An effective care coordination process is integral to high quality and equitable healthcare[[1]] and should be evaluated. The Pae Ora (Healthy Futures) Bill outlines significant health reforms for Aotearoa New Zealand that prioritises improved health services for “all of us”. The aims are “simpler and more coordinated” care that is “more equitable, accessible, cohesive and people-centred”.[[2]] Measurement of care coordination may assist evaluation of how the reforms’ aims are being achieved. However, we are unaware of New Zealand-based research that explores care coordination within primary care. Therefore, we present a definition of care coordination that has been mapped to measurement tools.

A systematic review by the Agency for Healthcare Research and Quality (AHRQ)[[3]] found a paucity of care coordination-specific measures. Their definition of care coordination is the most cited[[4]] and describes a process that occurs most often during and in response to care transitions, which includes between providers, across settings, between encounters or care episodes and within same-service care teams. Informed by their review, they organised requirements of the care coordination process into nine activities (Table 1) and suggested measures for each.[[3,4]] Appendix 1 illustrates how these measures map according to the activities. As a process that occurs across settings and providers, the AHRQ framework highlights that all team members involved in a patient’s care participate in these activities.

To consider the AHRQ’s evidence-based and measurable description of care coordination within New Zealand, we considered a rural primary care setting. Rural New Zealanders have a significant higher mortality rate than those living in urban areas[[5]] and contend with reduced access to health services while experiencing higher costs for services that are available,[[6]] and these inequities are compounded for Māori.[[5]] Such factors contribute to complex and chronic medical conditions that require care to be frequently transferred between providers and across settings,[[7]] which is when the care coordination process occurs.[[3]] Therefore, rural primary care is an appropriate setting from which to consider care coordination.

We applied the nine activities of the AHRQ framework to hypothetical clinical scenarios. We drew on our experiences as primary care providers (e.g., pharmacist and general practitioner (GP)) in a rural community with a significant proportion of Māori residents. No patient information was accessed, and the scenarios combine common clinical encounters.

We imagined the persona of a woman with end-stage renal failure being considered for dialysis who is Māori, in her late 50s, and works in management from her rural residence but frequently travels to urban centres. She lives in a self-contained unit with her supportive whānau, including two mokopuna who are in their final years of school. She is an active member of the community, being the secretary on several land trusts. She regularly initiates contact with her GP, community pharmacist and the hospital-based renal team. The scenarios (Table 2) describe episodes of care, including a transition to and from hospital for anaemia-induced mild heart failure.

View Tables 1 & 2.

Gaps are apparent throughout activities of care coordination in our experience of delivering complex medical care. Responsibility is not clearly established for aspects of care across healthcare settings, which can cause delays, errors, and frustrations (e.g., medicine changes; outpatient appointments scheduling coordination). Communication exchange between health providers can default to patients-as-messengers, who are surprised to learn that their GP or pharmacist is unaware of changes. When care transitions across settings, information transfer often requires manual updates to patient files and/or contacting another provider to ensure appropriate follow-up. Determination of patient goals, and what supports are required to achieve these, often require patients to volunteer this information and self-advocate. Multiple care plans from different health services cause confusion, and follow-up often depends on a patient alerting providers of a change. Education about self-management is not always tailored to support implementation of recommendations (e.g., equipment access; response to self-measurements). Community resources can be difficult to access, and health providers are not routinely empowered to address population needs.

Patients who contend with complex chronic medical conditions need high-quality care for improved health,[[8]] and the process of care coordination is a cornerstone of high-quality primary care.[[1]] A systemic review[[9]] of care coordination measures found the activities most evaluated are communication and information transfer, how needs and goals are assessed and self-management support. Few studies measured how monitoring and follow-up responds to change in care needs and creation of proactive plans of care. The review highlighted the importance of understanding care coordination from multiple perspectives including patient/family, healthcare provider and the system representative. Patient experiences of care coordination are influenced by severity of health conditions, age and ethnicity,[[10]] which may explain the lack of generalised descriptions of patient-level care coordination experience despite multiple survey tools.[[9]] Healthcare providers focus on information transfer, with digital technology being both an enabler and barrier to improving coordination,[[11]] and system-level representatives highly ranked data sharing, multiple healthcare providers taking charge of aspects of care, and patient needs.[[12]]

Our anecdotal experience highlights the need to prioritise the measurement and evaluation of care coordination in New Zealand. “Care coordination” is only mentioned once in the latest Budget 2022 Initiatives by Vote – Health as part of the $1 million “Comprehensive Primary Care Teams” initiative that “will combine traditional primary care services (GPs and registered nurses) with physiotherapists, practice-based pharmacists, care coordinators, and registered social workers/kaiāwhina”.[[13]] Care coordination must be understood, acted upon and structurally supported to enable a team process, rather than exist as an individual’s role. This process consists of nine measurable activities[[9]] that all providers who are involved in an individual’s care should perform. Mention of “care coordination” in policies and job descriptions should align with evidenced-based definitions, so that collaboration is prioritised; all team members are resourced to understand, and participate in, the activities of care coordination; and evaluation can occur.

The “Comprehensive Primary Care Teams” establishment investment should be evidenced-based and focussed on the process of high-quality care coordination that occurs most often during care transitions between providers and across settings. Research and evaluation are important approaches to ensure investment in care coordination will improve health.

View Appendix.

