Continuity of care for people with multimorbidity: the development of a model for a nurse-led care coordination service

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Kate M Davis
Marion Eckert
Amanda Hutchinson
Joanne Harmon
Greg Sharplin
Sepehr Shakib
Gillian Caughey


nurses, model of care, continuity of patient care, chronic disease management, transition and care


Objective: To collaboratively develop a model of nurse-led care, within a multidisciplinary team and support continuity of care at the primary-secondary interface for people with multimorbidity. Background: Existing models of care are frequently based on a medical model, designed to manage a single disease condition, and thus pose a significant challenge to provide healthcare for people with multimorbidity. Particular design elements for models of care affecting the primary-secondary interface have been previously demonstrated, however, these have not been applied to the development of a nurse-led model of care for people with multimorbidity. Study design and methods: This paper, the first in a series of two, is part of a broader action research study and reports on the development of a model which will subsequently be assessed in terms of feasibility to provide a nurse-led care coordination service for people with multi-morbidity. This paper reports on the first action research cycle and methodology including a literature search, stakeholder engagement forums, validation workshop, team meetings, and professional engagement and validation. Results: Data from two stakeholder forums were sorted into 257 ‘structure, process and outcome’ statements and 86 goal related statements. These were cross referenced with design elements on models of care from the literature and finally aggregated into themes. The aggregated themes were then integrated into a model of care for a nurse–led care coordination service. The model consists of an overarching component, 4 domains and 6 operational areas with underpinning criteria. Conclusion: Through stakeholder consultation, consideration of the strengths of previous models and building blocks, a new nurse-led model of care that provides a pathway for transitional healthcare management at the primary -secondary interface has been developed. Inclusion of governance and culture within the model’s domains enables the approach to be pragmatic and adaptable, contributing to the potential for successful change management and model implementation in the clinical workplace. Further evaluation and refinement of the model is planned and will be reported on, in part 2 of this two-part series.

Implications for research, policy, and practice: These findings provide direction for model implementation and further research required regarding nurse-led models of care. The supporting documents, systems, and processes reported, positions the model to support change and guide clinical practitioners and nursing management working at the primary-secondary healthcare interface. The future success of model implementation could provide evidence for health workforce policy and coordinated healthcare management.

What is already known about this topic:

  • Particular design elements for models of care affecting the primary-secondary interface have been previously demonstrated.

  • Interventions delivered at the primary-secondary care interface, particularly stepped care and models of shared care are effective for the management of depression.

  • Established model design elements and interventions to improve continuity of care at the primary-secondary interface have not been applied to nurse- led models of care for chronic conditions and still require development within research settings.

What this paper adds:

  • A new person-centred nurse-led model of care coordination, with healthcare management activities intended to support and enable development of the person’s agency in their healthcare optimisation.

  • A model with specific domains and criteria with the potential for application to nurse-led services across primary and secondary settings, for a range of patients.

  • Inclusion of governance and culture as domains within the model, to enable the best possibility for change, model implementation and continuity of care between the primary-secondary healthcare interface.

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