care plan case study

Nursing Care Plans

Download these FREE nursing care plan examples for different conditions. Know their pathophysiology, interventions, goals, and assessment in this database. You can also visit our nursing care plans guide for tips on how to write nursing care plans.

13 Heart Failure Nursing Care Plans

Utilize this comprehensive nursing care plan and management guide to provide optimal care for patients with heart failure. Gain valuable insights on nursing assessment, interventions, goals, and nursing diagnosis specifically tailored for heart failure in this guide.

Nursing Care Plans (NCP): Ultimate Guide and List

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Fall Risk and Fall Prevention Nursing Care Plan

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Risk for Infection and Infection Control Nursing Care Plan and Management

This nursing care plan and management guide can assist nurses in providing care for patients who are at risk for infection. Get to know the nursing assessment, interventions, goals, and nursing diagnosis for infection prevention and control.

Unstable Blood Glucose Levels (Hyperglycemia & Hypoglycemia) Nursing Care Plan and Management

This guide will equip you with valuable knowledge about conducting thorough nursing assessments, implementing evidence-based nursing interventions, establishing appropriate goals, and identifying nursing diagnoses associated with unstable blood glucose levels.

Grieving & Loss Nursing Care Plan and Management

Utilize this comprehensive guide to assist you in developing a well-rounded nursing care plan tailored specifically for individuals experiencing grief. By following the outlined steps and recommendations, you can effectively address the unique needs and challenges associated with grieving.

Knowledge Deficit & Patient Education Nursing Care Plan and Management

Utilize this comprehensive nursing care plan and management guide to effectively educate patients and provide health teachings. Gain knowledge on the nursing assessment process, evidence-based nursing interventions, goal-setting, and nursing diagnoses specific to addressing knowledge deficit.

Activity Intolerance and Generalized Weakness Nursing Care Plan and Management

Nurses play a vital role in recognizing and caring for patients with general weakness or intolerance to activity. Whether it’s due to a patient’s recent surgery or chronic condition, decreased tolerance to activity can greatly impact a their ability to perform daily tasks and their overall well-being. You can use this nursing care plan guide for generalized weakness to help you create nursing interventions and nursing diagnosis for this condition.

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• Clinical Journal of Oncology Nursing
• Number 6 / December 2021
• Supplement, December 2021, Survivorship Care

Breast Cancer: Survivorship Care Case Study, Care Plan, and Commentaries

Amber Whitton-Smith

Rachael Schmidt

Kristie Howlett

Rachée Hatfield

This case study highlights the patient’s status in care plan format and is followed by commentaries from expert nurse clinicians about their approach to manage the patient’s long-term or chronic cancer care symptoms. Finally, an additional expert nurse clinician summarizes the care plan and commentaries, emphasizing takeaways about the patient, the commentaries, and additional recommendations to manage the patient. As can happen in clinical practice, the patient’s care plan is intentionally incomplete and does not include all pertinent information. Responding to an incomplete care plan, the nurse clinicians offer comprehensive strategies to manage the patient’s status and symptoms. For all commentaries, each clinician reviewed the care plan and did not review each other’s commentary. The summary commentary speaks to the patient’s status, care plan, and nurse commentaries.

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Related Articles

Sleep quality and associated factors among survivors of breast cancer: from diagnosis to one year postdiagnosis, cardiovascular disease incidence and cardiovascular health among diverse women with breast and gynecologic cancers, associations of demographic and social factors on health-related quality-of-life changes among older women with breast or gynecologic cancer.

Breast Cancer: Survivorship Care Case Study, Care Plan, and Commentaries

Affiliation.

• 1 Saint Louis University.
• PMID: 34800110
• DOI: 10.1188/21.CJON.S2.34-42

This case study highlights the patient's status in care plan format and is followed by commentaries from expert nurse clinicians about their approach to manage the patient's long-term or chronic cancer care symptoms. Finally, an additional expert nurse clinician summarizes the care plan and commentaries, emphasizing takeaways about the patient, the commentaries, and additional recommendations to manage the patient. As can happen in clinical practice, the patient's care plan is intentionally incomplete and does not include all pertinent information. Responding to an incomplete care plan, the nurse clinicians offer comprehensive strategies to manage the patient's status and symptoms. For all commentaries, each clinician reviewed the care plan and did not review each other's commentary. The summary commentary speaks to the patient's status, care plan, and nurse commentaries.

Keywords: breast cancer; care plan; case study; survivorship care.

• Breast Neoplasms* / therapy
• Survivorship*

How to Write a Nursing Care Plan

Nursing care plan components, nursing care plan fundamentals.

Knowing how to write a nursing care plan is essential for nursing students and nurses. Why? Because it gives you guidance on what the patient’s main nursing problem is, why the problem exists, and how to make it better or work towards a positive end goal. In this article, we'll dig into each component to show you exactly how to write a nursing care plan. 

A nursing care plan has several key components including, 

• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections otherwise, it won’t make sense!

• Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for their patients
• Expected outcome - The measurable action for a patient to be achieved in a specific time frame. 
• Nursing interventions and rationales - Actions to be taken to achieve expected outcomes and reasoning behind them.
• Evaluation - Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

>> Related: What is the Nursing Process?

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Before writing a nursing care plan, determine the most significant problems affecting the patient. Think about medical problems but also psychosocial problems. At times, a patient's psychosocial concerns might be more pressing or even holding up discharge instead of the actual medical issues. 

After making a list of problems affecting the patient and corresponding nursing diagnosis, determine which are the most important. Generally, this is done by considering the ABCs (Airway, Breathing, Circulation). However, these will not ALWAYS be the most significant or even relevant for your patient. 

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data . Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

This information can come from, 

Verbal statements from the patient and family

Vital signs

Blood pressure

Respirations

Temperature

Oxygen Saturation

Physical complaints

Body conditions

Head-to-toe assessment findings

Medical history

Height and weight

Intake and output

Patient feelings, concerns, perceptions

Laboratory data

Diagnostic testing

Echocardiogram

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and the objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

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There are 4 types of nursing diagnoses.  

Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis

Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing

Health promotion - Improve the overall well-being of an individual, family, or community

Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing diagnosis statement. 

The three main components of a nursing diagnosis are:

Problem and its definition - Patient’s current health problem and the nursing interventions needed to care for the patient.

Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed

Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific diagnostic label/used in the place of defining characteristics for risk nursing diagnosis

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART is an acronym that stands for,

It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. A medical diagnosis is made by a physician or advanced healthcare practitioner.  It’s important to remember that a medical diagnosis does not change if the condition is resolved, and it remains part of the patient’s health history forever. 

