scholarly journals Closing the communication Loop: a hybrid mixed methods implementation study of a clinical communication tool for team-based care (Preprint)

2020 ◽  
Author(s):  
Amna Husain ◽  
Eyal Cohen ◽  
Raluca Dubrowski ◽  
Trevor Jamieson ◽  
Allison Kurahashi ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Continuity Of Care ◽  
Implementation Research ◽  
Asynchronous Communication ◽  
Barriers And Facilitators ◽  
Relative Advantage ◽  
Care Providers ◽  
Clinical Communication ◽  
Circle Of Care ◽  
Team Based Care

BACKGROUND Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and healthcare providers often experience poor communication and fragmented care [1,2]. Through a sequential program of research, the Loop Research Collaborative developed a web-based clinical communication system for team-based care. Loop assembles the circle of care centred on a patient, in private networking spaces called Patient Loops. The patient, and/or their caregiver, is part of the Patient Loop. The communication is threaded; it can be filtered and sorted in multiple ways; it is securely stored and can be exported for upload to a medical record. OBJECTIVE The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research. METHODS The study was a Hybrid Type II mixed methods design to simultaneously evaluate Loop’s clinical and implementation effectiveness, and implementation barriers and facilitators in six healthcare sites. Data included monthly user check-in interviews and bi-monthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework of Implementation Research (CFIR) and Loop usage extracted directly from the Loop system. RESULTS We recruited 25 initiating healthcare professionals (iHCPs) across six sites who then identified patients and/or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers (HCPs) consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 with a range of 0-28. The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital EMRs and patient portals were barriers to its adoption. While participants acknowledged Loop’s potential value for engaging the patient and caregiver, and for improving communication within the patient’s circle of care, Loop’s relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care. CONCLUSIONS Fundamental structural and implementation challenges persist toward realizing Loop’s potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for healthcare provider compensation for asynchronous communication.

scholarly journals The barriers and facilitators to implementing dementia education and training in health and social care services: a mixed-methods study

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Claire A. Surr ◽  
Sahdia Parveen ◽  
Sarah J. Smith ◽  
Michelle Drury ◽  
Cara Sass ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Behaviour Change ◽  
Social Care ◽  
Education And Training ◽  
Barriers And Facilitators ◽  
Care Providers ◽  
Care Services ◽  
Health And Social Care ◽  
And Training ◽  
Dementia Education

Abstract Background The health and social care workforce requires access to appropriate education and training to provide quality care for people with dementia. Success of a training programme depends on staff ability to put their learning into practice through behaviour change. This study aimed to investigate the barriers and facilitators to implementation of dementia education and training in health and social care services using the Theoretical Domains Framework (TDF) and COM-B model of behaviour change. Methods A mixed-methods design. Participants were dementia training leads, training facilitators, managers and staff who had attended training who worked in UK care homes, acute hospitals, mental health services and primary care settings. Methods were an online audit of care and training providers, online survey of trained staff and individual/group interviews with organisational training leads, training facilitators, staff who had attended dementia training and managers. Data were analysed using descriptive statistics and thematic template analysis. Results Barriers and facilitators were analysed according the COM-B domains. “Capability” factors were not perceived as a significant barrier to training implementation. Factors which supported staff capability included the use of interactive face-to-face training, and training that was relevant to their role. Factors that increased staff “motivation” included skilled facilitation of training, trainees’ desire to learn and the provision of incentives (e.g. attendance during paid working hours, badges/certifications). “Opportunity” factors were most prevalent with lack of resources (time, financial, staffing and environmental) being the biggest perceived barrier to training implementation. The presence or not of external support from families and internal factors such as the organisational culture and its supportiveness of good dementia care and training implementation were also influential. Conclusions A wide range of factors may present as barriers to or facilitators of dementia training implementation and behaviour change for staff. These should be considered by health and social care providers in the context of dementia training design and delivery in order to maximise potential for implementation.

scholarly journals Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR)

