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Nurse home visitors in Nurse-Family Partnership® (NFP) work with mothers experiencing social and economic adversities to improve their and their children's health. Collaboration between nurse home visitors and primary care providers (PCPs: healthcare providers and social workers embedded within obstetrics, paediatrics and family medicine practices) can improve service delivery for families experiencing the greatest adversities. However, little is known about how and to what extent PCPs collaborate with home visiting nurses. We conducted a single exploratory case study between April 2019 and February 2020 to better understand how PCPs collaborate with home visiting nurses to meet family needs in one NFP site, purposefully selected for strong collaboration. We conducted in-depth qualitative interviews with 22 PCPs, including 5 nurses, 7 physicians, 7 social workers and 3 non-direct care professionals, including patient navigator and hospital executives. Interviews were recorded, transcribed, validated and coded inductively. Codes were grouped into broader categories and thematic memos across provider role were written to triangulate perspectives. Healthcare providers interacted with home visiting nurses mainly during the referral process, while social workers provided more specific examples of service co-ordination. In this case study, we saw mutual awareness, co-operation and collaboration to serve families with high needs. Even in this case, purposefully selected to represent strong collaboration, there were opportunities to enhance co-ordination to improve the health and social needs of young families experiencing adversity.

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In order to meet the unique needs of local populations, health and care providers need to come together as a collective. A model of integration in line with the NHS Long Term Plan will support transformation, sustainability and meeting the increasing demands on the NHS. Due the complexity and variety of services in care communities, it is vital that organisations and the third sector acknowledge and understand one another with greater depth. Primary care networks (PCNs) support this by dissolving organisational boundaries, with services wrapping around each other and moving forward as one system. This article describes how one PCN in Wirral committed to appreciating each service's roles. By engaging regularly in different ways, members of the PCN were able build on professional relationships. The refocusing and reconnecting regularly as a collective team enabled a more streamlined approach to proactive, place-based patient care while providing professionals with improved working relationships, skill-sharing and increased job satisfaction.

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BACKGROUND: dying in one's preferred place is a quality marker for end-of-life care. Little is known about preferred place of death, or the factors associated with achieving this, for people with dementia. AIMS: to understand preferences for place of death among people with dementia; to identify factors associated with achieving these preferences. POPULATION: adults with a diagnosis of dementia who died between December 2015 and March 2017 and who were registered on Coordinate My Care, an Electronic Palliative Care Coordination System. DESIGN: retrospective cohort study. ANALYSIS: multivariable logistic regression investigated factors associated with achieving preferred place of death. RESULTS: we identified 1,047 people who died with dementia; information on preferred and actual place of death was available for 803. Preferred place of death was most commonly care home (58.8%, n = 472) or home (39.0%, n = 313). Overall 83.7% (n = 672) died in their preferred place. Dying in the preferred place was more likely for those most functionally impaired (OR 1.82 95% CI 1.06-3.13), and with a ceiling of treatment of 'symptomatic relief only' (OR 2.65, 95% CI 1.37-5.14). It was less likely for people with a primary diagnosis of cancer (OR 0.52, 95% CI 0.28-0.97), those who were 'for' cardio-pulmonary resuscitation (OR 0.32, 95% CI 0.16-0.62) and those whose record was created longer before death (51-250 days (ref <50 days) OR 0.60, 95% CI 0.38-0.94). CONCLUSIONS: most people with dementia want to die in a care home or at home. Achieving this is more likely where goals of treatment are symptomatic relief only, indicating the importance of advance care planning.

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The third sector has played a significant role internationally in the delivery of adult social care services for many years. Its contribution to care co-ordination activities for older people, however, in England and elsewhere, is relatively unknown. A scoping review was therefore conducted to ascertain the character of the literature, the nature and extent of third sector care co-ordination activity, and to identify evidence gaps. It was undertaken between autumn 2013 and summer 2014 and updated with additional searches in 2016. Electronic and manual searches of international literature using distinct terms for different approaches to care co-ordination were undertaken. From a total of 835 papers, 26 met inclusion criteria. Data were organised in relation to care co-ordination approaches, types of third sector organisation and care recipients. Papers were predominantly from the UK and published this century. Key findings included that: a minority of literature focused specifically on older people and that those doing so described only one care co-ordination approach; third sector services tended to be associated with independence and person-centred practice; and working with the statutory sector, a prerequisite of care co-ordination, was challenging and required a range of features to be in place to support effective partnerships. Strengths and weaknesses of care co-ordination practice in the third sector according to key stakeholder groups were also highlighted. Areas for future research included the need for: a specific focus on older people's experiences; an investigation of workforce issues; detailed examination of third sector practices, outcomes and costs; interactions with the statutory sector; and an examination of quality assurance systems and their appropriateness to third sector practice. The main implication of the findings is a need to nurture variety within the third sector in order to provide older people and other adults with the range of service options desired.