Examples of medical diagnosis include, 

Chronic Lung Disease (CLD)

Alzheimer’s Disease

Endocarditis

Plagiocephaly 

Congenital Torticollis 

Chronic Kidney Disease (CKD)

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

Physiological

Complex physiological

Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

Pain assessment

Position changes

Fall prevention

Providing cluster care

Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

Based on the evaluation, it can determine if the goals and interventions need to be altered. Ideally, by the time of discharge, all nursing care plans, including goals should be met. Unfortunately, this is not always the case - especially if a patient is being discharged to hospice, home care, or a long-term care facility. Initially, you will find that most care plans will have ongoing goals that might be met within a few days or may take weeks. It depends on the status of the patient as well as the desired goals. 

Consider picking goals that are achievable and can be met by the patient. This will help the patient feel like they are making progress but also provide relief to the nurse because they can track the patient’s overall progress. 

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Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan. The nursing plan is constantly updated with changes and new subjective and objective data. 

Key aspects of the care plan include,

Outcome and Planning

Implementation

Through subjective and objective data, constantly assessing your patient’s physical and mental well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a helpful and powerful tool.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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Nursing Case Studies with Answers

Explore Nursing Case Studies with Answers and examples in Carepatron's free downloadable PDF. Enhance your nursing knowledge and prepare for exams with practical scenarios.

By Wynona Jugueta on Mar 25, 2024.

Fact Checked by Ericka Pingol.

What is a case study?

A case study in medicine is a detailed report of a patient's experience with a disease, treatment, or condition. It typically includes the patient's medical history, symptoms, diagnostic tests, treatment course, and outcome.

Some key things to know about medical case studies template . First, they delve deep into the specifics of a single case, providing a rich understanding of a particular medical situation.

Medical professionals use case studies to learn about rare diseases, unusual presentations of common conditions, and the decision-making process involved in complex cases.

Case studies can identify exciting areas for further investigation through more rigorous clinical trials. While informative, they can't be used to develop general treatment guidelines because they only focus on a single case.

Overall, medical case studies are valuable tools for medical education and research, offering insights into human health and disease complexities.

Printable Nursing Case Studies with Answers

Download this Nursing Case Studies with Answers to analyze complex clinical situations, identify priority needs, and develop effective care plans tailored to individual patients.

What is in a nursing case study?

A nursing case study is a detailed examination of a patient's health condition, treatment plan, and overall care journey, specifically from the perspective of nursing practice. These case studies are essential components of nursing education and professional development, providing valuable insights into clinical scenarios and patient care experiences.

In a case nursing study template , various elements are typically included to comprehensively understand the patient's situation. First and foremost, the case study outlines the patient's demographic information, including age, gender, medical history, and presenting symptoms. This demographic overview sets the stage for understanding the context in which healthcare interventions occur.

Moreover, nursing case studies often delve into the nursing assessment process, highlighting the initial and ongoing assessments nurses conduct to gather relevant patient health status data. These assessments involve physical examinations, vital sign monitoring, and assessment tools to identify potential health issues and risk factors.

Critical thinking skills are essential in nursing case studies, as they enable nurses to analyze complex clinical situations, identify priority needs, and develop effective care plans tailored to individual patients. Nursing students and experienced nurses use case studies as opportunities to enhance their critical thinking abilities and clinical decision-making processes.

Nursing case studies serve several vital purposes within healthcare education and professional practice, whether they are a primary care physician or a group of nursing students. Let's explore each purpose in detail:

Enhancing clinical reasoning skills

One primary purpose of nursing case studies is to enhance nursing students' and practicing nurses' clinical reasoning skills. By presenting realistic patient scenarios, case studies challenge individuals to analyze clinical data, interpret findings, and develop appropriate nursing interventions. This process promotes critical thinking and problem-solving abilities essential for effective nursing practice.

Applying theoretical knowledge to practice

Nursing case studies provide a bridge between theoretical knowledge and practical application. They allow nursing students to apply concepts learned in the classroom to real-world patient care situations. By engaging with case studies, students can integrate theoretical principles with clinical practice, gaining a deeper understanding of nursing concepts and their relevance to patient care.

Facilitating interdisciplinary collaboration

Another purpose of nursing case studies is to facilitate interdisciplinary collaboration among healthcare professionals. Nurses often collaborate with physicians, specialists, therapists, and other team members in complex patient cases to deliver comprehensive care. Case studies offer opportunities for nurses to explore collaborative decision-making processes, communication strategies, and teamwork dynamics essential for providing quality patient care.

Promoting evidence-based practice

Nursing case studies are crucial in promoting evidence-based practice (EBP) within nursing and healthcare settings. Nurses can make informed decisions about patient care interventions by analyzing patient scenarios and considering current research evidence. Case studies encourage nurses to critically evaluate research findings, clinical guidelines, and best practices to ensure the delivery of safe, effective, and patient-centered care.

Fostering professional development

Engaging with nursing case studies contributes to the ongoing professional development of nurses at all stages of their careers. For nursing students, case studies provide valuable learning experiences that help prepare them for clinical practice. For experienced nurses, case studies offer opportunities to refine clinical skills, stay updated on emerging healthcare trends, and reflect on past experiences to improve future practice.

How to write a nursing case study?

Writing a nursing case study involves several essential steps to ensure accuracy, relevance, and clarity. Let's break down the process into actionable steps:

Step 1: Select a patient case

Begin by selecting a patient case that presents a relevant and compelling healthcare scenario. Consider factors such as the patient's demographic information, medical history, presenting symptoms (e.g., joint stiffness, pain), and healthcare needs (e.g., medication administration, vital signs monitoring). Choose a case that aligns with your learning objectives and offers meaningful analysis and discussion opportunities.

Step 2: Gather relevant data

Collect comprehensive data about the selected patient case, including medical records, test results, nursing assessments, and relevant healthcare documentation. Pay close attention to details such as the patient's current health status, past medical history (e.g., diabetes), treatment plans, and any ongoing concerns or challenges. Utilize assessment tools and techniques to evaluate the patient's condition thoroughly and identify areas of clinical significance.

Step 3: Assess the patient's needs

Based on the gathered data, evaluate the patient's needs, considering physical, emotional, social, and environmental factors. Assess the patient's pain levels, mobility, vital signs, and other relevant health indicators. Identify any potential complications, risks, or areas requiring immediate attention. Consider the patient's preferences, cultural background, and individualized care requirements in your assessment.

Step 4: Formulate nursing diagnoses

Formulate nursing diagnoses that accurately reflect the patient's health needs and priorities based on your assessment findings. Identify actual and potential nursing diagnoses related to the patient's condition, considering factors such as impaired mobility, ineffective pain management, medication adherence issues, and self-care deficits. Ensure your nursing diagnoses are specific, measurable, achievable, relevant, and time-bound (SMART).

