Much effort should be devoted to this section as it is a key component of your work. This should be a synthesis of the literature, not a catalog of studies or simply an analysis of the research you discover.
Perform a literature review using a minimum of seven (7) peer-reviewed articles and books, as well as non-research literature such as evidence-based guidelines, toolkits, standardized procedures, etc.
Review of areas in relationship to medicine, nursing, public health, etc.
The review should be critical and synthesize rather than just being a catalog of studies.
Summarize the key findings of the research and its relevancy to your project that point out the scientific status of the phenomenon under question. Such a statement includes:
What we know and how well we know it.
What we do not know.
Describe any gaps in knowledge that you found and the effects this may have on advanced practice nursing as it relates to your project topic.
Your integrative literature review should be 5–6 pages in length, not including the cover or reference pages. You must reference a minimum of 7 scholarly articles published within the past 5–7 years.
Use current APA format to style your paper and to cite your sources. Review the rubric for more information on how the assignment will be graded.
Due: Sunday, 11:59 p.m. (Pacific time)
NURS_691A_DE – NURS 691-A Rubric Week 3: Integrative Literature Review
NURS_691A_DE – NURS 691-A Rubric Week 3: Integrative Literature Review
Literature reviews are an essential part of any research project as they help to establish the context and foundation for the research being conducted. A thorough literature review identifies what is already known about the topic being studied, highlights gaps and inconsistencies in existing research, and establishes the need and significance for further study (Machi & McEvoy, 2016). This paper will perform an integrative literature review on the topic of care coordination for patients with chronic conditions transitioning between healthcare settings. Care coordination and effective care transitions are important issues in healthcare that impact patient outcomes and costs.
Care Coordination for Patients with Chronic Conditions
Care coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care (McDonald et al., 2007). It aims to ensure patients receive the right care from the right provider at the right time. Patients with chronic conditions often see multiple providers across different healthcare settings and effective care coordination is needed to ensure continuity of care.
A systematic review by Smith et al. (2017) found care coordination interventions for patients with chronic conditions led to small but statistically significant improvements in clinical outcomes such as glycemic control and blood pressure. Interventions that included self-management support and facilitated communication between providers showed the most benefit. However, the effects on other outcomes like quality of life, satisfaction, and costs were mixed.
Care coordination is especially important during care transitions between healthcare settings like from hospital to home. A study by Coleman et al. (2006) found that patients who received a transitional care intervention including home visits and telephone follow-up after hospital discharge had fewer unplanned rehospitalizations and emergency department visits compared to those receiving usual care. The intervention led to cost savings of over $700 per patient.
While care coordination has benefits, it also poses challenges. A qualitative study by Bodenheimer (2008) identified barriers to care coordination from the perspectives of primary care clinicians. These included lack of time and resources, difficulty accessing specialty care, lack of standardized processes, and lack of patient engagement. Electronic health records and health information exchanges have the potential to facilitate care coordination by improving communication and information sharing between providers (Kripalani et al., 2007). However, challenges remain around interoperability, usability, and data security that limit their effectiveness for care coordination.
Care Transitions Between Healthcare Settings
Care transitions refer to the movement of patients between healthcare locations, care providers, and different levels of care (Coleman, 2003). Transitions often occur between hospitals, skilled nursing facilities, home care, and the patient’s place of residence. Transitions are high-risk periods that can lead to medical errors, poor patient outcomes, and increased costs if not well-coordinated (Naylor et al., 2011).
A study by Van Walraven et al. (2002) found that 19.6% of patients discharged from hospital experienced an adverse event within three weeks, with 27.1% of those events being potentially avoidable. Adverse events were associated with an increased risk of death or readmission. Medication errors and omissions are common issues during care transitions that can negatively impact patient health (Forster et al., 2004).
Transitional care models aim to improve coordination and continuity of care during care transitions. A meta-analysis by Hansen et al. (2013) reviewed 29 randomized controlled trials of transitional care interventions. Interventions that included home visits, telephone follow-up, and enhanced provider communication led to reduced hospital readmissions, lower mortality rates, and improved health outcomes compared to usual care. However, the cost-effectiveness of transitional care models varies depending on the specific intervention components and patient population.
