed about the impact health inequities and social challenges have on achieving optimal medicines-related outcomes. Participants frequently identified the individuality of patients, the wide variation in their health needs, and the various barriers in accessing care, such as financial difficulties. There were instances described where patients only sought help when acutely unwell, delaying the opportunity to introduce appropriate medicines for chronic disease prevention.
Many participants reflected on the value of knowing the patient and forming long-term relationships, with some feeling these relationships were vital to managing continuity of care. Others believed the patient–prescriber relationship was an important part of why they work in general practice.
It's not just about the same person it’s that person who knows them and their family…and what supports they have or don’t have. (NPr2)
That's actually part of general practice that’s very important to me…I think that relationship with the patient in terms of looking after their health care in general is hugely important. (GP7)
Many participants felt that good relationships assist in developing trust with the patient, which they believe is crucial to understanding a patient’s medicines-related needs.
Once you build the relationship, they’re much more likely to actually take the medicines you’re recommending. (NPr4)
Some participants mentioned the variation in personalities and style of practice that exists between prescribers. They felt it was important to be mindful of patient preferences, as some patients may engage more effectively with a particular prescriber. Others suggested multiple prescriber involvement may not suit all patients. Concerns were expressed about the risk of mixed messaging and unnecessary confusion experienced by patients when medicines are prescribed by more than one prescriber, especially if the patient experiences health literacy challenges. Participants agreed that consistency in the patient–prescriber relationship facilitates improved understanding of patient-related requirements and avoids the need for a patient to repeat their story or answer unnecessary questions.
Participants agreed that a team approach to health care is essential to manage the increasing pressures experienced by general practice staff. Although some participants felt they were more able to cope with a growing workload by sharing it, others suggested that delivering health services differently may provide better quality and more appropriate care to some patients.
…the demands are huge on us as GPs…it’s a team effort to look after people in the 21st century. (GP4)
I think that to reduce inequity we need to deliver services differently …say a different model of care. (PP4)
…having more than one prescriber involved…it does mean that…we can share the load. (NPr1)
A few participants questioned the term ‘continuity of care’. They felt that it lacks clarity now that a team approach to health care exists.
…when you talk about continuity of care, what actually does that mean?…It means a lot of different things for a lot of different people, so we almost need a bit of clarity around what that means. (NPr4)
Despite this, most participants agreed that better connections between health disciplines across all health settings was vital to managing continuity of care and improving patient safety. Generally, participants felt more confident prescribing with others they knew. However, concerns were expressed about a lack of appreciation by secondary care clinicians of the clinical expertise required by general practice prescribers, when managing medicines in patients with complex health needs.
Several participants identified the significance of trust and goodwill between prescribers, particularly when prescribing for the same patient or when continuing medicines previously commenced by others. Most participants felt that an interdisciplinary team approach to prescribing provides better patient care because it incorporates different perspectives and expertise, provides an opportunity to share knowledge and challenge one another, and provides different options to deal with sometimes quite complicated decision-making, particularly in patients with multimorbidity.
…and there’s other advantages…you’re getting different pairs of eyes with new knowledge or…different expertise. (GP6)
The unique skills and expertise of non-medical prescribers were acknowledged by many participants. Pharmacists and nurses felt that the ability to prescribe medicines enabled them to provide more streamlined, cost-efficient care because the patient did not need to return to the GP for a prescription for their ongoing medicines.
[Prior to gaining prescribing rights] I was seeing patients to talk to them about their medicines…making a list of…recommendations… meaning the patient was having to come back and see their GP…and incur further costs and time to do that PP2
However, a few non-medical prescribers interviewed felt they were not always accepted by GPs and sometimes had to prove themselves. Concerns were also expressed about a lack of clarity regarding individual roles and expectations of prescribers when different disciplines prescribe concurrently. It was felt that this impacts on managing continuity of care.
Variations in prescribing practice between prescribers was a concern expressed by many participants. There was general agreement that consistency in decision-making is important especially when prescribing medicines concurrently for a patient. Participants discussed the difficulties experienced when some prescribers are more casual than others or have differing opinions about a patient’s on-going care.
To improve consistency in decision-making, regular communication between prescribers, either formally or informally, was considered essential by participants. Several stressed the importance of avoiding unnecessary confusion and error by talking with one another about proposed medicine changes or specific treatment plans, particularly when dealing with complex medicine regimens. Participants thought the physical environment they worked in either enhanced or inhibited good communication. Some felt that being geographically situated in close proximity to others encouraged casual or impromptu conversations, whereas others described purpose-built general practices where shared spaces were available for discussion and collaboration.