Step 5: Develop a care plan

Develop a comprehensive care plan outlining the nursing interventions and strategies to address the patient's identified needs and nursing diagnoses. Prioritize interventions based on the patient's condition, preferences, and care goals. Include evidence-based nursing interventions to promote optimal health outcomes, manage symptoms, prevent complications, and enhance the patient's overall well-being. Collaborate with other healthcare professionals as needed to ensure coordinated care delivery.

Step 6: Implement and evaluate interventions

Implement the nursing interventions outlined in the care plan while closely monitoring the patient's response to treatment. Administer medications, provide patient education, perform nursing procedures, and coordinate care activities to effectively meet the patient's needs. Continuously evaluate the effectiveness of interventions, reassessing the patient's condition and adjusting the care plan as necessary. Document all interventions, observations, and outcomes accurately and comprehensively.

Step 7: Reflect and seek assistance

Reflect on the nursing case study process, considering what worked well, areas for improvement, and lessons learned. Seek assistance from nursing instructors, preceptors, or colleagues if you encounter challenges or have concerns about the patient's care. Collaborate with interdisciplinary team members to address complex patient issues and ensure holistic care delivery. Continuously strive to enhance your nursing practice through ongoing learning and professional development.

Nursing Case Studies with Answers example (sample)

Below is an example of a nursing case study sample created by the Carepatron team. This sample illustrates a structured framework for documenting patient cases, outlining nursing interventions, and providing corresponding answers to guide learners through the analysis process. Feel free to download the PDF and use it as a reference when formulating your own nursing case studies.

Download this free Nursing Case Studies with Answers PDF example here 

Why use Carepatron as your nursing software?

Carepatron stands out as a comprehensive and reliable solution for nursing professionals seeking efficient and streamlined workflows in their practice. With a range of features tailored to the needs of nurses and healthcare teams, Carepatron offers unparalleled support and functionality for managing various aspects of patient care.

Nurse scheduling software

One of the key advantages of Carepatron is its nurse scheduling software , which simplifies the process of creating and managing schedules for nursing staff. With intuitive scheduling tools and customizable options, nurses can easily coordinate shifts, manage availability, and ensure adequate staffing levels to meet patient needs effectively.

Telehealth platform

In addition, Carepatron offers a robust telehealth platform that facilitates remote patient monitoring, virtual consultations, and telemedicine services. This feature enables nurses to provide continuity of care beyond traditional healthcare settings, reaching patients in remote areas or those unable to attend in-person appointments.

Clinical documentation software

Furthermore, Carepatron's clinical documentation software streamlines the documentation process, allowing nurses to easily capture patient data, record assessments, and document interventions. The platform supports accurate and efficient documentation practices, ensuring compliance with regulatory standards and promoting continuity of care across healthcare settings.

Commonly asked questions

In clinical terms, a case study is a detailed examination of a patient's medical history, symptoms, diagnosis, treatment, and outcomes, typically used for educational or research purposes.

Case studies are essential in nursing as they provide real-life scenarios for nurses to apply theoretical knowledge, enhance critical thinking skills, and develop practical clinical reasoning and decision-making abilities.

Case studies in nursing education offer benefits such as promoting active learning, encouraging problem-solving skills, facilitating interdisciplinary collaboration, and fostering a deeper understanding of complex healthcare situations.

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• v.23(1); Jan-Mar 2023

Language: English | French

Nursing Care Coordination in Primary Healthcare for Patients with Complex Needs: A Comparative Case Study

Marlène karam.

1 Faculty of Nursing, Université de Montréal, Quebec, Canada

Maud-Christine Chouinard

Yves couturier.

2 Department of Social Work, Université de Sherbrooke, Quebec, Canada

Isabelle Vedel

3 Department of Family Medicine, McGill University, Quebec, Canada

Catherine Hudon

4 Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Quebec, Canada

Associated Data

Introduction:.

Despite nurses’ substantial role in care coordination, few education programs exist to better support them in this role. Identification of a set of core care coordination activities across heterogeneous care coordination programs would facilitate the development of a standard of practice. We sought to examine care coordination activities across two care coordination programs in Family Medicine Groups in Quebec, and their relationship to the program design.

We performed a comparative case study of two care coordination programs in primary care targeting frequent users of healthcare services and people with Alzheimer’s disease and related disorders. Data collection included documents and semi-structured interviews with key informants.

Several activities were common to both programs, such as patient identification; assessment, development of an individualized service plan; and linking patients and caregivers with professionals and services. However, their components were different due to the impact of the integrated care program design, policy environment, and the target patient populations’ complex needs.

Discussion:

The homogeneity or heterogeneity of patients’ complex needs shapes their care trajectory and the intensity of their care coordination needs. As the complexity of these needs grows, so does the necessity to build the care coordinators’ capacity for integrated care.

Malgré le rôle important des infirmières dans la coordination des soins et des services, peu de programmes de formation existent pour mieux les soutenir dans l’exercice de celui-ci. L’identification d’un tronc commun d’activités de coordination des soins et services effectuées par les infirmières à travers différents programmes de coordination faciliterait l’élaboration d’une norme de pratique en vue de rehausser leur formation à cet égard. Cette étude examine les activités de coordination des soins et services effectuées par les infirmières dans deux programmes de coordination hétérogènes déployés dans les groupes de médecine de famille au Québec, et la façon dont la conception du programme impacte celles-ci.

Méthodes:

Nous avons réalisé une étude de cas comparative de deux programmes de coordination des soins et services en première ligne ciblant les usagers fréquents des services de santé et les personnes atteintes de la maladie d’Alzheimer et des troubles apparentés. La collecte de données comprenait une analyse documentaire et des entretiens semi-dirigés avec des informateurs clés.

Résultats:

Plusieurs activités étaient communes aux deux programmes, telles que l’identification des patients ; évaluation, élaboration d’un plan de services individualisé ; et la mise en relation des patients et des soignants avec des professionnels et des services. Cependant, leurs composantes étaient différentes en raison de l’impact de la conception du programme de soins intégrés, de l’environnement politique et des besoins complexes des populations de patients cibles.

L’homogénéité ou l’hétérogénéité des besoins complexes des patients façonne leur trajectoire de soins et l’intensité de leurs besoins de coordination des soins. À mesure que la complexité de ces besoins augmente, la nécessité de renforcer la capacité des coordonnateurs de soins en matière de soins intégrés augmente également.

Introduction

Ensuring coordinated care between health and social care services has become a well-established policy and practice concern in most developed countries [ 1 ]. Indeed, care coordination has been identified as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of healthcare systems [ 2 ]. However, and despite the proven benefits, care coordination is still difficult to accomplish. Barriers include the high level of health system fragmentation [ 3 , 4 ], the growing complexity of patients’ health and social care needs [ 5 , 6 ], the numerous participants and organizations involved in coordinating care [ 7 ], the shared accountability of the process, which contributes to ambiguity as to who is responsible for making it run smoothly [ 8 ], the underfunding and lack of reimbursement of added time and effort required for care coordination [ 6 , 8 ], and the various health information technology challenges [ 9 ]. Consequently, improving care coordination has required effort across all levels, i.e. patient and provider, services and organizations, and health system [ 8 ].

