Care Coordination Research Articles

Care coordinator delivered Method of Levels therapy for people reporting first-episode psychosis: Experiences and views of service user, care coordinator, and team manager participants of the CAMEO trial

BackgroundWithout effective and timely support, psychosis can lead to negative personal, economic, and societal outcomes. Care coordinators play a key role in the delivery of early intervention in psychosis services, which aim to improve outcomes and promote recovery for people experiencing first-episode psychosis. Enhancing the support offered by care coordinators could improve outcomes and reduce levels of service user disengagement. This study aimed to understand participants’ views on the acceptability of a transdiagnostic talking therapy, called Method of Levels (MOL), delivered by care coordinators in early intervention in psychosis services. It also sought to understand participants’ experiences of the MOL training and supervision programme, and to identify any barriers that might impact on the implementation of the approach in routine practice.MethodsSemi-structured interviews and focus groups were conducted with service users (n = 14), care coordinators (n = 6), and team managers (n = 6) from early intervention in psychosis services. Interviews and focus groups were transcribed and reflexive thematic analysis was used to analyse the data.ResultsThree themes were identified: ‘Digging deeper to find my own solutions’; (2) ‘Prepared for practice?’; and (3) ‘Levels of implementation’. Participants described how the use of MOL enabled service users to explore problems in greater depth and generate their own solutions to these. Care coordinators generally reported feeling ready to deliver the intervention after attending MOL training and were able to integrate the approach into their practice in a flexible way. High workloads limited care coordinators’ capacity to attend MOL supervision regularly, reducing their overall confidence in delivering the approach. This impacted on the degree to which care coordinators used MOL in their practice.ConclusionsFindings suggest that MOL delivered by care coordinators could be a helpful approach for people experiencing first-episode psychosis. Care coordinators found it difficult to attend clinical supervision, however, which represents a barrier to implementation. This issue will need to be addressed before care coordinator delivered-MOL for first-episode psychosis can be evaluated in a larger study or implemented in practice.

Collaboration strategies for bridging health, behavioral health, and social services in California's Medi-Cal Whole Person Care Pilot Program.

To identify collaboration strategies used to integrate health, behavioral health, and social services for Medicaid members in California's Medi-Cal Whole Person Care Pilot program (WPC). WPC was a social care intervention implemented to identify and address eligible members' health, behavioral health, and social needs. Data included semi-structured key informant interviews conducted in 2018-2019 (n = 221) and 2021 (n = 167); pilot-level surveys; whole-network surveys of 507 organizations in all 25 pilots participating in WPC; and documents submitted by pilots to the state. Pilots served a total of 247,887 unique members between 2017 and 2021, the majority of whom were non-white (72%) and over half of whom experienced homelessness. Data were collected as part of the statewide evaluation of WPC. We analyzed qualitative data to examine strategies used by pilots to integrate care, network data to identify pilots that improved cross-sector collaboration (i.e., strengthened density or multiplexity of cross-sector ties) following WPC implementation, and comparative case analysis to identify strategies that differentiated pilots that improved collaboration from those that did not. Pilots used multiple strategies to facilitate the integration of care. Network analyses identified 10 pilots that significantly improved either density or multiplexity of cross-sector ties, and one pilot with high cross-sector collaboration prior to WPC. Compared to pilots that did not improve cross-sector collaboration, these pilots meaningfully engaged partners in program design and implementation, used braided funds, and leveraged WPC to support broader systems change. These pilots also reported fewer challenges in developing and managing contractual relationships and ensuring meaningful use of data-sharing infrastructure by frontline staff responsible for care coordination. Data sharing is necessary but not sufficient for systems alignment. Collaboration strategies focused on addressing financial barriers to integration and strengthening normative and interpersonal integration are also needed.

