Continuity of care: validation of a self-report measure to assess client perceptions of mental health service delivery.

The psychometric characteristics of an instrument to assess perceived continuity of care among mental health patients were examined. 441 adults with severe and persistent mental illness were recruited from 70 inpatient, outpatient, emergency and community treatment programs (n = 259 females; M age = 42.5, SD = 10.3 years) in Alberta, Canada. Respondents completed a 43-item self-report questionnaire to rate perceived continuity. Item quality was assessed by examining missing data and frequency distributions. In a randomly selected subsample (n = 171), exploratory factor analysis identified 3 dimensions: (1) perceived attentiveness to individual needs or changes in illness or life circumstances (Individualized Care; alpha = .64); (2) perceptions of a coherent system characterized by good communication between providers (Responsive System; alpha = .71); and (3) perceived responsiveness on the part of a primary provider (Responsive Caregiver; alpha = .52). In a second random subsample (n = 181), confirmatory factor analysis provided support for this 3-factor structure and the inclusion of a second-order "continuity" factor (alpha = .72), and informed further item reduction. Split-half reliability for the second-order factor was calculated. Associations between the factors and "objective" measures of continuity, as well as relevant clinical, quality of life, and service satisfaction variables, are reported. Use of the measure for clinical and research purposes and its limitations are considered.

Continuity of care and health outcomes among persons with severe mental illness.

OBJECTIVES: Continuity of care is considered to be essential to the effective treatment of persons with severe mental illness, yet evidence to support the association between continuity and outcomes is sparse because of a lack of longitudinal studies and of comprehensive continuity measures. The purpose of this study was to examine the relationship between continuity of care and outcomes. METHODS: A new multilevel measure of service continuity, the Alberta Continuity of Services Scale for Mental Health (ACSS-MH), was used in a 17-month follow-up study of 486 adults with severe mental illness in three health regions of Alberta, Canada. RESULTS: Endpoint information was obtained for 411 participants (85 percent). The mean continuity score reported by patients was 131+/-20 out of a possible 185. The mean continuity score as rated by observers was 39+/-10 out of a possible 59. Higher levels of observer-rated continuity were associated with older age, lower annual household income, a diagnosis of psychotic disorder, and no suicidality or alcohol use. Continuity was also significantly associated with a better quality of life at endpoint (generic and disease specific), better community functioning, lower severity of symptoms, and greater service satisfaction. The associations between continuity and quality of life held after adjustment for empirically identified confounders. CONCLUSIONS: Positive relationships between continuity of care and health outcomes among persons with severe mental illness suggest that efforts at improving continuity in and among mental health services are worthwhile.

Continuity of care in mental health services: toward clarifying the construct.

OBJECTIVE: To clarify "continuity of care" (COC), a construct associated with the delivery of services for persons suffering from severe and persistent mental illness (SPMI), with attention to the service recipient's perception of COC. METHOD: The study involved a systematic appraisal of the literature on COC, supplemented by interviews with 36 SPMI patients and their families. Statements highlighting attributes of COC were extracted from both sources. RESULTS: Comments by patients and families corresponded to descriptions of COC in the mental health literature. Attribute classifications by independent teams of judges showed good consistency. The following 4 attribute domains of the COC construct were identified: service delivery, accessibility, relationship base, and individualized care. CONCLUSIONS: Service recipients' perceptions of COC overlapped with representations of the construct in the mental health literature. The qualitative inquiry resulted in a draft, 47-item, self-report questionnaire for use in studies of interventions designed to facilitate COC.

History and measurement of continuity of care in mental health services and evidence of its role in outcomes.

OBJECTIVES: The objective of this study was to provide a brief history of the concept of continuity of care, to update evidence of its association with patient outcomes, and to identify optimal characteristics of a continuity-of-care instrument. METHODS: Articles describing recent (1990 to 2002) empirical work on continuity of care were drawn from a broader set of 305 articles about continuity of care that were obtained from a systematic literature search. RESULTS AND DISCUSSION: The literature shows that ideas about continuity of care have changed in concert with general service delivery changes over the decades. Since 1997, only eight studies have used operationally defined measures either to describe continuity of care in mental health services or to examine the association of continuity of care with outcomes for adults with severe and persistent mental illness. Only three groups of researchers have published articles on development of continuity-of-care measures. CONCLUSIONS: There is little evidence that continuity of care results in better client outcomes, which may be primarily attributable to the underdevelopment of measures. Measurement of continuity of care must become more sophisticated before key questions about the association of continuity of care with outcomes can be examined and before the effectiveness of interventions designed to improve continuity of care can be rigorously evaluated.