Background Patients with severe mental illness (SMI) require continuity of care. Continuity of care refers to the uninterrupted contact of patients with the service delivery system, and includes three main dimensions: cross-sectional, longitudinal, and relational continuity. Cross-sectional care continuity refers to the provision of comprehensive care during a single episode, longitudinal continuity to the provision of care over time, and relational continuity to the quality of the patient-provider relationship. In Europe, healthcare systems have developed differently from two basic models: national health (NHS) and regulated-market systems (RMS). It is unclear which healthcare system model is more performant in the delivery of continuity of care. Therefore, we examined the care provision, regulation, and financing features in two NHS – England and Veneto (Italy) – and three RMS countries – Germany, Belgium, and Poland –, and assessed empirically the system’s performance in cross-sectional, longitudinal, and relational care continuity.
Methods 6,418 SMI patients were recruited from psychiatric hospitals in the five countries and followed up one year after admission. Data were collected on their use of services and contact with care professionals. Care continuity was assessed using several indicators: the time gap between hospital discharge and outpatient care, access to services, number of contacts with psychiatrists and other care professions, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients‘ characteristics and robust standard errors were computed to account for the clustering effect of the recruiting hospitals.
Results Important differences were found between healthcare systems. NHS countries, particularly Veneto, had more effective longitudinal and cross-sectional care continuity than RMS countries: patients had a longer gap between hospital discharge and outpatient care (RR=1.71, p<0.001), had half the chance to access to supported living (OR=0.54, p<0.05), and to access different professions (RR=0.76, p<0.01). However, Germany had similar results to England, while Poland had lower performance measures, despite a mixed NHS and RMS model. Relational continuity had mixed results, patients being slightly less satisfied in RMS than in NHS countries (RR=0.90, p<0.01) but having a higher helping alliance (RR=1.07, p<0.01).
Conclusion Organisational features have an impact on cross-sectional and longitudinal continuing care delivery. Although the relationship between healthcare provision, regulation, and financing mechanisms, and care continuity is complex to disentangle, stronger regulation of care provision and financing at a local policy level should be considered for care continuity. Yet, relational care continuity seemed less affected by organisational mechanisms.
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