The Effectiveness of Electronic Medical Records (RME) On Hospital Service Quality

This study investigates The Medical Record Department (MRD) plays a pivotal role in the hospital administration framework at Shri Balaji Hospital, ensuring the efficient management and organization of patient health data. As an essential component of healthcare delivery, the MRD is responsible for maintaining accurate, comprehensive, and up-to-date records for all patients treated at the facility. This includes not only clinical data such as diagnosis, treatment plans, and surgical histories, but also administrative information vital for billing, insurance, and regulatory compliance. At Shri Balaji Hospital, the MRD operates under strict protocols to guarantee the confidentiality and security of patient records in accordance with legal and ethical standards. The department is crucial for the coordination of multidisciplinary care, as it facilitates the timely and accurate sharing of medical information between healthcare professionals, thus ensuring continuity of care and improving patient outcomes. The MRD also plays a significant role in hospital operations by supporting functions such as audits, quality control, and risk management. It ensures that the hospital adheres to national healthcare standards, including those set by accrediting bodies and government regulations. In this regard, the department’s meticulous record-keeping supports the hospital’s efforts in continuous quality improvement and patient safety initiatives.

Digital Information Ecosystems in Modern Care Coordination and Patient Care Pathways and the Challenges and Opportunities for AI Solutions

The integration of digital technologies into health care has significantly enhanced the efficiency and effectiveness of care coordination. Our perspective paper explores the digital information ecosystems in modern care coordination, focusing on the processes of information generation, updating, transmission, and exchange along a patient’s care pathway. We identify several challenges within this ecosystem, including interoperability issues, information silos, hard-to-map patient care journeys, increased workload on health care professionals, coordination and communication gaps, and compliance with privacy regulations. These challenges are often associated with inefficiencies and diminished care quality. We also examine how emerging artificial intelligence (AI) tools have the potential to enhance the management of patient information flow. Specifically, AI can boost interoperability across diverse health systems; optimize and monitor patient care pathways; improve information retrieval and care transitions; humanize health care by integrating patients’ desired outcomes and patient-reported outcome measures; and optimize clinical workflows, resource allocation, and digital tool usability and user experiences. By strategically leveraging AI, health care systems can establish a more robust and responsive digital information ecosystem, improving care coordination and patient outcomes. This perspective underscores the importance of continued research and investment in AI technologies in patient care pathways. We advocate for a thoughtful integration of AI into health care practices to fully realize its potential in revolutionizing care coordination.

Perspectives of Clients and Health Care Professionals on the Opportunities for Digital Health Interventions in Cerebrovascular Disease Care: Qualitative Descriptive Study.

Cerebrovascular diseases (CVDs) are a major and potentially increasing burden to public health. Digital health interventions (DHIs) could support access to and provision of high-quality health care (eg, outcomes, safety, and satisfaction), but the design and development of digital solutions and technologies lack the assessment of user needs. Research is needed to identify opportunities to address health system challenges and improve CVD care with primary users of services as the key informants of everyday requirements. This study aims to identify opportunities for DHIs from clients' and health care professionals' perspectives to address health system challenges and improve CVD care. This study used a qualitative, descriptive approach. Semistructured, in-person interviews were conducted with 22 clients and 26 health care professionals in a single tertiary-level hospital in Finland between August 2021 and March 2022. The data were analyzed using a deductive and inductive content analysis. Identified opportunities for DHIs in CVD care were organized according to clients, health care professionals, and data services and classified into 14 main categories and 27 generic categories, with 126 subcategories of requirements. DHIs for clients could support the long-term management of health and life changes brought on by CVD. They could provide access to personal health data and offer health information, support, and communication possibilities for clients and their caregivers. Health care professionals would benefit from access to relevant patient data, along with systems and tools that support competence and decision-making. Intersectoral and professional collaboration could be promoted with digital platforms and care pathways. DHIs for data services could enhance care planning and coordination with novel predictive data and interoperable systems for data exchange. The combined study of client and health care professional perspectives identified several opportunities and requirements for DHIs that related to the information, availability, quality, acceptability, utilization, efficiency, and accountability challenges of health systems. These findings provide valuable social insights into digital transformation and the emerging design, development, and use of user-centered technologies and applications to address challenges and improve CVD care and health care.

