Care Coordination Processes in Transitional Care for Patients With Heart Failure

Abstract

Background: Transitional care components are well studied, but their coordination has not been systematically reviewed. Viewing transitional care through a social network framework can focus attention on processes leading to information and relationship transferal to ensure continuity and may lead to new strategies to improve transitional care. Objective: The aim of this study was to examine care coordination processes in transitional care interventions for older adults with heart failure by integrating a social network analysis approach. Methods: PubMed, Scopus, and CINAHL were searched to capture transitional care interventions (a) involving care coordination for older adults with heart failure transitioning from hospital to home and (b) published in the United States from 2010 to 2020. Study characteristics, intervention characteristics, and care coordination processes (ie, participants, interactions among participants, and their characteristics) were extracted. Results: In 17 studies reviewed, the number of individual roles involved in care coordination varied from 3 to 32. Nurses and pharmacists were the most common interventionists. Six studies involved informal caregivers. In-person interactions were most common among individuals within settings; interactions across settings were typically assisted by technology. Despite high variability among the individuals and interactions involved, a common triadic process was found through which interventionists, patients, and primary care providers or outpatient cardiologists aimed to facilitate the transfer of information and care relationships from hospital to community. Conclusions: High variability in transitional care is likely because the processes are highly relational. Using a network analysis may help uncover the relational structures and processes underlying transitional care to inform intervention development.

Elusive but hopefully not illusive: coordinating care for patients with heart failure with preserved ejection fraction

“…The number of professionals involved in care coordination for older adults with heart failure varies from 3 to 32 6. This kind of fragmentation means it is incumbent on healthcare professionals to spend time learning a patient’s history, recent care and current needs and then adjusting their work to the work of other involved healthcare professionals 7.…”

“…5 The number of professionals involved in care coordination for older adults with heart failure varies from 3 to 32. 6 This kind of fragmentation means it is incumbent on healthcare professionals to spend time learning a patient's history, recent care and current needs and then adjusting their work to the work of other involved healthcare professionals. 7 Up to 37% of clinical time is spent on coordination activities, such as reading and actioning correspondence from other services, sending referrals and searching for information on care provided in other services that is not readily on hand, although this time is rarely written into clinical schedules.…”