Discharging the complex patient - changing our focus to patients’ networks of care providers

Fig. 1. Patient Network of Care Diagram. A diagram such as this one was created for each study participant using information gained from the bedside interview. If a main care provider could be identified, they were displayed on the network diagram in red. For formally rostered patients, it was not assumed that the main care provider was their FP. Instead, the main care provider was the one the participants saw as the key care figure in their everyday life, or the one providing services of greatest importance to them. Distances from the patient to the provider were used as representations for the frequency of appointments with the provider. These were estimated based on direct questions about how frequently each provider was seen. A similar logic was used to dictate the size of the box for each provider, representing the relative importance of the provider to the patient and their network of care. Lines were used to connect patients to providers and providers to providers. Solid lines indicated relationships between patients and providers that had a personal dimension to them (patient and provider knew one another). In contrast, dashed lines between patients and providers indicated the…

Fig. 2a. Participant 21. The FP is heavily involved in patient care, acting as the main care provider within this network. Involvement of specialists and a social worker arose from referrals made by the FP, who remains informed about care received from these other providers longitudinally. The cardiologist involvement, in particular, is recent and reflects the FP’s effectiveness in bringing another provider into the network for a new health problem (pulmonary hypertension)

Fig. 2b. Participant 25. The FP operates out of a teaching clinic, where the patient may see a resident, clerk or nurse practitioner at any given appointment (unless they request to see the FP, in which case they must wait weeks). While there are no issues regarding formal communication and relay of visit notes between the clinic and the patient’s specialists, the patient is not clear about who is to provide their main COPD care: their respirologist or FP. The patient feels that not being able to see the FP themselves consistently contributes to this lack of clarity. When at their clinic, the most consistent message is to defer to their respirologist for COPD management. By contrast, the respirologist only wants to see them following acute events. This patient has had numerous hospitalizations due to COPD exacerbations, and the hospital has become an important provider in their network of care

Fig. 2c. Participant 15. Following a diagnosis of follicular lymphoma, the previously healthy patient, who only occasionally visited an FP, saw an oncologist become the main care provider and central figure in their network. The oncologist is in regular communication with other providers such as the FP and with a hematologist who was brought into the network and performed an eventual transplant procedure. The oncologist’s temporary role as main care provider was also highlighted by an incident where the patient went to the ED suspecting they had a blood clot. It was this individual that followed up and was in communication with the hospital to determine what had happened

Fig. 2d. Participant 4. This patient sees their nephrologist as their main care provider, despite having an FP and being attached to other specialists who are also seen regularly. The patient feels that this specialist is the most involved in their care. Furthermore, the nephrologist’s work revolves around being informed about care received from the patient’s other physicians (e.g., knowing what medications have been prescribed by the hypertension specialist and ensuring these will not worsen kidney function), reinforcing their role as the most central provider. The FP’s role is limited in this particular network to a very peripheral role, being seen far less frequently than the patient’s other physicians. Of note, the patient feels their network lacks centrality and a true team-based approach