Published by: Elsevier
Published by
Keywords
Continuity of care
; Care coordination
; Continuum of care
; Case management
; Adolescents
; Children and youth services
Introduction
Continuity of care is believed to be an important prerequisite and characteristic for providing youth care of high quality (Holland, Faulkner, & Perez-del-Aguila, 2005). One of the arguments to reorganize youth care systems is often to improve continuity of care (Stroul et al., 1998, Vanderplasschen et al., 2006). Despite a wide range of services, contextual differences and the use of various terms to refer to child and youth services, we will use the term ‘youth care’ consistently throughout this article to refer to all types of planned interventions aimed at improving the living situation of youngsters between 16 and 25 in vulnerable situations. These youngsters often experience multiple and complex problems and need support on various life domains (Fernandes-Alcantara, 2014). They are registered in various services and systems, such as mental health care, child welfare, medical care, educational and juvenile justice systems (Tobon, Reid, & Brown, 2015). Deinstitutionalization in child and youth welfare and protection services from the 1950s onwards, led to the creation of a complex and fragmented system of diverse agencies and service providers, including specific and specialized services for various types of problems. The complexity and fragmentation of professional youth care is recognized as a pertinent problem and an important reason why youngsters drop out of care (De Winter & Noom, 2003).
Continuity of care has been identified as a central feature of youth care services of high quality, and a broad range of interventions have been implemented to improve continuity of care, such as case management, care coordination, wraparound care, transitional care, critical time intervention or integrated care, in particular to serve hard-to-reach populations and youngsters experiencing problems on different life domains (Cortis, 2012, Ungar et al., 2014). Despite the increasing focus on continuity of care, the concept is poorly defined and not universally understood, resulting in divergent practices (Heaton, Corden, & Parker, 2012). A comprehensive review of continuity of health care demonstrated clear conceptual changes over time and its entanglement with related concepts like coordination of care, integrated care, client-centered care and case management (Uijen, Schers, Schellevis, & van den Bosch, 2012). The concept is also closely related to specific themes in youth care research like accessibility (Ådnanes & Steihaug, 2013) and transitions within and out of youth care (McNicholas et al., 2015, Rachas et al., 2016). Continuity of care appears to be particularly important in the provision of youth services due to the specific transitions in adolescents' care trajectories and interrelation between the problems they experience (Fernandes-Alcantara, 2014). Within specific areas that provide support for children and youth such as foster care, child and adolescent mental health care and the juvenile justice system, the importance of continuity of care is acknowledged, mainly as an a priori understood concept and prerequisite for quality care. However, in their review of continuity and related concepts Uijen et al. (2012) criticize the limitations of research looking only from a partial conceptual framework.
In other domains, the concept of continuity of care has been studied longer and more intensively, resulting in established conceptual frameworks and theoretical approaches. A frequently cited model in general practice is the one originating from the work of Freeman and colleagues (Freeman, Shepperd, Robinson, Ehrich, & Richards, 2001), which was later updated in publications by Haggerty (Haggerty et al., 2003) and Freeman (Freeman and Hughes, 2010, Freeman et al., 2007), leading to a model that differentiates between three generic dimensions of continuity of care: relational, management and informational continuity.
Relational continuity is about the relationship between care provider and service user. It is – or should be – characterized by a long-standing and personal caring relation over a longer period of time. Relationship continuity can be seen as the ‘glue’ between past, present and future care. The aim is to provide service users a sense of predictability and coherence of support. In short, it has been described as “a continuous therapeutic relationship with a clinician” (Freeman & Hughes, 2010, p. 4).
Management continuity focuses on flexible and seamless care across the boundaries of single service providers. Managerial continuity is often linked to chronic and complex disorders, and focuses on the management aspects of care provision. From this perspective, continuity is achieved when services are provided in a complementary and timely manner. Management continuity also concerns the consistency of treatment by sharing clinical information and information on treatment planning and coordination of care (Freeman & Hughes, 2010).
Informational continuity encompasses assessment of clients' needs, problems and assets and gives insight in previous care episodes, persons' values and context. The focus can be on either the diagnosis or the person. A differentiation can be made between information documented in treatment plans, which tends to focus on individuals' specific problems and support needs, and informally accumulated information by practitioners who interact with clients and get to know their preferences, values and context (Freeman and Hughes, 2010, Reid et al., 2002).
If these distinct dimensions of continuity are provided, individuals should experience continuity of care in contacts with service providers. The experience of continuity by service users themselves, is a cornerstone, defined as “the experience of a coordinated and smooth progression of care from the patients' point of view (experienced continuity)” (Freeman et al., 2001; p. 7). Experienced continuity is related to how well services perform on specific dimensions that contribute to the subjective perception of continuity of care (Heaton et al., 2012). According to Haggerty et al. (2003), continuity of care is about whether a client experiences care over time as coherent and connected. This experience seems to be the result of a satisfactory information flow, positive interpersonal skills, and expert coordination of care. Research also showed the importance of the paradigm of care (e.g. diagnostic/disease model vs. person-centered/strengths-based approaches) as a potential mediator of the operationalization of these dimensions of continuity of care (Reid et al., 2002).
While these different dimensions of continuity of care are well-documented for primary care, family medicine and mental health care, relatively few studies have focused on continuity in youth care as a central theme. Consequently, the aim of this study is to explore the concept of continuity of care and how it is operationalized in youth services, based on a systematic review of available peer-reviewed literature on this topic. Two core research questions will be addressed: (1) What are constitutive elements of continuity in youth care and how are these elements operationalized? (2) What are the benefits and barriers of implementation of continuity of care in youth care? The presented dimensions of continuity will be used to frame these questions (Freeman & Hughes, 2010).
Section snippets
Method
A systematic literature search was performed using following databases: ISI Web of Science, PubMed, ProQuest, ERIC, APA PsychNET and Elsevier Science Direct. We looked for studies published between 1990 and 2016 about youth care services and interventions focusing on ‘continuity of care’ and related concepts such as ‘coordination of care’ and ‘case management’ (see Fig. 1: Selection Flow Chart). Title and abstract were searched with following key words: “youth”, “youngsters”, “adolescents” AND
Study characteristics
Table 1 provides an overview of the 28 included studies, highlighting the country, study design, aim of the study, study informants and setting/care system for each study (see Table 1). Our search strategy resulted in a wide variety of articles, since continuity of care was mentioned in various ways in the selected articles. Continuity could be a central aspect of the research question or the studied intervention or program, or rather be a conclusion regarding a specific intervention. Since
Discussion
Based on this review of 28 studies on continuity of youth care, we conclude that this theme has seldom been the central focus in youth care research. Applying the model by Freeman and Hughes (2010), initially developed in general practice, proved to be effective to screen the literature and to uncover how continuity is conceptualized in youth care research. As this model incorporates various dimensions of continuity of care (management, relational, information and experienced continuity), it
Conclusion
This systematic review of 28 studies regarding continuity of youth care shows a fragmented research area with different and sometimes vague definitions of continuity of care. This results in a partial operationalisation of the different dimensions of continuity. The focus in most publications is on management continuity, while other dimensions of continuity are underrepresented in youth research. The application of an integrated model of continuity of care, in which different dimensions of
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- This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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- The authors declare that there is no conflict of interest.