Care Coordination Services Research Articles

Generating Team-Based Strategies to Reduce Health Inequity in Cancer Care.

Despite increased emphases on reducing racial disparities in the U.S. health care system, interprofessional care teams may inadvertently perpetuate health disparities through lack of awareness or experience in supporting individualized, patient-centered goals of care. Racial disparities can lead to health inequity. Persistent health disparity gaps exist among Black patients with multiple myeloma (MM) when compared with non-Black patients. Black patients experience a two-fold increase in MM risk and earlier age of onset compared with non-Black patients. Black patients are also less likely to receive timely access to some therapies, undergo autologous stem cell transplant, or enroll in clinical trials. This article describes a large-scale, equity-focused implementation science initiative aimed at identifying and overcoming racial disparities and health inequity among patients with MM through quality improvement goals identified by each of the interprofessional cancer care teams. Interprofessional cancer care teams in two large oncology systems as well as four community clinics were engaged in this study along with their patients with MM. Geographic areas included the following: Chicago, IL; Washington, DC; Charlotte, NC; Columbus, OH; Denver, CO; and Indianapolis, IN. Interprofessional teams included hematologists/oncologists, primary care physicians, nurse practitioners/physician assistants, and case managers/nurse navigators. Teams collectively examined and compared their own beliefs and attitudes about their patients' goals for MM treatment and management versus those of their patients to uncover and address discordances. Medical records from the clinics were audited to evaluate disparities in treatment and practice at the point of care. Live, team-based audit-feedback sessions were implemented among teams to examine data sets, as well as utilize the data to address interprofessional factors that could enhance more equitable care. Data from comparative surveys between patients and interprofessional team members revealed significant discordances that enabled health care teams to recognize gaps and identify ways to improve patient-centered care, such as shared decision-making. Through audit-feedback sessions, interprofessional teams were able to collaboratively meet and discuss methods to improve access to care coordination services and other strategies aimed at alleviating disparities. Baseline chart audits revealed and confirmed disparities of care including patient/disease characteristics, treatment history, clinical practice metrics, and patient-centered measures. Follow-up chart audits conducted 6 months later measured changes in documented practice behavior. Action plans developed by the interprofessional teams as a result of this study intend to address sustainable reductions in health disparities among patients with MM to improve health equity and overall care. This implementation science initiative and data results have several implications for case managers caring for diverse patients with MM in both large health systems and smaller community practices. Results punctuate the importance of identifying and supporting diverse patients' individualized goals and preferences in their care journey to mitigate health inequity and maximize health outcomes. The value of working collaboratively as an interprofessional team is evident in the study results, as is the role of the case manager in appropriate resource allocation to mitigate health disparities. Lessons learned from this initiative may also be applied to other case management settings where complex care delivery and interprofessional teams are at work.

Designing Interoperable Health Care Services Based on Fast Healthcare Interoperability Resources: Literature Review.

With the advent of the digital economy and the aging population, the demand for diversified health care services and innovative care delivery models has been overwhelming. This trend has accelerated the urgency to implement effective and efficient data exchange and service interoperability, which underpins coordinated care services among tiered health care institutions, improves the quality of oversight of regulators, and provides vast and comprehensive data collection to support clinical medicine and health economics research, thus improving the overall service quality and patient satisfaction. To meet this demand and facilitate the interoperability of IT systems of stakeholders, after years of preparation, Health Level 7 formally introduced, in 2014, the Fast Healthcare Interoperability Resources (FHIR) standard. It has since continued to evolve. FHIR depends on the Implementation Guide (IG) to ensure feasibility and consistency while developing an interoperable health care service. The IG defines rules with associated documentation on how FHIR resources are used to tackle a particular problem. However, a gap remains between IGs and the process of building actual services because IGs are rules without specifying concrete methods, procedures, or tools. Thus, stakeholders may feel it nontrivial to participate in the ecosystem, giving rise to the need for a more actionable practice guideline (PG) for promoting FHIR's fast adoption. This study aimed to propose a general FHIR PG to facilitate stakeholders in the health care ecosystem to understand FHIR and quickly develop interoperable health care services. We selected a collection of FHIR-related papers about the latest studies or use cases on designing and building FHIR-based interoperable health care services and tagged each use case as belonging to 1 of the 3 dominant innovation feature groups that are also associated with practice stages, that is, data standardization, data management, and data integration. Next, we reviewed each group's detailed process and key techniques to build respective care services and collate a complete FHIR PG. Finally, as an example, we arbitrarily selected a use case outside the scope of the reviewed papers and mapped it back to the FHIR PG to demonstrate the effectiveness and generalizability of the PG. The FHIR PG includes 2 core elements: one is a practice design that defines the responsibilities of stakeholders and outlines the complete procedure from data to services, and the other is a development architecture for practice design, which lists the available tools for each practice step and provides direct and actionable recommendations. The FHIR PG can bridge the gap between IGs and the process of building actual services by proposing actionable methods, procedures, and tools. It assists stakeholders in identifying participants' roles, managing the scope of responsibilities, and developing relevant modules, thus helping promote FHIR-based interoperable health care services.

