A
Meanings and Challenges of Care Coordination in Primary Health Care: Scoping ReviewA
LuanaCamargoBrito
MD
1,2,4✉Phone+55 11 91839-1711Emailcamargo.luana@unifesp.brLeonardoCarnut
PhD
1LúciaDias
da
Silva GuerraPhD
31Federal University of São Paulo (UNIFESP)São PauloBrazil
2Hospital Sírio-Libanês (HSL)São PauloBrazil
3University of Santo Amaro (UNISA)São PauloBrazil
4Rua Bela Cintra, 20101415-001São PauloSPBrazil
Luana Camargo Brito, MD1,2 ; Leonardo Carnut, PhD1 ; Lúcia Dias da Silva Guerra, PhD3
1 Federal University of São Paulo (UNIFESP), São Paulo, Brazil
2 Hospital Sírio-Libanês (HSL), São Paulo, Brazil
3 University of Santo Amaro (UNISA), São Paulo, Brazil
Corresponding author:
Luana Camargo Brito, MD
Rua Bela Cintra, 201, São Paulo – SP, 01415-001, Brazil
Email: camargo.luana@unifesp.br
Phone: +55 11 91839 − 1711
A
ABSTRACT
Background
Care coordination is a core attribute of Primary Health Care (PHC), yet its conceptual, methodological, and contextual approaches remain insufficiently mapped. This study aimed to synthesise international evidence on care coordination in PHC, emphasising main approaches and barriers.
Methods
A scoping review was conducted following PRISMA-ScR guidelines. Searches were performed in July 2024 across PubMed/Medline, LILACS/BVS, Scopus, EMBASE, and Web of Science, including studies published between 2014 and 2024. Eligible publications addressed care coordination in PHC in different contexts worldwide. Exclusion criteria were studies restricted to specific diseases, previous reviews, unavailable full text, older than 10 years, or not centred on coordination. Screening was performed in Rayyan, yielding 26 included studies.
Results
Five thematic categories emerged: (1) management of the patient care journey within the health system; (2) coordination across hospital–primary–secondary care transitions; (3) interprofessional and intersectoral collaboration; (4) information integration and interoperability; and (5) case-management approaches for specific populations. Barriers included organisational and resource constraints, service fragmentation, technological limitations, gaps in care transitions, and challenges of professional and sociocultural engagement.
Interpretation: Despite being a key PHC function, care coordination remains difficult to implement. Advancing institutional capacity, technological infrastructure, and active engagement of professionals and users is essential to strengthen continuity of care.
A
Funding:
No funding was received.
INTRODUCTION
Care coordination is recognised as a core attribute of Primary Health Care (PHC), supporting the organisation and follow-up of users’ journeys across different points of the health system [1, 2]. It is a dynamic process that brings together clinical, administrative, and managerial actions—at the individual level, through relational continuity between patient and provider; at the organisational level, through informational continuity among professionals and teams; and at the system level, through managerial continuity across services and systems—linking care over time and across multiple professionals, teams, and levels of care [3, 4, 5].
The consolidation of this attribute requires effective coordination mechanisms, reliable access to clinical information, professional commitment to longitudinal follow-up, and service organisation that sustains continuity [6]. The effectiveness of coordination depends on structured communication strategies, clear definition of roles, and integration across different levels of care [7], in addition to the deliberate engagement of patients, professionals, and managers in building relationships and exchanging information [8].
However, approaches to care coordination vary according to institutional arrangements, organisational culture, available resources, and the characteristics of health systems in each national context. Understanding this plurality of perspectives is essential to strengthening the role of PHC as the coordinator of care. This study aims to map the international scientific literature on care coordination within PHC, highlighting the diversity of approaches and the main challenges to its effective implementation across different healthcare settings.
METHODS
Search strategy and selection criteria
We conducted a scoping review in accordance with PRISMA-ScR guidelines [9]. This method was chosen for its ability to identify knowledge gaps, map the extent of the literature, and clarify key concepts [10]. Searches were carried out in five electronic databases: PubMed/MEDLINE, LILACS/BVS, Scopus, EMBASE, and Web of Science, on 2 July 2024. For PubMed, the following search terms were applied: “Intersectoral Collaboration” OR “Continuity of Patient Care” OR “Ambulatory Care Sensitive Conditions” OR “Health Services Accessibility” AND “Primary Health Care”. No language restrictions were applied.