2019 ◽  
Author(s):  
Martin Muddu ◽  
Andrew K. Tusubira ◽  
Brenda Nakirya ◽  
Rita Nalwoga ◽  
Fred C. Semitala ◽  
...  
Keyword(s):  
Health Care ◽  
Health System ◽  
Health Care Providers ◽  
Implementation Research ◽  
Barriers And Facilitators ◽  
Health System Strengthening ◽  
Prior Work ◽  
Care Providers ◽  
Inner Setting ◽  
Hiv Integration

AbstractBackgroundPersons Living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to, and facilitators of, integrating HTN screening and treatment into HIV clinics in Eastern Uganda.MethodsWe conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews with health services managers, health care providers and hypertensive PLHIV (n=83). Interviews were transcribed verbatim. Three qualitative researchers used both deductive (CFIR model-driven) and inductive (open coding) methods to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration.ResultsOf the 39 CFIR constructs assessed, 17 were relevant to either barriers or facilitators to HTN/HIV integration. Six constructs strongly distinguished performance and were barriers, three of which were in the Inner setting (Organizational Incentives & Rewards, Available Resources, Access to Knowledge & Information); two in Characteristics of individuals (Knowledge & Beliefs about the Intervention and Self-efficacy) and one in Intervention characteristics (Design Quality & Packaging). Four additional constructs were weakly distinguishing and negatively influenced HTN/HIV integration. There were four facilitators for HTN/HIV integration related to the intervention (Relative advantage, Adaptability, Complexity and Compatibility). The remaining four constructs negatively influenced HTN/HIV integration but were non-distinguishing.ConclusionUsing the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration in the Inner setting, Outer setting, Characteristics of individuals and implementation Process, HTN/HIV integration is of interest to patients, health care providers and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on the facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.Contribution to the literatureWe used the widely used and validated CFIR to assess the HIV program for HTN/HIV integration.To our knowledge, this is the first study to explore barriers and facilitators to integrating hypertension screening and treatment into HIV clinics using the CFIR.The barriers and facilitators identified are a basis for designing contextualized implementation interventions for HTN/HIV integration in Uganda and other LMIC using a health system strengthening approach.

scholarly journals Implementation of the Human Papillomavirus School-entry Requirement in Puerto Rico: Barriers and Facilitators Using the Consolidated Framework for Implementation Research

2021 ◽  
Author(s):  
Vivian Colón-López ◽  
Roxana Soto-Abreu ◽  
Diana T. Medina-Laabes ◽  
Olga L. Díaz-Miranda ◽  
Ana P. Ortiz ◽  
...  
Keyword(s):  
Puerto Rico ◽  
Human Papillomavirus ◽  
Implementation Research ◽  
Hpv Vaccine ◽  
Qualitative Interviews ◽  
Healthcare Providers ◽  
Negative Influence ◽  
Barriers And Facilitators ◽  
School Entry ◽  
Relative Advantage

Abstract Background: In 2018, Puerto Rico (PR) enacted a Human papillomavirus (HPV) vaccine school-entry requirement for students ages 11 to 12. Using the Consolidated Framework for Implementation Research (CFIR), we aimed to identify potential barriers and facilitators of this implementation.Methods: We conducted a total of 36 qualitative interviews with key informants who were stakeholders from different organizations (Department of Health, Schools, Healthcare Providers, and Community organizations in favor of the requirement) from July 2018 to January 2020. Three researchers performed the interview guide, data coding, and analysis according to the CFIR framework. We evaluated construct rating variability between the organizations to determine barriers and facilitators. Results: The strongest facilitators determined under the CFIR construct include the stakeholder's awareness of the parent's and student's needs to meet the HPV school-entry requirement. Other facilitators include initiatives for school-entry policies and the relative advantage of this requirement over different strategies. The strongest barriers included the cost for private providers to administer the HPV vaccine, the negative influence of social media about the vaccine, which affected parents' acceptance, and the lack of school nurses as available staff resources for the school entry requirement. Conclusions: Findings from this study can be used to improve implementation (adaptations/modifications) and inform other US states and countries in earlier stages of consideration of the adoption of similar immunization policies. Most barriers can be modifiable with the implementation of educational programs/training across schools, considering that they are the first line of response to parents of this school entry requirement.