Needs of youth enrolled in a statewide system of care: A latent class analysis

ObjectiveAccess to wraparound care coordination within systems of care (SOC) is increasing nationwide for youth with emotional and behavioral disorders and their families. Though wraparound care coordination serves a broad population of youth who experience a variety of complex needs, less is known about the impact of wraparound services based on these specified needs. Using latent class analysis, the current study aimed to first identify classes of youth based on their presenting needs and then examine the impact of class membership on treatment experiences and outcomes at baseline and six-month follow-up. MethodCaregiver-reported data from 1243 youth enrolled in wraparound care coordination services within a statewide SOC were used. Latent class analysis was used to determine classes of youth needs and regression results examined whether baseline characteristics, child and family team meeting characteristics, mental health outcomes, and perceptions of care differed based on identified classes. ResultsResults revealed five distinct classes of youth needs: Behavioral Needs, ADHD-related Behavior Needs, Educational Needs, Mental Health Needs, and Multi-Needs. Overall participants saw improvement in all follow-up outcomes. Significant between-class differences were also found in all outcome categories measured. ConclusionThe current results further solidify the benefits of comprehensive wraparound care within a SOC. Additionally, understanding youth’s needs and their impact on treatment services allows for more targeted care for youth and their families.

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.

1037-P: Evaluating the Impact of Telemedicine Care Coordination on Access to Care in Oregon’s Pediatric Type 1 Diabetes Population

Background: Children with type 1 diabetes (T1D) require close monitoring with visits every 3-4 months. COVID-19-induced telemedicine expansion (TE) may alleviate the challenge of high visit frequency that children with type 1 diabetes (T1D) face. However, telemedicine’s impact on access to care may be limited if patients lack adequate support for telemedicine. Purpose: The study objective was to evaluate the impact of telemedicine care coordination services (CCS) on visit frequency in an urban medical center without CCS versus a rural outreach program with established CCS. Methods: We evaluated EHR data from 790 children receiving care between July 2018 - December 2021. We estimated differences in likelihood of adequately-timed monitoring care (ATMC) over time by patient CCS status using Generalized Estimating Equations. Results: Just prior to TE, patients receiving CCS were 25.6% less likely to receive ATMC (95% CI: 51.6%, 114%). Following TE, likelihood of ATMC increased from 28.8% to 58.2% among those receiving CCS and decreased from 38.7% to 22.0% among those not receiving CCS; increases in ATMC were 3.55 times greater in patients receiving CCS relative to those not (95% CI: 2.10, 6.01). Conclusions: Telemedicine may only increase the number of T1D patients meeting goal visit frequency when paired with CCS. Disclosure E.S.Mitchell: None. S.B.Andrea: Research Support; Eli Lilly and Company. I.Guttmann-bauman: None.

Chronic Care Management in Medicare

Medicare involvement in the management of chronic medical conditions began through a Centers for Medicare & Medicaid Services (CMS) physician payment rule in 2015. The rule provided for payment to physicians and physician extenders (physician assistants and nurse practitioners) for coordinating care services for Medicare enrollees with at least two chronic conditions, which were expected to last at least 12 months or until the patient's death, and that place them at significant risk of death, acute exacerbation and/or decompensation, or functional decline. Conditions eligible for chronic care management were listed by CMS and procedures for implementation were created.

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.

