Care Coordination Interventions Research Articles

CARE COORDINATION INTERVENTIONS FOR DEMENTIA CAREGIVERS: AN INTEGRATIVE REVIEW

Abstract Alzheimer’s disease is a serious illness with an extended caregiving experience however care coordination interventions often lack integration of palliative care. The aim of this integrative review is to identify existing care coordination interventions which integrate palliative care for community dwelling individuals with dementia and their caregivers. An integrative review guided by the Whittemore and Knafl framework was conducted, and the Mixed Methods Appraisal Tool was utilized to assess study quality. The systematic search was initially conducted in June 2021 and repeated in May 2023 to ensure no additional studies were available in collaboration with a medical informationist. Nine interventions across eighteen publications were identified that incorporated informal family caregivers and were aimed at improving care coordination for community dwelling PLWD and their caregivers. Only a single intervention used the term palliative care while the remaining interventions included traditional components of palliative care such as advance care planning, symptom management, and emotional support. Many existing care coordination interventions are not grounded in theory or conceptual models and have been studied in a homogenous sample which is not representative of the population. Further study of the existing interventions in a more heterogenous sample is needed. Additional research is necessary to better understand the lived experience of those persons with dementia and their caregivers to reduce burden associated with care coordination activities.

Dementia in multimorbidity: scoping review and priorities for research and care

AbstractBackgroundMost people with clinical dementia have at least two other conditions. This co‐occurrence of multiple conditions, known as multimorbidity, is associated with worse quality of life, increased mortality and greater healthcare costs. However, there is limited research on the bidirectional interaction of physical multimorbidity and all‐cause dementia.We aimed to review and summarize key themes in this area, especially in the context of recent pharmacological advances.MethodWe searched PubMed and Google Scholar, updating the search strategy of a 2014 review of comorbidity and dementia. We added new key words reflecting recent trends in Alzheimer’s disease research, including: “amyloid”, “biomarker” and “disease‐modifying”. We searched the resulting papers’ references and citations and generated a narrative review of the literature grouped by research methodology.ResultSeveral key themes emerged from the published literature. Epidemiological studies confirmed that most people with dementia have multimorbidity. They additionally identified multimorbidity as a risk factor for dementia or cognitive impairment and found it to be associated with dementia progression and worse quality of life.Studies on the association between multimorbidity and biomarkers of neurodegeneration were either negative or found an inverse relationship. People with multimorbidity were found to be significantly under‐represented in clinical trials, especially those of dementia drugs.Qualitative research on healthcare delivery highlighted the importance of family carers and communication between providers, and a review of care coordination interventions identified important factors that optimize transitions of care.There was also recognition of the need to address racial and ethnic disparities in people with multimorbidity and dementia. Several papers called for a comprehensive understanding of dementia in relation to the whole person and society.ConclusionHaving multiple conditions alongside dementia poses challenges for patients, caregivers and clinicians. Multimorbidity is an important consideration for those designing representative clinical trials, and it may be more difficult to treat dementia in people with several comorbid conditions.This work highlights the need for specific research into the relative contributions of multimorbidity and other person‐centered characteristics on clinically meaningful outcomes. In the context of new and costly therapies, this will inform equitable allocation of research and healthcare resources.

Growth of Remote Therapeutic Monitoring Lands New Opportunities for Case Management.

An increase in the use of remote therapeutic monitoring (RTM) has been spurred by nationwide factors including the COVID-19 pandemic, authorized reimbursement of RTM by the Centers for Medicare & Medicaid Services, and more frequent use of big data analytics in health care delivery. This article discusses the use of RTM by care teams at the point of care and explores the role of the case manager in RTM to address patients' unmet needs. Although RTM may be utilized across inpatient and outpatient levels of care, this article focuses on outpatient care such as community clinics, provider groups, and home health care. When implemented along with care management interventions, RTM applications have the potential to improve patient adherence, enhance communication between patients and their providers, streamline resource allocation, and address social determinants of health impacting patient care and outcomes. RTM reimbursement models are rapidly evolving, utilizing real-world and patient-reported data to identify and initiate timely, individualized solutions that meet the holistic needs of each patient. Use of an RTM system allows the case manager to build rapport with the patient while quickly identifying care gaps and delivering appropriate interventions that can maximize patient outcomes. RTM can drive savings and bring revenue to the system or practice while providing salient documentation of social determinants of health that can be addressed with validation of proven care coordination interventions.

