Introduction: Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination. This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare.
Methodology: We followed Arksey and O’Malley’s methodological framework for scoping reviews. We carried out a systematic search across CINAHL, MEDLINE, Scopus and ProQuest. Only empirical studies were included. We performed a thematic analysis using deductive (the American Nurses Association Framework) and inductive approaches. Findings were discussed with a group of experts.
Results: Thirty-four articles were included in the synthesis. Overall, nursing care coordination activities were synthesized into three categories: those targeting the patient, family and caregivers; those targeting health and social care teams; and those bringing together patients and professionals. Interpersonal communication and information transfer emerged as cross-cutting activities that support every other activity. Our results also brought to light the nurses’ contribution to care coordination efforts for patients with complex needs as well as critical components that should be present in every care coordination intervention for this clientele. These include an increased intensity and frequency of activities, relational continuity of care, and home visits.
Conclusion: With the growing complexity of patient’s needs, efforts must be directed towards enabling the primary healthcare level to effectively play its substantial role in care coordination. This includes finding primary care employment models that would facilitate multidisciplinary teamwork and the delivery of integrated care, and guarantee the delivery of intensive yet efficient coordinated care.
Over the last two decades, integration has become a major concern for many governments and healthcare systems [1, 2, 3, 4]. With limited financial resources, aging populations, and comorbid chronic diseases [5, 6, 7], many countries have recognized the need to move from fragmented and discontinued care towards a more integrated healthcare system . Studies showed the potential of integrated care to improve continuity of care, accessibility, quality and safety of care, as well as cost effectiveness of services . Care coordination around patients’ needs has been acknowledged as a core dimension of integration that facilitates the provision of comprehensive and seamless care . It has also been recognized as a key responsibility for primary healthcare .
As complexity grows, so does the need for a stronger primary healthcare able to deliver more care in the community and coordinate care within primary care and across care levels [12, 13]. Millions of people worldwide have complex needs that span beyond what the healthcare system typically provides . Fragmentation of health and social care services causes patients with complex needs to bear the major responsibility for navigating their own pathway through services and providers  and they experience systems as being confusing and overwhelming . For these patients, care coordination and integration of health and social care services are even more relevant.
Although the aim of care coordination is widely agreed upon, there is still a lack of global consensus around a single conceptual model and much ambiguity in the definitions of care coordination . The Agency for Healthcare Research and Quality defines care coordination as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services” . A variety of approaches has been adopted to deliver coordinated care in practice. Case management is perhaps the most intensive intervention for caring for people with complex health and social needs . Case management has been established as a targeted, community-based and proactive approach to care that involves case finding, assessment, care planning, and care coordination . Patient navigation is another approach that has emerged within primary care as a means to link patients and families to primary care services, specialist care, and community-based health and social services to provide holistic patient-centred care . The Agency for Healthcare Research and Quality has identified several other approaches and terms that are often used synonymously or in conjunction with care coordination, namely collaborative care, disease management, care management, and the Chronic Care Model . However, irrespective of the approach that is adopted, an essential dimension of effective care coordination is the involvement of a multidisciplinary primary care team that functions as a cooperative, cohesive unit to provide the right care in the right place at the right time .
Within primary healthcare, the role of care coordinator can be undertaken by professionals who come from various backgrounds, including nursing, social work, physiotherapy and occupational therapy, as long as they are equipped with and trained on the necessary skills . The choice of a designated care coordinator is often dependent on contextual factors, the population of interest, and the goals of the program. Indeed, a foundational element of care coordination is a holistic care perspective that includes addressing clinical/medical as well as the broader determinants of health . It is this very perspective that gave both nurses and social workers their legitimate position in organizing and managing care for a complex population. However, one might be better equipped than the other depending on the patient’s condition and the disciplinary expertise this condition primarily calls for. For instance, social care expertise is particularly important for patients in the rehabilitation and reablement phases and those with a functional decline , while nursing clinical expertise may be more relevant for patients suffering from serious pathologies such as cancer . In either case, health and social care professionals still have to work collaboratively and use their unique skills and disciplinary expertise as needed. Primary care practices that have the capacity (e.g. structure, resources) have implemented a team-based model of care coordination where the social worker and registered nurse carry out a joint patient assessment. This care coordination model proved effective in increasing communication between health and social services and in improving care for complex patients such as older health consumers .