In the province of Quebec (Canada), and in other international health systems, care coordination in primary healthcare for patients with complex health and social needs poses a significant challenge. In 2000, Family Medicine Groups (FMGs) were implemented to improve the organization and delivery of primary healthcare services. FMGs are primary healthcare practices that consist of a group of family physicians working closely with registered nurses and other health and social care professionals to provide services to registered patients [ 9 ].

In recent years, several projects have been carried out in FMGs to reduce fragmentation and improve healthcare delivery through better coordination of services for patients with complex needs. These projects targeted patients with Alzheimer’s disease and related disorders [ 10 ], cancer survivors [ 11 ], and frequent users of healthcare services [ 5 ], among others. Within these projects, registered nurses often played the role of care coordinators for the different target patient populations. Although this role can be undertaken by professionals from various backgrounds [ 12 ], for these projects, nurses were deemed a relevant choice based on the population of interest’s needs that require nursing competencies, and contextual factors such as the availability of nursing staff in every FMG.

The paradox is that while nurses are increasingly expected to play a substantial role in care coordination, they still know little about care coordination principles, namely because teaching these principles is still not fully integrated in the primary care nursing curriculum or in continuing education programs [ 13 ]. Enabling healthcare professionals to work in interdisciplinary teams, to collaborate, communicate and integrate care as part of teams is thought to be a major lever for the provision of high quality and coordinated care [ 14 ]. A recent study showed that nurses’ activities in FMGs do not always include a high level of collaboration—such as face-to-face meetings, individualized service planning, or problem resolution—between the members of an interprofessional team, let alone with the services and professionals of regional health authorities [ 15 ].

Another challenge is related to the fact that care coordination interventions vary widely in structure [ 16 ]. In Quebec, care coordination projects presented significant structural variations across FMGs. Moreover, when several care coordination projects were conducted in one FMG, they included a different list of care coordination components, carried out by the same nurses. Furthermore, within the same FMG, one project may be operationalized differently, according to the nursing staff’s work habits and the family physician’s preferences.

There is a need to identify a set of “core activities” that would be relevant to all patients with complex needs across heterogeneous care coordination programs if the aim is to develop a standard of practice for nurses performing this task.

In this study, we aim to examine the differences and similarities in terms of care coordination activities across two heterogeneous care coordination programs in FMGs in Quebec, and how these similarities and differences are related to the program design.

Conceptual frameworks

For the description of the care coordination program design and policy environment, we used the Integrated Care Case Study Descriptive Template. This framework was developed to enable the comparison of integrated models of care across diverse geographies and contexts and has been validated through multiple research projects. The template examines design elements and activities of the integrated care program, and the policy context that supported the program [ 17 ].

As for the care coordination activities within the intervention, in a recent scoping review, the authors of this study developed a model of nursing care coordination activities for patients with complex needs [ 18 ]. In this model, activities were grouped into three categories, namely the activities that target the patient, family and caregivers; those that target health and social care professionals and services; and those that bring the patient and professionals together. A fourth category was identified as cross-cutting, supporting and enhancing every other activity, i.e. interpersonal communication and information transfer. We used this model to examine the nursing care coordination function in the current study.

We followed a case study approach to compare the nursing care coordination function in two programs in Quebec. Merriam (2009) defines case study methodology as “an in-depth description and analysis of a bounded system” [ 19, p. 40 ].

The case is “a single entity, a unit [that you] can ‘fence in’ [like] a single person who is a case example of some phenomenon, a program, a group, an institution, a community, or a specific policy” [ 19, p. 40 ]. In our study, the case was defined as the care coordination program in FMGs. A deep understanding of the program as a whole seemed like an essential prerequisite for capturing the essence of the nursing function within this program.

Case selection

For Merriam (2009), cases are selected based on the research purpose and question, and for what they could reveal about the phenomenon or topic of interest [ 19, p. 46 ]. Thus, we sought to include two programs that were implemented in FMGs, for patients with complex health and social care needs, and where care coordination is performed by nurses, in order to identify the common core of these two programs as well as the cross-cutting nursing skills, which are essential to optimal care coordination. Also, the programs were purposely selected to provide variation in target patient populations to help us investigate how different patients’ needs might affect care coordination. Therefore, Case 1 was “the V1SAGES program” which is a case management program, which aimed to improve care for frequent users of healthcare services [ 5 ]; and Case 2 was the “Quebec Alzheimer Plan”, which aimed to improve the care provided to people with Alzheimer’s disease and related disorders [ 10 ].

Data collection

Data collection took place between August 2020 and March 2021. Two types of data were used, documents and semi-structured interviews with key informants. These informants are either project managers or senior researchers who had an in-depth knowledge of the program, and were involved in the development, implementation and evaluation of the two programs. Together, these methods provided a synergistic and comprehensive view of the care coordination programs being studied. We looked for research publications, unpublished records such as master’s theses, publicly available records, and private documents (such as protocols and standards of care, care coordinators’ training records, clinical tools, communication and coordination tools, and patients’ informed consent forms) (see Appendix A). Five semi-directed interviews were also conducted with key informants and lasted approximately 90 minutes each. The interview guide was based on the dimensions of the Integrated Care Case Study Descriptive Template. Interviews were instrumental in refining and completing the preliminary results of the documentary analysis in an iterative approach.

Data extraction and analysis

For each program, the following variables were extracted from the documents and completed through semi-structured interviews: policy context, history, detailed description and implementation phases, health and social care partners and community resources involved, characteristics of target patient populations, care coordination activities, clinical tools, coordination tools, staffing model, human and material resources, and evaluation.

Data collection (documents and interviews) and analysis were performed concurrently. NVivo 12 software was used for data organization and management. Analysis was thematic [ 20 ], using both deductive (using the Integrated Care Case Study Descriptive Template and the model of nursing care coordination activities for patients with complex needs) and inductive approaches, and followed a two-stage process. First, a within-case analysis studied each intervention comprehensively and provided an in-depth description of the above-mentioned variables. Then, at the end of this stage, a comparative cross-case analysis was performed. It aimed to develop a global explanation and “to build abstractions across cases ” [ 19 ]. In concrete terms, cross-case analysis aimed to identify the common core of the two programs (regardless of the specificity of the target population), the differences linked to the target population, and the cross-cutting nursing care coordination activities.

Ethical considerations

This study received institutional approval from the Comité d’Éthique de la Recherche du Centre Intégré Universitaire de Santé et de Services Sociaux de l’Estrie – Centre Hospitalier Universitaire de Sherbrooke.

