Nursing Care Coordination in Primary Healthcare for Patients with Complex Needs: A Comparative Case Study.

Introduction: Despite nurses' substantial role in care coordination, few education programs exist to better support them in this role. Identification of a set of core care coordination activities across heterogeneous care coordination programs would facilitate the development of a standard of practice. We sought to examine care coordination activities across two care coordination programs in Family Medicine Groups in Quebec, and their relationship to the program design. Methods: We performed a comparative case study of two care coordination programs in primary care targeting frequent users of healthcare services and people with Alzheimer's disease and related disorders. Data collection included documents and semi-structured interviews with key informants. Results: Several activities were common to both programs, such as patient identification; assessment, development of an individualized service plan; and linking patients and caregivers with professionals and services. However, their components were different due to the impact of the integrated care program design, policy environment, and the target patient populations' complex needs. Discussion: The homogeneity or heterogeneity of patients' complex needs shapes their care trajectory and the intensity of their care coordination needs. As the complexity of these needs grows, so does the necessity to build the care coordinators' capacity for integrated care.

Introduction: Malgré le rôle important des infirmières dans la coordination des soins et des services, peu de programmes de formation existent pour mieux les soutenir dans l'exercice de celui-ci. L'identification d'un tronc commun d'activités de coordination des soins et services effectuées par les infirmières à travers différents programmes de coordination faciliterait l'élaboration d'une norme de pratique en vue de rehausser leur formation à cet égard. Cette étude examine les activités de coordination des soins et services effectuées par les infirmières dans deux programmes de coordination hétérogènes déployés dans les groupes de médecine de famille au Québec, et la façon dont la conception du programme impacte celles-ci. Méthodes: Nous avons réalisé une étude de cas comparative de deux programmes de coordination des soins et services en première ligne ciblant les usagers fréquents des services de santé et les personnes atteintes de la maladie d'Alzheimer et des troubles apparentés. La collecte de données comprenait une analyse documentaire et des entretiens semi-dirigés avec des informateurs clés. Résultats: Plusieurs activités étaient communes aux deux programmes, telles que l'identification des patients ; évaluation, élaboration d'un plan de services individualisé ; et la mise en relation des patients et des soignants avec des professionnels et des services. Cependant, leurs composantes étaient différentes en raison de l'impact de la conception du programme de soins intégrés, de l'environnement politique et des besoins complexes des populations de patients cibles. Discussion: L'homogénéité ou l'hétérogénéité des besoins complexes des patients façonne leur trajectoire de soins et l'intensité de leurs besoins de coordination des soins. À mesure que la complexité de ces besoins augmente, la nécessité de renforcer la capacité des coordonnateurs de soins en matière de soins intégrés augmente également.

Better understanding care transitions of adults with complex health and social care needs: a study protocol.

BACKGROUND: Adults with chronic conditions who also suffer from mental health comorbidities and/or social vulnerability require services from many providers across different sectors. They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. In response, the literature has stressed the need for a collaborative approach amongst providers to facilitate the care transition process. A better understanding of care transitions is the next step towards the improvement of integrated care models. The aim of the study is to better understand care transitions of adults with complex health and social care needs across community, primary care, and hospital settings, combining the experiences of patients and their families, providers, and health managers. METHODS/DESIGN: We will conduct a two-phase mixed methods multiple case study (quantitative and qualitative). We will work with six cases in three Canadian provinces, each case being the actual care transitions across community, primary care, and hospital settings. Adult patients with complex needs will be identified by having visited the emergency department at least three times over the previous 12 months. To ensure they have complex needs, they will be invited to complete INTERMED Self-Assessment and invited to enroll if positive. For the quantitative phase, data will be obtained through questionnaires and multi-level regression analyses will be conducted. For the qualitative phase, semi-structured interviews and focus groups will be conducted with patients, family members, care providers, and managers, and thematic analysis will be performed. Quantitative and qualitative results will be compared and then merged. DISCUSSION: This study is one of the first to examine care transitions of adults with complex needs by adopting a comprehensive vision of care transitions and bringing together the experiences of patients and family members, providers, and health managers. By using an integrated knowledge translation approach with key knowledge users, the study's findings have the potential to inform the optimization of integrated care, to positively impact the health of adults with complex needs, and reduce the economic burden to the health and social care systems.

Interprofessional collaboration between general practitioners and primary care nurses in Belgium: a participatory action research.

Given the sociodemographic challenges facing the Belgian primary care system, it is essential to strengthen interprofessional collaboration (IPC) between healthcare providers. Therefore, our aims for this study were to assess IPC between general practitioners (GPs) and nurses; identify target priorities for improving IPC; and facilitate the planning and implementation of the proposed improvement strategies. Based on diversity criteria, six groups of GPs and nurses were chosen for a participatory action research. Participants performed a SWOT analysis of their IPC to identify strengths and weaknesses of their collaboration practice configurations. Main factors limiting IPC were related to the type of financing system which impeded or facilitated multidisciplinary team meetings, a weak functional integration, and a lack of interprofessional education. Overall, communication and task delegation were co-identified as common priorities. Actions prioritized by each group were related to these two priorities and accounted for local, specific needs. Communication could be supported through improved tools and dedicating time for multidisciplinary team meetings. Task delegation was more challenging and raised questions related to nurses' training, legislation, and payment systems. IPC seems to be easier to achieve when healthcare professionals belong to the same organization and consider themselves a team.

Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations.

INTRODUCTION: The objectives of this study were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement. METHODS: Using a descriptive qualitative design, individual interviews and focus groups with patients, healthcare providers and managers were analysed according to a mixed thematic analysis based on a deductive (Rainbow Model of Integrated Care) and an inductive approach. RESULTS AND DISCUSSION: Participants highlighted the individualized service plan as a significant tool to foster a shared person-focused vision of care, information exchanges and concerted efforts. Openness to collaboration was also considered as an enabler for community stakeholders' engagement. The lack of recognition of community-based organisations by certain providers and the time required to participate in individualized service plans were outlined as barriers to professional integration. Limited opportunities for community stakeholders to be involved in decision-making within case management programs were reported as another constraint to their engagement. Cultural differences between organisations regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may negatively affect community stakeholders' engagement. Formal consultation mechanisms and improvement of communication channels between healthcare providers and community stakeholders were suggested as ways to overcome these barriers. CONCLUSION: Efforts to improve care integration in case management programs should be directed toward the recognition of community stakeholders as co-producers of care and co-builders of social policies across the entire care continuum for people with complex needs.

Case Study With a Participatory Approach: Rethinking Pragmatics of Stakeholder Engagement for Implementation Research.

The case study design is particularly useful for implementation analysis of complex health care innovations in primary care that can be influenced by the context of dynamic environments. Case studies may be combined with participatory approaches where academics conduct joint research with nonacademic stakeholders, to foster translation of findings results into practice. The aim of this article is to clarify epistemological and methodological considerations of case studies with a participatory approach. It also aims to propose best practice recommendations when using this case study approach. We distinguish between the participatory case study with full co-construction and co-governance, and the case study with a participatory approach whereby stakeholders are consulted in certain phases of the research. We then compare the epistemological posture of 3 prominent case study methodologists, Yin, Stake, and Merriam, to present the epistemological posture of case studies with a participatory approach. The relevance, applications, and procedures of a case study with a participatory approach methodology are illustrated through a concrete example of a primary care research program (PriCARE). We propose 12 steps for designing and conducting a case study with a participatory approach that may help guide researchers in the implementation analysis of complex health care innovations in primary care.

Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review.

INTRODUCTION: Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination. This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare. METHODOLOGY: We followed Arksey and O'Malley's methodological framework for scoping reviews. We carried out a systematic search across CINAHL, MEDLINE, Scopus and ProQuest. Only empirical studies were included. We performed a thematic analysis using deductive (the American Nurses Association Framework) and inductive approaches. Findings were discussed with a group of experts. RESULTS: Thirty-four articles were included in the synthesis. Overall, nursing care coordination activities were synthesized into three categories: those targeting the patient, family and caregivers; those targeting health and social care teams; and those bringing together patients and professionals. Interpersonal communication and information transfer emerged as cross-cutting activities that support every other activity. Our results also brought to light the nurses' contribution to care coordination efforts for patients with complex needs as well as critical components that should be present in every care coordination intervention for this clientele. These include an increased intensity and frequency of activities, relational continuity of care, and home visits. CONCLUSION: With the growing complexity of patient's needs, efforts must be directed towards enabling the primary healthcare level to effectively play its substantial role in care coordination. This includes finding primary care employment models that would facilitate multidisciplinary teamwork and the delivery of integrated care, and guarantee the delivery of intensive yet efficient coordinated care.

Implementation of Primary Palliative Care in five Belgian regions: A qualitative study on early identification of palliative care needs by general practitioners.

BACKGROUND: To deliver optimal palliative care, a Care Pathway for Primary Palliative Care (CPPPC) was developed. This CPPPC was implemented by general practitioners (GPs) in territories of five Belgian palliative care networks (2014-2016). Belgian doctors have much therapeutic freedom, and do not commonly follow guidelines. OBJECTIVES: To assess how palliative care was provided by GPs before the CPPPC and its implementation project were presented publicly. METHODS: Between 2013 and 2015, seven focus groups with GPs were conducted. Participants included 15 GPs in three French-speaking focus groups and 26 GPs in four Dutch-speaking focus groups, with diversity for age, gender, palliative care experience and practice context. Some GPs implemented the CPPPC later. RESULTS: GPs considered each palliative care case unique and disliked strict protocols. However, they expressed a need for peer review and reflective frameworks. GPs felt it is important to identify palliative care patients 'timely', but found this difficult. Screening methods help, but are not widely used. GPs struggled most with identifying palliative care needs in non-oncological patients. Bad news breaking was considered difficult. Continuity of care was considered very important. However, advance care planning seemed more widely practised by Dutch-speaking GPs than by French-speaking GPs. The taboo of palliative care provoked emotional discussions. CONCLUSION: Palliative care frameworks which help GPs to deliver 'tailor-made' care have more chance to be adopted than strict protocols. GPs should be given education for bad news breaking. Palliative care and advance care planning practices differ locally: guideline dissemination plans should respect these local differences.