<p>The Winter Strategy – a Multifaceted Integrated Care Intervention to Support People with Chronic and Complex Care Needs during the Australian Winter Period</p>

Introduction: Health care demands increase over the winter period, especially for people with chronic diseases. Hospital avoidance programs have potential to address seasonal surges. Methods: An integrated care intervention was provided to patients at high risk of hospitalisation during the 2017 and 2018 winters in Northern New South Wales, Australia. Patients received increased support including general practice sick day action plans, automated admission notifications to the general practitioner, and care coordination services. Outcomes were provider and patient experience and preventable hospitalisation rates. Results: The program enrolled 1244 participating patients from 37 general practices with at least 12 months follow-up. It was associated with marked improvements in provider and patient experience. However, when compared to a propensity score matched control group there was no difference in hospital utilisation or emergency presentation rates. Discussion and Conclusion: An integrated care strategy to address chronic care needs of patients in winter was well received by practitioners and patients, but did not translate to changes in hospital utilisation or emergency presentation rates. Areas for improvement include: strengthening inter-professional engagement between hospital, specialists and primary care providers, more tailored support services for patients with complex health needs, and a more expansive set of process measures beyond hospital and emergency utilisation to assess impact.

Realigning theory with evidence to understand the role of care coordination in mental health services research.

Current theoretical models intended to guide health services research and evaluation lack care coordination-its features and impacts. These aspects are critical for understanding the role of care coordination in healthcare use, quality, and outcomes. In this Focus article, we briefly review the well-known Andersen individual behavioral model (IBM) of healthcare use and the Donabedian health system and quality model (HSQM) together with recent practice-based evidence. We propose a new integrated theoretical model of healthcare and care coordination. The model can serve as a guide for future research to better understand the variation in care coordination services and delivery and its added value to improving mental health in different real-world settings.

Identifying Children With Medical Complexity for Care Coordination in Primary Care Settings.

Characteristics of a cohort of 98 children with medical complexity (CMC) insured by Medicaid were identified within an urban/rural pediatric practice for embedded nurse care coordination. Ninety percent of enrolled children fit the predefined requirements of requiring 3 or more subspecialists for their care. Neurology, orthopedic surgery, endocrinology, and gastroenterology were the most frequent subspecialists engaged in longitudinal care. The expected neurodevelopmental disabilities (cerebral palsy, spina bifida, Down syndrome, and other complex syndromes) were found in 64% of the patients. By applying a secondary definition to include children with complex neurodevelopmental or genetic syndromes, 98% of the patients were considered to be medically complex. The use of reliable and adequate criteria to identify medical complexity is important to determine which patients would most benefit from care coordination services, and our method was deemed successful.

THE POWER OF RURAL PARTNERSHIP: MEETING NEEDS AND FOSTERING INNOVATION THROUGH THE WYOMING GWEP

Abstract The challenges of supporting the health and social needs of older adults and caregivers in rural and frontier areas are well-documented. It is common for rural older adults to experience barriers in accessing geriatric specialists, care coordination services, and caregiver support and education programs. The Wyoming Geriatric Workforce Enhancement Program (WyGWEP) is an innovative partnership comprising an academic geriatrics program, primary care delivery sites, single-unit on aging representing community-based organizations, and a tribal health program. This partnership, funded by the Health Resources and Services Administration, provides the infrastructure to assess needs, provide education and training, create programs to address gaps in care, implement practice innovation, and advocate for needs of rural older adults. This symposium includes five presentations detailing the unique projects of the WyGWEP partnership and the impact of this collaborative work on a variety of stakeholders. The results of a mixed-methods evaluation of the WyGWEP partnership will describe the benefits to the partners and areas for growth. A collaborative effort to assess the needs of older adults informs recommendations to support rural aging in place. Schenck et al. will describe the adaptation of the widespread ECHO model for use with dementia caregivers in rural and remote locations. Representatives from Wyoming’s only Program for All-Inclusive Care of the Elderly (PACE) will explain the cost of a recent decision to de-fund and close this important program. Finally, the impact of a novel Chronic Care Management implementation program will be discussed, including sustainable billing revenue produced by rural primary care clinics.