This scoping review focuses on the role of registered nurses in care coordination. Nurse-led care coordination interventions proved effective in improving access to appropriate treatment ; reducing costs [25, 26, 27]; improving clinical outcomes [27, 28] and quality of care ; improving communication between staff ; increasing safety of vulnerable patients during transition ; and reducing their unplanned readmissions [19, 31]. It should be noted that, depending on local needs and resources, nurses might be employed to undertake exclusive care coordination activities [32, 33] or they might combine care coordination with wider team management responsibilities or with clinical care provision .
Despite the substantial involvement of nurses in care coordination efforts, their contribution still has to be clearly “defined, measured and reported to ensure appropriate financial and systemic incentives for the professional care coordination role” .
To date, there persists a lack of knowledge about interventions and activities performed by registered nurses for patients with complex health and social care needs in primary healthcare. An in-depth analysis of how the nursing care coordination role for patients with complex needs is operationalized is clearly needed. The Agency for Healthcare Research and Quality also stressed the need for care coordination frameworks to be enriched by empirical data. In 2010, the Agency developed a framework and specified that “this framework provides a starting place for understanding care coordination… and is intended to grow with the field… since care coordination is a rapidly growing evidence base field” .
This scoping review draws on previous theoretical work and aims to provide a synthesis of care coordination interventions as operationalized by nurses for patients with complex health and social care needs in primary healthcare. Our research questions are: What care coordination interventions are currently performed by registered nurses in primary healthcare? Who are the target complex patient populations? What activities do these interventions involve?
In 2013, the American Nurses Association developed a framework for measuring nurses’ contributions to care coordination . This framework was based on several other theoretical frameworks including the one developed by the Agency for Healthcare Research and Quality for healthcare. The American Nurses Association’s framework has the strength of providing a roadmap for how conceptualization of nursing’s role in care coordination can be operationalized, quantified and measured, and includes thirteen constructs that comprise the nursing care coordination processes. Thus, we considered it a particularly suitable starting point for our review. However, care coordination activities described in the American Nurses Association Framework were cross- cutting, relevant to all settings of care and services, while we were specifically interested in the primary healthcare level and target complex patient populations.
We followed the methodology proposed by Arksey and O’Malley  and further developed by Levac et al. . This methodological framework offers six stages for carrying out scoping reviews: Identifying the research question; Identifying relevant studies; Selecting studies; Charting the data; Collating, summarizing, and reporting the results; Consulting experts.
Two hundred and thirteen full-text articles were screened; 34 articles met the inclusion criteria and were included in the synthesis. Our search results and the retrieval and selection of studies are presented in the flow diagram below (Figure 2). The 34 studies included in our synthesis reported on 26 different interventions. When the same care coordination intervention was reported in several articles, only the paper that provided a full description of this intervention was coded. However, the content of these other papers contributed to the consolidation and further clarification of the extracted data. Table 1 presents all included papers, their main features and results.