Patients' perceptions of continuity of care across primary care level and emergency departments in Belgium: cross-sectional survey.

OBJECTIVES: To assess patients' perceptions of continuity of care (COC) across primary care level and emergency departments (EDs) and to identify contextual and individual factors that influence this perception. DESIGN: Cross-sectional multicentre survey. SETTING: Five EDs in Brussels and Wallonia. PARTICIPANTS: 501 adult patients referred to the ED by their primary care physician (PCP). Patients with cognitive impairment or in critical condition were excluded. RESULTS: Patients perceived high levels of the three types of COC. On an individual level, older patients showed a perception of higher levels of continuity. Lower levels of informational and management continuity were observed among patients suffering from chronic diseases and patients with a high level of education. Patients also perceived a redundancy of medical exams, in parallel to a high degree of accessibility between care levels. On an organisational level, three structural factors were identified as barriers to COC, namely, ED workload, suboptimal sharing information system and the current fee-for-service payment system that encourages competition and hinders coordination between actors. CONCLUSION: Belgian healthcare services seem satisfying for patients and easily accessible. However, efforts need to be directed towards improving their efficiency. A stronger primary care level is also needed to benefit the healthcare system by reducing overuse of emergency services. On the individual level, a more enhanced patient-centred approach could be beneficial in improving patients experience of care.

Comparing interprofessional and interorganizational collaboration in healthcare: A systematic review of the qualitative research.

BACKGROUND: Interprofessional and interorganizational collaboration have become important components of a well-functioning healthcare system, all the more so given limited financial resources, aging populations, and comorbid chronic diseases. The nursing role in working alongside other healthcare professionals is critical. By their leadership, nurses can create a culture that encourages values and role models that favour collaborative work within a team context. OBJECTIVES: To clarify the specific features of conceptual frameworks of interprofessional and interorganizational collaboration in the healthcare field. This review, accordingly, offers insights into the key challenges facing policymakers, managers, healthcare professionals, and nurse leaders in planning, implementing, or evaluating interprofessional collaboration. DESIGN: This systematic review of qualitative research is based on the Joanna Briggs Institute's methodology for conducting synthesis. DATA SOURCES: Cochrane, JBI, CINAHL, Embase, Medline, Scopus, Academic Search Premier, Sociological Abstract, PsycInfo, and ProQuest were searched, using terms such as professionals, organizations, collaboration, and frameworks. METHODS: Qualitative studies of all research design types describing a conceptual framework of interprofessional or interorganizational collaboration in the healthcare field were included. They had to be written in French or English and published in the ten years between 2004 and 2014. RESULTS: Sixteen qualitative articles were included in the synthesis. Several concepts were found to be common to interprofessional and interorganizational collaboration, such as communication, trust, respect, mutual acquaintanceship, power, patient-centredness, task characteristics, and environment. Other concepts are of particular importance either to interorganizational collaboration, such as the need for formalization and the need for professional role clarification, or to interprofessional collaboration, such as the role of individuals and team identity. Promoting interorganizational collaboration was found to face greater challenges, such as achieving a sense of belonging among professionals when differences exist between corporate cultures, geographical distance, the multitude of processes, and formal paths of communication. CONCLUSIONS: This review sets a direction to follow for implementing changes that meet the challenge of a changing healthcare system and the transition towards non-institutional care. It also shows that collaboration between nurses and healthcare professionals from different healthcare organizations is still poorly explored. This is a major limitation in the existing scientific literature, especially given the potential role that could be played by nurses in enhancing interorganizational collaboration.

Interprofessional Collaboration between General Physicians and Emergency Department Teams in Belgium: A Qualitative Study.

This study aimed to assess interprofessional collaboration between general physicians and emergency departments in the French speaking regions of Belgium. Eight group interviews were conducted both in rural and urban areas, including in Brussels. Findings showed that the relational components of collaboration, which are highly valued by individuals involved, comprise mutual acquaintanceship and trust, shared power and objectives. The organizational components of collaboration included out-of-hours services, role clarification, leadership and overall environment. Communication and patient's role were also found to be key elements in enhancing or hindering collaboration across these two levels of care. Relationships between general physicians and emergency departments' teams were tightly linked to organizational factors and the general macro-environment. Health system regulation did not appear to play a significant role in promoting collaboration between actors. A better role clarification is needed in order to foster multidisciplinary team coordination for a more efficient patient management. Finally, economic power and private practice impeded interprofessional collaboration between the care teams. In conclusion, many challenges need to be addressed for achievement of a better collaboration and more efficient integration. Not only should integration policies aim at reinforcing the role of general physicians as gatekeepers, also they should target patients' awareness and empowerment.