The Need for Co-Creation of Care with Multi-Morbidity Patients—A Longitudinal Perspective

Kuipers, Sanne Jannick; Nieboer, Anna P.; Cramm, Jane Murray

doi:10.3390/ijerph17093201

Cited by 6 publications

(5 citation statements)

References 38 publications

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“…We explored the potential value of augmenting traditional risk stratification with SDOH assessments to identify patients who could benefit from care coordination. Our results support current evidence (Kuipers et al., 2019, 2020) showing that care coordination and co‐creation of care was associated with improved patient well‐being and reductions in some key SDOH barriers. Our findings also support the previous research that demonstrate that care coordination driven by SDOH risk attribution may reduce barriers to care (Dias et al., 2019; Kellezi et al., 2019).…”

Section: Discussionsupporting

confidence: 90%

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Singer

Porta

2022

Health Social Care Comm

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Health and well‐being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim‐driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well‐being. To address the gap of risk‐informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non‐randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N = 216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t‐tests were incorporated to evaluate statistical significance of the intervention group. Impact on well‐being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well‐being [feeling anxious (t = 4.051; p < 0.000)] and reduced SDOH barriers [food access (t = 4.662; p < 0.000); housing (t = 2.203; p = 0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well‐being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well‐being.

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Section: Discussionsupporting

confidence: 90%

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Singer

Porta

2022

Health Social Care Comm

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“…15-item version ofthe Social Production Function Instrument for the Level of Well-being (SPF-ILs) (both patients and carers); [ 51 , 116 , 142 , 143 ];…”

Section: Figurementioning

confidence: 99%

Co-Production Performance Evaluation in Healthcare. A Systematic Review of Methods, Tools and Metrics

Marsilio

Fusco

Gheduzzi

et al. 2021

IJERPH

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Co-produced practices and publications in the healthcare sector are gaining momentum, since they can be a useful tool in addressing the sustainability and resilience challenges of health systems. However, the investigation of positive and, mainly, negative outcomes is still confused and fragmented, and above all, a comprehensive knowledge of the metrics used to assess these outcomes is lacking. To fill this gap, this study aims to systematically review the extant literature to map the methods, tools and metrics used to empirically evaluate co-production in health services. The search took place in six databases: Scopus, Web of Science, Psych INFO, PubMed, Cochrane and CINAHL. A total of 2311 articles were screened and 203 articles were included in the analysis, according to PRISMA guidelines. Findings show that outcomes are mainly investigated through qualitative methods and from the lay actor or provider perspective. Moreover, the detailed categorisation of the quantitative measures found offers a multidimensional performance measurement system and highlights the impact areas where research is needed to develop and test new measures. Findings should also promote improvements in empirical data collection on the multiple faceted co-produced activities and spur the consciousness of the adoption of sustainable co-productive initiatives.

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“…This can be facilitated by adopting streamlined two-way referral processes, developing a collaborative model of care, and having an aligned fee structure agreed upon by all stakeholders along the care journey, embedded into the care programmes [44,66]. Guidelines have to be co-developed not only with fellow providers but patients as well to minimise potential gaps in the referral and right-sitting processes [67].…”

Section: Discussionmentioning

confidence: 99%

Identifying Key Themes of Care Coordination for Patients with Chronic Conditions in Singapore: A Scoping Review

et al. 2023

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A projected rise in patients with complex health needs and a rapidly ageing population will place an increased burden on the healthcare system. Care coordination can bridge potential gaps during care transitions and across the care continuum to facilitate care integration and the delivery of personalised care. Despite having a national strategic vision of improving care integration across different levels of care and community partners, there is no consolidation of evidence specifically on the salient dimensions of care coordination in the Singapore healthcare context. Hence, this scoping review aims to uncover the key themes that facilitate care coordination for patients with chronic conditions in Singapore to be managed in the community while illuminating under-researched areas in care coordination requiring further exploration. The databases searched were PubMed, CINAHL, Scopus, Embase, and Cochrane Library. Results from Google Scholar were also included. Two independent reviewers screened articles in a two-stage screening process based on the Cochrane scoping review guidelines. Recommendation for inclusion was indicated on a three-point scale and rating conflicts were resolved through discussion. Of the 5792 articles identified, 28 were included in the final review. Key cross-cutting themes such as having standards and guidelines for care programmes, forging stronger partnerships across providers, an interoperable information system across care interfaces, strong programme leadership, financial and technical resource availabilities and patient and provider-specific factors emerged. This review also recommends leveraging these themes to align with Singapore’s national healthcare vision to contain rising healthcare costs.

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The Need for Co-Creation of Care with Multi-Morbidity Patients—A Longitudinal Perspective

Cited by 6 publications

References 38 publications

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Co-Production Performance Evaluation in Healthcare. A Systematic Review of Methods, Tools and Metrics

Identifying Key Themes of Care Coordination for Patients with Chronic Conditions in Singapore: A Scoping Review

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