Review Article - Journal of Primary Care and General Practice (2021) Volume 4, Issue 1

Interventions to improve care coordination in primary care: A narrative review.

Regula Cardinaux¹, Nicolas Ochs¹, Carole Michalski², Jacques Cornuz¹, Nicolas Senn¹, Christine Cohidon^1*

¹Department of Family Medicine, University of Lausanne, Switzerland

²Faculty of Biology and Medicine, University of Lausanne, Switzerland

Corresponding Author:

Dre C. Cohidon
Center for Primary Care and Public Health (Unisanté)
Department of Family Medicine
University of Lausanne
Switzerland
E-mail: Christine.cohidon@unisante.ch

Accepted date: December 08, 2020

Citation: Cardinaux R, Ochs N, Michalski C, Cornuz J, Senn N, et al. Interventions to improve care coordination in primary care: A narrative review. J Prim Care Gen Pract 2020:4(1):61-79.

Abstract

Background: Care coordination in primary care is one of the main challenges for the future of health systems. We reviewed the literature to identify interventions that could improve coordination in the primary care setting. Methods: We conducted a literature review of articles referenced in the PubMed database between January 2000 and Avril 2020, (MESH terms: “Primary Care / Primary Health Care”, “Coordination / Care Coordination / Coordinated Care / Coordinating” and “Physician / General practitioner / Family practitioner / Primary care providers”). Two independent reviewers took part in the selection, data extraction and content analysis. All individual similar interventions were pooled and described for their overall benefit / harm on patients’coordination. Interventions were grouped according to categories described in the literature. Results: We found 4044 publications, of which 103, evaluating care coordination interventions, met inclusion criteria. We classified 62% of care coordination interventions into the category "Structuring relationships between service providers and patients" and 59% into "Systems to support the coordination of care”. The interventions involving "case managers", "multidisciplinary teams", "patient education" "care plans", and "electronic health records" were associated with the greatest number of articles describing positive effects. Conclusion: This narrative review illustratesthe wide variety of studied interventions to optimize the coordination of care in primary care. Future research assessing impact of these interventions on patient management are necessary.

Introduction

The increasing numbers of elderly and chronically ill patients places a considerable burden on the health care system, including a significant impact on costs [1]. As a result, many industrialized countries have begun reviewing their health systems to provide better care for these types of patients. One of the major challenges is reducing care fragmentation, principally by improving continuity of care and developing care coordination is one way to tackle this [2, 3]. In this context, primary care (PC) is well placed to play a major role in the management of patients with multiple, complex medical problems and functional impairment. For example, promoting care at home by strengthening outpatient management may help respond to hospital congestion, improve the quality of life of patients and reduce costs at the same time [1]. However, this requires a fundamental rethink of primary care organization, especially reinforcing care-coordination aspects within practices without overloading PC teams.

In a literature review on care coordination published in 2007, from more than 40 identified care coordination definitions the authors compiled the following working definition of care coordination: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care is often managed by the exchange of information among participants responsible for different aspects of care” [4]. A care coordination framework therefore involves several health partners around the care. Ideally, it should provide appropriate patient-centered management, limiting fragmentation of care, loss of information, treatment errors and redundancy of examinations and emergency department visits [5].

In 2006, Powell Davies published a literature review on interventions relating to care coordination in the general practice [6]. The most frequently reported interventions showing beneficial effect on patient health were relationships between service providers (65.5%), coordination of clinical activities (61.3%) and use of systems to support the coordination of care (60.5%) while studies reporting an effect on patient satisfaction were those tending to improve relationships between service providers (66.7%), support for clinicians (57.1%), communication between service providers (54.5%) and support for patients (50.0%).

Many health system organization changes have taken place over the past 15 14 years worldwide, particularly in PC and interventions aimed at improving care coordination in family practice have been the subject of an increasing number of scientific studies [7, 8].