Understanding the Impact of Healthcare Providers’ Perspectives on Cancer Control in Rural Communities: A Qualitative Study

This study seeks to understand how healthcare providers perceive systemic- and individual-level factors affecting rural patients’ access to care and how this information impacts providers’ approach to cancer screening and prevention recommendations. Over a six-month period in 2021, we conducted semi-structured interviews with primary care providers, nurse navigators, and community health workers affiliated with a regional health system to better understand their perceptions of cancer control in rural communities. Thematic analysis was conducted to identify key themes and develop a conceptual framework to describe the pathway between information-gathering and care coordination – as well as how trust affects these relationships. We found that provider beliefs about barriers facing rural patients influence care recommendations and patient interactions. These beliefs and subsequent interactions affect trust between providers and patients, which influences whether rural patients are willing to believe providers, their adherence to care recommendations, and the information patients are willing to share with providers.

Development and Analysis of a Treatment Timeliness Dashboard for Patients With Head and Neck Cancer at a Tertiary Academic Multidisciplinary Clinic

Improving timeliness represents a critical opportunity to maximize patient experience, quality of care, and overall health of a co-located multidis­ciplinary cancer (MDC) program. The primary objective was to develop a timeli­ness dashboard using a primary nursing care coordination model to track met­rics selected for care efficiency. The secondary objective was to identify whether timeliness improved with implementation of an MDC clinic with expanded visi­bility to care coordination. A nursing care coordination model was developed to perform data collection alongside frontline patient care to track patients’ jour­ney with cancer. A spreadsheet was first used but then transitioned to a web-based database based on nursing feedback. Timeliness metrics were collected from May 2019 through April 2023 with descriptive analysis performed to iden­tify trends. Results signify implementation of a co-located MDC with primary nursing care coordination has improved timeliness. The project showcases the importance of nursing care coordination in a high-volume clinic with increased visibility to patients’ journeys with cancer. It also demonstrates establishing and updating standardized work procedures for data collection, cleaning, and analy­sis for quality of care monitoring.

Incorporating value-informed advanced nursing practice into APRN education

Value-informed advanced practice nursing capitalizes on the high-value nursing model of care to meet population health needs and address rising healthcare costs. However, nurse practitioners (NPs) often lack knowledge about value-based care, which limits their ability to lead systems-based changes to improve outcomes and lower costs. Identifying the key domains for value-informed advanced nursing practice can support curricular alignment with competency-based education. A review of the peer-reviewed and gray literature identified an initial list of domains that impact the success of value-based NP care. These domains were then confirmed and validated through interviews with eight NP practice owners. The final seven key domains of value-informed advanced nursing practice – Leadership/High Value Culture, Quality and Analytics, Care Coordination, Collaboration and Community Connections, Financial Management, Care Redesign, and IT Infrastructure and Interoperability – align with the sub-competencies established by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculty. Learning activities are offered to facilitate NP understanding of value-informed nursing practice and meet selected sub-competencies. Incorporating the key domains for value-informed advanced nursing practice into NP and Doctor of Nursing Practice education prepares emerging and seasoned NPs to lead systems-level change and improve care delivery.

Implementing Primary Care Reform in France: Bargaining, Policy Adaptation, and the Maisons de Santé Pluriprofessionnelles

Context: The organization of primary care in France has long remained a secondary issue on the political agenda. The government began to address the difficulties of care access and coordination in the 2000s, when a seemingly viable solution emerged from the field: the maisons de santé pluriprofessionnelles (MSPs). In a corporatist system and a predominantly private sector, the government chose an incentive-based contractual policy to encourage providers to join these structures. This article analyzes the implementation of this policy, which depends on private providers’ commitment. Methods: The article offers a comparative case study of six MSPs. Data were collected through semistructured interviews, observation sessions, and document analysis. Findings: First, the article shows that the emergence of MSPs has only been possible thanks to an unprecedented alliance between general practitioners, the state, and the health insurance fund. Second, it argues that MSP policy implementation relies on a complex bargaining process between private providers and public authorities that enables the former to shape it to their local needs. Conclusions: MSP implementation experiences raise questions both about the understanding of medical corporatism in France and the assimilation of policy changes and local variation through policy implementation.

Ecuadorian healthcare professionals’ perspectives on attributes of asthma care coordination: a qualitative study

ObjectiveThis study explored the attributes of asthma care coordination from the perspective of healthcare professionals at different levels of care in Ecuador.DesignQualitative descriptive study. The Integrated Health Networks Model was...