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INTRODUCTION: Older people with chronic conditions often receive poor care because of the fragmented way in which their services are delivered from multiple sources. Providers have limited tools to directly capture the views of older people about their experiences of care co-ordination. The study aim was to design and test a survey tool to capture the experiences of older people with chronic conditions regarding how well their health and (where applicable) social care was co-ordinated. METHOD: To inform the questionnaire development, we reviewed the literature on existing surveys and care co-ordination theory, and on the health status of our target audience (people aged 65 or over with one or more chronic conditions and not in hospital or residential institutions). We also consulted stakeholders including those working in health and social care services and those with expertise in the subject area. We grouped questions around experiences of care in three dimensions: care in the home environment, planned transitions in care and unplanned situations. We also designed the questions so they could be mapped onto three recognised dimensions of continuity of care - management continuity, information continuity and relational continuity - as articulated in the international literature. The questionnaire was tested using focus groups and cognitive interviews and piloted with people aged 65 and over with at least one chronic condition, using a postal survey. We used service user records in 32 general practices located in four areas and a population database held by one local authority in England as the sampling frame. RESULTS: The pilot achieved an overall response rate of 27.6% (n = 562 responses). Ninety five percent of respondents answered 30 or more of the 46 questions and three respondents answered fewer than 10 questions. Twenty four items achieved one or more positive correlations greater than 0.5 with other survey items and four instances of positive associations greater than 0.7 were found. DISCUSSION/CONCLUSION: The growing focus on care co-ordination demonstrates the need for a tool that can capture the experiences of patients accessing care across organisational and professional boundaries, to inform the improvement of care co-ordination activities from a patient perspective. Early results suggest that our tool may have a contribution to make in these areas. However, more work is required to test the efficacy of the tool on a larger scale and in different settings, and to find ways of improving response rates.

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Care co-ordination is reported to be an effective component of chronic disease (CD) management within primary care. While nurses often perform this role, it has not been reported if they or other disciplines are best placed to take on this role, and whether the discipline of the co-ordinator has any impact on clinical and health service outcomes. We conducted a rapid review of previous systematic reviews from 2006 to 2013 to answer these questions with a view to informing improvements in care co-ordination programmes. Eighteen systematic reviews from countries with developed health systems comparable to Australia were included. All but one included complex interventions and 12 of the 18 involved a range of multidisciplinary co-ordination strategies. This multi-strategy and multidisciplinarity made it difficult to isolate which were the most effective strategies and disciplines. Nurses required specific training for these roles, but performed co-ordination more often than any other discipline. There was, however, no evidence that discipline had a direct impact on clinical or service outcomes, although specific expertise gained through training and workforce organisational support for the co-ordinator was required. Hence, skill mix is an important consideration when employing care co-ordination, and a sustained consistent approach to workforce change is required if nurses are to be enabled to perform effective care co-ordination in CD management in primary care.

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PURPOSE OF THE STUDY: The provision of end-of-life (EoL) care in long-term-care settings remains largely underdeveloped in most Chinese societies, and nursing home residents often fail to obtain good care as they approach death. This paper systematically describes the development and implementation mechanisms of a novel Dignity-Conserving EoL Care model that has been successfully adopted by three nursing homes in Hong Kong and presents preliminary evidence of its effectiveness on enhancing dignity and quality of life (QoL) of terminally ill residents. DESIGN AND METHODS: Nine terminally ill nursing home residents completed the McGill Quality of Life Questionnaire and the Nursing Facilities Quality of Life Questionnaire at baseline and 6 months post-EoL program enrollment. Wilcoxon signed rank test was used to detect significance changes in each QoL domains across time. RESULTS: Although significant deterioration was recorded for physical QoL, significant improvement was observed for social QoL. Moreover, a clear trend toward significant improvements was identified for the QoL domains of individuality and relationships. IMPLICATIONS: A holistic and compassionate caring environment, together with the core principles of family-centered care, interagency and interdisciplinary teamwork, as well as cultural-specific psycho-socio-spiritual support, are all essential elements for optimizing QoL and promoting death with dignity for nursing home residents facing morality. This study provides a useful framework to facilitate the future development of EoL care in long-term-care settings in the Chinese context.

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The NHS and Social Care in England are facing one of the biggest financial challenges for a generation. Commissioners and providers need to work on collaborative schemes to manage the increasing demand on health and social care within a period of financial constraint. Different forms of care co-ordination have been developed at different levels across the world. In the north-west of England, the Trafford health and social care economy have been working through a competitive dialogue process with industry to develop an innovative and dynamic solution to deliver seamless co-ordination for all patients and service users. The strategy is to develop a new Patient Care Co-ordination Centre, which will be responsible for the delivery of co-ordinated, quality care. The Patient Care Co-ordination Centre will work at clinical, service, functional and community levels across multiple providers covering risk stratification, preventative, elective and unscheduled care. I am the clinical lead for the Patient Care Co-ordination Centre and during my year as an Advancing Quality Alliance Integrated Care Fellow, I have had the opportunity to study examples of care coordination from UK and international sites. The learning from these visits has been assimilated into the design process of the Patient Care Co-ordination Centre.