Our narrative review aims to identify and describe recent care coordination interventions in PC and describe their effects on patient care management from 2000 to 2020.

This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

Search strategy

We conducted a narrative review of the Medline Ovid SP database (through PubMed) from January 2000 to April 2020, using the following MESH terms: “Primary Care / Primary Health Care”, “Coordination / Care Coordination / Coordinated Care / Coordinating” and “Physician / General practitioner / Family practitioner / Primary care providers”.

Data sources and search

Two independent reviewers examined and selected articles in two stages. A first selection was based on the article title. The second selection was after reading the article abstract. Disagreements related to selections were resolved through discussion to reach consensus. The inclusion criteria are the MESH terms detailed above. We retained interventional, observational, and qualitative studies as well as expert opinions.

The exclusion criteria were no link to care coordination or general medicine, or a too specific target population (for example, children only, American veterans, Australian aborigines, single disease). We also excluded paid articles and non-English- or non-French-language articles.

Data extraction

The same two researchers extracted data from the articles using a standardized predefined data extraction form we built, containing the major characteristics of the articles including, year and country of publication, type of study, care coordination interventions, results obtained. If a study was assessing multiple interventions strategies, each individual intervention was extracted. This explains why the sum of the percentages presented in (Table 1) is greater than 100. We also classified coordination interventions according to the nine categories of Powell Davies et al. with addition of a new category related to practice facilitators (Table 1). Extending the classification of Powell Davis et al, [6] we now produce a comprehensive directory of the studied care coordination interventions including precise definitions of each individual intervention.

Table 1: Classification of studies included in the review, adapted form Powell Davies et col.

Data synthesis and analysis

We the same two researchers qualitatively described and evaluated the different types of interventions as having globally: 1) an effect on care coordination (positive or negative) or 2) no effect on care coordination (as used in other studies). Disagreements were resolved during discussion, and when necessary, a third author was consulted. Our evaluation was according to the results of the intervention study, regardless of the measured outcome (e.g. doctor's experience, measurement of blood pressure, patient satisfaction). Finally, articles not describing interventions but only opinions of professionals regarding care coordination, initially selected, were classified as "not applicable, NA".

Results

Articles included in the study

We identified 4044 articles in the initial screen. After the first selection based on the title, 515 articles were retained and after a second selection step reading the abstracts, 220 were kept. Finally, we read articles entirely and selected 103 articles for analysis and data extraction (Figure 1).

Figure 1: Review flow chart of the research results.

Classification of selected articles according to the types of interventions and their effects

From the 103 articles, we identified 26 different types of intervention (sometimes evaluated in combination) and classified them into the 10 specified categories (the 9 categories proposed by Powell Davis et al and the one added regarding practice facilitators) [6]. More than half of the articles described interventions aimed at ‘using systems to support the coordination of care’ (59% of articles) and ‘structuring the relationships between service providers and patients’ (62%). To a lesser extent, articles described interventions targeting ‘coordinating clinical activities’ (32%), ‘support for patients’ (31%), and ‘support for service providers’ (30%). Interventions regularly involving higher organizational levels (associations, federations, governments) or political policies concerning payment methods, laws, or arrangements were significantly less represented (15% in total). (Table 2).

Table 2: Definition of the interventions

The characteristics of the selected studies are presented in detail in (Table 3).

Table 3: Characteristics of the studies included in the review.

Concerning the impact of interventions, most teamwork intervention studies (28/33) report a beneficial effect, followed by case manager (27/36), electronic patient records (20/22), training / education of patients (19/25), and care plans (17/20). (Table 4) and (Figure 2) (and Supplementary Table S1) list the 26 types of interventions we identified and their global impact on care coordination namely (positive, negative (only 4 studies reported strict negative associations), none or not applicable).

Figure 2: Number of studies according to their category of intervention and their outcome.

