Continuity drives care coordination

In its practice brief on the continuity and coordination of care, the World Health Organisation (WHO) points out that “continuity enables care coordination by creating the conditions and ongoing relationships to support seamless interactions among multiple providers, within interdisciplinary teams or in care settings or sectors.” By presenting the results chain or the hierarchy of contributions that may be anticipated from a package of interventions and processes to deliver the desired outcomes, it becomes clear that for the design, implementation, and evaluation of care coordination, one should include continuity of care and vice versa. Not doing so, or looking at one concept without the other, would easily result in an oversimplification and misunderstanding of both concepts. Moreover, acknowledging that for achieving continuity and coordination of care a range of approaches and interventions is needed, neither continuity of care nor coordination of care should be understood as a simple intervention. Instead, both are complex in nature and nested in a broader strategy. To better understand continuity and coordination of care there is a need for theory-based evaluation of these related concepts. The scarcity of such evaluation and research efforts is mentioned by WHO in the practice brief. The International Journal of Care Coordination welcomes (more) high-quality, theory-based research including the application of approaches, such as Theory of Change and Realist Research, when studying or evaluating continuity and coordination of care. This approach to research enables us to better understand why continuity and coordination of care works (or not), how, for whom, and when. Answers to these questions are of increasing importance with complex strategies for continuity and coordination of care getting adopted in different contexts. Mixed methods research combining qualitative and quantitative data collection and analysis is at the heart of theory-based research. In the current issue of the International Journal of Care Coordination studies are reported that include either qualitative or quantitative data. The first paper presents a synthesis of social workers coordination activities for patients with complex needs in primary healthcare. In their scoping review, Couturier et al. shed light on the significant role social workers play in care coordination with the aim to support aligning the work of social workers with that of other professionals in primary care. Notwithstanding interprofessional collaboration is common in practice, the authors mention it is rarely supported by training and hence recommend further attention to the education and training of social workers to enable them to act effectively in care coordination and team-based care delivery. Kokorelias et al. examined the challenges associated with supporting low-income seniors as they transition from hospital to home and explored what role, if any, patient navigation models of care should have in addressing housing needs. While supporting older adults certainly does not fall entirely on patient navigation models of care, this study contributes to our knowledge about the opportunities such models of care share in responsibility for meeting older adults’ needs, including facilitating referrals where and when needed. In their paper, Lee and Williams report on a study investigating predictive factors of caregiver burden of those who are caring for an individual with cognitive decline. Moreover, this study may be considered as one of the first studies that comprehensively investigates the effect of healthcare-related factors on caregiver burden using a nationally representative sample of caregivers of individuals with cognitive impairment. Based on the study findings, Lee and Williams emphasise that sufficient information for medical and/or nursing tasks and on how to navigate the healthcare system should be provided at an appropriate caregiver educational level to support caregivers. The final article in this issue of the International Journal of Care Coordination clarifies how prematurity and low birth weight are correlated with access to a medical home later in childhood at ages 6–17 years. In doing so, Eubanks et al. analysed data from the 2016–2018 National Survey of Children’s Health. Based on their study findings, the authors call for further investigation to optimise the transition of care from neonatal intensive care unit (NICU) follow up clinics into primary care for the patients at high risk for lacking accessible and high-quality care later in childhood.