We included studies published between 2014 and 2024 that addressed care coordination within Primary Health Care (PHC) contexts worldwide, regardless of study design (qualitative, quantitative, or mixed methods). Eligible publications explored approaches, strategies, or barriers related to care coordination in PHC services, involving adult or pediatric populations. Exclusion criteria were: studies focused exclusively on specific clinical conditions, previous reviews on the same topic, articles without full-text availability, studies published more than 10 years ago, and publications where care coordination was not the central focus.
Study selection
Screening was performed independently by pairs of reviewers, with disagreements resolved by consensus. A total of 23,575 records were initially identified. Screening was supported by the collaborative platform Rayyan. After removing duplicates (n = 3,862) and records without full-text availability (n = 13,069), 6,644 titles and abstracts were reviewed. Of these, 6,483 were excluded for not meeting eligibility criteria. A total of 161 full-text articles were assessed; four could not be retrieved, resulting in 157 reviewed in full. The main reasons for exclusion were: restricted focus on specific conditions/comorbidities (n = 61), emphasis on attributes of PHC other than coordination (n = 24), and lack of centrality of care coordination (n = 45). After this assessment, 26 studies were included. The PRISMA flow diagram details the selection process (Fig. 1).
Fig. 1
PRISMA flow diagram
Source: authors’ elaboration (2025).
Data extraction and analysis
Data extraction was carried out manually and independently by three reviewers (names of authors), with disagreements resolved by consensus. Records of included studies were exported from Rayyan into a spreadsheet, and additional columns were created for data extraction, including: country of origin, study design, target population, study objective, key concepts of care coordination, and main findings. Data were synthesised descriptively and thematically, grouping studies into analytical categories according to their content.
Additional procedures
No individual patient data were requested from study authors, and grey literature was not assessed. No statistical pooling (meta-analysis) was performed due to the narrative nature of the results. This review was not registered in PROSPERO, as this platform does not apply to scoping reviews.
RESULTS
A total of 26 scientific articles published between 2014 and 2024 were included, covering experiences from a wide range of countries and regions, including Brazil, the United States, Canada, the United Kingdom, Australia, Portugal, Chile, Germany, Spain, Argentina, Hong Kong, and Singapore, as well as global multicenter studies. Considerable methodological diversity was observed, with a predominance of qualitative approaches (n = 11), followed by mixed methods (n = 8), quantitative studies (n = 6), one scoping review, and one theoretical/reflection paper.
The main focuses and challenges identified across the studies are summarised in Table 1. The articles addressed issues ranging from the organisation of patient flows across different levels of care, integration between healthcare tiers, interprofessional collaboration, and the use of information technologies, to strategies for monitoring specific populations. Recurring barriers included role overlap, lack of protocols, weaknesses in back-referral from other levels of care to PHC, communication gaps, systemic fragmentation, and technological limitations.
Table 1 provides a synthesis of the included studies, detailing authors, year, country/continent, and methodological approach.