|AUTHORS, YEAR OF PUBLICATION||STUDY DESIGN/OBJECTIVES||CARE COORDINATION INTERVENTIONS||TARGET POPULATION||NURSE’S EMPLOYMENT ARRANGEMENT, LOCALISATION, CONTEXT||SUMMARY OF CARE COORDINATION ACTIVITIES|
|Aragonès & al; 2012||Cluster RCT/Assess the effectiveness of a multi-component programme to improve the management of depression||Case management||Patients with moderate to severe depression||Exclusive case management role;
Primary care centres, Catalonia, Spain
|Provide self-management, psychological and emotional support; encourage and monitor adherence to treatment; monitor side effects and clinical results; improve social support; coordinate care between patient, primary care and specialized care providers; document information and transfer to GP|
|Berra & al; 2007||Clinical trial and program dissemination project/Reflect on lessons learned in developing the “Heart to Heart” program||Case management||Low-income, ethnically-diverse populations at elevated risk of cardiovascular disease events||Exclusive case management role; Primary care clinics, California, USA||Provide intensive and individualized care and guideline-based pharmacotherapy; provide education and counseling; support behavior change; coordinate access to community resources; link and partner with GP and specialty services|
|Bleijenberg & al; 2016. (intervention described in Bleijenberg 2013)||Cluster RCT/Determine the effectiveness of a primary care program on the daily functioning of older people||Nurse-led care intervention||Community-dwelling frail people aged 60 and older||Exclusive care coordination role; General practices, the Netherlands||Assess patient’s needs at home; develop care plans; monitor and follow up; support caregivers; promote self management; coordinate care with GP and health care teams|
|Boyd & al; 2007 (same intervention as in Boyd 2008; Boult 2008; Boult 2011; and Boult 2013)||Pilot test and preliminary results of an RCT/Test the feasibility of a new model of health care designed to improve the quality of life and the efficiency of resource use||Guided care||Older patients with multimorbidity and functional disability and who had generated high insurance expenditures for health care||Exclusive care coordination role; Non-academic urban primary care practice, Baltimore, USA||Assess the global patient’s status at home; develop a plan of care; monitor, follow up and respond to change; communicate and coordinate the efforts of all involved health care professionals; support patient and caregivers’ activation, engagement and self-management using motivational interviewing; facilitate access to community resources; facilitate care transition|
|Coburn & al; 2012||RCT/Evaluate the Health Quality Partners program’s effect on mortality||Community based nurse care management||65 years of age and older with multimorbidity||Exclusive care management role; A network of primary care practices, eastern Pennsylvania, USA||Target eligible patients; visit at home when necessary; assess patient’s needs; develop a care plan; monitor, follow up and respond to change; support self management and behavior change; assess and promote patient adherence to treatment; reconcile errors/omissions with the GP; coordinate care with health and social care providers and family
members; facilitate care transition; manage advance directives; document in patient records
|Ekers & Wilson; 2008||Audit of symptom outcome and satisfaction/Examine the impact of interventions delivered in routine primary care clinics by nurses||Case management||Patients with moderate to severe depression||Case management with other primary care duties; General practitioner practices, the North East of England||Assess patient’s symptoms and risk factors; manage medication; support behavioral activation; discuss cases with psychiatric nurse and GP; respond to changes|
|Friedman & al; 2009||RCT/Report the impact of a primary care health promotion nurse intervention||Disease management||High risk patients with disability (or their caregiver) and recent significant (or expected) health care utilization||Exclusive disease management role; Home visits, counties in western New York, in West Virginia, and in Ohio, USA||Visit patient at home; assess their status; monitor medication list; provide education and support for self management and behavior change and maintenance; facilitate communication between patient and family and GP|
|Gabbay & al; 2013||RCT/Determine whether the addition of nurse case managers to usual care would result in improved outcomes||Case management||Diabetic patients at high risk for complications, in an underserved Hispanic population||Exclusive case management role; Primary care clinics within two health systems in Central Pennsylvania, USA||Monitor and follow-up; provide counseling and enhance motivation to change and medication adherence; engage in phone and email conversations with patient between visits when needed; make referrals to specialty services when necessary; discuss medication list with GP|
|Hudon & al; 2015 (same intervention as in Hudon 2018)||Qualitative study/Examine the experience of patients and their family members with care integration in a case management program by primary care RN||Case management||Frequent users of health care services who had chronic diseases||Case management role with other primary care duties; Family medicine groups, Province of Quebec, Canada||Assess patient’s needs and resources; develop a personalized care plan; involve patient in decision-making; provide education, counseling, self management support; build trust through interpersonal communication; improve transition, communication and coordination with and among healthcare and community partners|