Abstract 14711: Prediction of Persistent High-Need High-Cost Cardiology Patients With and Without Renal Failure

Introduction: Heart failure (HF) and coronary artery disease (CAD) are increasingly complex disease entities, in particular in older patients with multiple long-term conditions. High-Need High-Cost (HNHC) patients are at risk of receiving inefficient care that does not contribute to better outcomes. Prediction models may help to identify patients at risk of becoming HNHC with potential benefit for care coordination interventions. Aim: To predict persistent HNHC status at outpatient presentation for cardiovascular populations with HF, CAD, with and without renal failure (HF&RF; CAD&RF). Methods: We performed a retrospective cohort study in the claims database of a large healthcare insurer in the Netherlands. We included patients with consecutive data between 2015 - 2019, at their first outpatient appointment in 2016. Potential predictors were based on the previously published Persistent High Utilizer (PHU) model and collected in the year prior to presentation. HF, CAD and RF were defined by Diagnosis Treatment Combination insurance codes. The outcome of interest was PHU status, defined as belonging to the top 10% of total annualized healthcare expenditures for three consecutive years. To account for inflation, all costs were scaled towards 2015. Predictor effects were quantified through logistic multivariable regression analysis as odds ratios. Models were validated internally by bootstrapping procedure. Model performance was assessed as discrimination, quantified by the C-statistic. Results: 219.567 patients were included, of whom 2.0% ( n =4286) became PHU. The most important predictors were chronic kidney disease diagnosis (OR 3.1 95%CI 2.4-4.1), gastroenterology involvement (OR 3.0 95%CI 2.7-3.3) and COPD diagnosis (OR 2.1 95%CI 1.8-2.5). Model performance in the overall population was good (C-statistic 0.77). Model performance varied in the more homogeneous populations with HF ( n =2261; n =157 PHU), CAD ( n =7221; n =292 PHU), HF&RF ( n =163; n =40 PHU) and CAD&RF ( n = 196; n =34 PHU) resulting in C-statistics of 0.74, 0.78, 0.60 and 0.67 respectively. Conclusions: Persistent HNHC status can be predicted in the outpatient setting for patients with HF and CAD. These models can be used to select cardiology patients for HNHC care coordination.

Measure what matters: considerations for outcome measurement of care coordination for children with neurodevelopmental disabilities and medical complexity.

Care Coordination (CC) is a significant intervention to enhance family's capacity in caring for children with neurodevelopmental disability and medical complexity (NDD-MC). CC assists with integration of medical and behavioral care and services, partnerships with medical and community-based supports, and access to medical, behavioral, and educational supports and services. Although there is some consensus on the principles that characterize optimal CC for children with NDD-MC, challenges remain in measuring and quantifying the impacts of CC related to these principles. Two key challenges include: (1) identification of measures that capture CC impacts from the medical system, care provider, and family perspectives; and (2) recognition of the important community context outside of a hospital or clinical setting. This study used a multilevel model variant of the triangulation mixed methods design to assess the impact of a CC project implemented in Alberta, Canada, on family quality of life, resource use, and care integration at the broader environmental and household levels. At the broader environmental level, we used linked administrative data. At the household level we used quantitative pre-post survey datasets, and aggregate findings from qualitative interviews to measure group-level impacts and an embedded multiple-case design to draw comparisons, capture the nuances of children with NDD-MC and their families, and expand on factors driving the high variability in outcome measures. Three theoretical propositions formed the basis of the analytical strategy for our case study evidence to explore factors affecting the high variability in outcome measures. This study expanded on the factors used to measure the outcomes of CC and adds to our understanding of how CC as an intervention impacts resource use, quality of life, and care integration of children with NDD-MC and their families. Given the heterogeneous nature of this population, evaluation studies that account for the variable and multi-level impacts of CC interventions are critical to inform practice, implementation, and policy of CC for children with NDD-MC.

Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study.

For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients' needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients' full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs. In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey. Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

Transforming Health Care from Volume to Value: Leveraging Care Coordination Across the Continuum

The care continuum represents a longitudinal, patient-centered view of clinical care within an integrated health system, providing patients consistency in discrete healthcare encounters, while accounting for their medical needs and personal context. Failure of effective care coordination occurs when patient transitions between care settings are disjointed or fragmented. These failures account for a substantial portion of the waste in the United States healthcare system. In this article, we propose target areas for care coordination interventions and describe potential cost savings. We focus on maximizing the appropriate utilization of the Emergency Department by promoting urgent cares, primary care providers, community healthcare workers, targeted interventions for high utilizers, observation units, and hospital-at-home programs. We describe strategies for working across the care continuum to build multimodal post-discharge care programs and partnerships, such as nurse discharge navigators, early clinician follow-up, specialty post-acute care clinic visits, community partnerships, and collaborations with post-acute care settings. To help drive improvement across other hospital systems, we propose a tangible blueprint for interventions to address failures of care coordination across the care continuum.