A
A
Article title | Authors | Year | Country/ Continent | Method |
|---|---|---|---|---|
Práticas de enfermagem na coordenação do cuidado na atenção primária à saúde | Veloso CM et al. | 2024 | Brazil / South America | Mixed-methods study (qualitative and quantitative) |
Factors affecting the experience of joined-up, continuous primary care in the absence of relational continuity: an observational study | Burch P et al. | 2024 | England / Europe | Qualitative study (observational, multiple cases) |
Where’s the Disconnect? Exploring Pathways to Healthcare Coordinated for Youth Experiencing Homelessness in Toronto, Canada, Using Grounded Theory Methodology | Hudani A et al. | 2024 | Canada / North America | Qualitative study (Grounded Theory + thematic analysis) |
Clinician- and Patient-Identified Solutions to Reduce the Fragmentation of Post-ICU Care in Australia | Leggett N et al. | 2024 | Australia / Oceania | Qualitative study |
Continuity and care coordination of primary health care: a scoping review | Khatri R et al. | 2023 | Multicountry (56 studies, mostly in high- and middle-income countries) / Global | Scoping review |
Avaliação da coordenação do cuidado na atenção primária à saúde: comparando o PMAQ-AB (Brasil) e referências internacionais | Cruz MJB et al. | 2022 | Brazil / South America | Quantitative study |
Continuidade e coordenação do cuidado: interface conceitual e contribuições dos enfermeiros | Santos MT et al. | 2022 | Brazil / South America | Theoretical-reflective study |
Transitional Care Management from Emergency Services to Communities: An Action Research Study | Batista J et al. | 2021 | Portugal / Europe | Mixed-methods study (qualitative and quantitative) |
Technology-facilitated care coordination in rural areas: What is needed? | Gill E et al. | 2020 | United States / North America | Mixed-methods study (qualitative and quantitative) |
Coordination of Care Could Improve: Canadian Results from the Commonwealth Fund International Health Policy Survey of Primary Care Physicians | Sovran V et al. | 2020 | Canada / North America | Quantitative study |
Coordenação e longitudinalidade da atenção primária à saúde na Amazônia brasileira | Rabelo ALR et al. | 2020 | Brazil / South America | Quantitative study |
Electronic care coordination systems for people with advanced progressive illness: a mixed-methods evaluation in Scottish primary care | Finucane AM et al. | 2019 | Scotland / Europe | Mixed-methods study (qualitative and quantitative) |
Coordinación de la atención entre niveles y sus factores asociados en dos subredes de la red municipal de salud de la ciudad de Rosario, Argentina | Puzzolo J et al. | 2019 | Argentina / South America | Quantitative study |
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 | Davis KM et al. | 2019 | Australia / Oceania | Mixed-methods study (qualitative and quantitative) |
Community Health Workers as an Extension of Care Coordination in Primary Care: A Community-Based Cosupervisory Model | Gunderson JM et al. | 2018 | United States / North America | Other methods (experience report with preliminary evaluation) |
Family Medicine Clinic: a case study of a hospital–family medicine practice redesign to improve chronic disease care in the community in Singapore | Lim YW et al. | 2018 | Singapore / Asia | Mixed-methods study (qualitative and quantitative) |
Implementation of a comprehensive program to improve coordination of care in an urban academic health care system | Hsiao YL et al. | 2018 | United States / North America | Qualitative study (case study with semi-structured interviews) |
Network integration and care coordination: the case of Chile’s health system | Almeida PF et al. | 2018 | Chile / South America | Qualitative study |
Care coordination and provider stress in primary care management of high-risk patients | Okunogbe A et al. | 2017 | United States / North America | Quantitative study |
Minding the Gap: Factors Associated With Primary Care Coordination of Adults in 11 Countries | Penm J et al. | 2017 | 11 countries / Global | Quantitative study |
Continuity of clinical management and information across care levels: perceptions of users of different healthcare areas in the Catalan national health system | Waibel S et al. | 2016 | Spain / Europe | Qualitative study |
Impact of health literacy, accessibility and coordination of care on patient’s satisfaction with primary care in Germany | Altin SV et al. | 2015 | Germany / Europe | Quantitative study |
Improving EHR Capabilities to Facilitate Stage 3 Meaningful Use Care Coordination Criteria | Cross DA et al. | 2015 | United States / North America | Mixed-methods study (qualitative and quantitative) |
Patients’ experience of Chinese Medicine Primary Care Services: Implications on Improving Coordination and Continuity of Care | Chung VCH et al. | 2015 | Hong Kong / Asia | Quantitative study (cross-sectional) |
Development and validation of the Medical Home Care Coordination Survey for assessing care coordination in the primary care setting from the patient and provider perspectives | Zlateva I et al. | 2015 | United States / North America | Mixed-methods study (qualitative and quantitative) |
Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems | Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. | 2014 | United States / North America | Other methods (technical/policy guideline document) |
DISCUSSION
The Multiple Meanings of Care Coordination
The analysis of the studies shows that care coordination can be understood through different perspectives, which, while interconnected, vary according to context, objectives, and the operational mechanisms employed. The main meanings identified in the literature were organised into subcategories: Care coordination as management of the patient care journey; Coordination across hospital–primary–secondary care transitions; Care coordination as information integration and interoperability; Care coordination as interprofessional and intersectoral collaboration; Case-management–oriented coordination and follow-up for specific populations.