Individualized Coordination and Empowerment for Care Partners of Persons with dementia (ICECaP): Feasibility and acceptability

BackgroundInformal care partners (CPs) of persons with dementia (PWDs), who are at risk of negative health outcomes, benefit from psychosocial interventions. Individualized Coordination and Empowerment for CPs of PWDs (ICECaP) is a year-long, multi-component intervention comprised of in-person and telehealth psychoeducation and emotional support from dementia care coordinators (DCCs). ICECaP feasibility and acceptability were examined during a pilot randomized controlled trial. MethodFeasibility was determined by study enrollment (relative to screening) and study completion. Acceptability was examined with CP-rated intervention satisfaction and DCC-completed surveys of CP engagement, using one-sample Wilcoxon tests to evaluate differences between observed and null hypothesized medians. Implementation fidelity was also evaluated. Analyses of variance and Chi-square tests identified demographic differences in study completion and DCC-reported CP engagement. ResultsStudy enrollment (91.4 %) and study completion (85.4 %) were both high when compared to findings from a recent meta-analysis of CP psychosocial interventions. Completion was similar across groups (ICECaP vs. control) and demographics. CPs and DCCs communicated twice monthly, most commonly via email. On average, DCCs spent 68 min total per CP monthly; number and duration of contacts varied widely. CPs responded positively on the satisfaction survey, and DCCs mostly responded positively about CP communication, engagement, and responsiveness. Communication was reportedly more difficult with employed CPs and CPs with ≥16 years of education. ConclusionICECaP was both feasible and acceptable. DCC time spent with CPs occurred primarily virtually and varied widely, reflecting both individualization within the intervention and the unpredictability of dementia care for CPs.ClinicalTrials.govNCT04495686.

Health data analytics for population health management: A review of best practices and challenges

Health data analytics has become an indispensable tool for optimizing population health management by offering data-driven insights that improve healthcare outcomes, enhance preventive care, and inform policy-making. This review explores best practices in health data analytics, including predictive analytics, risk stratification, patient segmentation, and data integration. It highlights successful implementations in healthcare systems that demonstrate the positive impact of these practices on care coordination, resource allocation, and disease prevention. However, the paper also addresses several challenges hindering the widespread adoption of health data analytics, such as data privacy concerns, interoperability issues, and integrating diverse data sources. Ethical, technical, and operational barriers further complicate its effective use. The review concludes with recommendations for improving the adoption and effectiveness of health data analytics, emphasizing the need for strong data governance, improved interoperability, enhanced data quality, and workforce development. These strategies can maximize the benefits of health data analytics in advancing population health management.

Immune-related adverse event detection in liver cancer patients treated with immune checkpoint inhibitors: Nationwide exploratory survey in Japan.

This study aimed to comprehensively assess the incidence of immune-related adverse events (irAEs) and the detection systems in place for patients with liver cancer undergoing treatment with immune checkpoint inhibitors (ICIs), using a self-administered anonymous questionnaire. The questionnaire was designed to gather crucial insights into the management of irAEs in these patients. A self-administered anonymous questionnaire was sent to 456 liver disease collaborative base hospitals and cancer care coordination base hospitals in Japan. Responses were received from 112 facilities, indicating a response rate of 25%. The region with the highest response rate was Kanto (22%, 24 sites), followed by Kyushu (19%, 21 sites), Chubu (14%, 15 sites), and Kinki (14%, 15 sites). The number of patients with hepatocellular carcinoma (HCC) who received ICI treatment varied, with a mean±SD of 20.4±19.4 cases per year per facility. The number of full-time physicians who provided ICI treatment for HCC was 4.2±3.3 (mean±SD), ranging from 0 to 24 per facility. Of these, the majority included hepatologists and oncologists, whose numbers were 3.3±2.4 (mean±SD) (range, 0-11) and 0.8±1.0 (0-3), respectively. Gastroenterologists and internal medicine specialists participated in the treatment at some facilities. The survey results revealed that physicians administered ICI therapy for an average of 20 HCC cases per institution, with more than 17 types of irAEs reported. The most common irAEs were hepatic dysfunction, followed by thyroid dysfunction, skin disorders, interstitial pneumonia, and renal dysfunction.

