Nurses’ and Patients’ Perspectives on Care Coordination Across Health Care and Social Services Sectors: A Qualitative Study

BackgroundNurse care coordinators strive to build connections between different organizations to assist patients with complex needs in navigating the healthcare system. However, they often lack adequate support in their roles and encounter challenges related to the tasks themselves and to organizational and systemic factors.PurposeThis study aims to evaluate a care coordination program in Quebec from the perspectives of both providers and beneficiaries.MethodsWe used a qualitative research design following an experience-based co-design approach.19 semi-structured interviews were held, ten with nurse care coordinators and nine with older adults and informal caregivers. An interview guide based on Valentijn et al. framework was used. Data were analysed using both deductive and inductive approaches.ResultsFactors influencing care coordination practice and the experience of older adults were identified. These include growing complexity of needs, patient-centered care, trusting relationships, interprofessional collaboration, communication tools, role clarity, shared values and objectives, the merger of health and social care institutions, and governmental guidelines and standards.ConclusionMany integrated care objectives are effectively implemented. Despite nurses' efforts, older adults have expressed a need for more presence from care coordinators and better communication. This stems from the increasing complexity of patients' needs and situations, as well as the nursing shortage. The study provides a systemic perspective on the challenges of a care coordination program at various levels. As such, it offers valuable insights for care providers, staff managers, and policymakers in integrated healthcare systems, enabling targeted improvements and offering guidance for broader application.