|Jansen & al; 2011||RCT/Compare the effects of case management and usual care||Case management||Community-dwelling older adults with dementia symptoms and their informal caregivers||Exclusive case management role; Home visits, West-Friesland, the Netherlands.||Visit patient at home; assess patient and caregiver situation; formulate a care plan with them; provide them education; improve their social support; refer them to relevant healthcare professionals; monitor and follow-up; provide phone consultations; inform the GP; discuss cases with peers; document and share information|
|Katon et al; 2012 (same intervention as in Trehearne 2014)||RCT/Evaluate the cost-effectiveness of a collaborative treatment program||Collaborative care management||Patients with poorly controlled diabetes mellitus, CHD, or both and comorbid depression||Exclusive care management role; Primary care clinics of an integrated healthcare system, Washington State, USA.||Visit patient at home; identify clinical goals; develop individualized care plans; monitor, follow up and respond to change; provide patient education and support for self management; review and discuss cases with GP and specialists|
|Mastal & al; 2007||Case study/Explore innovative practices in two disability care coordination programs||Care management||Adults with severe and persistent mental illness who had developed type II diabetes||Care management role with leadership responsibilities; Home visits, RN is located in both the community mental health center and the primary care center, Vermont, USA||Visit patient at home; assess their health; accompany them in their trips out of their home if desired; provide education and self management support; link the mental health and primary care systems; interact with, educate and learn from mental health providers; serve as a resource to patient and providers|
|McNab & Gillespie; 2015 (same nurses’ role as in McNab &al; 2016)||Case study/Report on a program that aims to improve coordination and integration of services, and reduce unnecessary hospital readmissions||Integrated care||Older people with chronic and complex illness who are at risk of further exacerbation and/or hospitalisation||Exclusive role of liaison nurse; Within the larger Mount Druitt Community Health Centre; in homes; and at general practitioner practices, West of Sydney, Australia||Visit patient at home; identify their needs; initiate care planning; support self-management, provide a single point of contact and a familiar face for patient and teams; manage communication, case conferencing and care coordination between professionals involved in patient’s care; make referrals into health and social care|
|Meng & al; 2009||RCT/Evaluate the effect of a primary care nurse intervention on paid personal assistance use and expenditures||Disease management-health promotion||Community dwelling older people with disabilities and recent significant health care utilization||Exclusive role of disease management-health promotion; Home visits, New York, West Virginia, and Ohio, USA||Visit patient at home; co-create goals; collaborate with patient, GP and MDT to create care plans, support behavior change, medication management and treatment adherence; provide education and support for self management to patient and caregivers; facilitate transition and communication between the GP, patient and caregivers|
|Metzelthin & al; 2013||Mixed methods/Examine the implementation of the interdisciplinary care approach and participants experiences||Case management||Community-dwelling frail older people (> 70 years)||Case management role with other primary care duties; General practices, the south of the Netherlands||Contribute to patients targeting; visit patient at home; perform a comprehensive assessment; inform and cooperate with patient, caregivers and MDT for the formulation and execution of a treatment plan; monitor and follow up; facilitate the protocol implementation|
|Newcomer & al; 2004||RCT/Present patient outcomes after 12 months of participation to the preventive case management program||Case management||Older people with chronic condition||Exclusive case management role; Primary care medical groups within Sharp HealthCare of San Diego, California||Perform health risk screening and contribute to triage; formulate multidimensional care plan interventions; provide education; assist patient in preparing their appointments with the GP; monitor and facilitate treatment adherence; reconcile medication; provide referrals and assistance with services access; communicate with GP; facilitate health plan processes navigation; coordinate with the hospital discharge planners; monitor and adapt risk status|
|Roth & al; 2012||Study cohort/Examine Community Care Managers’ assessments and interventions compared with PCP care||Care management||The most vulnerable older adults enrolled in a community Special Needs Plan (based on patient’s categories of diagnoses and disease severity to predict medical expenditures)||Exclusive care management role; Evercare Special Needs Plan site located in central Florida, USA||Visit patient at home; assess their needs; develop a personalized care plan; promote preventive services; engage with GP; provide health education and caregiver support; coordinate services; facilitate transitions and communication between all parties including the patient|
|Ruikes & al; 2016||Cluster Controlled Trial/Evaluate the effectiveness of a general practitioner–led program integrating cure, care, and welfare for the prevention of functional decline||Case management||Community-dwelling frail older people (> 70 years)||Unclear*; General practices, Nijmegen, the Netherlands||Visit patient at home; involve them in setting goals based on the assessment of their needs; formulate individualized care plans; ensure patient acknowledges these plans; review medication with GP and pharmacist and document decisions in the care plan; maintain treatment contact with patient and caregivers; organize and participate to team meetings|