Participants were unanimous in the view that the patient’s general practice clinical record supports information exchange between prescribers in the general practice setting. A common view, particularly when multiple prescribers are involved in a single patient’s care, was that a shared clinical record was vital for on-going safe clinical decision-making, and allows for information continuity.
…that’s the only way this can work if you see somebody else’s patient or somebody else see[s] my patient that they have full access to all my clinical notes and prescribing. (GP4)
However, concerns were expressed about the clarity and accuracy of information in the clinical record when multiple people are contributing to it over time. Some participants believed documentation should include the clinical reasoning associated with prescribing decisions. Others emphasised the importance of consistency in how and what prescribers document. Various situations were described where unnecessary complications, confusion and errors occurred because medicines-related information was inaccurate, unclear or difficult to retrieve. This was particularly evident when participants discussed the challenges associated with ‘repeat prescribing’.
…unless the GP is really on to watching the repeat prescription requests…it’s really easy…to continue with medicines that were intended to be stopped. (PP3)
Participants were particularly critical of the lack of integration between the general practice clinical record and records in other health settings, particularly hospital and specialist services. There was general agreement that patients transition between these services regularly, resulting in unnecessary risks when prescribers, regardless of the setting they are in, are unable to access a patient’s complete, up-to-date and accurate medicine record.
On-going and sometimes complex decision-making associated with chronic disease care was considered an important source of discontinuity and clinical risk. Participants used terms such as ‘reviewing’, ‘following up’, ‘delegating’ to describe the continuous, ever-changing nature of medicines management. Monitoring a patient’s response to medicines over time was considered vital; however, participants encountered challenges when dealing with certain medicines or when patients were not seen regularly.
…people going on leave and leaving people who are needing warfarin dosing…no-one’s picking up the blood test because it hasn’t been handed over to anyone…the patient gets confused…warfarin can be a real problem. (GP3)
I think of the young men in their late thirties…they may have hypertension and we’re talking about being on a medication long-term…some of those people we catch up with…every year or two when they present for an acute problem…we have some gaps in that follow up and continuity of care. (NPr3)
There were a variety of opinions concerning responsibility for medicines-related decision-making. Generally, participants felt the GP was responsible for ensuring a patient’s entire medicine regimen is safe and effective when more than one prescriber is involved. Although some participants associated responsibility only with the process of writing a prescription, others felt responsible for ensuring appropriate processes were in place for on-going medicines monitoring and patient follow-up.
I mean she accepts responsibility for her practice…but the overall responsibility stays mine. (GP4)
I feel responsible for my own prescribing…but if you’re talking about a patient…who's responsible for that patient’s prescribing…people would say the GP…but…if someone else then comes along and looks at…their medicines and thinks…that’s not evidenced based or that’s contributing to this…then it becomes my responsibility to kind of do something about that. (NPr4)
Discussion
This is believed to be the first qualitative study to specifically explore medicines-related continuity of care in general practice, from the perspective of different prescribing disciplines. The findings are consistent with work on continuity of care more generally that suggests the importance of developing trusting and respectful relationships with patients.2,5,25 Participants in this study considered that good relationships between prescriber and patient were important for on-going decision-making because they facilitated better understanding of a patient’s social and clinical needs, and provided valuable insight into reasons why a patient may require more support to understand and to use medicines appropriately. This was considered especially important when clinicians unknown to the patient become involved. These findings have important implications now that non-medical prescribers are prescribing alongside GPs. Previous studies show that patients are more confident engaging with unfamiliar clinicians if referred by one they trust, who knows and understands their clinical history and on-going clinical needs.5 The findings align with recent research that suggests vulnerable people are more likely to engage, ask questions and learn about the benefits of medicines, if provided with the opportunity to communicate with someone they know and trust.26
Participants raised concerns about complexities associated with medicines-related decision-making in patients with multimorbidity, particularly when many prescribers are involved over time. Previous research suggests that patients with multimorbidity regularly experience care from different prescribers across all health settings.17,27–29 This influences the ability to maintain good patient–prescriber relationships and deliver on-going safe and coordinated medicines-related care.19,29 The findings align with research indicating that the use of single-disease clinical guidelines challenges the concept of continuity of care in these patients21 and increases the likelihood of inappropriate medicines combinations, over time.19,23,27,30 Now that a range of disciplines with various scopes of practice are prescribing medicines in general practice, the challenge will be to maintain relational continuity of care, reduce fragmentation of care and provide patients with a prescribing team who have the right expertise and experience to safely manage medicines in ways that are adapted to suit an individual patient’s needs.
