Identifying Care Coordination Interventions Provided to Community-Dwelling Older Adults Using Electronic Health Records

How external and agency characteristics are related to coordination in homecare - findings of the national multicenter, cross-sectional SPOTnat study

BACKGROUND

Homecare client services are often distributed across several interdependent healthcare providers, making proper care coordination essential. However, as studies exploring care coordination in the homecare setting are scarce, serious knowledge gaps exist regarding how various factors influence coordination in this care sector. To fill such gaps, this study's central aim was to explore how external factors (i.e., financial and regulatory mechanisms) and homecare agency characteristics (i.e., work environment, workforce, and client characteristics) are related to care coordination in homecare.

METHODS

This analysis was part of a national multicentre, cross-sectional study in the Swiss homecare setting that included a stratified random sample of 88 Swiss homecare agencies. Data were collected between January and September 2021 through agency and employee questionnaires. Using our newly developed care coordination framework, COORA, we modelled our variables to assess the relevant components of care coordination on the structural, process, and outcome levels. We conducted both descriptive and multilevel regression analyses-with the latter adjusting for dependencies within agencies-to explore which key factors are associated with coordination.

RESULTS

The final sample size consisted of 1450 employees of 71 homecare agencies. We found that one explicit coordination mechanism ("communication and information exchange" (beta = 0.10, p <.001)) and four implicit coordination mechanisms-"knowledge of the health system" (beta = -0.07, p <.01), "role clarity" (beta = 0.07, p <.001), "mutual respect and trust" (beta = 0.07, p <.001), and "accountability, predictability, common perspective" (beta = 0.19, p <.001)-were significantly positively associated with employee-perceived coordination. We also found that the effects of agency characteristics and external factors were mediated through coordination processes.

CONCLUSION

Implicit coordination mechanisms, which enable and enhance team communication, require closer examination. While developing strategies to strengthen implicit mechanisms, the involvement of the entire care team is vital to create structures (i.e., explicit mechanisms) that enable communication and information exchange. Appropriate coordination processes seem to mitigate the association between staffing and coordination. This suggests that they support coordination even when workload and overtime are higher.

Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial

BACKGROUND

As populations are aging, a growing number of home care clients are frail and use multiple, complex medications. Combined with the lack of coordination of care this may pose uncontrolled polypharmacy and potential patient safety risks. The aim of this study was to assess the impact of a care coordination intervention on medication risks identified in drug regimens of older home care clients over a one-year period.

METHODS

Two-arm, parallel, cluster randomized controlled trial with baseline and follow-up assessment at 12 months. The study was conducted in Primary Care in Lohja, Finland: all 5 home care units, the public healthcare center, and a private community pharmacy.

PARTICIPANTS

All consented home care clients aged > 65 years, using at least one prescription medicine who were assessed at baseline and at 12 months.

INTERVENTION

Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide on further actions. Each patient's physician made the final decisions on medication changes needed. Outcomes were measured as changes in medication risks: use of potentially inappropriate medications and psychotropics; anticholinergic and serotonergic load; drug-drug interactions.

RESULTS

Participants (n = 129) characteristics: mean age 82.8 years, female 69.8%, mean number of prescription medicines in use 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated tendency for effectiveness, particularly in optimizing central nervous system medication use. Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the medication changes actually implemented.

CONCLUSION

The care coordination intervention used in this study indicated tendency for effectiveness when implemented as planned. Even though the outcome of the intervention was not optimal, the value of this paper is in discussing the real world experiences and challenges of implementing new practices in home care.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02545257). Registered September 9 2015.

Profiling Patient Characteristics Associated With the Intensity of Nurse Care Coordination

The purpose of this study was to identify characteristics of chronically ill community-dwelling older adults that differentiate the intensity of care provided by nurse care coordinators. We performed data mining on electronic health records, nurses' activity logs, and health status measures from 784 care episodes provided to 196 older adults. An inductively created decision tree identified nine groups from a combination of the six participant characteristics including medication regimen complexity, cognition, physical and mental health, hospital admission, and physical functioning. Overall there was a 5-hr difference in the intensity (or contact hours) per quarter of nurse care coordinators between individuals in the highest versus lowest intensity groups. The highest intensity group presented higher medication complexity and lower mental/physical health status. With caseloads of 30 to 35 participants, nurse care coordinators were able to provide care based on participant needs that were not influenced by regulatory payment requirements.