Narrative synthesis of identified interventions

Electronic Health Records (EHRs) is one of the most investigated interventions, showing several levels of interconnection between caregivers, in most surveys. Studies show EHRs improve information sharing [9-13] and care coordination [9, 10, 13-19]. However, this depends on good team cohesion [20] and limited use within the practice [21]. EHRs are also positively associated with patient [22, 23] and physician [13, 22, 23] satisfaction. Their use could have an impact on certain quantifiable clinical parameters such as blood pressure or glycated hemoglobin [22, 24, 25]. Some authors, however, have highlighted the limitations of using EHRs, such as their complexity and lack of fit to existing software or with medical decision-making processes and care plans [26]. Lastly, the information content of EHRs alone is not sufficient to ensure care coordination in complex cases [27] and has little influence on distribution of roles and responsibilities between physicians [10].

Care plans mainly correspond to individualized patientprocedures (as opposed to guidelines) and are put into place by the practice care coordinator (or case manager (CM), the FD and / or a specialist, in cases of complicated single disease management (for example diabetes). Care plans are rarely used for management of multi-morbid patients (for example adding blood pressure, LDL cholesterol and glycosylated hemoglobin measures). Several studies reported positive effects of a care plan on patient [23, 28, 29] and health professional satisfaction [23, 30], for controlling patient symptoms [29, 31-33] and vital signs [22, 24], as well as a decreasing length of hospital care and therefore health costs [34]. A 2013 literature review [35] concluded that care plans promoted care coordination by the clinician, but this was rarely perceived by patients.

Case management intervention can take many forms. It frequently includes health professionals other than the PC physician, often nurses [24, 30, 34, 36-41], whose mission is to coordinate care of patients having one or more pathologies. Tasks were found to mainly involve managing a care plan and vary from overseeing patient parameters to patient ‘empowerment’. Others who took on the case manager role include PC physicians [18, 42, 43], medical assistants [28, 37] and sometimes family caregivers [38], particularly if they are the patient’s guardian. Positive effects observed encompass improved patient [28, 40] and health professional satisfaction [30, 44], improved patient outcomes [18, 31-33, 45] or of vital signs [24]. Additionally, a decrease in hospital stay and therefore hospital costs [18, 28, 31, [33, 34, 41, 46-49]. Analysis of the 2010 Commonwealth study [50] showed that presence of a care manager both reduced the risk of problems arising from failure to coordinate care after hospitalization and had a positive effect on outpatient care. In addition, an Australian study from 2002 describes the "care coordinator" as an "information supplier" rather than a provider of health care [43].

Training of care providers covers workshops and courses designed to improve a health professional's skills for a particular intervention. In this respect, a Spanish study on collaboration in a nephrology department [51], showed FDs considered feedback from nephrologists as a form of teaching, which lead them to feel more satisfied. In Cramm and Niboer's 2012 study in Holland [52], health professional training was an integral part of the process of various Disease Management Programs. An American study from 2007 [46], analyzing two models of disability care coordination organization in which CMs taught other health professionals, showed a clear benefit of teaching in the reduced number of hospitalizations, and improved selfmanagement of patients.

The use of the Guidelines has been studied frequently. Interventions covered in the Chronic Care Model [52-55] that use guidelines and protocols, correlate with improved relational coordination. In other interventional approaches with several interacting components, guideline use appears to facilitate care coordination, in particular behavioral changes that [25, 56] lead to physician satisfaction [51] and improvement of certain patient parameters, such as blood pressure or HbA1c control [25, 33, 55].

A multi-disciplinary team is a specific collaboration among several categories of health professionals where teams can be spread over multiple sites. On the other hand, a co-location corresponds to a health professional team whose members work in the same building (such as a primary care center). We distinguish the two as often, health professionals working under the same roof do not work together. Several studies have shown positive effects of working as a team, including beneficial changes in patient behavior, improvement of patient vital signs [24] and symptoms, decreased use of emergency services and hospitalizations [41, 57], lower health costs [33, 48], improved patient satisfaction [23, 58] and better connection [52, 53, 58, 59].