Case 1: The V1SAGES program

Description of the project.

The V1SAGES (Vulnerable Patients in Primary Care: Nurse Case Management and Self-Management Support) program was initiated in 2012, in the Saguenay–Lac-Saint-Jean (SLSJ) region of Quebec. The evidence indicated that, despite what the creation of FMGs has offered in terms of improved accessibility and continuity of care for certain patients with chronic diseases [ 21 ], the most vulnerable groups still face major challenges, mainly due to the lack of service coordination and integration [ 22 ]. These vulnerable patients often attempt to fill the existing gap between their complex needs and the ability of the healthcare system to meet their needs by using health and social care services excessively and in an uncoordinated way [ 23 ]. The development of case management (CM) programs for frequent users was identified as a potential solution following a major consultation process organized by the Agence de santé et des services sociaux du Saguenay–Lac-Saint-Jean [ 24 ]. Stakeholders involved in this consultation included health and social care professionals, community-based organizations, managers, policymakers, and researchers. This decision was reinforced by two main criteria: A significant body of evidence in the literature on the effectiveness of CM on emergency department use and cost as well as on social and clinical outcomes [ 25 , 26 , 27 ]; and, a recent promising—though still in the early stages of development—experience of CM programs in the six health and social services centres (HSSC) of the SLSJ region. HSSCs include hospital, community, and long-term services, but not FMGs. The expansion of CM within FMGs was thought to be a complementary intervention that would help to better respond to the complex needs of vulnerable patients and improve service integration [ 22 ].

Pre-implementation interviews conducted with stakeholders aimed to describe the contextual factors, the existing services and their integration level, as well as the challenges and issues related to the implementation of CM intervention [ 22 ]. The intervention was then rolled out in four FMGs over a period of six months, and had four components: “Evaluation of patient needs and resources, implementation and sustainability of an individualized service plan tailored to patients’ priorities with the collaboration of the healthcare and community partners, care coordination among the healthcare and community partners, and provision of self-management support for patients and their families” [ 5, p. 233 ].

Registered nurses (RNs) were assigned as case managers. The majority were already working within the FMGs and a few were recruited to build nursing staff capacity for this intervention. They had a bachelor’s degree and 10 to 17 years of experience [ 28 ]. Their expertise and existing relationships with the medical teams and partners (e.g. community pharmacists) were considered valuable assets for this intervention [ 22 ]. Nurses received training to fulfill this role. Nurse case managers spent approximately half of their time in CM, with a caseload of approximately 25 frequent users of healthcare services [ 28 ]. During this phase, the implementation-related challenges and obstacles faced by FMG teams and stakeholders were identified.

As one key informant explained, doctors played a central role in facilitating or obstructing the implantation:

“In one of the FMGs, the medical manager said, ‘No, my nurse will not play the role [of case manager]’; so even if the nurse shows a lot of leadership, is very skilled, unfortunately, it [the intervention] stopped there for this clinic”.

Another informant confirmed by saying:

“You definitely need a change champion, but it still takes a lot of change facilitation for it to happen; a lot of collaboration with managers, regional authorities and FMGs”.

The next phase—post implementation—analyzed the implementation process. Studies also assessed the effect of the V1SAGES intervention on psychological distress and patient activation, and stakeholders’ perception of the intervention [ 5 ] as well as the experience of patients and their family members with the CM intervention [ 28 ].

In 2018, a 4-year project was launched with the objective of implementing this same CM intervention in ten primary care clinics across five Canadian provinces (Newfoundland, Nova Scotia, New Brunswick, Quebec, and Saskatchewan). As one key informant explained during the interview:

“We [the research team] built on our recent experience with V1SAGES and the lessons we’ve learned to develop an improved CM intervention on a larger scale. We called the enhanced CM intervention PriCARE (Partners for Patients First)”.

Table 1 presents the common design and policy environment of V1SAGES and PriCARE as well as the differences between the two CM interventions. Ongoing studies within PriCARE aim to identify the next steps to expanding this CM intervention in primary care across Canada. Thus, they examined the implementation of the intervention, contextual factors, mechanisms, and barriers and facilitators. Research methodologies include an implementation analysis, a realist evaluation and a logic analysis of the intervention [ 23 , 29 , 30 , 31 , 32 ]. They also analyze patient engagement across the different phases of this study [ 31 ].

V1SAGES and PriCARE: Design and policy environment.

Legend: CM: Case manager; ED: Emergency department; EHR: Electronic health record; GP: General practitioner also known as family physician; ISP: Individualized service plan; IT: Information technology; IUHSSC: Integrated university health and social services centres (resulted from merging neighbouring health and social services centres with all the other public healthcare organizations, such as youth centres, rehabilitation centres and university teaching hospitals under a single governing body per regional territory); MD: Medical doctor; RN: Registered nurses; SW: Social worker.

Case 2: The Quebec Alzheimer Plan

Description of the plan.

Alzheimer’s disease (AD) and other related major neurodegenerative diseases (MND) have a considerable impact on Quebec society, at all levels, and this impact is worsening dramatically due to population aging [ 34 ]. Among Quebeckers aged 65 and over, 100,000 had the disease in 2009, and this figure is expected to rise to 200,000 by 2030 [ 10 ]. Moreover, up to 80% of people with AD have at least one other chronic disease [ 35 ]. In addition to causing disability among older people, AD affects families and informal caregivers’ health and financial status, and puts tremendous pressure on the health system and on society [ 10 , 34 , 36 ]. For all these reasons, MND care became a priority for the Quebec Ministry of Health and Social Services (MSSS), which mandated a committee of experts to develop an action plan on AD and related disorders, in 2007. Two years later, the committee delivered its report in which it presented seven priority actions, with 24 recommendations on how to carry them out, and a strategy for implementing the plan with five related recommendations [ 10 ]. Following the publication of the report, several FMGs set up spontaneous interventions in order to improve the identification, diagnosis and care of people with AD at the primary care level.

The MSSS commissioned a research team to provide an accurate picture of these interventions in order to effectively implement and operationalize the recommendations included in the expert committee report [ 37 ]. Then, an action plan was developed based on some of the recommendations from the experts’ report. Indeed, although the experts’ recommendations cover the continuum of care, the Ministry team had to prioritize the measures to be implemented, as they had a limited annual budget allocation. Therefore, and considering the growing consensus among Canadian experts and decision-makers that the focus of dementia care should shift from specialist to primary healthcare [ 38 ], strategy implementation focused on strengthening the primary care level to ensure early diagnosis of and follow-up with patients with AD and their caregivers, in the community. Although there is still no treatment to cure AD, the benefits of early diagnosis (such as rapid access to medication, the ability to plan for the future, and the ability to postpone institutionalization) are well established [ 39 ]; and, primary healthcare clinicians are ideally positioned to establish this early diagnosis and ensure follow-up [ 38 ].