|Schraeder & al; 2008||Non-randomized comparison/Test the effectiveness of a management intervention on healthcare utilisation and cost||Case management||Chronically ill community dwelling older people at high-risk for mortality, functional decline, or increased health services use||Exclusive case management role; Primary care practice, East central Illinois (intervention); West central Illinois (comparison), USA||Visit patient at home; perform a comprehensive assessment and integrate it with the GP’s; develop a care plan with the GP; adjust it when necessary; monitor and follow up; provide patient education and support for self management and behavioral change; monitor the need for educational interventions; visit patient during transitional periods and provide ongoing monitoring and assessment; build a personal relationship with patient; communicate with and transfer information to GP and team; coordinate supportive services|
|Scrymgeour & al; 2013||Mixed methods/Assess the effectiveness of the Continuity of Cancer Care pilot||Care coordination||Patients with varying stages of cancer progression||Exclusive care coordination role; General practices in New Zealand||Provide emotional support, verbal guidance and support for self management to patient and family; include patient and family in care; respect patient’s values and beliefs; serve as a main point of contact available when needed; advocate on behalf of patient with other healthcare providers; link patient with GP, MDT and services|
|Spencer; 2019||Quasi-experimental uncontrolled before and after design involving a retrospective review/Evaluate a quality improvement project||Care coordination||Underserved, uninsured community with Type II diabetes||Exclusive care coordination role; Community Health in Partnership Services (CHIPS) clinic, St. Louis City, Missouri, USA||Form a meaningful relationship with patient and providers; clarify roles and responsibilities with patient; act as a resource for the team; assist patient and family completing the plan of care; document; provide technical support; make referrals when necessary|
|Suijker & al; 2016||Cluster Randomized Trial/Evaluate the effects of nurse-led multifactorial care to prevent disability||Care coordination||Patients aged 70 years and over at increased risk of functional decline||Exclusive care coordination role; General practices, north-west of the Netherlands||Visit patient at home; conduct a comprehensive assessment; co-construct care plan with patient and GP where roles are clearly defined; monitor and follow-up; collaborate with patient, GP and MDT|
|Thyrian & al; 2017||Cluster Randomized Trial/Test the effectiveness and safety of Dementia Care Management||Care management||Patients aged 70 years and over, living at home, and diagnosed as having dementia||Exclusive care management role; General practices, municipalities of Mecklenburg-Western Pomerania, Germany||Visit patient at home; conduct a comprehensive assessment; discuss intervention tasks with MDT; inform the GP and establish an individualized care plan with them; cooperate with the caregiver, GP, and health and social care providers; manage treatment, care and medication; provide caregiver support and education; monitor and follow-up|
|Unutzer & al; 2008||Prospective pilot study (mixed methods)/Test the feasibility of and generate preliminary evidence for the efficacy of a care management program||Care management||Patients aged 60 years and over with depression and osteoarthritis pain||Exclusive care management care; Primary care clinics, University of Washington’s Practice Network, Washington, USA||Conduct a comprehensive assessment; manage medication; support activation; provide education and support for self management; coordinate with GP and specialist; monitor and follow-up and respond to change|
|Van Leeuwen & al; 2015||Economic evaluation and a stepped-wedge cluster-RCT/Evaluate the cost-effectiveness of the Geriatric Care Model||Integrated care||Frail persons aged 65 years and over at increased risk of functional decline||Exclusive care coordination role; Primary care practices, two regions in the Netherlands||Visit patient at home; conduct a comprehensive assessment; establish a care plan with GP; discuss it with patient; inform and involve patient in decision making; document; monitor and follow up; coordinate care with MDT and community network professionals|
|Yuille; 2015||Qualitative descriptive study/Identify, from the perspective of RNs, the strengths, gaps, barriers, and opportunities for optimizing nursing roles in the delivery of cancer survivorship care in primary settings||Chronic disease management||Patients with varying stages of cancer progression||Chronic disease management with other primary care duties; Local Health Integration Networks across Ontario, Canada.||Establish a long standing and trusting relationship with patient; serve as their “go to” person; provide emotional support; provide education and support for self management; manage care; assist patient and family navigate through the healthcare system; arrange and coordinate services for them; facilitate access to community resources; facilitate transitions.|
Authors used several terms to describe care coordination interventions. The included papers reported on case management [34, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52], care management [33, 53, 54, 55, 56, 57, 58], disease management [59, 60, 61], guided care [32, 62, 63, 64, 65], integrated care [66, 67, 68], care coordination [69, 70, 71], and nurse-led care interventions [72, 73]. Definitions of these interventions were not always provided and, as reported in Table 1, we noted variations in care coordination activities within the same type of intervention. For instance, within case management interventions, a comprehensive initial assessment of patient and family needs and goals was explicitly mentioned in several, but not all, studies [46, 47, 48, 49, 50, 51, 52].