Co-location benefits include promoting teaching of constructive health-related behaviors to patients [56, 60], improving communication between FDs and specialists, particularly in the mental health area, with a less stigmatizing approach to patient mental health care and better coordination between somatic and psychic care [61]. But the results are inconsistent [62] [63].

Patient education can take many forms but is usually via a series of courses that increase a patient’s autonomy towards understanding and managing their disease. Powell-Davis et al. restricted this category to joint teaching for several health professionals or education about shared care. We devised a less restrictive patient education category, including any intervention where a patient receives education about their illness or general healthy living advice, usually as part of a multi-level approach. Of note, most patient education intervention studies have been carried out in specialized areas such asthma or diabetes, showing significant benefits of treatment education for disease control. Education also brings benefit in terms of relational coordination [52-54], patient symptoms [32, 33], behaviors related to health [46, 56] ("health behavior"), vital parameters [24, 25], some quality and satisfaction scores [40], such as the ACIC score [52] (Assessment of Chronic Illness Care, often used to evaluate the chronic care model) as well as being linked to decreased hospitalizations [64] and health costs [33].

A Case conference is any intervention where there is a formal meeting between the PCP and / or case manager and / or other specialists to discuss patient management [6]. Often associated with the care plan, this intervention has been linked positively to patient [22, 23, 65] and physician satisfaction [23] and decreased hospitalizations [34] and health costs [18, 48, 65].

Multidisciplinary consultations are consultations involving multiple health professionals at the same time. This could be a council in the presence of the patient in a broad network context [18, 67].

Two studies [36, 66] on the use of telephone intervention by CMs did not show benefit whatever the outcome measure. However, if a hotline was in place, other studies identified telephone contact as a facilitator of care coordination in particular cases [11, 68, 69], or as a factor promoting a sense of care coordination by the patient [70]. Similarly, in combination with other interventions, such as the care plan, telephone use may lead to improvement in patient symptoms [29, 68]. A form of telemedicine, telecare, used to coordinate remote care, provides a device that acts as care provider, measuring vital parameters and other quantifiable values and sending them to the FD, case manager or nurse in charge. The only study we identified looked mainly into facilitators and barriers of integrating a telecare system for patients with chronic conditions and therefore nothing relevant can be drawn from it in terms of impact [71].

Proformas or transmission documents, are standardized forms of predefined templates for PCPs to fill to be able to send their patients to specialists, or, conversely for specialists to complete to respond to PCP’s requests [6]. The few studies that focused on this intervention [29]; associate the documents with better patient satisfaction and improvement of patient symptoms. However, a Norwegian study in 2014 [72] showed that hospital doctors rated the quality of PCP Med faxes good in only 16.5% of cases and perceived the lack of associated information and fact that some patients were referred to hospitals without good reason as important barriers to cooperation with family doctors (not accounted among studies having an impact).

Multi-disciplinary joint consultations are consultations in the presence of multiple caregivers [6]. This could be council in the presence of the patient, built into a broad framework [66].

The joint-care provider appointment arrangement involves the intervention of a third party to assist the patient. It is usually a case manager or direct integration into a multidimensional intervention framework and is positively associated with relational coordination [52-54] and decreased hospitalizations [41, 49]. According to a 2012 study [73], the care provider arrangements are usually in written form, such as contracts and specify, for example, patient-specialist referral (templates) or the referral procedure (chronology of care). In a guideline format, most health professionals considered arrangements for patient transfer processes useful, however this intervention worked better if health professionals had good prior relationships. The few studies on this type collaboration between FDs and specialists reported a decrease in numbers of drug prescriptions [74], specialized consultations and "inappropriate" enquiries as well as PCP satisfaction and interest for this specialized consultation [51, 69, 75].