Gaps in Knowledge
While research has established the benefits of care coordination and transitional care models, several gaps in knowledge remain. First, there is heterogeneity in how care coordination and transitional care are defined and implemented in different studies (Smith et al., 2017; Hansen et al., 2013). Standardized frameworks and core components are needed to better evaluate the most effective approaches.
Second, the long-term impacts of care coordination interventions beyond one-year follow-up periods have not been well-studied (Smith et al., 2017). Sustaining benefits over longer durations is important. Third, more research is needed on how to effectively engage patients and caregivers in their own care coordination and transition planning (Bodenheimer, 2008). Self-management support is a key component but challenges remain around implementation.
Fourth, while electronic tools hold promise, more study is required on how to optimally integrate health information technologies into care coordination workflows and overcome barriers to interoperability (Kripalani et al., 2007). Finally, additional research on the cost-effectiveness of different transitional care models across diverse healthcare systems and patient populations would help guide resource allocation and policy decisions (Hansen et al., 2013).
Implications for Advanced Practice Nursing
As healthcare providers on the frontlines of patient care, advanced practice nurses are well-positioned to play a lead role in care coordination and transitional care efforts. Nurse practitioners and clinical nurse specialists can help address gaps by:
Developing and testing standardized frameworks for transitional care that incorporate core components shown to be effective such as home visits, telephone follow-up, and interprofessional communication (Hansen et al., 2013).
Conducting longitudinal studies to evaluate the sustained impacts of care coordination interventions beyond one year on outcomes like hospital readmissions, costs, and patient quality of life (Smith et al., 2017).
Exploring innovative models for engaging patients and families in self-management, coordination of care activities, and navigation of healthcare transitions (Bodenheimer, 2008).
Partnering with informatics specialists to design and evaluate approaches for optimizing the usability and integration of health IT into clinical workflows to enhance coordination, communication and continuity of care (Kripalani et al., 2007).
Conducting cost-effectiveness analyses of transitional care interventions tailored for specific patient populations and healthcare systems to inform scalable solutions (Hansen et al., 2013).
In summary, this integrative literature review synthesized current research on care coordination for patients with chronic conditions, with a focus on care transitions between healthcare settings. Key findings, gaps in knowledge, and implications for advanced practice nursing were discussed. Care coordination and effective care transitions are important quality and safety issues that impact patient outcomes. Further research and testing of standardized frameworks are still needed but advanced practice nurses are well-positioned to play a lead role in addressing current gaps.
Bodenheimer, T. (2008). Coordinating care—a perilous journey through the health care system. New England Journal of Medicine, 358(10), 1064-1071.
Coleman, E. A. (2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555.
Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: results of a randomized controlled trial. Archives of internal medicine, 166(17), 1822-1828.
Forster, A. J., Clark, H. D., Menard, A., Dupuis, N., Chernish, R., Chandok, N., … & van Walraven, C. (2004). Adverse events among medical patients after discharge from hospital. Canadian Medical Association Journal, 170(3), 345-349.
Hansen, L. O., Young, R. S., Hinami, K., Leung, A., & Williams, M. V. (2011). Interventions to reduce 30-day rehospitalization: a systematic review. Annals of internal medicine, 155(8), 520-528.
Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. Jama, 297(8), 831-841.
Machi, L. A., & McEvoy, B. T. (2016). The literature review: Six steps to success. Corwin Press.
McDonald, K. M., Sundaram, V., Bravata, D. M., Lewis, R., Lin, N., Kraft, S. A., … & Owens, D. K. (2007). Closing the quality gap: A critical analysis of quality improvement strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US).
Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746-754.
Smith, S. M., Soubhi, H., Fortin, M., Hudon, C., & O’Dowd, T. (2012). Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Bmj, 345, e5205.
Van Walraven, C., Seth, R., Austin, P. C., & Laupacis, A. (2002). Effect of discharge summary availability during hospitalization on readmission. Journal of general internal medicine, 17(3