Research and project details

sEffective integration of care between community (primary) and hospital care (secondary) services is essential for a patient whose needs extend beyond the initial episode, and continuity of care is required by the next level of provider.  

This may include referral to a hospital if a primary care doctor alone cannot manage the condition or the continuation of medication and check-ups in the primary care setting or outpatients of the hospital after a hospital admission.

Clinical handover at different levels of care

emergency chart

At its most basic level, ‘integrated or continuity of healthcare’ consists of communication and coordination of care across different services and levels of care; transfer of patient-specific information from one healthcare provider to another and to the patient/family.  It puts patients at the centre of both the design and delivery of care and meets their needs through apparently seamless, efficient and effective services.  Integration and continuity of care begin with the crucial stage of information exchange about the patient’s current medical condition(s) and required care, termed “clinical handover”.  

This should also include the patient and their family carers as they often need to care for the patient on a daily basis and regularly have to make complex decisions about self-care.  Clinical handover and subsequent continuity of care can occur at several levels:

  1. from primary to secondary care;
  2. from secondary to primary care and to other community or social services;
  3. from secondary to secondary care;
  4. within a hospital or care institution.

What are the consequences of ineffective Clinical Handover? 

There are many implications of poor clinical handover and they all apply at different levels of care.

  1. Delays in making medical diagnosis
  2. Incorrect treatment given to patients
  3. Adverse events including disability and death
  4. More readmissions to hospital
  5. Prolonged stay in hospital
  6. Loss of confidence in healthcare provision and decreased service satisfaction, resulting in increased levels of complaints and litigation
  7. Inadequate patient-centred care with low self-management ability for patients
  8. Increases health care expenditure for health system and patients

Poor clinical handover particularly effects discharge follow-up which is required for long-term conditions and surgical cases. Once the patients have been discharged, if poorly managed and follow-up instructions are not adhered to, they can fall through the net leading to adverse conditions at home requiring readmission. This leads to crisis complications, worsens prognosis and puts an unnecessary increased pressure on already scarce resources.

Definition of Primary and Secondary care

Primary care

Activity of a healthcare provider who acts as a first point of consultation for all patients. Generally, primary care practitioners are based in the community, as opposed to the hospital and refer to specialists in hospital or outpatient clinics for more complex or inpatient care. These can be called General Practitioners (GPs), Family Doctors or local doctors etc.

Hospital care (Secondary or Tertiary healthcare)

Hospitals usually provide inpatient and outpatient services delivered by medical specialists who generally do not have first contact with patients, e.g. cardiologists, urologists and dermatologists.

A tertiary health centre provides specialised consultative care, usually on referral from primary or secondary medical care personnel, by specialists working in a centre that has facilities for special investigation and treatment.  Examples include: specialist cancer care, neurosurgery (brain surgery), burns care and plastic surgery. Many tertiary centres also provide secondary care too for their immediate catchment area population.

Where primary care is still developing or there is no integration between primary and specialist care services, patients may self-refer to secondary or tertiary care providers for specialist health care needs or use them as primary care providers. India is currently in such a situation.