The target patient populations identified in the included studies were also diverse. We have gathered them into seven categories according to their common areas of vulnerability as presented in the “Complex health and social care needs” model (Figure 1) above, as well as their frequent use of health care services. Table 2 displays this categorization.
|CATEGORIES OF PATIENT POPULATIONS WITH COMPLEX NEEDS||IDENTIFIED TARGET POPULATIONS IN INCLUDED STUDIES|
|1. Patients with severe mental illness||Patients with moderate to severe depression [43, 52]|
|2. Patients with common or severe mental illness + chronic condition(s)||Adults with severe and persistent mental illness who had developed type II diabetes 
Patients with poorly controlled diabetes mellitus, coronary heart disease or both and comorbid depression 
Patients aged 60 years and over with depression and osteoarthritis pain 
|3. Patients with social vulnerability + chronic condition||Low-income, ethnically diverse populations at elevated risk of cardiovascular disease events, including those with existing coronary heart disease or diabetes 
Diabetic patients at high risk for complications, in an underserved Hispanic population 
Underserved, uninsured community with type II diabetes 
|4. Older people with physical, cognitive, psychosocial or psychiatric vulnerabilities (+ significant healthcare use)||Community-dwelling frail people aged 60 and older 
Community-dwelling frail older people (> 70 years) [49, 51]
Patients aged 70 years and over at increased risk of functional decline 
Frail persons aged 65 years and over at increased risk of functional decline 
Older patients with multimorbidity and functional disability and who had generated high insurance expenditures for health care 
Community dwelling older people with disabilities and recent significant health care utilization 
High risk patients with disability (or their caregiver) and recent significant (or expected) health care utilization 
The most vulnerable older adults (based on patient’s categories of diagnoses and disease severity to predict medical expenditures) 
Chronically ill community dwelling older people at high-risk for mortality, functional decline, or increased health services use 
|5. Old age people + chronic condition(s)||Older people with chronic and complex illness who are at risk of further exacerbation and/or hospitalisation 
65 years of age and older with multimorbidity 
Community-dwelling older adults with dementia symptoms and their informal caregivers 
Patients aged 70 years and over, living at home, and diagnosed as having dementia 
Older people with chronic conditions 
|6. Patients living a transition to end-of life/palliative stage||Patients with varying stages of cancer progression [61, 69]|
|7. High costs and frequent users of health care services||Frequent users of healthcare services who had chronic diseases |
In addition to the variations in care coordination activities within the same type of intervention, we noted a variation when we tried to compare care coordination activities according to target patient populations. For instance, within the category of older patients with multiple vulnerabilities and significant use of healthcare services (category 4), facilitating care transitions was not mentioned in all studies, although present in several studies [32, 50, 56, 60].
We were able to synthesize overall nursing care coordination activities into three categories: activities targeting the patient, family and caregivers; those targeting health and social care professionals and services; and those bringing together patient and professionals. One last category was found to be cross-cutting, supporting and enhancing every other activity, namely interpersonal communication and information transfer (Figure 3). In the following section, we present the four categories and their respective activities; a more detailed description of these activities is provided in Appendix 2.
Thus, they are embedded in many of the other activities described earlier, such as assessing patients’ individual needs and goals, facilitating their participation in care, involving them in the development of their own care plan, serving as their main point of contact and advocating for them, and helping them state their individual preferences for care at the end of life. Patients’ activation and empowerment also include linking patients with health and social care teams in order to enable engaged participation and shared decision-making as described further below.
We have also identified a list of additional performed activities aimed at supporting patient and family activation and empowerment, frequently using motivational interviewing principles and cognitive and behavioural strategies [32, 33, 34, 45, 46, 53, 59]. These include the provision of:
These activities are not sequential but rather iterative. Typically, a comprehensive assessment is needed in order to identify patients who would benefit from a care coordination intervention; in turn, patients identified as target beneficiaries require a comprehensive assessment of their needs and goals in order to develop their care plan.