Priority access to a health service, like gatekeeping, is an official or informal arrangement between the PCP and specialists to refer "priority" patients; described in an Italian 2010 study [24]. This intervention showed convincing results for improving patients’ self-health knowledge and ability to make changes beneficial to their health ("empowerment"). This type of selfmanagement organization could optimize referral to specialists or hospitals [69].

Reminder systems are interventions put in place to remind a health professional to do a particular test or procedure, for example using computer systems or specified in the CM’s protocol. They are usually part of other interventions and have shown a positive association with relational continuity [52- 54], behavioral changes [24, 56], and vital signs, such as blood pressure [24].

Supervision for PHC clinicians involves some form of verification of the work done by one health professional by another, such as supervision of CMs by experienced nurses [24], or by the PCP following the patient. Studies show positive associations with behavioral change [24], patient satisfaction [23], and improvement of vital signs, such as blood pressure [22, 24].

Assistance for patient appointments facilitates a patient’s access to care, for example, when the CM makes the appointment with the health professional. This intervention is associated with patient satisfaction [23, 28, 41], improvement of their symptoms [29, 33], and decreased emergency services use [49] and health costs [33, 48]. Caregiver education is like training patients, but in this case applies to the patient’s caregiver companions or entourage. The only study [30] clearly mentioning this intervention is part of a treatment plan, with a team comprising a CM in place and showed a high level of satisfaction from the patients' entourage.

Gatekeeping is an intervention regulating access to specialized consultations and costly examinations and therapies. It requires a patient to see a predefined health professional, usually the PCP, before consulting secondary health professionals. A gatekeeping study from 2000 [76] showed a significant decrease in the number of specialist visits and hospitalizations, without however, reducing the number of emergency room visits, or influencing patient satisfaction or the patient’s impression of easier access to specialists. However, a second study from 2015, reported improved quality of care [17]. Of note, is another study exploring ‘own GP’s’ in a population of diabetic patients showing a link to decreased use of emergency services [77].

Along these lines, formal agreement intervention is an agreement between group practices and other health care establishments [18]. One study concluded that formal agreements have a positive impact on the continuity and accessibility of care [70]. Several studies using different study designs investigated the mode of personnel remuneration, but results are inconclusive. A 2010 study [37] investigating a combined pay-for-performance intervention with a practice case manager intervention did not show quality of care improvement of this combined interventions, while a 2017 Chinese study combining a chronic care model with financial incentives for healthcare professionals, reported a positive effect on hospitalizations but a negative effect on patient quality of life [55]. An article on the effect of capitation funding and presence of a care coordinator did not show significant association with improved quality of care or health costs [47].

Practice facilitators help the practice organize and prioritize its quality improvement activities (“quality improvement”). They also help practice staff build a culture of "teamwork" and make them more "responsive to change" as suggested by Gray et al [78]. Facilitators are usually outside the practice, do not necessarily need medical training and have no contact with patients. A New Zealand study published in 2012 [39] showed that use of a facilitator led to improvements in coordination, teamwork, knowledge of the patients being treated as well as chronic disease management.

Discussion

This review of the recent literature of the past 17 years highlights the large number of interventions evaluated concerning coordination of care within PC or in connection with other health care providers. Many of the care coordination interventions, though sometimes contrasting, bring tangible benefits of transferring clinical and / or organizational information leading to improved care pathways, better objective health parameters and lower health costs. The interventions that deliver the most concrete coordination benefits involve presence of a case manager, individualized care plans and patient electronic health records. Overall, these interventions favor multi-disciplinary teamwork within the PC practice.

Concerning the actors of care coordination, the PCP appears to play a central role. On the other hand, many interventions concern nurses with varying degrees of specialization, in care coordinator or case manager roles [24, 30, 36, 37, 79], sometimes but not always linked to the PCP practice. Other players regularly involved in coordination activities are medical assistants [37] and sometimes caregivers [38], described in large-scale studies but without mention of their specific role. In the definition of care coordination adopted in this study, the patient is also an important player, evidenced by the number of studies seeking to improve patient autonomy about their disease (s) and day-today disease management (“empowerment”). This element has been pointed out by Reynolds in 2017 in her systematic review about chronic diseases management interventions in PC [7].

