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. 2023 Feb 2;23(1):5.
doi: 10.5334/ijic.6729. eCollection 2023 Jan-Mar.

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

Marlène Karam  1 , Maud-Christine Chouinard  1 , Yves Couturier  2 , Isabelle Vedel  3 , Catherine Hudon  4
Affiliations

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

Marlène Karam et al. Int J Integr Care. .

Abstract
in English, French

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.

Keywords: care coordination; case study; complex needs; continuing education; integrated care; nurses.

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Conflict of interest statement

The authors have no competing interests to declare.

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