Finally, we were able to identify three main features of the activities targeting the patient and family: 1) they may occur during home visits; 2) they are undertaken in close collaboration with the general practitioner and health and social care teams. This is particularly relevant when targeting eligible patients and care planning; 3) they are complementary to and do not replace the general practitioner’s activities. Nurses organized care that the general practitioner was not able to organize due to lack of time or because they did not have the knowledge of services available [51, 66, 67], and seemed to be very effective in areas that are less extensively addressed by the general practitioner such as complex assessments of function and social support  or self-management support . Overall, collaboration between nurses and general practitioners resulted in a broader assessment of a patient’s health and the development of more comprehensive care plans  thus, improving health management.
Nurses are playing an increasingly central role in care coordination. However, no previous model has provided an in-depth analysis of this role for patients with complex health and social care needs in primary care.
Our conceptual framework of care coordination provides an extensive description of each care coordination activity (or domain). This new information could constitute a valuable contribution that facilitates the design and implementation of care coordination interventions for patients with complex needs.
Furthermore, our synthesis of care coordination interventions is based on empirical studies and with a focus on the way these interventions are operationalized. We propose a pragmatic model of care coordination for patients with complex needs that would be close to the field reality of health and social care professionals.
Our results showed the multitude of interventions used to coordinate care around patients with complex health and social care needs in primary health care. This heterogeneity was expected and confirms the fact that care coordination can be operationalized in different ways. Care coordination interventions also differ on the basis of their context, the population of interest, and the goals of the program .
The care coordination model that we propose should not be regarded as a manual to be followed but rather as a tool to guide professionals and decision makers tailoring their own intervention based on the needs of their target patient population as well as their contextual and environmental realities. The success and failure of integrated care interventions, including care coordination, have always been context dependent [79, 80].
Our findings also confirmed the fact that the care coordination role may be undertaken exclusively or combined with other primary care duties. In fact, nurses seem to perform the same care coordination activities independently of their employment arrangement. We hypothesize, though, that what may be different is the caseload of nurses and, again, the intensity of their support. Goodman (2010) showed that exclusive case managers provided greater input to their patients and higher contact time per month than did nurses who undertook other duties concurrently . However, the authors also pointed out the increased cost of exclusive case management. Therefore, healthcare organizations are faced with the challenge of finding employment models that can ensure balance between efficiency and intensive care coordination for target patient populations or individuals.
This review shed light on critical components of care coordination that are specific to patients with complex needs. Firstly, although the care coordination model may seem to include the same activities for patients with long-term conditions without particular complexity, the main difference is the greater frequency and intensity of activities when caring for patients with complex needs. Several studies highlighted the need for care coordination to be targeted according to the varying intensity of needs [19, 81]. Leutz (1999) and Kodner (2002) addressed the question of “who needs what level of integration” [82, 83]. The authors suggested that different levels of integration should exist for patients according to their needs, their capacity for self-direction, and the specific challenges they face in obtaining appropriate care . Our findings illustrate how complex patient groups would require a broader span, more intense, and more thoroughgoing interventions. Garcia et al. (2018) conceptualized a spectrum of care management need that ranges from complex patients who have sufficient skills and resources thus “not needing intensive care management” to “patients needing more than intensive care management” . For the first group, patient navigation, a less intensive intervention, may address their needs effectively by reducing barriers and bridging gaps in service . The patient navigation role may indeed be played by nurses and social workers or by lay persons trained adequately . Patients at the other end of the spectrum are those requiring more specialized interventions beyond those offered by care management . Between these two extremes of the spectrum, there are the patient populations identified in our review and for whom a comprehensive, intensive care coordination intervention, by a professional, is necessary. In fact, the included studies described patient navigation as one component of a wider intervention.
Primary care registered nurses provide a broad range of services for patients with long-term conditions without particular complexity. These include chronic disease prevention and management, medication management, health education and therapeutic interventions . These activities seem to be very present when coordinating care for patients with complex needs. Indeed, our findings highlighted activities related to their clinical skills such as conducting a comprehensive assessment including for medical needs and goals; careful monitoring of patient symptoms; early identification of exacerbations; medication reconciliation and early identification of adverse effects; providing patient education that includes self-management of their medical conditions and recognizing alarming symptoms, as well as providing direct evidence-based care. Previous results indicate that when nurses are an integral part of direct care through the management of the interdisciplinary team, programs have a great opportunity to improve quality of care and clinical outcomes, and reduce beneficiaries’ need for hospitalization [87, 88].