Care coordination as management of the patient care journey:
Some studies emphasise care coordination as the capacity of PHC to organise and monitor patients’ pathways across the different points of the health system, bringing together clinical and administrative actions. In this sense, care coordination in PHC is seen as a multilateral process that integrates care over time, involving multiple professionals and institutions, and covering a continuum that extends from prevention to rehabilitation, across diverse settings such as home, community, and health services [5]. PHC is described as fostering continuity, comprehensiveness, and integration between levels of care, which requires institutionalised protocols and communication flows [2].
Care coordination is also described as an intentional action within complex contexts, supported by the strengthening of relationships among stakeholders and by the qualified exchange of information. This practice relies on institutional tools such as electronic medical records, referral and counter-referral pathways, and joint planning [8].
Furthermore, it has been proposed that coordination is grounded in the organised integration of actions among multiple actors—including patients, families, professionals, and health services—mediated by effective communication, clearly defined responsibilities, and instruments that enable the flow of clinical and managerial information along the care continuum [11]. To sustain this journey, coordination is articulated at three levels: individual (patient–provider relationship), organisational (collaborative work across teams and institutions), and systemic (interactions across sectors and public policies) [5]. For instance, in an analysis of care networks in Rosario, Argentina, communication and information flow were highly valued and associated with continuity between primary and specialised care [12], as discussed in the next section.
Coordination across hospital–primary–secondary care transitions:
A
Another set of studies examines coordination during transitions across levels of care, especially from hospital to PHC or home. Leggett et al. [7] emphasise the need for structured links between intensive care units and PHC—clear communication, defined roles, and integrated records—to sustain continuity for survivors of critical illness. In Portugal, Batista et al. [13] analyse transitional care for older adults after emergency visits, showing gaps in continuity and communication and the need for structured interventions. In Australia, Davis et al. [14] describe implementing a nurse-led model to coordinate care between secondary and primary care for people with multimorbidity, with proactive follow-up; together, these studies underscore the value of structured transitions to limit discontinuities. Extending this view to Latin America, Chile’s experience indicates that successful transitions also depend on system-level arrangements: Almeida et al. [15] describe integrated networks supported by institutionalised tools—protocols, referral maps, a demand-management physician role, shared electronic records, and monitoring of waiting lists—aligning with the need to couple structured communication with network governance. In Singapore, Lim et al. [16] report a partnership between a public hospital and a private family medicine clinic with shared electronic records, multidisciplinary teams, and co-management of complex cases, which patients perceived as improving access, continuity, and coordination. Hsiao et al. [17], in turn, describe a programme integrating hospital services, primary care, and community organisations to strengthen continuity through structured transitions.
Care coordination as information integration and interoperability:
The literature indicates that integrating information and achieving system interoperability are foundational for effective coordination. Finucane et al. [18] report that shared electronic records support clinical decision-making and enable anticipatory care planning, especially for people with advanced illness. Similarly, Gill et al. [19] describe challenges in rural settings, where electronic records and digital tools could aid patient monitoring yet face practical constraints. Further studies [20, 21, 22, 23] show that clinical data integration, communication between providers, and alignment of care processes are essential to ensure continuity, safety, and quality.
Care coordination as interprofessional and intersectoral collaboration:
Several authors emphasise coordination across teams, sectors, and levels of action. Gunderson et al. [24] describe community health workers as bridges between communities, patients, and services, expanding access and follow-up of social and clinical needs. According to Santos [11], coordination requires user-centred practice, effective communication, and relationship-building, particularly in more complex situations; Cruz [8] highlights organisational supports—such as matrix support, case conferences, and mechanisms for sharing information and accountability—to sustain coordination. For example, Hudani et al. [25] present coordination as an intersectoral arrangement that builds more coherent pathways for homeless youth, overcoming fragmentation and institutional barriers.