One of the priorities established in the report concerned “providing access to personalized, coordinated assessment and treatment services for people with Alzheimer’s and their family/informal caregivers” [ 10, p. 16 ]. To this end, the report recommended the implementation of a physician-and-nurse partnership, originating in FMGs and including the patient and caregivers, in which nurses would play the role of Alzheimer’s patient navigators and be in charge of care coordination and continuity of patient services. During one interview, a key informant stated:

“The key was, the real key, the real concrete product, was to create a nurse-doctor duo focused on assessment, hoping that the joint assessment would have a culture-changing effect. And that, I think, was pretty good. I think the plan [the Quebec Alzheimer Plan] can be quite proud of the culture shift effect around the time of the evaluation”.

Other recommendations related to this specific priority covered the support needed by FMGs to reach their objectives in terms of staffing, training, standardized assessment tools and practice guides, and specialized teams and services.

Implementation of the MSSS plan (the Quebec Alzheimer Plan [QAP]) was rolled out in two phases: a pilot phase and a deployment phase.

The pilot phase (2012–2016): The MSSS launched a call for proposals for the development of innovative, local projects tailored to each FMG’s needs and context. Therefore, local actors had room to maneuver as to the type of proposals they designed as long as they targeted the Ministry’s objectives: Building the FMG’s capacity to diagnose AD early and follow-up with patients and caregivers in the community, through an interdisciplinary approach where FMG registered nurses are the care coordinators, acting as patient navigators [ 40 , 41 ].

At least one nurse per project was added to the team. All nurses received training focused primarily on the interdisciplinary approach in FMGs to identify, assess and follow up with patients and caregivers [ 42 ]. They kept their initial caseload of patients, and no specific specialization was required from nurses since these responsibilities were rather consistent with the role of FMG registered nurses, as stipulated in a consultation document between the Quebec Order of Nurses and Quebec Federation of General Practitioners [ 43 ].

“The idea was that every nurse could manage this [new responsibility], because the QAP did not want a patient who has dementia and diabetes and hypertension to see one FMG nurse for their diabetes, another nurse for their dementia, and another nurse for their hypertension, thus recreating a fragmentation that is completely deleterious to the patient”.

Nineteen projects, led by family physician “advocates”, were retained (a total of 42 FMGs), and received protocols, training and funding as well as the support of designated project managers for two years (2014–2016) [ 44 , 45 , 46 ].

This phase was characterized by a great diversity of projects and enabled the experimentation of a variety of changes in clinical practice, the development of assessment tools and clinical pathway guides, and the identification of best practices [ 47 ]. In fact, a continuous evaluative study was set up during this phase to enable monitoring and progressive adjustment of service structures based on encountered challenges and to support their transferability to other contexts [ 48 ], in other words, to prepare for the scale-up phase. For instance, the research team explored the conditions associated with the change in FMGs following the passive dissemination of recommendations for the diagnosis and management of AD [ 49 ]. They also assessed the impact of the QAP on the detection and management of AD and other neurocognitive disorders in primary healthcare [ 50 ]. A questionnaire evaluating the knowledge, attitude and practice of family physicians regarding both dementia care and the QAP was also developed and validated in order to measure progress in the implementation of dementia strategies and their impact [ 38 ]. Our key informants believed that:

“many family physicians were not initially convinced that dementia is a health problem that should be managed at the primary healthcare level. It took a lot of energy and resources to convince them. I think the added value of this project was also that those doctors now know that. The relationship between the FMGs and the memory clinic is clearer: Everyone has a better understanding of what they have to do”.

The deployment phase (2016–2020): The scale-up of the QAP to the entire province of Quebec. Under the responsibility of the regional health authorities, the implementation of the best practices identified in the previous phase began in FMGs and then expanded to all primary care services offered to patients with AD and their caregivers. The MSSS maintained the funding and the support of project managers for another three years and published an “Implementation guide for the deployment of the best clinical and organizational practices” [ 51 ]. The guide provided healthcare professionals with an interdisciplinary clinical process to be followed at the primary care level and helped clarify the referral process to memory clinics. It also enabled the recognition of the nurses’ role in the detection and diagnosis of AD and related disorders. Beyond 2021 (Phase 3), the aim is to gradually integrate the management of dementia into a comprehensive care approach for older people at the primary care level and across care levels with a focus on teamwork in FMGs and on interorganizational collaboration throughout the continuum of care. Table 2 presents the design and policy environment of the QAP.

Quebec Alzheimer Plan: Design and policy environment.

AD: Alzheimer’s disease; ADL: activities of daily living; IADL: instrumental activities of daily living; GP: General practitioner also known as family physician; MMSE: Mini Mental State Examination-Folstein; MoCA: Montreal Cognitive Assessment; GDS-15 and GDS-5: Geriatric Depression Scale; MSSS: Ministry of Health and Social Services. IHSSC: Integrated health and social services centres; IUHSSC: Integrated university health and social services centres; NCD: Neurocognitive disorders.

Cross-case analysis

Nursing care coordination activities as related to the program’s design (segmentation, coordination, engagement, and success measures).

In both programs, it is well established that care coordinators perform their activities while applying the principles of interprofessional collaboration, patient and family-centred care and collaborative leadership. Care coordination activities undertaken by case managers and patient navigators are shown in Table 3 as related to the programs’ designs. However, it is important to remember that the QAP was implemented in all FMGs across the province with various degrees of implementation and that FMGs had considerable autonomy over the design and the implementation of their projects. Therefore, some care coordination activities may have varied from one FMG to another.

Nursing care coordination activities across cases.

Key sources (in addition to interviews with experts): MSSS,2019 [ 52 ]; MSSS, 2014 [ 53 ]; Danish et al., 2020 ([ 31 ]; Nicol-Clavet, 2017 [ 54 ].

Legend: ADL: activities of daily living; CM: Case manager; CVA: Cerebral vascular accident; ED: Emergency department; EHR: Electronic health record; GP: General practitioner also known as family physician; IADL: instrumental activities of daily living; MSSS: Ministry of Health and Social Services; TIA: Transient ischemic attack.

“The problem with the QAP is that it is Quebec-wide, so there are as many modes of organization as there are different FMGs” one key informant reminded us.

As shown in Table 3 , many care coordination activities are common to both programs, yet the difference lies in their components. For instance, patient identification using clinical judgement and relevant clinical assessment tools was found in both programs. However, in the QAP, emphasis was put on cognitive evaluation while in V1SAGES, assessment covered broader risk factors such as the patient’s previous use of health and social care services. Another example is follow-up steps, which were much more detailed and targeted in the QAP than in VISAGES, where elements of this activity remained unspecific since they are dependent on the individualized service plan. Other common activities (but with different components) are: Comprehensive assessment of patient and family needs, goals and patient’s clinical and functional status; co-development of an individualized service plan as a road map for all involved parties; follow-up and change monitoring as well as response to change; communication, referrals and linking patients and caregivers with professionals and services; educational self-management support for patients and caregivers; and relational continuity of care based on trust. Nurses were only involved in data collection in the QAP.