Estimating the workload of a multi-disciplinary care team using patient-level encounter histories

ABSTRACT Healthcare spending in the United States is concentrated on a small percentage of individuals, with 5% of the population accounting for 50% of annual spending. Many patients among the top 5% of spenders have complex health and social needs. Care coordination interventions, often led by a multidisciplinary team consisting of nurses, community health workers and social workers, are one strategy for addressing the challenges facing such patients. Care teams strive to improve health outcomes by forging strong relationships with clients, visiting them on a regular basis, reconciling medications, arranging primary and speciality care visits, and addressing social needs such as housing instability, unemployment and insurance. In this paper, we propose a simulation algorithm that samples longitudinal patient-level encounter histories to estimate the staffing needs for a multidisciplinary care team. Our numerical results illustrate multiple uses of the algorithm for staffing under stationary and non-stationary patient enrollment rates.

Lessons learnt from the process of designing care coordination interventions through participatory action research in public healthcare networks of six Latin American countries

BackgroundThe participation of health professionals in designing interventions is considered vital to effective implementation, yet in areas such as clinical coordination is rarely promoted and evaluated. This study, part of Equity-LA II, aims to analyse the design process of interventions to improve clinical coordination, taking a participatory-action-research (PAR) approach, in healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. This participatory process was planned in four phases, led by a local steering committee (LSC): (1) dissemination of problem analysis results and creation of professionals’ platform, (2) selection of problems and intervention (3) intervention design and planning (4) adjustments after evaluation of first implementation stage.MethodsA descriptive qualitative study based on documentary analysis, using a topic guide, was conducted in each intervention network. Documents produced regarding the intervention design process were selected. Thematic content analysis was conducted, generating mixed categories taken from the topic guide and identified from data. Main categories were LSC characteristics, type of design process (phases, participants’ roles, methods) and associated difficulties, coordination problems and interventions selected.ResultsLSCs of similar composition (managers, professionals and researchers) were established, with increasing membership in Chile and high turnover in Argentina, Colombia and Mexico. Following results dissemination and selection of problems and interventions (more participatory in Chile and Colombia: 200–479 participants), the interventions were designed and planned, resulting in three different types of processes: (1) short initial design with adjustments after first implementation stage, in Colombia, Brazil and Mexico; (2) longer, more participatory process, with multiple cycles of action/reflection and pilot tests, in Chile; (3) open-ended design for ongoing adaptation, in Argentina and Uruguay. Professionals’ time and the political cycle were the main barriers to participation. The clinical coordination problem selected was limited communication between primary and secondary care doctors. To address it, through discussions guided by context and feasibility criteria, interventions based on mutual feedback were selected.ConclusionsAs expected in a flexible PAR process, its rollout differed across countries in participation and PAR cycles. Results show that PAR can help to design interventions adapted to context and offers lessons that can be applied in other contexts.

Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care

Health-related social needs are increasingly being screened for in primary care practices, but it remains unclear how much additional financing is required to address those needs to improve health outcomes. To estimate the cost of implementing evidence-based interventions to address social needs identified in primary care practices. A decision analytical microsimulation of patients seen in primary care practices, using data on social needs from the National Center for Health Statistics from 2015 through 2018 (N = 19 225) was conducted. Primary care practices were categorized as federally qualified health centers (FQHCs), non-FQHC urban practices in high-poverty areas, non-FQHC rural practices in high-poverty areas, and practices in lower-poverty areas. Data analysis was performed from March 3 to December 16, 2022. Simulated evidence-based interventions of primary care-based screening and referral protocols, food assistance, housing programs, nonemergency medical transportation, and community-based care coordination. The primary outcome was per-person per-month cost of interventions. Intervention costs that have existing federally funded financing mechanisms (eg, the Supplemental Nutrition Assistance Program) and costs without such an existing mechanism were tabulated. Of the population included in the analysis, the mean (SD) age was 34.4 (25.9) years, and 54.3% were female. Among people with food and housing needs, most were program eligible for federally funded programs, but had low enrollment (eg, due to inadequate program capacity), with 78.0% of people with housing needs being program eligible vs 24.0% enrolled, and 95.6% of people with food needs being program eligible vs 70.2% enrolled. Among those with transportation insecurity and care coordination needs, eligibility criteria limited enrollment (26.3% of those in need being program eligible for transportation programs, and 5.7% of those in need being program eligible for care coordination programs). The cost of providing evidence-based interventions for these 4 domains averaged $60 (95% CI, $55-$65) per member per month (including approximately $5 for screening and referral management in clinics), of which $27 (95% CI, $24-$31) (45.8%) was federally funded. While disproportionate funding was available to populations seen at FQHCs, populations seen at non-FQHC practices in high-poverty areas had larger funding gaps (intervention costs not borne by existing federal funding mechanisms). In this decision analytical microsimulation study, food and housing interventions were limited by low enrollment among eligible people, whereas transportation and care coordination interventions were more limited by narrow eligibility criteria. Screening and referral management in primary care was a small expenditure relative to the cost of interventions to address social needs, and just under half of the costs of interventions were covered by existing federal funding mechanisms. These findings suggest that many resources are necessary to address social needs that fall largely outside of existing federal financing mechanisms.

Mental Health Care Use Among Children and Adolescents With High Health Care Costs in Ontario, Canada

Research on patients with high health care costs has examined mainly adults, with little focus on mental health care use. To examine the characteristics and costs of children and adolescents with high health care costs who use mostly mental health care and whether and why they persist in the high-cost state. This population-based, retrospective cohort study used health care records from Ontario, Canada, on all children and adolescents (age 0-17 years) covered under a universal health care system from January 1, 2012, to December 31, 2019. All children and adolescents in and above the 90th percentile of the cost distribution in 2012 for whom costs related to mental health care accounted for 50% or more of their costs were defined as patients with high mental health care costs. Data were analyzed from August 2019 to December 2022. High health care costs. Patients with high mental health care costs were characterized in terms of their sociodemographic characteristics; chronic physical health, mental health, and behavioral conditions; and health care costs (in 2021 Canadian dollars) by health service and type of care (mental health care vs non-mental health care). Patients were followed up until 2019 to assess whether they persisted in the high-cost state and to examine factors associated with persisting in that state. In 2012, there were 273 490 children and adolescents with high health care costs (mean [SD] age, 6.43 [5.99] years; 55.8% male; mean cost, $7936.40; 95% CI, $7850.30-$8022.40). Of these, 20 463 (7.5%) were classified as having high mental health care costs (mean cost, $10 040.20; 95% CI, $9822.80-$10 257.50). Asthma (30.3%), attention-deficit/hyperactivity disorder (35.8%), and mood and/or anxiety disorders (94.9%) were the most common chronic physical, behavioral, or mental health conditions. Few patients with high mental health care costs persisted in the high-cost state beyond 3 years (19.0%). Mood and/or anxiety disorders (relative risk ratio [RRR], 6.17; 95% CI, 3.19-11.96) and schizophrenia spectrum disorders (RRR, 2.98; 95% CI, 2.14-4.14) were identified as the main factors associated with persistence in the high-cost state. In this cohort study of children and adolescents with high health care costs, some patients had high levels of mental health care use and high costs of care, but few of these persisted in the high-cost state for 3 or more years. These findings may help inform the development of care coordination interventions and service delivery models, such as youth integrated services, to reduce costs and improve outcomes for children and adolescents.

Model for Achieving a Coordinated Access to Lung Cancer Care in Selected Public Health Facilities in KwaZulu-Natal, South Africa: Protocol for a Qualitative Study.

