Table 2.

Patient factors challenging continuity of care

Challenges to continuity	Case scenario	Potential solutions
Poor comprehension	Lack of understanding of multiple conditions requiring monitoring	Standardised and clear patient education
		Caregiver education
		Home care support
Immobility	Difficulty getting to lab	Home lab visits
		Telephone or tele-health visits
		Self-monitoring with home INR testing
Fear	Fear of medication and polypharmacy	Standardised and clear patient education
Lack of interest/attention/concern/motivation	Patient not committed to anticoagulation	Provide education and encouragement to make it easier for the patient and provider to do the right thing
Cognitive dysfunction – dementia or delirium	Acute illness with delirium may interfere with ability to understand or remember medication	Written information
		Education of caregivers and or community providers either in person or over phone
Lack of social support	Wife not able to travel to regional care centre	Provide caregiver support
		Provide information regarding community resources
		Tele-health visit for wife to review medication information