This study provides new information about core care coordination activities that would be relevant to heterogeneous populations of patients with complex needs and could constitute a valuable contribution to facilitating the development of a standard of practice for nurses performing this task. If we aim to develop a capacity building program, the standard of practice constitutes an essential step in the process of designing continuing education.

Moreover, organizational and policy context is widely recognized as an important factor affecting integrated care programs [ 55 ]. Another contribution of our study is the illustration, with empirical data, of the interrelation between macro, meso and micro components of integrated care programs. To our knowledge, this is the first study to examine care coordination activities as they are embedded in the design of an integrated care program and to show empirically how the design and policy environment (macro) could have a direct impact on the meso (interprofessional and interorganizational) and micro (nurse, patient and caregiver) components of the program.

Summary of findings

Our results show several differences and similarities in care coordination activities across these two heterogeneous programs. We also show how these variations are related to the program design which is impacted, in turn, by the policy context. Indeed, one of the main differences between the two programs, related to the policy context, is the scope and financing allocated to the programs. V1SAGES is the initiative of a research team and was developed on a much smaller scale than the QAP, which was a Ministry-driven plan that was extended to the entire province. One of the consequences was that, in the case of the QAP, all nurses working in FMGs kept their caseloads and were trained on early detection of AD in the older people. In parallel, in the V1SAGES and PriCARE program, only a few nurses were trained to carry out case management responsibilities. Wodchis et al. (2020) describe four types of policy support for integrated care, two of which are financing and payment, and workforce and staffing [ 56 ]. The authors identify expanding the roles of providers, adding new roles, and finding new ways of working as successful innovative policies, which might explain the positive outcomes of both programs despite the variation in financing.

In addition, while both programs targeted patients with complex health and social care needs, another main difference lies in the characteristics of these needs which had an impact on many design elements and their related care coordination activities. Firstly, the identification of frequent healthcare users was mainly based on administrative data followed by a comprehensive assessment, while in the QAP, patients entered the project following the results of their clinical assessment.

Secondly, the presence of a well-identified medical condition in the QAP target population shaped the patient care trajectory as based on disease management and care while also covering psychosocial needs of patients and their caregivers. Therefore, the design and implementation of the QAP project focused on early detection of AD and early patient referral to specialized care. Clinical tools that were developed and the staff training that were delivered aimed to optimize these two aspects. Consequently, the care coordination activities also focused on early identification assessment, follow-up and referral. The referral process was also facilitated by the presence of well-identified specialized memory clinics. In parallel, frequent users of healthcare services are a more heterogeneous target patient population and present various profiles [ 57 ]. A single care trajectory based on disease would not be relevant or feasible. This heterogeneity required a more intensive care coordination intervention such as case management, where less emphasis is placed on disease and more on integrating health and social care services [ 12 ]. Interdisciplinary teamwork was reflected in the development of and follow-up on the individualized service plan by health and social care professionals who met regularly and established their communication and information transfer pathways. Nurses’ training also focused on case management theories and case studies.

As for similarities, both programs are committed to a proactive approach where the ultimate goal is the provision of care at the right level—primary care—and time for patients with complex needs. Studies reporting on similar initiatives show better health outcomes and reduction in preventable hospitalizations and emergency departments use [ 58 ]. Yet, the implementation and the sustainability of such initiatives have proved challenging over the years [ 17 , 59 , 60 ]. Key informants from both programs reflected on these challenges in the Quebec context, offering a better understanding of the elements that facilitate and hinder such initiatives and enabling comparisons across countries. Beyond the availability of human resources, these include: 1) the absence of a change champion who is dedicated to achieving organizational change, motivating teams and bringing together stakeholders at the local level. The contributions of operational managers to integrated care programs have been consistently highlighted in the literature [ 61 , 62 , 63 ], and they have been identified as being instrumental to overcoming active resistance to the changes connected to the innovation’s implementation [ 64 ]; 2) the presence of an “ infertile ground ” for collaboration. This means the lack of previous experiences or initiatives related to interorganizational collaboration. In both programs, the degree of interprofessional maturity varied across clinical settings, especially beyond the walls of the FMGs. Collaboration between professionals who belong to different organizations is indeed known to pose a serious challenge given the different management styles and philosophies and the not-easily achieved sense of belonging to a team [ 65 ]; 3) the lack of role clarity which clearly constituted an obstacle to the commitment of some family physicians who felt that dementia care does not fall within the primary care level’s range of responsibilities. In their review, Cameron et al (2014) [ 61 ] showed the importance for all parties to understand the roles and responsibilities of individuals and agencies or organizations. They also noted the equal importance of having clear legal and financial frameworks for the distribution of these responsibilities; 4) the need to think of the entire continuum of care when designing the program and to make sure it does not create more fragmentation. While the sole purpose of vertical integration is the provision of comprehensive and continuous care across clinical contexts and providers [ 66 ], limited resources to develop an integrated care model that covers the entire continuum may lead to this model creating more fragmentation. Appraising the options before pursuing integration would help decision makers to demarcate target groups and establish the most relevant scope of the new service [ 67 ]. This strategy is supported by the Laws for Integration as formulated by Leutz, “You can integrate some of the services for all people, or all of the services for some people, but you cannot integrate all the services for all of the people” [ 68 ]. And finally, 5) the challenge of ensuring the sustainability of the program when research teams or project managers withdraw and hand it over to local teams. Lessons from previous experiences indicate the necessity of supporting instruments such as care or quality standards, sustained funding mechanisms and regional or local governance structures [ 69 ], and the relevance of using collaborative approaches, early in the process, to co-create and implement sustained and successful integrated care models [ 70 ].

Implications of the results on education and practice

In both of the programs included in this study, staff training was delivered prior to the implementation, which confirms the need to invest in the education and training of care coordinators whether through continuing education programs facilitated through the workplace or through the nursing curriculum. Our results identify a set of core activities that would be relevant to heterogeneous target patient populations. Building care coordinators’ capacity to perform these activities seems like a necessity considering the increasing complexity of patients’ needs and situations [ 71 ]. In addition to these core activities, competencies such as leadership and interprofessional communication also need to be included in training programs in order to change service delivery towards successful integrated care [ 72 ]. Moreover, this study illustrates the embedment of care coordination activities within integrated care programs’ design and emphasizes the need for theoretical aspects of integrated care to be covered too. Indeed, it has been established that transformations towards integrated care require a good understanding of the various dimensions of integration [ 73 ].