Secondly, the establishment of a relational continuity of care with the patient and family also emerged as a critical component of care coordination for patients with complex needs. In addition to the intensity of support, our results emphasize the availability of the care coordinator out of hours and when urgent issues arise, which leads to the development of a great relational continuity of care. In fact, for patients with complex needs, integrated care often means a single point of entry and a personal contact with a designated care coordinator . Our findings show how nurses become patients’ “go to” person at all times. Studies showed that relational continuity improved preventive care, reduced hospitalization, enhanced adherence to treatment, and increased satisfaction with care [90, 91].
Finally, home visits seem to be particularly important when coordinating the care of patients with particular needs or certain complex needs. This is mainly in response to the target patient populations’ vulnerability and sometimes functional decline , but also because it allows nurses to gain more insight into the patient’s living environment, including safety issues [33, 48] and caregiver burden , which are crucial to care planning. Nevertheless, home visits should not be regarded as an isolated activity, but rather as a feature of a comprehensive care coordination intervention whose first step is to know the patient and caregiver in order to identify what care or service they need .
It is widely recognized that complex interventions are often not delivered or adhered to as intended . Yet, studies included in our review rarely reported on their assessment of intervention fidelity. Furthermore, we do not know if nurses performed one activity more than another, or whether they needed capacity building for the least performed activities. Future research should address these two areas since answers might explain, at least partly, the limited efficacy of some interventions.
Also, it would be interesting to attempt and establish a classification of activities according to their value, i.e. efficacy versus time and resource consumption.
Our scoping review did not aim to compare the nurses’ role in care coordination to that of another professional. Future research could highlight the specificity of each professional and their added value in the coordination of care.
In practice, the co-location of health and social care professionals has gained considerable attention over the last few years for what it offers in terms of facilitating multidisciplinary teamwork and the delivery of integrated care . Our findings reaffirm the fact that no single professional has the ability to complete the task independently, and that “close” collaboration between health and social care services is particularly important for eective care coordination. This review could therefore constitute an additional argument in favour of the staff co-location.
Finally, recognizing care coordination in practice requires defining the work and purposefully examining when, where and how it is happening . This synthesis would support the development of a system to document nurses’ care coordination activities as a way of ensuring appropriate financial and societal recognition of their contribution to high quality, efficient and integrated care.
To our knowledge, this is the first study to synthesize nursing care coordination activities for patients with complex needs in primary healthcare. We were able to propose an exhaustive model of care coordination, as well as a comprehensive description of patients’ complex health and social care needs. Another major strength would be the validation of our findings by a patient-research-partner.
As for limitations, this scoping review did not provide a comparison between care coordination interventions or their efficacy. The complexity and heterogeneity of interventions represent a real challenge for comparison and necessitate the use of research designs other than a scoping review. Another limitation could be related to the fact that our findings are based on the description of activities as provided in included studies. These descriptions were sometimes poor or lacked important elements, so we may have missed details or features of some activities. However, to mitigate the missing information, we examined all articles reporting on the same intervention.
A multitude of interventions are used to coordinate the care of patients with complex health and social care needs in primary health care. Despite this heterogeneity, they share a commonality in that they involve a great frequency and intensity of care coordination activities related to the complex needs of the target patient populations. Care coordinators establish a great continuity of care with these patients due to their availability outside of regular hours and when urgent issues arise. As complexity grows, efforts must be directed towards enabling the primary healthcare level to effectively play its substantial role in care coordination. This includes finding primary care employment models that would facilitate multidisciplinary teamwork and the delivery of integrated care, and guarantee the delivery of intensive yet efficient coordinated care.
Elodie MONTAIGNE, Registered Nurse MSc.
Primary care interdisciplinary team of Brocéliande, Plélan-Le-Grand, France.
Paramedical training department, University of Rennes 1, Rennes, France.
One anonymous reviewer.
The authors have no competing interests to declare.
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