Case-management–oriented coordination and follow-up for specific populations:
Some studies view coordination through the lens of individualised follow-up for specific groups. The Council on Children with Disabilities and the Medical Home Implementation Project Advisory Committee [26] propose a patient- and family-centred coordination framework for children and youth with special health-care needs. Within the Veterans Health Administration, Okunogbe et al. [27] surveyed primary-care teams working in medical-home models and found that time spent coordinating care for high-risk patients—who often have multiple medical and psychosocial problems—was associated with higher provider stress, underscoring the central role of coordination in this context. Davis et al. [14] and Batista et al. [13] highlight the need for case-management strategies and individualised care plans for vulnerable populations to sustain continuity across levels of care. Taken together, these perspectives point to the complex, multifaceted, and adaptable nature of coordination, and its central role in delivering comprehensive, continuous, high-quality care.
Barriers to Care Coordination in Primary Health Care
Despite theoretical advances and methodological innovation, the studies reviewed indicate that implementing care coordination in PHC remains fraught with challenges. The literature identifies constraints that limit effective coordination across diverse settings, spanning organisational, professional, technological, and relational domains: Organisational, structural, and resource barriers; Service fragmentation and communication failures; Limitations in information, interoperability, and technological tools; Challenges of engagement, capacity-building, and sociocultural context; Financing, incentives for collaborative practice, and public policy.
Organisational, structural, and resource barriers:
Workforce overload, weak institutional pathways, resource constraints, and limited adoption of information and communication technologies restrict the reach of coordination; in many settings, implementation relies on informal workarounds and individual effort, which can entrench precariousness and expand workloads [2, 11, 28]. The absence of policies and protocols for care transitions, poor communication between hospitals and PHC, time and staffing constraints, and low engagement of patients/caregivers hinder continuity, increasing risks of readmission and fragmentation [13, 14, 16]. In addition, historical segmentation, hospital-centred models, staff turnover, and centralised decision-making hamper full service integration [15].
Service fragmentation and communication failures:
In the Canadian context, Sovran et al. [29] report that key barriers to care coordination include fragmentation between primary care and other levels, communication difficulties among professionals, and limitations of information systems for sharing patient data.
The literature also notes factors that contribute to poor communication and fragmented care—high staff turnover, variation in team accountability, lack of clearly defined roles, underuse of institutional procedures, restrictive scheduling systems, absence of integrated protocols, and restrictive information policies—which recur as barriers [5, 6, 7, 25, 28].
Limitations in information, interoperability, and technological tools:
In Gill et al. [19], barriers to coordination arise chiefly from fragmentation among electronic health systems that do not communicate with one another. Rural settings magnify these problems because of geographic dispersion, limited resources, constrained access to specialists, and the use of multiple non-integrated records.
Accordingly, lack of interoperability, difficulties in creating/updating records, and restricted sharing of clinical information recur as obstacles. Fragmented systems, weak cross-platform integration, and information loss hinder continuity of care [18, 19, 20, 23, 29].
Challenges of engagement, capacity-building, and sociocultural context:
Among the obstacles to care coordination identified by Santos et al. [11] are workload pressures—particularly among nurses—arising from multiple competing roles. Workforce shortages and limited managerial support further undermine coordination. On the patient side, limited health literacy, cultural/linguistic barriers, and low participation hinder access, adherence, and chronic-disease management, especially in settings of greater vulnerability [13, 22, 24, 25, 27, 30, 31].
Financing, incentives for collaborative practice, and public policy:
Evidence from public health systems points to inadequate financing, constraints of prevailing payment models, and a lack of incentives for collaborative practice as barriers to sustaining coordinated care—particularly in segmented systems [8, 29].
Thus, barriers to care coordination are multifactorial and cut across system levels. Their mitigation demands coordinated, system-wide responses: strengthening organisational structures, reinforcing communication networks, and investing in technologies that fit the realities of services, users, professionals, and local contexts—while recognising and supporting professionals and users as central actors in building coordination.
CONCLUSION
Care coordination is a defining function of PHC but takes multiple forms—management of patient journeys, transitions across levels of care, interprofessional work, information interoperability, and case management for specific groups—shaped by institutional and local conditions. Implementation is limited by organisational constraints, service fragmentation, communication gaps, digital incompatibilities, and, in many settings, shortfalls in financing and engagement. Consolidation will require system-level action: clear governance and roles, well-prepared teams, interoperable information systems suited to service realities, and meaningful involvement of patients and professionals. Future research should test pragmatic, context-sensitive models and document effects on continuity, equity, and resource use.
Declarations
Funding
No funding was received.
Competing interests:
The authors declare no competing interests.