Our results confirm that the choice of a care coordination program should be primarily based on the needs of the target patient population [ 18 ]. They also show how patients’ complex needs shape the design and implementation of the program. Indeed, our findings confirm that integrated care pathways, despite their proven benefits [ 74 ], are more effective when the care trajectories are predictable [ 75 ] and patients’ complex needs are homogeneous, and may be less effective in variable patient trajectories—where care needs to be more flexible [ 76 ]—such as those of frequent users of healthcare services. Moreover, the more complex the patient’s needs, the more the care trajectories put strain on them due to the multiple options and multiple alternatives they need to consider [ 75 ]. Our results suggest that, for these populations, a case management model of care coordination is perhaps the most relevant solution to implement given the intensity of its approach [ 12 ]. Case managers would play a crucial role in modelling patients’ care trajectories according to their complex and evolving needs.

Strengths and limitations

Care coordination and integrated care programs are complex, inherently context sensitive, and evolving over time [ 77 ]. Our comparative case study has the strength of illustrating these three components through two very different cases and confirming that this remains true despite the heterogeneity of programs. Another strength would be the use of The Integrated Care Case Study Descriptive Template. This conceptual framework allows us to structure data collection and analysis and include core components of the two innovations, but also to share knowledge across these examples that may be compared to other contexts. Finally, the input provided by key informants who had an in-depth knowledge of the programs, which gives considerable weight to our results.

As for limitations, data collection could have included observations or interviews with case managers and care navigators. However, the pandemic impeded their availability. Also, we did not examine patients’ experiences with care coordination but we plan to do so as part of a subsequent phase.

Comparative case studies of integrated care offer an in-depth understanding of how programs are designed and implemented worldwide to reduce fragmentation and improve the patient care experience. While they are intended to provide insights with regard to challenges in particular contexts, they can facilitate learning across borders and build strong national knowledge. Overall, organizational context, program design, policy environment, as well as the characteristics of patients’ complex needs have a major impact on implementation and delivery of care coordination programs. Despite the differences across care coordination programs targeting patients with complex needs, they share a commonality in that they tend to be adjusted to the homogeneity or heterogeneity of needs. As the complexity of patients’ needs grows, so does the necessity and urgency to build the care coordinators’ capacity for integrated care. Education and training programs should include clinical, leadership and professional competencies, as well as theoretical aspects of integrated care. Both the higher education institutions and workplaces are responsible for this capacity building.

Additional File

The additional file for this article can be found as follows:

Appendix A.

The document review.

Acknowledgements

The study received funding from the Quebec SPOR-SUPPORT Unit and to the Institut Universitaire de Première Ligne en Santé et Services Sociaux de l’Estrie-CHUS (IUPLSSS).

Funding Statement

Competing interests.

The authors have no competing interests to declare.

Author contributions

Elodie Montaigne, RN, MSc, Lecturer – University of Rennes 1, France and PhD student in community health – Laval University & VITAM Research center for sustainable health, Québec, Canada.

Amanda Phelan, School of Nursing and Midwifery, Trinity College Dublin, Ireland.

Lightning Bug

Plan of care: IVC Case Study

-Consider adding alkaline water to your routine

Consider Rapamycin weekly. There are five studies referenced below and see this  March 2023 review of off-label use in the post-COVID era. 

Shedding Light on Healthcare Algorithmic and Artificial Intelligence Bias

Impact of artificial intelligence in contemporary medicine.

When people go to a medical facility for help, they expect the doctor to make appropriate health decisions for their optimal health and outcome.

Doctors and other health care providers are increasingly using healthcare algorithms (a computation, often based on statistical or mathematical models, that helps medical practitioners make diagnoses and decisions for treatments) and  artificial intelligence (AI) , to diagnose patient illnesses, suggest treatments, predict health risks, and more. In some cases, this is fine. However, using healthcare algorithms and AI can sometimes worsen things for people from certain ethnic or racial groups. This is because algorithms and AI are based on data from one set of the population that may not work well for others.

Awareness of Bias

Healthcare algorithms and AI bias can contribute to existing health disparities for certain populations based on race, ethnicity, gender, age, or other demographic factors.

One reason for healthcare algorithm and AI bias is the lack of diversity in the data used to train computer programs. It is important to use data from patients with diverse demographic factors when creating AI computer programs to ensure the algorithm works well for everyone.

Another way bias can enter healthcare algorithms and AI is through the assumptions made by the people who create them. For example, if developers assume that some symptoms are more common in non-Hispanic White women than in Black/African American women. This can lead to algorithms producing unfair or inaccurate results for Black/African American women with those symptoms.

A Case Study

If a woman has had a cesarean delivery, also known as a C-section, there is a chance that a subsequent delivery can be attempted through a vaginal birth, which is known as Vaginal Birth after Cesarean Delivery or VBAC. However, there are known risks associated with attempting VBAC, such as uterine rupture or other complications.In 2007, the VBAC algorithm was designed to help healthcare providers assess the likelihood of safely giving birth through vaginal delivery. The algorithm considers many things, such as the woman's age, the reason for the previous C-section, and how long ago it happened. However, in 2017, in a study by Vyas, et al., researchers found the original algorithm was not correct. It predicted that Black/African American and Hispanic/Latino women were less likely to have a successful vaginal birth after a C-section than non-Hispanic White women. This caused doctors to perform more C-sections on Black/African American and Hispanic/Latino women than on White women.

After years of work by researchers, advocates, and clinicians, changes were made to the algorithm. The new version of the algorithm no longer considers race or ethnicity when predicting the risk of complications from VBAC. This means that doctors can make decisions based on more accurate and impartial information that works for all women, providing more equitable care regardless of race or ethnicity. To access more information about this case study, visit:  Challenging the Use of Race in the Vaginal Birth after Cesarean Section Calculator .

The Treatment Plan for Bias

There are best practices that healthcare data scientists and developers can incorporate to address the challenges of using algorithms and AI. These include:

• Have a more diverse body of people review and supervise the algorithms and AI.
• Use methods or techniques to best manage situations where there is not enough information available, like using synthetic data.
• Work with diverse communities to ensure the algorithms are helpful and don't cause harm.
• Introduce the algorithms gradually and carefully instead of all at once.
• Create ways for people to provide feedback and improve the algorithms over time.
• Involve diverse members of your workforce in developing the algorithms and validating patient data from various racial and ethnic backgrounds.

The Office of Minority Health (OMH) is focused on helping to reduce differences in health outcomes, known as health disparities, for racial and ethnic minority populations and American Indian and Alaska Native communities. By encouraging equity in the lifecycle of algorithms and AI, OMH and other federal agencies aim to lower the risk of bias and improve healthcare outcomes for everyone.

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