There was a lack of clarity around prescriber responsibility for medicines-related decision-making when a range of prescribers are involved in a single patient’s care over time. The findings in this study suggest the GP is largely considered responsible for clinical oversight of a patient’s entire medicine regimen, but a wide variation in opinions about personal responsibility when prescribing for patients was revealed. The legislative differences in prescribing rights of prescribers in this study could explain the wide variation in views on responsibility and are consistent with other research that found when prescribing as part of a team, responsibility is viewed as ‘shared’ or ‘partial’ and depends on prescribers’ competencies and experience.31 This has important implications for continuity of care now that different disciplines with different legislative responsibilities are making clinical decisions together.
Concerns were expressed about a general lack of awareness about the variations in prescribing rights and legal obligations that exist between prescribers from different disciplines in NZ. It is important the variations in scope of practice and skill sets of all prescribers are well understood and recognised by GPs and general practice leadership teams. Previous studies have confirmed the importance of role clarity and having clear understanding about individual responsibilities and competencies when different disciplines are prescribing together.32,33
Overall, GPs in this study valued the input of the non-medical prescribing workforce. There was general agreement that these prescribers assist in sharing the workload and can provide different options to manage some patients more effectively. But participants considered good relationships and regular communication and collaboration between prescribers (including those in other settings) was necessary to build confidence in each other’s knowledge and practising ability and enable a shared understanding about how best to clinically manage a patient over time. Continued efforts are required to encourage good communication between prescribers either in-person, via the general practice patient management system (PMS), or by using other electronic communication systems.
Participants in this study considered the importance of the patient’s clinical record when exchanging medicines-related information between prescribers. Concerns were revealed about difficulties associated with maintaining an accurate record, particularly as different prescribers contribute to it, over time. Participants described situations, especially when repeating medicines for patients’ unknown to them, where unnecessary confusion and unsafe decision-making occurred if the clinical record was not up to date. The study findings align with previous research that suggests the patients’ clinical record is pivotal to managing informational continuity of care.34
A significant concern raised by participants was the lack of an integrated medicines-related clinical record between health sectors. The findings align with studies that suggest patients with co-morbidities are most at risk of adverse medicine events when transitioning between general practice and hospital.16,35 Previous research confirms that accurate clinical information exchange across all health sectors supports prescribers in safe decision-making and is important when considering the informational and management aspects of continuity of care.36,37 Continued efforts are required nationally to develop integrated medicines-related technology within and between health sectors to support prescribers to exchange and have access to accurate and timely medicines-related information.
Strengths and limitations
A strength of this study was the richness and depth of data provided by 16 participants from a range of health disciplines, all with varying experience, knowledge and viewpoints. A strength of the research team was the different disciplines working together (a pharmacist, general practitioner and public health specialist), bringing different perspectives to the study analysis and interpretation of data.
Prescribers working in general practice settings across all of NZ were sought, although successful recruitment only included those from rural and urban North Island practices. Importantly, the absence of a perspective from Māori providers or participants of Māori descent is acknowledged. Participants from general practices with predominantly Māori and/or lower socioeconomic patient populations were included, although future research around medicines-related continuity of care particular to Māori populations is required. This study included only one registered nurse prescriber, which made it difficult to draw any conclusions particular to registered nurse prescribers, and most of the analysis regarding NPrs refers to nurse practitioners.
As this study focused on prescribers in the general practice setting, the perspectives of prescribers in other settings such as hospital and specialist health services were not sought.
Conclusion
When managing continuity of care, general practice prescribers are challenged by increasing multimorbidity, increasing medicines-related complexities and the non-integration of clinical records between health settings. Now that a range of health disciplines are prescribing medicines concurrently in general practice, more efforts are needed to understand how prescribers with various scopes of practice can work collaboratively to support safe, effective and equitable outcomes from medicines. Greater emphasis is required on developing good relationships with patients, improved interdisciplinary working relationships, and consistent and accurate exchange of medicines-related information, within and across all health settings.
Acknowledgements
The authors would like to thank the general practices and individual participants in this study. During a period of extreme and ongoing difficulties due to the COVID-19 pandemic, your enthusiasm to be involved was evident and encouraging. Thanks also to Donna Tietjens (University of Otago Wellington) who assisted with literature searching.
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Footnotes
A In the results, participants affiliation to a professional discipline are identified by the following letters: GP (general practitioner); PP (pharmacist prescriber) and NPr (nurse prescriber). Nurse practitioner and registered nurse prescriber data have not been separated out given the low number of registered nurse prescribers interviewed and the possibility for participants to be identified.