Ethics approval:
Not applicable.
Consent for publication:
Not applicable.
A
Author Contribution
LCB: conceptualization, methodology, screening, data curation, analysis, writing—original draft. LC: methodology, screening, supervision, validation, writing—review & editing. LDSG: methodology, screening, supervision, validation, writing—review & editing. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.
All authors approved the final manuscript.
A
Data Availability
All data were extracted from published studies cited herein.
Clinical trial number
not applicable.
REFERENCES
1.
Brazil. Ministério da Saúde. Portaria nº 4.279, de 30 de dezembro de 2010: Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do SUS. 2010 [cited 2025 Jan 11]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/prt4279_30_12_2010.htm
2.
Veloso CM, Martins MB, Pedreira NP, Santos EP, Azevedo Junior WS, Nascimento VG, et al. Práticas de enfermagem na coordenação do cuidado na atenção primária à saúde. Enferm Foco. 2024;15(Suppl 1):e–SUPL2024051.
3.
Bahr SJ, Weiss ME. Clarifying the model for continuity of care: a concept analysis. Int J Nurs Pract. 2019;25(2):e12704.
4.
Schultz EM, McDonald KM. What is care coordination? Int J Care Coord. 2014;17(1–2):5–24.
5.
Khatri R, Endalamaw A, Erku D, et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res. 2023;23:750. https://doi.org/10.1186/s12913-023-09718-8.
6.
Burch P, Whittaker W, Bower P, Checkland K. Factors affecting the experience of joined-up, continuous primary care in the absence of relational continuity: an observational study. Br J Gen Pract. 2024;74(742):e300–6. https://doi.org/10.3399/BJGP.2023.0208.
7.
Leggett N, Emery K, Rollinson TC, Deane AM, French C, Manski-Nankervis JA, et al. Clinician- and patient-identified solutions to reduce the fragmentation of post-ICU care in Australia. Chest. 2024;166(1):95–106. https://doi.org/10.1016/j.chest.2024.02.019.
8.
Cruz MJB, Santos AF, Macieira C, Abreu DMX, Machado ATGM, Andrade EIG. Avaliação da coordenação do cuidado na atenção primária à saúde: comparando o PMAQ-AB (Brasil) e referências internacionais. Cad Saude Publica. 2022;38(2):e00088121. https://doi.org/10.1590/0102-311X00088121.
9.
Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467–73. https://doi.org/10.7326/M18-0850.
10.
Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? BMC Med Res Methodol. 2018;18:143. https://doi.org/10.1186/s12874-018-0611-x.
11.
Santos MT, Halberstadt BMK, Trindade CRP, Lima MADS, Aued GK. Continuity and coordination of care: conceptual interface and nurses’ contributions. Rev Esc Enferm USP. 2022;56:e20220100. https://doi.org/10.1590/1980-220X-REEUSP-2022-0100en.
12.
Puzzolo J, Amarilla DI, Colautti M, Moreno MJ, De Paepe P, Vargas Lorenzo I, et al. Argentina Rev Salud Publica (Rosario). 2019;23(1):26–40. https://doi.org/10.31052/1853.1180.v23.n1.21276. Coordinación de la atención entre niveles y sus factores asociados en dos subredes de la red municipal de salud de Rosario,.
13.
Batista J, Pinheiro CM, Madeira C, Gomes P, Ferreira ÓR, Baixinho CL. Transitional care management from emergency services to communities: an action research study. Int J Environ Res Public Health. 2021;18(22):12052. https://doi.org/10.3390/ijerph182212052.
14.
Davis KM, Eckert MC, Shakib S, Harmon J, Hutchinson AD, Sharplin G, et al. 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. JMIR Res Protoc. 2019;8(12):e15006. https://doi.org/10.2196/15006.
15.
Almeida PF, Oliveira SC, Giovanella L. Network integration and care coordination: the case of Chile’s health system. Cien Saude Colet. 2018;23(7):2213–28. https://doi.org/10.1590/1413-81232018237.09622018.
16.
Lim YW, Ling J, Lim Z, Chia A. Family Medicine Clinic: a case study of a hospital–family medicine practice redesign to improve chronic disease care in the community in Singapore. Fam Pract. 2018;35(5):612–8. https://doi.org/10.1093/fampra/cmy007.