Design and Framework of a Technology-Based Closed-Loop Referral Project for Care Coordination of Social Determinants of Health.

Screening for social determinants of health (SDOH) has been mandated by health systems nationwide. However, a gap exists in closed-loop referral for care coordination between health care and social services. This article presents the framework of a technology-based project to facilitate closed-loop referral between health care and social service agencies in Greater Houston by leveraging and connecting the existing care coordination technology infrastructure. Ten health care and social service organizations in Greater Houston participated in the demonstration project initiated in January 2023. The authors leveraged and linked regional health information exchange (HIE) technology with a master patient index of >18 million, and sector-specific care coordination platforms to build closed-loop referral capacity between HIE-participating health care organizations and social service organizations to meet patient SDOH needs. Evaluation efforts will assess the reach, adoption, implementation, and the effectiveness of the closed-loop framework in improving social and health outcomes. The framework comprised the following 4 components: (1) establishment of collaborative governance for shared decision-making processes, fostering trust, alignment, and transparency among organizations; (2) development of technology linkages between existing platforms to facilitate seamless referrals between organizations and ensure visibility of referral outcomes; (3) integration of regional resource directories into technology infrastructure to ensure resource accessibility/quality; and (4) evaluation of the system's impact on health equity, efficiency, and cost reduction. This project aimed to close the loop for care coordination between health care and social service agencies, enable data evaluation to determine care coordination effectiveness, and lay the foundation for SDOH-related research/practice equitably.

Listening to families: qualitative analysis of family perspectives on the impact of participating in a complex care program

ABSTRACT Background Complex Care Programs (CCPs) provide care for children with medical complexity (CMC). The broad impact of CCP participation on families is unknown. This study sought to elucidate what families value about participation in a CCP and what additional benefit families hope CCPs will provide. Methods Surveys from families of CMC in a CCP were collected over the course of two years. Responses were summarized for two fixed response satisfaction questions. Qualitative responses to two open-ended questions exploring CCP value were analyzed using content analysis. Results Most families (95% and 97%) were somewhat or very satisfied with the CCP. All families would recommend the CCP to others. For the question “What has improved for your family?,” nearly half mentioned Impact on Family. Other prevalent themes were Tasks of Care Coordination and Addressing Medical Needs. For the question “What else would you like to see improve?” most families reported No Concerns. Other responses addressed Community Resources; Unmet Expectations; Care Plan Development; and Transitions. Discussion Families identified improvements related to CCP missions (i.e. care coordination and medical co-management) but also intangible impacts. Findings will help CCPs prioritize activities valued by families and direct development of a tool to evaluate family impact.

A comprehensive experience-based framework of actionable priorities to enhance Canada’s health and social care system: discussions with older persons, clinicians, managers, and decision-makers using nominal group technique

BackgroundExisting frameworks of older persons’ experiences in health and social care systems are usually based on single stakeholder perspectives and focused on limited aspects that are independent from one another. This study aimed to describe such experiences from the perspective of diverse stakeholders and develop a comprehensive experience-based framework for actionable priorities to enhance Canada’s health and social care system.MethodsWe adapted a nominal group technique with a qualitative approach. We formed four groups of stakeholders (4 older persons, 7 clinicians, 5 managers, 4 decision-makers) in the province of Quebec. First, participants individually completed a questionnaire to rank the six domains of an international set of metrics of quality of care for older persons in terms of their importance. Then, we conducted a remote discussion with each stakeholder group, obtained consensus on the priority domains, and explored personal/professional experiences explaining prioritization processes and what changes are needed. An inductive-deductive thematic analysis was conducted to develop a framework for actionable health and social care priorities.ResultsThe framework included six key categories revolving around a core category of ‘health equity’. (1) ‘Access to services and care’ focused on improved accessibility of healthcare navigators, primary and home care services, and end-of life care. (2) ‘Respect for older persons’ involved individuality and uniqueness, daily needs, advocacy in defence of vulnerability, and decision-making valuing care preferences. (3) ‘Involvement of family and friends’ encompassed formal recognition, responsibilities, and trajectories associated with caregiving. (4) ‘Communication and education’ consisted of adaptive communication between older persons, caregivers, and professionals and societal-level education and awareness-raising. (5) ‘Coordination and integration of care’ comprised health and social services organization, cross-sectoral approaches, and interdisciplinary collaboration. (6) ‘Responsiveness to evolving needs’ of older persons involved timely response to health transitions and promoting holistic approaches.ConclusionsThis study illustrates the complex challenges of caring for older persons. The framework suggests several areas for improvement in care practices and policies for older persons and caregivers. Proposed intervention targets include public healthcare system navigators, standardized goals of care practices respecting persons’ wishes, formal recognition of caregiver contributions, society-level education, cross-sectoral initiatives, and holistic approaches.

