Development and implementation of a nurse-led model of care coordination to provide health-sector continuity of care for people with multimorbidity: Protocol for a mixed methods study

Kate M. Davis, Marion C. Eckert, Sepehr Shakib, Joanne Harmon, Amanda D. Hutchinson, Greg Sharplin, Gillian E. Caughey

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background: Innovative strategies are required to reduce care fragmentation for people with multimorbidity. Coordinated models of health care delivery need to be adopted to deliver consumer-centered continuity of care. Nurse-led services have emerged over the past 20 years as evidence-based structured models of care delivery, providing a range of positive and coordinated health care outcomes. Although nurse-led services are effective in a range of clinical settings, strategies to improve continuity of care across the secondary and primary health care sectors for people with multimorbidity have not been examined. Objective: To implement a nurse-led model of care coordination from a multidisciplinary outpatient setting and provide continuity of care between the secondary and primary health care sectors for people with multimorbidity. Methods: This action research mixed methods study will have two phases. Phase 1 includes a systematic review, stakeholder forums, and validation workshop to collaboratively develop a model of care for a nurse-led care coordination service. Phase 2, through a series of iterative action research cycles, will implement a nurse-led model of care coordination in a multidisciplinary outpatient setting. Three to five iterative action research cycles will allow the model to be refined and further developed with multiple data collection points throughout. Results: Pilot implementation of the model of care coordination commenced in October 2018. Formal study recruitment commenced in May 2019 and the intervention and follow-up phases are ongoing. The results of the data analysis are expected to be available by March 2020. Conclusions: Nursing, clinician, and patient outcomes and experiences with the nurse-led model of care coordination will provide a template to improve continuity of care between the secondary and primary health care systems. The model template may provide a future pathway for implementation of nurse-led services both nationally and internationally. International Registered Report Identifier (IRRID): DERR1-10.2196/15006.

Original languageEnglish
Article numbere15006
JournalJournal of Medical Internet Research
Volume21
Issue number12
DOIs
Publication statusPublished - 1 Jan 2019

Keywords

  • Chronic disease
  • Continuity of patient care
  • Integrated health
  • Multimorbidity
  • Nurse led
  • Transitional

ASJC Scopus subject areas

  • Health Informatics

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