17.
Hsiao YL, Bass EB, Wu AW, Richardson MB, Deutschendorf A, Brotman DJ, et al. Implementation of a comprehensive program to improve coordination of care in an urban academic health care system. J Health Organ Manag. 2018;32(5):638–57. https://doi.org/10.1108/JHOM-09-2017-0228.
18.
Finucane AM, Davydaitis D, Horseman Z, Carduff E, Baughan P, Tapsfield J, et al. Electronic care coordination systems for people with advanced progressive illness: a mixed-methods evaluation in Scottish primary care. Br J Gen Pract. 2019;70(690):e20–8. https://doi.org/10.3399/bjgp19X707117.
19.
Gill E, Dykes PC, Rudin RS, Storm M, McGrath K, Bates DW. Technology-facilitated care coordination in rural areas: what is needed? Int J Med Inf. 2020;137:104102. https://doi.org/10.1016/j.ijmedinf.2020.104102.
20.
Cross DA, Cohen GR, Nong P, Day AV, Vibbert D, Naraharisetti R, Adler-Milstein J. Improving EHR capabilities to facilitate Stage 3 meaningful-use care coordination criteria. AMIA Annu Symp Proc. 2015;2015:448–455.
21.
Waibel S, Vargas I, Aller MB, Coderch J, Farré J, Vázquez ML. Continuity of clinical management and information across care levels: perceptions of users in the Catalan national health system. BMC Health Serv Res. 2016;16:466. https://doi.org/10.1186/s12913-016-1696-8.
22.
Zlateva I, Anderson D, Coman E, Khatri K, Tian T, Fifield J. Development and validation of the Medical Home Care Coordination Survey. BMC Health Serv Res. 2015;15:226. https://doi.org/10.1186/s12913-015-0893-1.
23.
Chung V, Yip B, Griffiths S, Lau CH, Wong MC, Yeoh EK, et al. Patients’ experience of Chinese medicine primary care services: implications on improving coordination and continuity of care. Sci Rep. 2015;5:18853. https://doi.org/10.1038/srep18853.
24.
Gunderson JM, Wieland ML, Quirindongo-Cedeno O, Asiedu GB, Ridgeway JL, O’Brien MW, et al. Community health workers as an extension of care coordination in primary care: a community-based cosupervisory model. J Ambul Care Manage. 2018;41(4):333–40. https://doi.org/10.1097/JAC.0000000000000255.
25.
Hudani A, Labonté R, Yaya S. Where’s the disconnect? Exploring pathways to healthcare coordinated for youth experiencing homelessness in Toronto, Canada, using grounded theory methodology. Qual Health Res. 2024;34(4):298–310. https://doi.org/10.1177/10497323231208417.
26.
Council on Children with Disabilities; Medical Home Implementation Project Advisory Committee. Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5):e1451–60. https://doi.org/10.1542/peds.2014-0318.
27.
Okunogbe A, Meredith LS, Chang ET, Simon A, Stockdale SE, Rubenstein LV. Care coordination and provider stress in primary care management of high-risk patients. J Gen Intern Med. 2018;33(1):65–71. https://doi.org/10.1007/s11606-017-4186-8.
28.
Rabelo ALR, Lacerda RA, Rocha ESC, Gagno J, Fausto MCR, Gonçalves MJF. Care coordination and longitudinality in primary health care in the Brazilian Amazon. Rev Bras Enferm. 2020;73(3):e20180841. https://doi.org/10.1590/0034-7167-2018-0841.
29.
Sovran V, Ytsma A, Husak L, Johnson T. Coordination of care could improve: Canadian results from the Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Healthc Q. 2020;23(2):6–8. https://doi.org/10.12927/hcq.2020.26283.
30.
Altin SV, Stock S. Impact of health literacy, accessibility and coordination of care on patient satisfaction with primary care in Germany. BMC Fam Pract. 2015;16:148. https://doi.org/10.1186/s12875-015-0372-0.
31.
Penm J, MacKinnon NJ, Strakowski SM, Ying J, Doty MM. Minding the gap: factors associated with primary care coordination of adults in 11 countries. Ann Fam Med. 2017;15(2):113–9. https://doi.org/10.1370/afm.2028.