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

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.

Co-Creating Descriptors and a Definition for Person-Centred Coordinated Health Care: An Action Research Study

The aim of this study was to co-create a definition and generic descriptors for person-centred coordinated care for Ireland generated from service users’ narratives.

An overarching action research approach was used to engage and empower people to tangibly impact health policy and practice. Through focus groups and a qualitative survey, primary data were collected from a national sample of health services users, caregivers and health care service users’ representative groups. Thematic analysis was used to analyse the data. Three major themes were co-produced as essential care elements. These were: ‘My experience of healthcare’, ‘Care that I am confident in’ and ...

Physician Assistants and Nurse Practitioners in Primary Care Plus: A Systematic Review

Shifting specialist care from the hospital to primary care/community care (also called primary care plus) is proposed as one option to reduce the increasing healthcare costs, improve quality of care and accessibility.

The aim of this systematic review was to get insight in primary care plus provided by physician assistants or nurse practitioners.

JICA Special Issue: Integrated Palliative and End of Life Care for People with Advanced Dementia or Frailty

This special issue now seems uncannily prescient in view of the devastating impact of COVID-19 on people with advanced dementia or severe frailty, particularly in care homes.

The pandemic has heightened awareness of the possibility of a sudden and rapid transition from relative health to a palliative or end of life stage. This has opened up conversations about the potential burden from intensive treatments that are likely to be futile and the benefits of advance care planning.

The collection of papers in this special issue will be of interest to readers involved in planning, commissioning or delivering palliative and end ...

Use of Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) for the screening of frailty and components of comprehensive geriatric assessment

Comprehensive geriatric assessment (CGA)—a key tool for geriatric medicine—is commonly used to assess older people’s health status and frailty. However, performing CGA in outpatient clinics is difficult because the assessment of cognition, activities of daily living (ADLs), depression, quality of life (QoL), nutrition, medications and social conditions is time consuming and requires the cooperation of medical staff. Frailty—an aspect of geriatric medicine that indicates the weakness of the body—is a critical measure of older adults’ physical function.

The Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) is a validated and simple ...

Indicators of an Integrated Home Care Model Shaped by the Needs of Patients Discharged from the Emergency Department

Developing community care models aims to satisfy the needs of patients’ in-home care comprehensively. This is crucial to decrease adverse events and prevent rehospitalization.

The growing burden of chronic diseases, patients experiencing fragmented care, and increasing demand for coordination across providers in the health and social sector correlates with the need for the integration of care. The starting point in developing an integrated care strategy should be identifying and assessing population needs.

Models of integrated care may enhance patient satisfaction, increase the perceived quality of care, and enable access to services. The term ‘new models of care’ refers to a ...

Achieving patient priorities: an alternative to patient-reported outcome measures (PROMs) for promoting patient-centred care

For the past two decades, patient-centredness has served as one of six acknowledged dimensions of healthcare quality. Initially, healthcare institutions described patient centredness superficially—clean waiting rooms, hotel-like bed and board, access to innovative medical technology—and measured it with crude satisfaction scales. The concept of patient-centred care evolved into a model attuned to the patient experience of care, defined by the interactions between patients and providers and the care environment.This patient experience model of patient-centred care has deep normative roots around principles of the patient as the locus of control and a demand for individualisation and customisation of ...

Leadership in integrated care networks: A literature review and opportunities for future research

This article reviews research on leadership in integrated care networks. It is timely as scholars and policy makers regard integrated care as a key part in reforming healthcare systems to cope with demographic aging, the rising prevalence of chronic diseases and the growing demand for long-term care.

In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics ...

Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis

To address the challenges of caring for a growing number of older people with a mix of both health problems and functional impairment, programmes in different countries have different approaches to integrating health and social service supports. The goal of this analysis is to identify important lessons for policy makers and service providers to enable better design, implementation and spread of successful integrated care models.

Integrated ambulatory care in the New Zealand health system: a scoping review

Integrated health systems, according to the World Health Organization (2017) are ''the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.'' This is a very important concept in today's day and age, as access to healthcare has become a challenge and the population has never been sicker.

In New Zealand and internationally, emerging trends across health systems include a fundamental shift of care from hospitals to community-based settings and increased integration of services to better link ...