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PURPOSE OF THE STUDY: Co-ordinated approaches to community-based care are a central component of current and proposed efforts to help vulnerable older adults obtain needed services and supports and reduce unnecessary use of health care resources. DESIGN AND METHODS: This study examines ElderHelp Concierge Club, an integrated community-based care model that includes comprehensive personal and environmental assessment, multilevel care co-ordination, a mix of professional and volunteer service providers, and a capitated, income-adjusted fee model. Evaluation includes a retrospective study (n = 96) of service use and perceived program impact, and a prospective study (n = 21) of changes in participant physical and social well-being and health services utilization. RESULTS: Over the period of this study, participants showed greater mobility, greater ability to meet household needs, greater access to health care, reduced social isolation, reduced home hazards, fewer falls, and greater perceived ability to obtain assistance needed to age in place. IMPLICATIONS: This study provides preliminary evidence that an integrated multilevel care co-ordination approach may be an effective and efficient model for serving vulnerable community-based elders, especially low and moderate-income elders who otherwise could not afford the cost of care. The findings suggest the need for multisite controlled studies to more rigorously evaluate program impacts and the optimal mix of various program components.

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BACKGROUND: Recent data show a falling cancer mortality in the general population without a similar shift in immigrant outcomes, leading to a greater cancer burden and mortality for immigrants. Our aims were to compare perceived patterns of care in immigrants and native-born cancer patients. PATIENTS AND METHODS: This was a hospital-based sample of first-generation immigrants and Australian-born Anglo patients in the first year following diagnosis. It was restricted to Chinese, Arabic, or Greek speakers. Eligible participants, recruited via 16 oncology clinics, were over 18, with cancer (any type or stage), and having commenced treatment at least 1 month previously. Five hundred and seventy-one CALD patients (comprising 145 Arabic, 248 Chinese, and 178 Greek) and a control group of 274 Anglo-Australian patients participated. RESULTS: Immigrants had difficulty communicating with the doctor (73% versus 29%) and understanding the health system (38% versus 10%). Differences were found in 'difficulty knowing who to see' (P = 0.0002), 'length of time to confirm diagnosis' (P = 0.04), wanting more choice about a specialist and hospital (P < 0.0001); being offered the opportunity to see a counselor (P < 0.0001); and actually seeing one (P < 0.0001). There were no significant self-reported differences regarding how cancer was detected, time to see a health professional, or type first seen; however, immigrants reported difficulty knowing who to see. Previous studies showed differences in patterns of care according to socioeconomic status (SES) and educational level. Despite adjusting for age, sex, education, marital status, SES, time since diagnosis, and type of cancer, we did not find significant differences. Instead, we found that understanding of the health system and confidence understanding English were important factors. CONCLUSIONS: This study confirmed that immigrants with cancer perceive an inferior quality of cancer care. We highlight potentially modifiable factors including assistance in navigating the health system, translated information, and cultural competency training for health professionals.

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INTRODUCTION: This policy paper considers what the long-term conditions policies in England and other countries could learn from the experience of the Care Programme Approach (CPA). The CPA was introduced in England in April 1991 as the statutory framework for people requiring support in the community for more severe and enduring mental health problems. The CPA approach is an example of a long-standing 'care co-ordination' model that seeks to develop individualised care plans and then attempt to integrate care for patients from a range of providers. POLICY DESCRIPTION: The CPA experience is highly relevant to both the English and international debates on the future of long-term conditions management where the agenda has focused on developing co-ordinated care planning and delivery between health and social care; to prioritise upstream interventions that promote health and wellbeing; and to provide for a more personalised service. CONCLUSION: This review of the CPA experience suggests that there is the potential for better care integration for those patients with multiple or complex needs where a strategy of personalised care planning and pro-active care co-ordination is provided. However, such models will not reach their full potential unless a number of preconditions are met including: clear eligibility criteria; standardised measures of service quality; a mix of governance and incentives to hold providers accountable for such quality; and genuine patient involvement in their own care plans. IMPLICATIONS: Investment and professional support to the role of the care co-ordinator is particularly crucial. Care co-ordinators require the requisite skills and competencies to act as a care professional to the patient as well as to have the power to exert authority among other care professionals to ensure multidisciplinary care plans are implemented successfully. Attention to inter-professional practice, culture, leadership and organisational development can also help crowd-in behaviours that promote integrated care.