scholarly journals Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR)

2020 ◽  
Author(s):  
Martin Muddu ◽  
Andrew K. Tusubira ◽  
Brenda Nakirya ◽  
Rita Nalwoga ◽  
Fred C. Semitala ◽  
...  
Keyword(s):  
Implementation Research ◽  
Self Efficacy ◽  
Healthcare Providers ◽  
Health System Strengthening ◽  
Relative Advantage ◽  
Prior Work ◽  
Care Providers ◽  
Hiv Services ◽  
Increased Risk ◽  
Hiv Integration

Abstract Background: Persons Living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to and facilitators of integrating HTN screening and treatment into HIV clinics in Eastern Uganda. Methods: We conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews and focus group discussions with health services managers, health care providers and hypertensive PLHIV (n=83). Interviews were transcribed verbatim. Three qualitative researchers used the deductive (CFIR-driven) method to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration. Results: Barriers to HTN/HIV integration arose from six CFIR constructs: organizational incentives & rewards, available resources, access to knowledge & information, knowledge & beliefs about the intervention, self-efficacy and planning. The barriers include: lack of functional BP machines, inadequate supply of anti-hypertensive medicines, additional workload to providers for HTN services, PLHIV’s inadequate knowledge about HTN care, sub-optimal knowledge, skills and self-efficacy of healthcare providers to screen and treat HTN and inadequate planning for integrated HTN/HIV services. Relative advantage of offering HTN and HIV services in a one-stop centre, simplicity (non-complex nature) of HTN/HIV integrated care, adaptability and compatibility of HTN care with existing HIV services are the facilitators for HTN/HIV integration. The remaining CFIR constructs were non-significant regarding influencing HTN/HIV integration. Conclusion: Using the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration, HTN/HIV integration is of interest to patients, healthcare providers and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.

scholarly journals Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR)

2020 ◽  
Author(s):  
Martin Muddu ◽  
Andrew K. Tusubira ◽  
Brenda Nakirya ◽  
Rita Nalwoga ◽  
Fred C. Semitala ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Implementation Research ◽  
Health System Strengthening ◽  
Relative Advantage ◽  
Prior Work ◽  
Care Providers ◽  
Increased Risk ◽  
Inner Setting ◽  
Hiv Integration

Abstract BackgroundPersons Living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to, and facilitators of, integrating HTN screening and treatment into HIV clinics in Eastern Uganda.MethodsWe conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews with health services managers, health care providers and hypertensive PLHIV (n=83). Interviews were transcribed verbatim. Three qualitative researchers used both deductive (CFIR model-driven) and inductive (open coding) methods to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration. ResultsOf the 39 CFIR constructs assessed, 17 were relevant to either barriers or facilitators to HTN/HIV integration. Six constructs strongly distinguished performance and were barriers, three of which were in the Inner setting (Organizational Incentives & Rewards, Available Resources, Access to Knowledge & Information); two in Characteristics of individuals (Knowledge & Beliefs about the Intervention and Self-efficacy) and one in Intervention characteristics (Design Quality & Packaging). Four additional constructs were weakly distinguishing and negatively influenced HTN/HIV integration. There were four facilitators for HTN/HIV integration related to the intervention (Relative advantage, Adaptability, Complexity and Compatibility). The remaining three constructs negatively influenced HTN/HIV integration but were non-distinguishing. ConclusionUsing the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration in the Inner setting, Outer setting, Characteristics of individuals and implementation Process, HTN/HIV integration is of interest to patients, health care providers and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on the facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.