Timely delivery of high-quality cancer care to all patients is barely achieved in South Africa and many other low- and middle-income countries, mainly due to poor care coordination and access to care services. After health care visits, many patients leave facilities confused about their diagnosis, prognosis, options for treatment, and the next steps in their care continuum. They often find the health care system disempowering and inaccessible, thereby making access to health care services inequitable, with the resultant outcome of increased cancer mortality rates. The aim of this study is to propose a model for cancer care coordination interventions that can be used to guide and achieve coordinated access to lung cancer care in the selected public health care facilities in KwaZulu-Natal. This study will be conducted through a grounded theory design and an activity-based costing approach that will include health care providers, patients, and their caregivers. The study participants will be purposively selected, and a nonprobability sample will be selected based on characteristics, experiences of the health care providers, and the objectives of the study. With the study's objectives in mind, communities in Durban and Pietermaritzburg were selected as study sites, for the study along with the 3 public health facilities that provide cancer diagnosis, treatment, and care in the province. The study involves a range of data collection techniques, namely, in-depth interviews, evidence synthesis reviews, and focus group discussions. A thematic and cost-benefit analysis will be used. This study receives support from the Multinational Lung Cancer Control Program. The study obtained ethics approval and gatekeeper permission from the University's Ethics Committee and the KwaZulu-Natal Provincial Department of Health, as it is being conducted in health facilities in KwaZulu-Natal province. As of January 2023, we had enrolled 50 participants, both health care providers and patients. Dissemination activities will involve community and stakeholder dissemination meetings, publications in peer-reviewed journals, and presentations at regional and international conferences. This study will provide comprehensive data to inform and empower patients, professionals, policy architects, and related decision makers to manage and improve cancer care coordination. This unique intervention or model will address the multifactorial problem of cancer health disparities. If successful, this study will affect the design and implementation of coordination programs to promote optimal cancer care for underserved patients. DERR1-10.2196/34341.

Do Families Exposed to Adverse Childhood Experiences Report Family Centered Care?

Background: Youth from marginalized groups may be less likely to receive quality health care services. Adverse Childhood Experiences (ACEs) are known to impact long-term health, but it is unclear if there is a relationship between ACEs and receipt of Family Centered Care (FCC)—one indicator of high-quality health care. To assess this relationship, this study used a nationally representative sample of youth from the National Survey of Children’s Health 2016–2017 combined data set. Caregivers of children who had at least one health care visit in the last 12 months (sub-sample n = 63,662) were asked about five indicators of FCC including if they felt the provider: (1) spent enough time, (2) listened carefully, (3) helped family feel like a partner, (4) provided information requested, and (5) showed sensitivity to culture. Methods: Logistic regression analyses examined the association between ACE score and each FCC quality indicator, as well between ACEs score and the overall FCC dichotomous score. Results: ACE exposure did not significantly predict access to a health care visit in the past 12 months. However, children with higher rates of ACEs were significantly less likely to receive FCC. Other factors that significantly predicted lower FCC included child race and ethnicity, insurance type, language in the home, and access to a regular health provider. Conclusions: Providers and health systems must identify, implement, and advocate for effective trauma-informed and care coordination interventions that ensure quality health care services for vulnerable children and families.

Social workers coordination in primary healthcare for patients with complex needs: A scoping review

Introduction Care coordination has been part of social work for some time. It has been recognized as contributing to care coordination for long-term care for the elderly and mental health but less is known about their contribution in primary care with patients with complex health and social needs. As social workers are increasingly present in primary healthcare, this scoping review aims to provide a synthesis of social workers’ coordination activities for patients with complex needs in primary healthcare. Methods CINAHL, Medline, Scopus, SocioIndex, Social Work Abstracts, and ProQuest databases were searched, from 2004 to 2020 for peer-reviewed literature. A thematic analysis using deductive and inductive approaches was used to conduct this scoping review. Results Eighteen studies on 11 different care coordination interventions were included. The care coordination activities have been classified into four categories: 1) activities that target the patient, family, and caregivers; 2) activities that target health and social care professionals and services; 3) activities that link the patient and family with health and social professionals and services; and 4) cross-cutting activities that support and enhance other activity. Discussion A variety of care coordination interventions conducted by social workers were identified, all of which included related but different activities. Still, the common aim is to reduce fragmentation of care. Social workers, because of their disciplinary skills characterized by linkages to nonmedical services, can make a significant contribution to the coordination of care in primary health care, in collaboration with nurses.

Adaptations to relational facilitation for two national care coordination programs during COVID-19.

