TY  - JOUR
AU  - Davis, Kate M
AU  - Eckert, Marion C
AU  - Shakib, Sepehr
AU  - Harmon, Joanne
AU  - Hutchinson, Amanda D
AU  - Sharplin, Greg
AU  - Caughey, Gillian E
PY  - 2019
DA  - 2019/12/9
TI  - Development and Implementation of a Nurse-Led Model of Care Coordination to Provide Health-Sector Continuity of Care for People With Multimorbidity: Protocol for a Mixed Methods Study
JO  - JMIR Res Protoc
SP  - e15006
VL  - 8
IS  - 12
KW  - continuity of patient care
KW  - multimorbidity
KW  - nurse led
KW  - integrated health
KW  - transitional
KW  - chronic disease
AB  - Background: Innovative strategies are required to reduce care fragmentation for people with multimorbidity. Coordinated models of health care delivery need to be adopted to deliver consumer-centered continuity of care. Nurse-led services have emerged over the past 20 years as evidence-based structured models of care delivery, providing a range of positive and coordinated health care outcomes. Although nurse-led services are effective in a range of clinical settings, strategies to improve continuity of care across the secondary and primary health care sectors for people with multimorbidity have not been examined. Objective: To implement a nurse-led model of care coordination from a multidisciplinary outpatient setting and provide continuity of care between the secondary and primary health care sectors for people with multimorbidity. Methods: This action research mixed methods study will have two phases. Phase 1 includes a systematic review, stakeholder forums, and validation workshop to collaboratively develop a model of care for a nurse-led care coordination service. Phase 2, through a series of iterative action research cycles, will implement a nurse-led model of care coordination in a multidisciplinary outpatient setting. Three to five iterative action research cycles will allow the model to be refined and further developed with multiple data collection points throughout. Results: Pilot implementation of the model of care coordination commenced in October 2018. Formal study recruitment commenced in May 2019 and the intervention and follow-up phases are ongoing. The results of the data analysis are expected to be available by March 2020. Conclusions: Nursing, clinician, and patient outcomes and experiences with the nurse-led model of care coordination will provide a template to improve continuity of care between the secondary and primary health care systems. The model template may provide a future pathway for implementation of nurse-led services both nationally and internationally. International Registered Report Identifier (IRRID): DERR1-10.2196/15006 
SN  - 1929-0748
UR  - http://www.researchprotocols.org/2019/12/e15006/
UR  - https://doi.org/10.2196/15006
UR  - http://www.ncbi.nlm.nih.gov/pubmed/31815675
DO  - 10.2196/15006
ID  - info:doi/10.2196/15006
ER  -