An Evaluation of the Dissemination and Implementation of a Google Apple Exposure Notification System for COVID-19 Risk Mitigation at a National Public University (Preprint)

2021 ◽  
Author(s):  
Cathy Lee Melvin ◽  
Katherine Regan Sterba ◽  
Ronald Gimbel ◽  
Leslie Andrew Lenert ◽  
Kathleen Buford Cartmell
Keyword(s):  
Mixed Methods ◽  
Health Care Providers ◽  
Specific Treatment ◽  
Implementation Strategies ◽  
Public University ◽  
Barriers And Facilitators ◽  
Phase Iii ◽  
Dissemination And Implementation ◽  
University Campus ◽  
Care Providers

BACKGROUND The infectivity characteristics of SARS-Cov-2 require expeditious testing and isolation of cases for pandemic control. The large proportion of very severe or deadly cases, combined with a lack of specific treatment options for SARS-CoV-2, makes it imperative to identify and isolate infected individuals and quickly test their exposed close contacts (ECC) to reduce the odds of continued spread. Compared to conventional contact tracing, cell phone-based exposure notification has potential to inform individuals of exposures more quickly, to identify a more complete set of true contacts, and to better assess extent of exposure. Promptly providing contacts with information about their exposure, allowing them to proactively measure their risks, and take actions that might safeguard their own and the public’s health. OBJECTIVE This paper describes a protocol to evaluate the implementation of a COVID-19 exposure notification application, the SC Safer Together App (Safer Together), on a large, public university campus. The purpose of this mixed methods study is to 1) characterize and evaluate communication, dissemination and implementation strategies used to promote and support the use of Safer Together and 2) examine implementation outcomes (reach, acceptability, adoption and use) as well as barriers and facilitators encountered from the perspective of multiple stakeholders. The study objectives are to: 1. Describe the content, intended audience(s), communication channels, and timing of multi-level communication, dissemination and implementation strategies used to deploy Safer Together. 2. Determine the reach, acceptability, adoption, and use of Safer Together among targeted audiences of university students, employees (University staff, faculty and emeritus faculty), and health care providers. 3. Characterize barriers and facilitators to implementation and use of Safer Together. METHODS A parallel convergent mixed methods design will be used to 1) describe implementation strategies (i.e., marketing, distribution, education) used to launch the program and 2) evaluate program reach, acceptability, adoption and use guided by the Reach, Effectiveness, Adoption, Implementation Maintenance (RE-AIM) framework. The study will focus on three phases of dissemination and implementation that include start-up/planning (phase I), early implementation as students return to University campus in Fall 2020 (phase II), and late implementation as students continue into the Spring 2021 semester (phase III). RESULTS The project was started on October 28, 2020 and is currently enrolling participants. The active implementation plan spans nine months (October 28, 2020 – August 31, 2021). CONCLUSIONS This study proposes a structured approach to evaluate implementation strategies associated with deployment of Safer Together, an exposure notification app, in a university setting from the viewpoint of students, employees, and university leadership. The instruments developed for this study and its results will inform future implementation of apps like Safer Together during pandemic conditions at major state universities and/or statewide. CLINICALTRIAL not applicable

scholarly journals Evaluating the Implementation of a Mobile Phone�Based Telemonitoring Program: Longitudinal Study Guided by the Consolidated Framework for Implementation Research (Preprint)

2018 ◽  
Author(s):  
Patrick Ware ◽  
Heather J Ross ◽  
Joseph A Cafazzo ◽  
Audrey Laporte ◽  
Kayleigh Gordon ◽  
...  
Keyword(s):  
Mobile Phone ◽  
Real World ◽  
Implementation Research ◽  
Heart Function ◽  
Single Case ◽  
Barriers And Facilitators ◽  
Relative Advantage ◽  
Implementation Success ◽  
Staff Members ◽  
Intervention Cost

