Implementation Outcomes and Their Determinants for Hospital-Led Care Coordination Interventions Targeting Patients With Complex Care Needs: A Qualitative Systematic Review.
Mary Malakellis, Anna Wong Shee, Sarah Wood and 5 others
PMID 40948454WHAT IT FOUND
Hospital care coordination for complex patients relied on clear roles, community knowledge, and relationships.
Nurses or social workers often delivered it. Training gaps and weak transition planning were common limitations after discharge.
Key findings
01Care coordinators, often nurses or social workers, were key innovation deliverers, and unfamiliarity with community resources limited appropriate linkage to services.
02Most included studies described screening and assessment (n=15), but only 3 described managing transitions across the care continuum and preparing for exit from the program.
03Real-time monitoring meant sites were able to anticipate or identify challenges and develop strategies to manage them.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The review included only 16 studies, and the authors say this may not represent the full range of implementation problems in practice. The included care coordination models were heterogeneous and often poorly described, making it hard to know which components mattered or whether findings transfer to your setting. Study quality was variable, with some papers lacking methodological rationale, theoretical framing, or reflexivity, and the review did not exclude papers for these reasons. Most studies were from developed countries, and English-only searching may limit relevance to other health systems. The review synthesised implementation determinants, not patient outcomes, so it cannot tell you whether coordination reduces admissions, ED visits, or costs.
Declared interests
The authors declared no conflicts of interest.
The easy way to misread this
Do not read this as evidence that hospital-led care coordination improves patient outcomes. It reviewed implementation factors, not effectiveness, and prior reviews found inconsistent effects on admissions, ED presentations, length of stay, and costs.