CONNECTING THE DOTS: CHRONIC CARE MANAGEMENT PROGRAM IMPLEMENTATION IN RURAL PRACTICES

Abstract As the focus of healthcare changes from a “sick” care model to a population health model, primary care and specialty clinic practices have new opportunities supported through Medicare reimbursement. The incorporation of team-based care coordination programs into clinic practices is an important step towards value-based care and achieving the Triple Aim: better health for the population, better care for individuals, and lower costs through improvements. Since 2019, six rural Wyoming primary care practices have completed training to implement and expand care coordination programs. HealthTechS3 provides participating clinics with team-based training in the implementation of the Chronic Care Management Program, Behavioral Health Integration, and other billable care coordination services. To date, 301 patients have enrolled in care coordination services. These practices have generated $350,000 in revenue. Using a consolidated implementation framework as a guide, critical components of successful rural care coordination program implementation are discussed.

Performance Measurement for Opioid Use Disorder Medication Treatment and Care Retention.

Performance Measurement for Opioid Use Disorder Medication Treatment and Care Retention.

Cost of providing co-located hepatitis C treatment at a syringe service program exceeds potential reimbursement: Results from a clinical trial

BackgroundCo-located hepatitis C treatment at syringe service programs (SSP) is an emerging model of care for people who inject drugs (PWID). Implementation of these models can be informed by understanding the program costs. MethodsWe conducted an economic evaluation of a hepatitis C treatment intervention at an SSP in New York City implemented as one arm of a randomized trial from 2017 to 2021. Start-up and operating costs were determined from the treatment program's perspective using micro-costing and were compared to potential Medicaid reimbursement. We applied nationally representative unit costs and wage rates. Results are reported in 2020 USD. ResultsThe treatment program was staffed by one physician and one care coordinator. Participants were offered hepatitis C clinical evaluation and treatment, a 45-min reinfection prevention education session, and additional care coordination as needed. The trial enrolled 84 PWID with hepatitis C in the intervention arm; 64 initiated treatment and 55 achieved sustained virological response. Start-up costs including training and equipment totaled $4677. Overhead costs including rent, utilities and software totaled $2229 per month. Clinical and care coordination totaled $4867 per participant, of which $3722 was care coordination. The total cost excluding startup was $6035 per enrolled participant and $7921 per treated participant; estimated potential reimbursement was $628 per enrolled participant. ConclusionOur results provide insight to US-based SSPs seeking to provide co-located hepatitis C care and highlight the intensive care coordination services provided. Successful implementation likely requires funding sources beyond health insurers or substantial changes to insurance reimbursement for care coordination.

Creating a proactive interdisciplinary approach to care: Embedding oncology care coordination within an oncology patient and family support program.

51 Background: The benefits of providing psycho-oncology services have been well documented in producing better effective team collaboration, patient outcomes, and reduced healthcare utilization. Cedars-Sinai Cancer spans five locations and serves over 11,000 patients a year. Their robust Patient and Family Support program (PFSP) includes psychiatry, palliative medicine, social work, nutrition, cancer rehabilitation, survivorship, and chaplaincy to envelop patients in multiple dimensions of support. A new oncology care coordination (CC) model embedded a social work (SW) and nurse (RN) CC within PFSP to identify and meet diverse unmet needs of patients through close interdisciplinary collaboration. Methods: Oncology CC was established within PFSP, containing an oncology SW CC and an oncology RN CC. Patients with higher acuity needs were identified through multiple avenues such as: health plan reporting and dashboards in the electronic medical record (EMR) providing alerts for patients with unmet needs. Preliminary data was captured on interdisciplinary collaboration and care coordination from a daily log kept by coordinators, as well as from the EMR. Results: Over 6 months (9/2021 to 2/2022), the PFSP CC team served 688 patients providing 1280 interventions. Of the 1280 interventions, 22% were coordination with other PFSP services; of which 54% was with SCM, 36% with Clinical SW, and 18% represented new referrals. 13% focused on outside services including medical devices, home health, and community resources. 6% comprised of post-discharge calls by the RN CC and 16% represented direct SW CC outreach. Care coordination such as appointment scheduling, assistance with prescriptions and communication with medical teams represented 9%, 1% and 11% of the interventions respectively. Conclusions: Results demonstrated for this subset of patients that the highest needs of oncology PFSP CC were SW and SCM, to address needs such as pain and symptom management, goals of care conversations and community resource linkage. Anecdotally, communication with primary oncology and other medical teams proved to be an essential role of the CC team, particularly to address inpatient to outpatient transitions of care. Discussion: CC team involvement is time-limited and appears to rely on the long-term relationship patients have with PFSP interdisciplinary team members for interventions to be long-lasting and effective. The CC team leveraged existing relationships that PFSP providers had established with primary oncology teams, allowing for timely care coordination. Future goals include: 1) developing an algorithm to better identify patients with higher acuity and unmet needs; 2) measuring impacts of CC services on care outcomes, health care utilization and reduced symptom burden; 3) expanding the CC team to serve more of the patient population.