Adaptations to implementation strategies are often necessary to support adoption and scale-up of evidence-based practices. Tracking adaptations to implementation strategies is critical for understanding any impacts on outcomes. However, these adaptations are infrequently collected. In this article we present a case study of how we used a new method during COVID-19 to systematically track and report adaptations to relational facilitation, a novel implementation strategy grounded in relational coordination theory. Relational facilitation aims to assess and improve communication and relationships in teams and is being implemented to support adoption of two Quadruple Aim Quality Enhancement Research Initiative (QA QUERI) initiatives: Care Coordination and Integrated Case Management (CC&ICM) and the Transitions Nurse Program for Home Health Care (TNP-HHC) in the Veterans Health Administration (VA). During 2021-2022, relational facilitation training, activities and support were designed as in-person and/or virtual sessions. These included a site group coaching session to create a social network map of care coordination roles and assessment of baseline relationships and communication between roles. Following this we administered the Relational Coordination Survey to assess the relational coordination strength within and between roles. COVID-19 caused challenges implementing relational facilitation, warranting adaptations. We tracked relational facilitation adaptations using a logic model, REDCap tracking tool based on the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) with expanded Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) dimensions, and member checking. Adaptations were analyzed descriptively and for themes using matrix content analysis. COVID-19's impact within the VA caused barriers for implementing relational facilitation, warranting eight unique adaptations to the implementation strategy. Most adaptations pertained to changing the format of relational facilitation activities (n = 6; 75%), were based on external factors (n = 8; 100%), were planned (n = 8; 100%) and initiated by the QA QUERI implementation team (n = 8; 100%). Most adaptations impacted adoption (n = 6; 75%) and some impacted implementation (n = 2; 25%) of the CC&ICM and TNP-HHC interventions. Systematically tracking and discussing adaptations to relational facilitation during the COVID-19 pandemic enhanced engagement and adoption of two VA care coordination interventions. The impact of these rapid, early course adaptations will be followed in subsequent years of CC&ICM and TNP-HHC implementation.

Coordination Models for Cancer Care in Low- and Middle-Income Countries: A Scoping Review.

Background: The coordination of cancer care among multiple providers is vital to improve care quality and ensure desirable health outcomes across the cancer continuum, yet evidence is scarce of this being optimally achieved in low- and middle-income countries (LMICs). Objective: Through this scoping review, our objective was to understand the scope of cancer care coordination interventions and services employed in LMICs, in order to synthesise the existing evidence and identify key models and their elements used to manage and/or improve cancer care coordination in these settings. Methods: A detailed search strategy was conducted, aligned with the framework of Arksey and O’Malley. Articles were examined for evidence of coordination interventions used in cancer care in LMICs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension Guidelines for Scoping Reviews, which included a checklist and explanation. The PRISMA flow diagram was utilised to report the screening of results. Data were extracted, categorised and coded to allow for a thematic analysis of the results. Results: Fourteen studies reported on coordination interventions in cancer care in LMICs. All studies reported a positive impact of cancer coordination interventions on the primary outcome measured. Most studies reported on a patient navigation model at different points along the cancer care continuum. Conclusions: An evidence-based and culturally sensitive plan of care that aims to promote coordinated and efficient multidisciplinary care for patients with suspicion or diagnosis of cancer in LMICs is feasible and might improve the quality of care and efficiency.

Improving patient well-being in the United States through care coordination interventions informed by social determinants of health.

Health and well-being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim-driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well-being. To address the gap of risk-informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non-randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N=216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t-tests were incorporated to evaluate statistical significance of the intervention group. Impact on well-being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well-being [feeling anxious (t=4.051; p<0.000)] and reduced SDOH barriers [food access (t=4.662; p<0.000); housing (t=2.203; p=0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well-being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well-being.

Associations between illness burden and care experiences among Medicare beneficiaries before or after a cancer diagnosis

IntroductionTo understand associations between a new measure of illness burden and care experiences in a large, national sample of Medicare beneficiaries surveyed before or after a cancer diagnosis. Materials and MethodsThe SEER-CAHPS Illness Burden Index (SCIBI) was previously developed using Surveillance, Epidemiology, and End Results (SEER)–Consumer Assessment of Healthcare Providers and Systems (CAHPS) linked data. The SCIBI provides a standardized morbidity score based on self- and other-reported information from 8 domains and proxies relative risk of 12-month, all-cause mortality among people surveyed before or after a cancer diagnosis. We analyzed a population of Medicare beneficiaries (n = 116,735; 49% fee-for-service and 51% Medicare Advantage [MA]; 73% post-cancer diagnosis) surveyed 2007–2013 to understand how their SCIBI scores were associated with 12 different care experience measures. Frequentist and Bayesian multivariable regression models adjusted for standard case-mix adjustors, enrollment type, timing of cancer diagnoses relative to survey, and survey year. Results and DiscussionSCIBl scores were associated (P < .001) in frequentist models with better ratings of Health Plan (coefficient ± standard error: 0.33 ± 0.08) and better Getting Care Quickly scores (0.51 ± 0.09). In Bayesian models, individuals with higher illness burden had similar results on the same two measures and also reported reliably worse Overall Care experiences (coefficient ± posterior SD: −0.17 ± 0.06). Illness burden may influence how people experience care or report those experiences. Individuals with greater illness burdens may need intensive care coordination and multilevel interventions before and after a cancer diagnosis.

