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

Abstract

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.

Keywords: care coordination; complex health and social care needs; integrated care; primary healthcare; registered nurses; review.

Figure 1

Complex health and social care needs. Source: Authors’ own elaboration. Key articles that guided this illustration include Garcia ME et al. 2018 [40]; Grembowski D, et al. 2014 [42]; Kuluski K, et al. 2017 [14].

Figure 2

Flow diagram detailing search results and study selection.

Figure 3

A model of nursing care coordination activities for patients with complex needs. Legend: COC = Continuity of care GP = General practitioner MDT = Multidisciplinary teams (including health and social care professionals).