What is known about this topic dSystem navigator roles for high-risk patients generally target populations whose medical condition and circumstances require support in accessing appropriate care. Concludes that the heterogeneity of models and interventions precludes direct comparison, but that navigators may be effective in assisting older patients as they transition between healthcare settings and in diverting older patients with serious and persistent medical conditions, from higher levels of care. AbstractTransitions between various healthcare services are potential points for fragmented care and can be confusing and complicated for patients, formal and informal caregivers. These challenges are compounded for older adults with chronic disease, as they receive care from many providers in multiple care settings. System navigation has been suggested as an innovative strategy to address these challenges. While a number of navigation models have been developed, there is a lack of consensus on the desired characteristics and effectiveness of this role. We conducted a systematic literature review to describe existing navigator models relevant to chronic disease management for older adults and to investigate the potential impact of each model. Relevant literature was identified using five electronic databases -Medline, CINAHL, the Cochrane database, Embase and PsycINFO between January 1999 and April 2011. Following a recommended process for health services research literature reviews, exclusion and inclusion criteria were applied to retrieved articles; 15 articles documenting nine discrete studies were selected. This review suggests that the role of a navigator for the chronically ill older person is a relatively new one. It provides some evidence that integrated and coordinated care guided by a navigator, using a variety of interventions such as care plans and treatment goals, is beneficial for chronically ill older adults transitioning across care settings. There is a need to further clarify and standardise the definition of navigation, as well as a need for additional research to assess the effectiveness and cost of different approaches to the health system.
IntroductionMiscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care.MethodsThis study explored multiple care transitions for an elderly hip fracture patient, post-surgery. Interviews and observations were conducted with the patient, their family caregivers, and health care providers, at each point of transition between four different care settings.ResultsFour key themes were identified over the patients care trajectory: ‘Missing Crucial Coversations’—Patient and family caregivers did not feel involved or informed about decisions in care; ‘Who’s Who’—Confusion about the role of health care providers; ‘Ready or Not’—Not knowing what to expect or what is expected; and, ‘Playing by the Rules’—Health system policies and procedures hinder individualized care.ConclusionStudy findings point to the need for the health care system to engage patients and family caregivers more fully and consistently in the process of care transitions as well as the importance of understanding these processes from multiple perspectives. Recommendations for system integration are proposed with a focus on transitional care.
A consultation process was undertaken with healthcare providers in the Waterloo Wellington region of southern Ontario to assess current system strengths, challenges and gaps in providing care to frail seniors. The findings were used to implement strategies for improving system integration.
There is growing recognition of the importance of sharing health information in home care; however, limited research exists to identify appropriate strategies, especially with home care providers. We engaged home care stakeholders from three locations in Ontario to determine facilitators, barriers, and recommendations for using health information in home care. The results suggest that health professionals recognize the potential of these systems to enhance communication through several emergent themes; however, there was a lack of agreement on the current facilitators, barriers, and recommendations for future interventions. More research is needed to achieve consensus before strategies for improvement can be initiated.
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