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What are the essentials in continuity of care on the chronic care trajectory for patients and family carers?


Linda Ljungholm ,

Department of health and caring sciences, Linnaeus University, Sweden, SE
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Charlotte Klinga,

Department of health and caring sciences, Linnaeus University, Sweden Department of Learning,Inforamtics, Management and Ethics (LIME), Karolinska Institutet, SE
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Anette Edin-Liljegren

Department of Learning,Inforamtics, Management and Ethics (LIME), Karolinska Institutet Department of Nursing, Umeå University, SE
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Introduction: Continuity of care is the hallmark of high quality in primary care. There is no consensus regarding how continuity should be defined, but at least three specific domains are described in the literature: relational, management and informational continuity. Research has primarily focused on relational continuity, i.e. meeting the same physician or other professional over time. High relational continuity has been associated with better health outcomes, lower mortality rates and healthcare consumption (1). People with chronic diseases need care that is coordinated and aligned with personal needs. However, the experiences of continuity among care recipients are poorly understood. 

Aim and Methods: The aim of this study was to explore essential aspects of continuity of care from the perspective of people with complex care needs and family carers. Sixteen patients with chronic diseases and twelve family carers from rural and urban areas in three separate regions in the south, middle, and north of Sweden were interviewed. The semi-structured interviews were analysed using constructivist grounded theory (GT). GT was chosen to allow for gathering and analysing rich data in interaction with the informants and constructing a conceptual understanding of data generated through a bottom-up perspective (2).

Results: Six interconnected categories constructed a conceptual model of continuity of care where the core category, time and space, linked the categories together. Tailored information about the patient’s past, present and future needs to be available and follow the patient care chain, regardless of whom is performing care. Mutual understanding about the patient’s needs facilitate tailoring information and co-create a trusting relationship in partnership with patients and family carers. Developing a trusting relationship requires meeting the same physician over time, although this varies depending on the medical and psychosocial situation, personal resources, and the care context. Clear roles and responsibilities, and multi-professional collaborations across organizations were important as the patients’ complex situations often required multiple competencies.  The categories work in synergy, not in isolation and the importance of each category varies between individuals, and across time and space, depending on each individual’s needs and resources.

Conclusions: Continuity of care was characterised by a holistic view of a person’s past, present and future, and personalized, timely care delivery at the right space. Continuity was perceived ‘here and now’ in the actual care situation, as well as through sustained relationships and interprofessional collaborations across different contexts over time.

Implications: The results provide insights into aspects that are essential to achieve continuity of care for people with complex care needs, which can be used for developing policies and guidelines for integrated care and for evaluating the quality of care from patients’ and family carers’ perspectives.

Keywords: continuity of care, older adults, complex care needs, chronic diseases, primary care


1.Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6):e021161.

2.Charmaz. Constructing grounded theory. Apractical guide thorugh qualitative analysis. London: Sage; 2006. 


How to Cite: Ljungholm L, Klinga C, Edin-Liljegren A. What are the essentials in continuity of care on the chronic care trajectory for patients and family carers?. International Journal of Integrated Care. 2022;22(S3):268. DOI:
Published on 04 Nov 2022.


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