Exploring Service Use Disparities among Suicidal Black Youth in a Suicide Prevention Care Coordination Intervention.

The aim of this study is to examine service utilization disparities among Black youth participating in Linking Individuals Needing Care (LINC), a 90-day research-informed suicide care coordination intervention. An open trial pilot was conducted to examine the effectiveness of LINC in increasing access to and engagement in mental health and non-mental health services among suicidal youth (N = 587). Other variables of interest included service use facilitators and service use barriers. Generalized linear mixed models with binomial distribution and logit link were performed to ascertain if service use facilitators and barriers were associated with service utilization and if disparities in service use and engagement existed between Black and White suicidal youth through a comparative analysis. Service utilization differences were found between Black and White youth. While Black and White youth were both likely to engage in individual therapy (OR = 1.398, p < .001) and non-mental health services (OR = 1.289, p < .001), utilization rates for mental health and medication management services were lower for Black (55.1% to 60.6%) youth compared to White (66.0% to 71.0%) youth. Specifically, Black youth were significantly less likely than Whites to receive medication management (OR = .466, p = .002). Systemic barriers such long waitlists for care (OR = 1.860, p = .039) and poor relationship with providers (OR = 7.680, p = .028) increased odds of engagement in non-mental health services. Clinical disorders and engagement in suicide-related behaviors increased the likelihood of obtaining care from both medication management and non-mental health services. Care coordination services for suicidal youth can increase access and engagement in mental health and non-mental health services. Culturally adapted models attending to cultural and social assets of Black families are needed to reduce disparities and suicide risk among Black youth.

A Community-Based Youth Diversion Program as an Alternative to Incarceration, Illinois, 2017-2019.

The US justice system unfairly targets youths of color; systemic reform plus interventions to keep youths out of the justice system are needed. The Juvenile Justice Collaborative provided care coordination and wraparound services to adolescents in a diversion program from 2017 to 2019 in Cook County, Illinois. Youths showed increased strengths and decreased needs by program's end. Youths who successfully completed the program showed reduced recidivism compared with nonprogram youths. Community-based alternatives to incarceration may decrease life disruption, promote positive health and social outcomes, and reduce further justice involvement. (Am J Public Health. 2022;112(9):1265-1268. https://doi.org/10.2105/AJPH.2022.306946).

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.

종양전문간호사의 노인 암환자 케어 코디네이션 경험에 관한 내용분석

Objectives This study aimed to analyze the experiences of oncology advanced practice nurses who provided care coordination services to elderly cancer patients. Methods This study was a descriptive study using content analysis method. Six oncology advanced practice nurses recruited from a University hospital were interviewed in-depth about their experiences of providing care coordination for elderly cancer patients. Data collection was conducted from September 18, 2017 to February 2, 2018. The data were analyzed using Krippendorf’s qualitative content analysis method. Results As a result, 30 themes, 14 themes clusters, and 5 categories were identified from the in-depth interviews. The 5 categories were ‘considering the characteristics of elderly cancer patients’, ‘advanced practice nurse as a partner for overall cancer treatment process’, ‘pride in the role of the advanced practice nurse’, ‘tasks for improvement of advanced practice nurse service’, ‘strategies for the improvement of nursing care for elderly cancer patients’. Conclusions Based on the results of this study, it is concluded that the benefits of care coordination service by advanced practice nurses should be recognized to provide more integrated healthcare services for elderly cancer patients. Consistent support and multidisciplinary collaboration should also be emphasized to increase the competency of advanced practice nurses in the field of oncology nursing.

Communication Over Incarceration: Improving Care Coordination Between Correctional and Community Mental Health Services.

Millions of people are incarcerated every year in the United States, many of whom have mental disorders and substance use disorders. Alongside the considerable churn of people into and out of U.S. jails and prisons, numerous barriers often impede information exchange between correctional and community mental health services, disrupting continuity of care and threatening the well-being of incarcerated and formerly incarcerated people. This Open Forum examines barriers to information sharing, a critical component of care coordination, between correctional and community mental health services and offers potential solutions to improve continuity of care in these contexts.