BACKGROUND Telemonitoring has shown promise for alleviating the burden of heart failure on individuals and health systems. However, real-world implementation of sustained programs is rare. OBJECTIVE The objective of this study was to evaluate the implementation of a mobile phone–based telemonitoring program, which has been implemented as part of standard care in a specialty heart function clinic by answering two research questions: (1) To what extent was the telemonitoring program successfully implemented? (2) What were the barriers and facilitators to implementing the telemonitoring program? METHODS We conducted a longitudinal single case study. The implementation success was evaluated using the following four implementation outcomes: adoption, penetration, feasibility, and fidelity. Semistructured interviews based on the Consolidated Framework for Implementation Research (CFIR) were conducted at 0, 4, and 12 months with 12 program staff members to identify the barriers and facilitators of the implementation. RESULTS One year after the implementation, 98 patients and 8 clinicians were enrolled in the program. Despite minor technical issues, the intervention was used as intended. We obtained qualitative data from clinicians (n=8) and implementation staff members (n=4) for 24 CFIR constructs. A total of 12 constructs were facilitators clustered in the CFIR domains of inner setting (culture, tension for change, compatibility, relative priority, learning climate, leadership engagement, and available resources), characteristics of individuals (knowledge and beliefs about the intervention and self-efficacy), and process (engaging and reflecting and evaluating). In addition, we identified other notable facilitators from the characteristics of the intervention domain (relative advantage and adaptability) and the outer setting (patient needs and resources). Four constructs were perceived as minor barriers— the complexity of the intervention, cost, inadequate communication among high-level stakeholders, and the absence of a formal implementation plan. The remaining CFIR constructs had a neutral impact on the overall implementation. CONCLUSIONS This is the first comprehensive evaluation of the implementation of a mobile phone–based telemonitoring program. Although the acceptability of the telemonitoring system was high, the strongest facilitators to the implementation success were related to the implementation context. By identifying what works and what does not in a real-world clinical context using a framework-guided approach, this work will inform the design of telemonitoring services and implementation strategies of similar telemonitoring interventions.

scholarly journals Barriers and facilitators to use of a clinical evidence technology in the management of skin problems in primary care: insights from mixed methods

2020 ◽  
Vol 108 (3) ◽  
Author(s):  
Marianne D. Burke ◽  
Liliane B. Savard ◽  
Alan S. Rubin ◽  
Benjamin Littenberg
Keyword(s):  
Primary Care ◽  
Mixed Methods ◽  
Clinical Evidence ◽  
Primary Care Providers ◽  
Patient Communication ◽  
Barriers And Facilitators ◽  
Care Providers ◽  
Skin Problem ◽  
Treatment Support ◽  
The Impact

Objective: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider’s perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial.Methods: Using a convergent mixed methods design, the authors had PCPs complete a post-trial survey and participate in interviews about using the CET for managing patients’ skin problems. Data from both methods were integrated.Results: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact.Conclusion: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management.

scholarly journals Perception and Willingness to Maintain Continuity of Care by Parents of Children with Asthma in Taiwan

2021 ◽  
Vol 18 (7) ◽  
pp. 3600
Author(s):  
Christy Pu ◽  
Yu-Chen Tseng ◽  
Gau-Jun Tang ◽  
Yen-Hsiung Lin ◽  
Chien-Heng Lin ◽  
...  
Keyword(s):  
Health Care ◽  
Willingness To Pay ◽  
Health Care Providers ◽  
Continuity Of Care ◽  
Care Providers ◽  
Exact Matching ◽  
Extra Effort ◽  
Referral Management ◽  
Children With Asthma ◽  
Outpatient Departments

To investigate caregivers’ attitudes toward continuity of care (COC) and their willingness to maintain continuity for their children with asthma under a national health insurance (NHI) system without strict referral management. We sampled 825 individuals from six pediatric outpatient departments in different parts of Taiwan from 2017 to 2018. We used a contingent valuation with a payment card method. Post-stratification weighting adjustment and coarsened exact matching were utilized. Multiple logistic regression was used to compare the willingness to pay and spend extra time maintaining continuity by parents. More than 80% of caregivers in the asthma group believed having a primary pediatrician was important for children’s health. Only 27.5% and 15.8% of caregivers in the asthma and control groups, respectively, believed changing pediatricians would negatively affect therapeutic outcomes. Regression analysis showed that the predicted willingness to pay for the asthma and non-asthma groups were NT$508 (SD = 196) and NT$402 (SD = 172), respectively, and there was a significant positive dose–response relationship between household income and willingness to pay for maintaining health care provider continuity. Caregivers’ free choices among health care providers may reduce willingness to spend extra effort to maintain high COC. Caregivers should be educated on the importance of COC.

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