A discrete choice experiment: Understanding patient preferences for managing chronic non-cancer pain.

The management of chronic non-cancer pain (CNCP) is complex. Concerns about adverse effects associated with opioid pain medications and a lack of funding for holistic programs present challenges for decision-making among clinicians and patients. Discrete choice experiments (DCE) are one way of assessing and valuing patient treatment preferences. DCE attributes and levels were generated through qualitative research and included number of medicines, side effects from medicines, pain interference, care management, risk of addiction, activity goals, preferred source of information on pain management and willingness to pay. The survey was administered to participants with CNCP recruited through an existing cohort study (n = 442) and a sample of people living with CNCP recruited through Australia's leading pain advocacy body (Painaustralia) (n = 256). The median age of participants was 58 years (SD 12.0), the majority were female. The analysis revealed two latent demographic classes: a younger group with higher levels of private health insurance and an older group with lower levels of private health insurance coverage. There were notable differences in preference. The younger cohort exhibited a greater willingness-to-pay to reduce pain interference, whereas the older group prioritized GP management, preferred more medicines and expressed fewer addiction concerns. Patients' treatment preferences diverged based on age and insurance status, underscoring the importance of understanding patient perspectives in treatment communication and care coordination. These findings provide insight into patient decision-making, which is important for promoting access to quality healthcare and engagement with evidence-based treatment of CNCP. A discrete choice experiment identified two groups: younger, with more private insurance, and older, with less private health insurance, each with unique pain management preferences. Clinicians should be aware that age and private health insurance may have an impact on a patient's preferences for CNCP management.

Impact of Integrated Pharmacist-Nurse-Radiology-Dietitian Teams on Polypharmacy Patient Outcomes: A Comprehensive Analysis

Polypharmacy, defined as the concurrent use of five or more medications, is a significant challenge in modern healthcare. It affects 10-20% of community-dwelling adults and 40-50% of people aged 65 years and older. This study presents a comprehensive assessment of the impact of integrated healthcare teams comprising pharmacists, nurses, radiologists, and dietitians on polypharmacy patient outcomes. The results indicated significant improvements across multiple domains: medication appropriateness scores increased by 65%, adverse drug events decreased by 45%, and hospital readmission rates decreased by 40%. Each professional contributed something unique: pharmacists reduced inappropriate medications through comprehensive medication reviews by 65%; hospital readmissions were reduced by nurses, who applied quality-enhanced care coordination for the best interest of the patient by 35%; radiologists increased treatment accuracy by 40%, providing advanced diagnostic support; and dietitians decreased drug-nutrient interaction complications by 55%. Economic analysis revealed substantial cost savings of approximately $2,500 per patient annually, and a 35% reduction in emergency department utilization. Patient-centered outcomes demonstrated a 55% increase in health-related quality of life and 60% improvement in medication adherence. Implementation barriers, resource constraints, and limitations in the reimbursement structure exist, but evidence strongly supports the effectiveness of such integrated healthcare teams in polypharmacy patient management. The study concluded that such collaborative care models are vital for better patient outcomes and healthcare resource utilization in an evolving practice around advanced medication management.

Nurses' and Nursing Assistants' Experiences With Teleconsultation in Small Rural Long-Term Care Facilities: Semistructured Interview Pilot Study.

