Nursing care coordination for patients with complex needs in primary healthcare: A scoping review

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Karam M, Chouinard MC, Poitras ME, Couturier Y, Vedel I, Grgurevic N, Hudon C


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.

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