Abstract
Objective This research identifies specific care coordination activities used by Aging in Place (AIP) nurse care coordinators and home healthcare (HHC) nurses when coordinating care for older community-dwelling adults and suggests a method to quantify care coordination.
Methods A care coordination ontology was built based on activities extracted from 11 038 notes labeled with the Omaha Case management category. From the parsed narrative notes of every patient, we mapped the extracted activities to the ontology, from which we computed problem profiles and quantified care coordination for all patients.
Results We compared two groups of patients: AIP who received enhanced care coordination (n=217) and HHC who received traditional care (n=691) using 128 135 narratives notes. Patients were tracked from the time they were admitted to AIP or HHC until they were discharged. We found that patients in AIP received a higher dose of care coordination than HHC in most Omaha problems, with larger doses being given in AIP than in HHC in all four Omaha categories.
Conclusions ‘Communicate’ and ‘manage’ activities are widely used in care coordination. This confirmed the expert hypothesis that nurse care coordinators spent most of their time communicating about their patients and managing problems. Overall, nurses performed care coordination in both AIP and HHC, but the aggregated dose across Omaha problems and categories is larger in AIP.
Meeting the Needs of Children with Medical Complexity Using a Telehealth Advanced Practice Registered Nurse Care Coordination Model