Sustainment stories: a qualitative analysis of barriers to sustainment of the National Rural Transitions of Care Nurse Program

BackgroundUnderstanding how to successfully sustain evidence-based care coordination interventions across diverse settings is critical to ensure that patients continue to receive high quality care even after grant funding ends. The Transitions Nurse Program (TNP) is a national intervention in the Veterans Administration (VA) that coordinates care for high risk veterans transitioning from acute care VA medical centers (VAMCs) to home. As part of TNP, a VA facility receives funding for a full-time nurse to implement TNP, however, this funding ends after implementation. In this qualitative study we describe which elements of TNP sites planned to sustain as funding concluded, as well as perceived barriers to sustainment.MethodsTNP was implemented between 2016 and 2020 at eleven VA medical centers. Three years of funding was provided to each site to support hiring of staff, implementation and evaluation of the program. At the conclusion of funding, each site determined if they would sustain components or the entirety of the program. Prior to the end of funding at each site, we conducted midline and exit interviews with Transitions nurses and site champions to assess plans for sustainment and perceived barriers to sustainment. Interviews were analyzed using iterative, team-based inductive deductive content analysis to identify themes related to planned sustainment and perceived barriers to sustainment.ResultsNone of the 11 sites planned to sustain TNP in its original format, though many of the medical centers anticipated offering components of the program, such as follow up calls after discharge to rural areas, documented warm hand off to PACT team, and designating a team member as responsible for patient rural discharge follow up. We identified three themes related to perceived sustainability. These included: 1) Program outcomes that address leadership priorities are necessary for sustainment.; 2) Local perceptions of the need for TNP or redundancy of TNP impacted perceived sustainability; and 3) Lack of leadership buy-in, changing leadership priorities, and leadership turnover are perceived barriers to sustainment.ConclusionsUnderstanding perceived sustainability is critical to continuing high quality care coordination interventions after funding ends. Our findings suggest that sustainment of care coordination interventions requires an in-depth understanding of the facility needs and local leadership priorities, and that building adaptable programs that continually engage key stakeholders is essential.

Evaluating the effectiveness of care coordination interventions designed and implemented through a participatory action research process: Lessons learned from a quasi-experimental study in public healthcare networks in Latin America.

Despite increasing recommendations for health professionals to participate in intervention design and implementation to effect changes in clinical practice, little is known about this strategy's effectiveness. This study analyses the effectiveness of interventions designed and implemented through participatory action research (PAR) processes in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay to improve clinical coordination across care levels, and offers recommendations for future research. The study was quasi-experimental. Two comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys of a sample of primary and secondary care doctors (174 doctors/network/year) were conducted using the COORDENA® questionnaire. Most of the interventions chosen were based on joint meetings, promoting cross-level clinical agreement and communication for patient follow-up. Outcome variables were: a) intermediate: interactional and organizational factors; b) distal: experience of cross-level clinical information coordination, of clinical management coordination and general perception of coordination between levels. Poisson regression models were estimated. A statistically significant increase in some of the interactional factors (intermediate outcomes) -knowing each other personally and mutual trust- was observed in Brazil and Chile INs; and in some organizational factors -institutional support- in Colombia and Mexico. Compared to CNs in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors. In distal outcomes, care consistency items improved in Brazil, Colombia and Uruguay INs; and patient follow-up improved in Chile and Mexico. General perception of clinical coordination increased in Brazil, Colombia and Mexico INs. Compared to CNs in 2017, only Brazil showed significant differences. Although more research is needed, results show that PAR-based interventions improved some outcomes regarding clinical coordination at network level, with differences between countries. However, a PAR process is, by definition, slow and gradual, and longer implementation periods are needed to achieve greater penetration and quantifiable changes. The participatory and flexible nature of interventions developed through PAR processes poses methodological challenges (such as defining outcomes or allocating individuals to different groups in advance), and requires a comprehensive mixed-methods approach that simultaneously evaluates effectiveness and the implementation process to better understand its outcomes.