Review of Care Coordination for Heart Failure Patients in Transitional Care: A Complex Systems Perspective

Friday, 20 July 2018

Sijia Wei
Kirsten Corazzini, PhD
School of Nursing, Duke University, Durham, NC, USA

Care Coordination Interventions for Geriatric Patients with Heart Failure Transitioning from Hospital to Community: A Literature Review

Introduction: There are great needs on improving care and reducing 30-day readmission rate for heart failure patients transitioning from hospital to the community. Care coordination has been identified as the key to achieve the triple aims (improve patient experience, quality of care, and reduce cost) and ensure patient-centered continuity of care for individuals with HF. No clear consensus has been reached on what are the key players and components to provide effective and efficient care coordination and how the various model of care coordination interventions influence care and health outcomes differently.

Purpose: The purpose of this systematic review is to understand the scope of participants involved and mechanisms or strategies used in recent care coordination interventions, as well as how different care coordination intervention models might improve readmission rate and other outcome measures.

Methods: PubMed, Scopus, and CINAHL were searched using key words related to care coordination, geriatric population, care transitions and heart failure to capture existing English articles published after 2010 in the United States. The Garrard Matrix method was used for the abstraction process to extract the authors, year published, objectives, study design, intervention, setting, sample, control group, measures,and results (Garrard, 2014). Nvivo 11 Plus was used to facilitate the coding and analysis process.

Results: 15 final articles were selected for the literature review. 5 key themes were identified:complex configuration of care coordination interventions, core care coordination agents, high variance and complexity in care coordination participants, high variance and complexity in care coordination components, and establishing and strengthening networks. Overall, care coordination interventions utilized and improved connectivity and consistency of care delivering by establishing stronger collaborative networks and addressing informational, relational, and systematic challenges in care transitions. Scope of care coordination participants and mechanisms vary greatly across studies and can be highly complex.

Conclusion: Although care coordination interventions are highly network-focused and agent-based, none of the studies has described and evaluated care coordination using social network perspective. Better understanding of how and what are the key care coordination components in reducing readmission rate and who is most suitable taking most of the care coordination responsibilities and actions is a significant gap in the literature.

Keywords: care coordination, transitions, geriatric, transitional care, heart failure