Care coordination across health care and social services sectors: patient and provider perspectives
Authors: Karam Marlène 
Published: January 2024

Introduction: This project is the result of a partnership between a research team including a patient partner, a clinical setting, and patients. The Nursing Department of the Integrated Health and Social Services Center (IHSSC) in Laval (Quebec, Canada) has implemented several care coordination functions for several years for patients with complex needs. These functions include those of liaison nurses in geriatrics, palliative care, home care and support, oncology, and many others. To date, no evaluation of these functions has been established.

The aim of this study is to establish a diagnosis of these current coordination practices, their effects from the perspective of the patients who benefit from them, and the facilitating factors and barriers according to the nurse coordinators. The Nursing Department’s request for this partnership is part of their process of continuous improvement of the quality of care and services offered to patients with complex needs.

Methods: A qualitative research method following an experience-based co-design approach is used. The Rainbow Model of Integrated Care (Valentijn et al., 2013) is the conceptual framework guiding this study. Between November 2022 and February 2023, individual interviews with 10 coordinators and 10 patients with complex health and social care needs will be conducted in order to explore their experiences and the facilitating factors and obstacles to coordination. Patients aged 65 and older, who had 3 or more hospitalizations or visits to the emergency department within the last 12 months, and suffer from one or more chronic conditions will be included. Interviews will take place at the time and place of their choice and last one hour. Nurses with 6 months or more of experience in their current position as care coordinator will be included.

Subsequently, two group interviews that bring together participating nurses and patients will identify joint improvement priorities in order to meet the needs expressed by the patients and the difficulties encountered by the coordinators.

Mixed thematic analysis combining inductive and deductive analysis (following the Rainbow Model of integrated care) will be conducted so as to allow us to collect stories and experiences, facilitating factors, barriers and areas for improvement according to the different levels (macro, meso and micro).

Expected Results: The expected results of this co-design approach include better alignment of the IHSSC care and services with the needs expressed by its target patients, leading to a better experience and better quality of care for them.

Discussion and conclusion: Partnering with clinical settings facilitates the knowledge translation and guides the decision-making of the partner organization in its process of restructuring the coordination services and reviewing this function.

Limitations: The relatively small number of participants limits the generalizability of the results to other settings and patient populations.

Suggestions for future research: Future research should include informal caregiver perspectives and identify unmet needs of specific subgroups of patients with complex needs.