Episodic Care

Episodic care refers to single encounters with clients, focused on a presenting concern (such as difficulty feeding a newborn) or identified condition (such as pregnancy). Midwives may provide episodic care in a variety of settings and contexts such as an EMCM that caters to a particular population or as part of an ad hoc one-time clinic in the community or hospital or midwives serving marginalized populations that would otherwise be unable to access care. Neither the midwife, nor the client should have the expectation of an ongoing care relationship. The College of Physicians and Surgeons of Ontario recommends physicians practicing in walk in clinic settings consider reminding patients of the differences between episodic care and having a primary care provider, and the benefits of the latter. The College of Physicians and Surgeons of Alberta has a similar recommendation, and physicians are required to explain the limitations of the episodic medical care.

Key points for midwives providing episodic care

  • Meet requirements of the CMO Standards of Practice
  • Information and handouts for clients that explain what services are available and alternatives for clients to access care when the clinic is closed or the midwife is unavailable.
  • Clear protocols and policies regarding managing test results, sending referrals and record keeping and sharing.
  • Clear process and policy to address complaints and concerns.

CMO Standards of Practice

The Standards of Practice apply to every registered midwife practicing in any setting. Midwives with concerns about meeting any of the CMO Standards can reach out to AOM OnCall to discuss this further.

When working outside of the traditional practice model; these standards in particular should be given some thought:

  • Work within the boundaries of the Midwifery Act related to scope of practice and the controlled acts authorized to midwives. (1)
  • Adhere to the Record Keeping Standard for Midwives. (5)
  • Ensure clients have 24-hour access to midwifery care throughout pregnancy, birth, and postpartum or, where midwifery care is not available, to suitable alternate care known to each client. (17)
  • Establish and work within systems that are clear to clients whether a sole practitioner, part of a primary care team of midwives, or a member of an interprofessional care team by:
    • developing and following a consistent plan of care
    • practicing with clearly defined roles and responsibilities based on scopes of practice
    • assuming responsibility for all the care you provide
    • ensuring that the results from all tests, treatments, consultations, and referrals are followed-up and acted upon in a timely manner
    • providing complete and accurate client information to other midwives or care providers ‘if’ care is transferred over to them
    • taking reasonable steps to ensure that a midwife or another care provider known to the client is available to attend the birth. (25)
  • Provide complete and accurate client information to the consultant at the time of consultation or transfer of care. (29)
  • Ensure that clients and health care providers know who the most responsible provider throughout the client’s care is, including when there are delegations, consultations, and transfers of care. (30)

Practice owners must also:

  • Ensure essential operational and clinical supplies are available to midwives in your practice. (11)
  • Develop and maintain quality improvement systems to support the professional performance of midwives and to enhance the quality of client care. (12)
  • Establish a system to deal with clients’ expressed concerns promptly, fairly, and openly. (53)

This is particularly relevant to practices who are administering a Schedule Q or R, for example, through which midwives are offering episodic care.

Available Services

Services offered should be clearly stated. For example: "We offer a walk-in clinic for pregnant individuals and those with newborns under six weeks who do not have another primary care provider."

Hours should be clearly explained, and information provided on where to seek care outside of those hours.

Efforts should be made to identify the program to community partners, and to create pathways that support clients in both routine and urgent transitions in care. Partnerships can also be explored to support episodic clients to link up with a primary care provider, for the pregnancy or beyond.

Protocols and Policies

The AOM has several template protocols and policies, which EMCMs and Schedules may adapt for their own use.

Critical Test Results and Follow Up

Midwives providing episodic care should have clear, documented processes that identify who is responsible for providing appropriate follow up on test results, including critical test results. Generally speaking, the ordering provider is responsible for the follow up on tests or ensuring that the responsibility for follow up has been delegated or assigned.

Documentation

The very nature of episodic care implies a lack of continuity of care and provider. This means it is particularly important to be explicit in the record that the client is accessing episodic care and that all assessments, informed choice discussions and any recommendations are documented thoroughly.

The Record Keeping Standard for Midwives sets out specific, rigorous expectations which can be adhered to through paper or electronic record systems. Notes represent what occurred, and if they are inadequate, it can be difficult demonstrate the care provided met the standard of care. If the client does have a primary care provider (PCP) and consents, a consultation note and a copy of any records made (ie. the OPR) should be shared with their PCP through a secure system.

Use of the Ontario Perinatal Record (OPR)

When seeing pregnant people, documenting any assessments, recommendations and care provided on the OPR is important; it is a clear and familiar format, which any other provider can refer to. Entries for Planned Birth Attendant and Family physician/Primary care provider can be: 'none' or 'currently seeking'. A policy should stipulate how clients can access this record (for example, they automatically receive a copy at the end of the visit, and/or it can be requested during clinic hours).

Complaints and Concerns

Midwives who work in models that offer continuity of care have the opportunity to develop a therapeutic alliance with clients grounded in reciprocal trust. A trusting therapeutic relationship is not only rewarding but it is also protective; both clients and midwives benefit when clients feel secure enough to directly address concerns with their provider. Building client trust is still essential in episodic care, however because of structural constraints it can be more challenging. Maintaining and communicating a clear policy for receipt and address of complaints is essential for all midwives regardless of how they are offering their services.

Helpful links:

College of Physicians and Surgeons of Alberta, Advice to the Profession: Episodic Care (2020)

College of Physicians and Surgeons of Ontario, Policy: Walk in Clinics (2019)

Healthcare Insurance Reciprocal of Canada:

AOM template protocols:

  • Client Complaints & Compliments
  • Client and Practice Group Commitments to Anti-Racism and Anti-Oppression
  • Clinical Documentation and Record Keeping
  • Management of Laboratory and Diagnostic Imaging Testing and Results
  • Routine IPAC Practices
  • Safety Incident Review
  • Workplace Harassment and Violence Policy and Procedures