In Quebec, the shortage of nurses during night shifts compromises the safety and quality of resident care, particularly in small residential and long-term care centers ("Centres d'hébergement et de soins de longue durée"; CHSLDs) located in rural areas. The need to ensure the continuous presence of nurses 24 hours a day in CHSLDs has become more pressing, forcing some facilities to implement exceptional measures such as on-call telephone services to ensure access to a nurse. In light of these challenging circumstances, the Direction nationale des soins et des services infirmiers of Quebec's Ministère de la Santé et des Services sociaux has rolled out a teleconsultation pilot project. This study aims to explore nurses' and nursing assistants' experience of integrating teleconsultation during night shifts in rural CHSLDs with ≤50 residents. The 6-month pilot project was rolled out sequentially in 3 rural CHSLDs located in 2 administrative regions of Quebec between July 2022 and March 2023. A total of 18 semistructured interviews were conducted with 9 nurses and nursing assistants between February and July 2023. Participants' experiences revealed that teleconsultation provided significant added value by improving clinical, administrative, and organizational practices. Some practices remained unchanged, indicating stable workflows. Workflow optimization through an expanded scope of practice ensured efficient and safe continuity of care. Enhanced collaboration between nurses and nursing assistants led to improved care coordination and communication. The leadership played a significant role in clarifying professionals' roles and in supporting effective adaptation to teleconsultation. This pilot project represents a significant step forward in improving care for CHSLD residents in Quebec. Teleconsultation not only makes it possible to overcome recruitment challenges and ensure the continuous presence of nurses during night shifts but also optimizes professional practices while ensuring the safety and quality of care provided to residents.

Enhancing Care Coordination in Oncology and Nononcology Thoracic Surgery Care Pathways Through a Digital Health Solution: Mixed Methods Study.

Health-system fragmentation in Quebec significantly impacts care coordination, leading to interruptions in patients' care pathways and adverse effects on their health. Coordinating interfacility service corridors is complex and requires collaboration between multiple health care providers (HCPs) and care settings. Effective care coordination is essential to ensure optimal patient management at transition points. This study aims to improve oncology and nononcology thoracic surgery care pathways by enhancing care coordination during interfacility transfers through a digital health solution. A multicenter implementation study was conducted across 2 health regions and 2 health care facilities in Quebec. We conducted 27 semistructured interviews with HCPs and managers to better understand the care pathways. Participatory design workshops were held with future users and key stakeholders at an early stage of the technology's design to validate the prototype's functionalities and workflows. A web survey was sent to all end users (N=13) to assess their experience with the platform. All participants (100%) either "agreed" or "strongly agreed" that the platform provided significant benefits. It enhanced interestablishment coordination (4/13, 31% agreed and 9/13, 69% strongly agreed) and continuity of care and services (8/13, 62% agreed and 5/13, 38% strongly agreed), and it contributed to better management and patient intake (10/13, 77% agreed and 3/13, 23% strongly agreed) and process fluidity (3/13, 77% agreed and 3/13, 23% strongly agreed). Surgeons from the McGill University Health Centre confirmed that the platform facilitated and secured information transmission (2/5, 40% agreed and 3/5, 60% strongly agreed) and kept track of oncology patient referrals, follow-up needs, and cases where surgery is unnecessary (2/5, 40% agreed and 3/5, 60% strongly agreed). Nursing staff from the Centre intégré de santé et de services sociaux de l'Outaouais and McGill University Health Centre reported high satisfaction with the platform's support during preoperative visit, surgery, and discharge processes. All participants perceived the platform as intuitive and easy to use. Additionally, participants valued its efficiency in providing rapid access to patient data, which reduces task time and ensures document security, thereby improving care coordination across facilities. The project's success has convinced the HCPs and senior management at both health care facilities to pursue long-term use of the Akinox digital health platform. This pilot project represents a significant advancement in thoracic surgery care pathways and the coordination of interfacility health care service corridors. The project provides care pathways that are adaptable to other surgical specialties. It also paves the way for improving care in cancer and other health care networks while highlighting the key role of nurse navigators in patient care management. The project underscores the value of strategic leadership and stakeholders' collaboration to improve care coordination and operational efficiency by demonstrating technology's essential role in patient care pathways.