Relational coordination: important element in care coordination across the continuum of care

Care pathway were originally used in (acute) hospitals. Currently there is an increasing interest in developing care pathways in other health care settings. Sabine Van Houdt, research fellow, Academic Center for General Practice, KULeuven – University of Leuven studied the effect of care pathways across boundaries of health care settings. Below is the abstract of her PhD dissertation. 

Background: Patients with complex chronic conditions often require care coordination to ensure a good quality of care. Strategies to improve care coordination do not always have the desired results. This is partly due to incomplete understanding of the key concepts of care coordination. The lack of clarity is a result of multiple existing definitions and theoretical frameworks for the study of care coordination, each with a different emphasis. In 2007, the Agency for Healthcare Research and Quality defined care coordination as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.” A uniform, comprehensive theoretical framework for the study of care coordination is needed to provide us more insight in the key concepts and the links between these key concepts. This insight is important when developing, implementing and evaluating strategies to improve care coordination.

Aim: This dissertation aims to gain more insight in care coordination by exploring key concepts of care coordination and the links between these key concepts. The secondary aim is to inquire care pathways as a possible strategy to improve care coordination in primary care and to bridge primary and hospital care.

These objectives are translated into the following research questions:

  1. What key concepts of care coordination and links between these key concepts can be identified in international literature and in daily experiences of patients and healthcare professionals?
  2. To which extent can care pathways support or create elements necessary to improve care coordination across boundaries of primary and hospital care and in primary care leading to more quality of care?
Prof. J. De Lepeleire (promotor) and S. Van Houdt, PhD

Prof. J. De Lepeleire (promotor) and S. Van Houdt, PhD

Methods: First, existing theoretical frameworks for the study of care coordination were identified through a literature review. An in-depth analysis of these theoretical frameworks was performed to identify key concepts of care coordination and links between these key concepts. Second, key concepts of care coordination and links between these key concepts were further explored in patients’ and primary healthcare professionals’ experiences of care coordination. A qualitative research design was used. Twenty-two patients who had breast cancer surgery were selected in three hospitals in Flanders (Belgium) and interviewed. Primary healthcare professionals involved in the care of these patients were invited to participate in a focus group. Six focus groups were organized. Data were analyzed using constant comparative analysis. Third, an in-depth analysis of multiple cases developing a new or evaluating an already existing care pathway was performed to assess to which extent key concepts of care coordination are supported or created by care pathways. Data were gathered using mixed methods, including structured face-to-face interviews, participant observations, documentation and a focus group. Multiple cases were analyzed performing a cross case synthesis to strengthen the results. Finally, an exploratory trial was performed to explore whether revising an existing care pathway would improve quality of care enhancing patient outcomes. A pre-post intervention postal survey was used. Quality of care was translated into process and outcome indicators. These indicators were measured in two groups receiving a postal questionnaire: one group before (pre-intervention) and another group after implementation of a revised care pathway (post-intervention).

Results: The in-depth analysis identified 14 key concepts of care coordination and links between these key concepts. Nine of the fourteen key concepts were further explored in patients’ experiences of care coordination. “Roles” and “quality of relationship” were identified as core key concepts. “Quality of relationship” was extended to “quality of relationship” with the patient. “Patient’s related factors ” was newly identified. These 15 key concepts of care coordination were found and further explored in healthcare professionals’ experiences. Links between these 15 concepts were identified, including 9 newly identified links.

The development of a care pathway across the primary-hospital care continuum, supported by a step-by-step scenario, enhanced existing and newly constructed structures, knowledge and information technology, administrative operational processes, defining and knowing each other’s roles, building qualitative relationships, exchanging information and formulating and sharing goals. Observed improvement in information towards patients, communication between healthcare professionals, coordination, patients consultation of a physiotherapist who is specialised in pelvic floor muscle exercise training and patient outcomes after implementing a revised care pathway were not statistically significant after correcting for multiple testing. Quality improvement is a continuous process. Therefor the hospital takes further initiatives together with patient associations to improve well-being of patients.

Conclusions: A comprehensive theoretical framework emerges bringing all results together. The developed theoretical framework emphasizes the importance of relational coordination when developing effective coordination strategies. Relational coordination refers to clearly defined roles, knowing and respecting each other’s roles, collaboration, the bond with and trust of the patient, communication and shared goals. External factors and (inter)organizational mechanisms should enhance these aspects of relational coordination. The developed theoretical framework also emphasizes that patient’s related factors influence care coordination affecting quality outcomes.

Care pathways across the primary-hospital care continuum enhance components of care coordination when certain pre-conditions are met.

Sabine Van Houdt – Project manager quality of care and primary care, Flemish Patient Platform sabine.vanhoudt@med.kuleuven.be