Comparing to the review conducted ten years ago by Powell Davis [3], we found the same main types of intervention, but the number of studies has significantly increased, allowing better identification of interventions that might positively modify care coordination.

It is important to note that the twenty-six interventions identified here do not only relate to care coordination, indicating the same interventions have several interacting roles in other aspects of health care. This is the case, for example, of case managers, the subject of abundant literature, including systematic reviews, investigating their role in case management of complex patients [80-82]. Our review is therefore complementary to existing publications of interventions with other important effects in primary care.

Strengths and limitations

One of the greatest difficulties for this study was to define the keywords, choose the interventions and categorize them. This was partly due to language, the definition of terms such as coordination of care, continuity, integration of care, case management, care management varies from one study to another. Often these terms overlap or are integrated into each other. In addition, many articles only give partial descriptions of the interventions studied, which often boil down to one term. While we relied in part on the work of the 2006 Powell- Davies team, it was not always possible to use the same definitions, influenced particularly by variations in the meaning of "coordination". Sometimes we used broader definitions for interventions; as for patient or caregiver training, where we did not restrict choice solely to interventions specifying training linked to care coordination. Many of the studies explored several types of interventions simultaneously and so it is common for us to cite the same article more than once in our categories, which may influence the number of "positive" or "negative" interventions. Some articles described interventions vaguely (e.g. simple communication between health professionals) and were not retained, even though an impact on coordination was possible. Finally, as this review has so many complex variables the findings should be placed alongside the findings of other more focused studies.

One of the strengths of this study is the systematic and rigorous identification of the most recently evaluated interventions for care coordination in primary care. In addition, the synthesis provides a clear overview of the interventions most likely to modify favorably care coordination. Future perspectives

We describe many investigated interventions with several correlating with improved coordination of patient care. However, there is still a long way to go before putting these beneficial innovations into practice. For instance, some countries implement electronic health records of patients or managers irregularly, as shown in the 2015 survey of the Commonwealth Fund [83]. The reasons for slow adoption of evidence-based interventions are multiple. The health care context (governance, health policy) may not necessarily favor implementation of new organizational models (due to lack of resources, inadequate remuneration, etc) [84-90]. In addition, the medical community is relatively reluctant to changes in practice, especially if it concerns non-clinical areas, as it is not perceived as activities that directly modify patients’ health outcomes. Overall, implementation requires clear political commitment and strong partnerships between the different domains. From this perspective, it seems important to develop research projects aimed at realizing proven interventions to establish a culture of implementation science [91-99]. In this regard, this narrative review should help to better identify priority interventions as it offers a global overview of interventions rather than focusing on a specific intervention [100-110].

An element that comes out from this study is the large range of measures used to evaluate an intervention’s impact. Measures can be directly related to care coordination components (better circulation of information, numbers of registered patients), indirect measures on health parameters (blood pressure, glycated hemoglobin), on aspects of experience and satisfaction or on costs. This makes of evaluation difficult, especially for objective comparisons even if a study concerns only one intervention. It therefore seems appropriate for researchers to agree on appropriate impact measures for health systems research. [110-119].

Conclusion

This narrative review of the recent literature shows that a significant number of interventions have been studied to optimize care coordination in primary care. Among the most compelling are electronic patient health records, individualized care plans and presence of case managers in the primary care practice. Future research is needed to assess the extent to which these interventions are implemented and what impact they have on patient management.

Disclosures

Ethics

No necessary ethic approval

Funding

The Public Health Office of the Canton of Vaud funded the research summarized in this paper.

Conflict of interest statement

The authors declare no conflict of interest.

Data availability statement

NA

Acknowledgment

Not applicable.

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