An effective care coordination process is integral to high quality and equitable healthcare[[1]] and should be evaluated. The Pae Ora (Healthy Futures) Bill outlines significant health reforms for Aotearoa New Zealand that prioritises improved health services for “all of us”. The aims are “simpler and more coordinated” care that is “more equitable, accessible, cohesive and people-centred”.[[2]] Measurement of care coordination may assist evaluation of how the reforms’ aims are being achieved. However, we are unaware of New Zealand-based research that explores care coordination within primary care. Therefore, we present a definition of care coordination that has been mapped to measurement tools.

A systematic review by the Agency for Healthcare Research and Quality (AHRQ)[[3]] found a paucity of care coordination-specific measures. Their definition of care coordination is the most cited[[4]] and describes a process that occurs most often during and in response to care transitions, which includes between providers, across settings, between encounters or care episodes and within same-service care teams. Informed by their review, they organised requirements of the care coordination process into nine activities (Table 1) and suggested measures for each.[[3,4]] Appendix 1 illustrates how these measures map according to the activities. As a process that occurs across settings and providers, the AHRQ framework highlights that all team members involved in a patient’s care participate in these activities.

To consider the AHRQ’s evidence-based and measurable description of care coordination within New Zealand, we considered a rural primary care setting. Rural New Zealanders have a significant higher mortality rate than those living in urban areas[[5]] and contend with reduced access to health services while experiencing higher costs for services that are available,[[6]] and these inequities are compounded for Māori.[[5]] Such factors contribute to complex and chronic medical conditions that require care to be frequently transferred between providers and across settings,[[7]] which is when the care coordination process occurs.[[3]] Therefore, rural primary care is an appropriate setting from which to consider care coordination.

We applied the nine activities of the AHRQ framework to hypothetical clinical scenarios. We drew on our experiences as primary care providers (e.g., pharmacist and general practitioner (GP)) in a rural community with a significant proportion of Māori residents. No patient information was accessed, and the scenarios combine common clinical encounters.

We imagined the persona of a woman with end-stage renal failure being considered for dialysis who is Māori, in her late 50s, and works in management from her rural residence but frequently travels to urban centres. She lives in a self-contained unit with her supportive whānau, including two mokopuna who are in their final years of school. She is an active member of the community, being the secretary on several land trusts. She regularly initiates contact with her GP, community pharmacist and the hospital-based renal team. The scenarios (Table 2) describe episodes of care, including a transition to and from hospital for anaemia-induced mild heart failure.

View Tables 1 & 2.

Gaps are apparent throughout activities of care coordination in our experience of delivering complex medical care. Responsibility is not clearly established for aspects of care across healthcare settings, which can cause delays, errors, and frustrations (e.g., medicine changes; outpatient appointments scheduling coordination). Communication exchange between health providers can default to patients-as-messengers, who are surprised to learn that their GP or pharmacist is unaware of changes. When care transitions across settings, information transfer often requires manual updates to patient files and/or contacting another provider to ensure appropriate follow-up. Determination of patient goals, and what supports are required to achieve these, often require patients to volunteer this information and self-advocate. Multiple care plans from different health services cause confusion, and follow-up often depends on a patient alerting providers of a change. Education about self-management is not always tailored to support implementation of recommendations (e.g., equipment access; response to self-measurements). Community resources can be difficult to access, and health providers are not routinely empowered to address population needs.

Patients who contend with complex chronic medical conditions need high-quality care for improved health,[[8]] and the process of care coordination is a cornerstone of high-quality primary care.[[1]] A systemic review[[9]] of care coordination measures found the activities most evaluated are communication and information transfer, how needs and goals are assessed and self-management support. Few studies measured how monitoring and follow-up responds to change in care needs and creation of proactive plans of care. The review highlighted the importance of understanding care coordination from multiple perspectives including patient/family, healthcare provider and the system representative. Patient experiences of care coordination are influenced by severity of health conditions, age and ethnicity,[[10]] which may explain the lack of generalised descriptions of patient-level care coordination experience despite multiple survey tools.[[9]] Healthcare providers focus on information transfer, with digital technology being both an enabler and barrier to improving coordination,[[11]] and system-level representatives highly ranked data sharing, multiple healthcare providers taking charge of aspects of care, and patient needs.[[12]]

Our anecdotal experience highlights the need to prioritise the measurement and evaluation of care coordination in New Zealand. “Care coordination” is only mentioned once in the latest Budget 2022 Initiatives by Vote – Health as part of the $1 million “Comprehensive Primary Care Teams” initiative that “will combine traditional primary care services (GPs and registered nurses) with physiotherapists, practice-based pharmacists, care coordinators, and registered social workers/kaiāwhina”.[[13]] Care coordination must be understood, acted upon and structurally supported to enable a team process, rather than exist as an individual’s role. This process consists of nine measurable activities[[9]] that all providers who are involved in an individual’s care should perform. Mention of “care coordination” in policies and job descriptions should align with evidenced-based definitions, so that collaboration is prioritised; all team members are resourced to understand, and participate in, the activities of care coordination; and evaluation can occur.

The “Comprehensive Primary Care Teams” establishment investment should be evidenced-based and focussed on the process of high-quality care coordination that occurs most often during care transitions between providers and across settings. Research and evaluation are important approaches to ensure investment in care coordination will improve health.

View Appendix.