MODELS OF COMMUNITY-BASED CARE COORDINATION

Background: Provisions of the Affordable Care Act have led to widespread interest in care coordination to enhance quality of care and cost outcomes in the management of chronic complex conditions. Incentives to improve continuity of care across providers and settings have led to a variety of innovative care coordination models.

Objective: The purpose of this presentation is to provide an overview of community-based care coordination models described in the current literature.

Methods: Peer-reviewed health services literature published in English between 2010 and 2014 was reviewed for descriptions of community-based care coordination models. Models were assessed for represented perspective, domain and mechanisms, as well as sensitivity to explain nursing contribution to team-based chronic disease management.

Findings and Conclusions: Community-based care coordination described in the literature can be broadly categorized into models of practice transformation, transitional care, as well as internally and externally embedded care managers. All models share the purpose of supporting processes and outcomes of team-based chronic care management. Practice models with a narrower focus were found for specific programs for disease management, patient navigation/linking to resources, self-care support, or medication management. Care coordination models varied in scope and representation according to patient, provider, or system perspectives. Multi-level and cross-level frameworks linking provider activities to population level outcomes were common. All sourced research showed limited generalizability due to bounding within geo-political, workforce, technology, and financial contexts. Contributions by nurses to improve quality and cost outcomes could not always be discriminated within the models. Further, care coordination models that were tested in rural and frontier communities were largely underrepresented.

Implications: Additional research is needed to study the role of nurses in community-based care coordination. Assessment of characteristics associated with improved performance outcomes will be key to practice and policy decisions pertaining to workforce development and training. Understudied rural settings with a large proportion of unskilled and lay workers in care coordination roles should become a priority focus of investigation. The development of evidence-based strategies to accelerate data-driven performance optimization of chronic care management will be critical to addressing widening urban-rural disparities (Singh & Siahpush, 2014). Future nursing research, that tests care coordination models in rural populations, will be needed to keep pace with delivery system transformation, which emphasizes a shift from acute care to prevention-based population health management for better service delivery to underserved populations.