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Abstract

Introduction

Care coordination has been part of social work for some time. It has been recognized as contributing to care coordination for long-term care for the elderly and mental health but less is known about their contribution in primary care with patients with complex health and social needs. As social workers are increasingly present in primary healthcare, this scoping review aims to provide a synthesis of social workers’ coordination activities for patients with complex needs in primary healthcare.

Methods

CINAHL, Medline, Scopus, SocioIndex, Social Work Abstracts, and ProQuest databases were searched, from 2004 to 2020 for peer-reviewed literature. A thematic analysis using deductive and inductive approaches was used to conduct this scoping review.

Results

Eighteen studies on 11 different care coordination interventions were included. The care coordination activities have been classified into four categories: 1) activities that target the patient, family, and caregivers; 2) activities that target health and social care professionals and services; 3) activities that link the patient and family with health and social professionals and services; and 4) cross-cutting activities that support and enhance other activity.

Discussion

A variety of care coordination interventions conducted by social workers were identified, all of which included related but different activities. Still, the common aim is to reduce fragmentation of care. Social workers, because of their disciplinary skills characterized by linkages to nonmedical services, can make a significant contribution to the coordination of care in primary health care, in collaboration with nurses.

Keywords

Delivery of health care integrated case management primary health care social work review [Publication type]

Introduction

Governments and healthcare authorities have a growing interest in the integration of care,¹ and numerous countries have recognized the need to change the fragmented healthcare system for a more coordinated one.² Significant cost growth related to health, aging populations, more sensitivity to the patient's point of view, and the quick increase of comorbid chronic diseases^3,4 seem to find some answers in a more coordinated care system. It has been noted that an integrated care system could improve population health and reduces or stabilizes per capita costs.⁵ Furthermore, through a systematic review, Baxter et al. showed evidence that integrated care increases patient satisfaction, improves the perceived quality of care and enables access to services.⁶

Case management is the most widely used professional coordination mechanism in Organisation for Economic Co-operation and Development countries and social workers occupy the majority of these positions around the world.⁷ Historically, case management has long been a component of the social work profession.⁸

Social workers play a significant role in care coordination centered on the needs and preferences of patients and their families.⁹ Their contribution is well known for patients with complex and chronic conditions who have traditionally been institutionalized in long-term care as the preferred option such as elderly people facing diminishing autonomy and people with mental health problems.¹⁰ However, less is known about the social workers’ specific contribution to the care coordination for people with complex health and social care needs in primary healthcare settings.

In the current study, complex needs are defined as: “Complex health and social care need result from multiple concurrent chronic conditions, functional and cognitive impairments, mental health challenges and social vulnerability, the individual's characteristics, and a major change in his life or care trajectory.”¹¹ As complexity increases,¹² the coordination of care requires more than the management of a single condition or disease,¹³ and must be more than simply coordinated through relational willingness. This is particularly important for people who require support with functional autonomy and chronic conditions impacted by social determinants of health.¹⁴ It becomes very relevant when patients with complex needs transition from one care context to another.¹⁵ Care coordination by social workers is also useful when the needs of the person with a chronic disease require services outside the broader health field (school, work, housing, etc.).

This significant contribution should be brought to light and appropriately acknowledged, especially given the relatively recent developments in social work. Several current developments require social workers to broaden their practices in the health sector.^16,17 The emerging profession of medical social workers¹⁸ or social prescribing strategies¹⁹ is still little-known in the social work field. But this expansion of social work has been shown to have positive effects on patients,^20,21 because it allows a broader consideration of the patient's needs.²² Two of the many driving forces behind these transformations of social work are the need for a more integrated organization of health and social services²³; and the development of coordination practices often assigned to social workers.²⁴ Other motives include 1) the dissemination of interprofessional conceptual models such as the chronic care model²⁵; 2) more open conceptions of health that include social determinants and well-being (e.g., the definition of the World Health Organisation where health includes well-being); 3) the priority given by public policy to biopsychosocial complex clinical situations²⁶; 4) community, population and primary care approaches that raise the need for a more home-based, community-based, ambulatory, or transitional intervention²⁷; 5) more integrated organization of health and social services²²; and 6) the development of coordination practices often assigned to social workers.²⁴ Some even believe that these developments are part of a renewed recognition for social workers, who are increasingly called upon to play a central role in the modernization of social and health care systems.²⁸ To fulfill these functions and meet the expectations of this new organization of services, social workers must be closer or present in medical clinics, which is not always the case. Their contribution to health must be more considered, which is also not always the case, even by social workers themselves.¹⁰

Care coordination programs or interventions are highly dependent on the trajectories of care considered by the policymakers. They are also highly dependent on the nature of the target population and the national and regional history of the service organization.²⁹ Nevertheless, the National Association of social workers (NASW),⁹ a US-based organization, advocates that the contributions of social workers working as case managers “shall participate in ongoing, formal evaluation of her or his practice to advance client well-being, assess the appropriateness and effectiveness of services and supports, ensure competence, and improve practice.”

The Agency For Healthcare Research and Quality identified several terms that are sometimes used interchangeably to name coordination of care, for instance, collaborative care, disease management, case management, care management, chronic care model, and care or patient navigation.³⁰ This abundant literature regarding all those appellations reflected there is some ambiguity and little consensus around a conceptual model and in the definitions of care coordination.³¹ This heterogeneity raises a challenge in synthesizing the knowledge about care coordination.

In primary healthcare, care coordination activities are carried out by different categories of professionals.¹¹ Although care coordination is part of the social workers’ activities, primary healthcare is still an underrepresented sector in the social work literature for primary care. Due to the limited number of studies on this theme in the field of social work, a lack of knowledge persists about care coordination activities provided by social workers for patients with complex health and social care needs in primary healthcare. As social workers are increasingly present in primary healthcare, this scoping review focuses on charting specific disciplinary aspects of care coordination activities of these professionals for these organizations. A comprehensive understanding of the social workers’ activities and their contribution to care coordination in this context could help align their work with that of other professionals when patients with complex needs are involved.

This scoping review aims to provide a synthesis of the existent literature on social workers’ coordination activities for patients with complex needs in primary healthcare. If we aim at developing a comprehensive social work coordination intervention for a complex need population, which activities should be included? This synthesis attempts to answer this question by answering these specific questions: 1) Who are the targeted complex patient populations? 2) In which organizational context do the care coordination interventions take place? 3) What activities do they involve? and 4) What care coordination interventions are currently enacted by social workers in primary healthcare?

Methods

This scoping review followed standard five steps which are: 1) formulating a research question, 2) identifying and 3) selecting relevant studies, 4) charting the data of the selected studies, and 5) analyzing, collating, summarizing, and interpreting the data.³² The questions for this review have been presented previously. The search strategy was carried out across multiple databases: CINAHL, Medline, Scopus, SocioIndex, Social Work Abstracts, and ProQuest (dissertation and thesis). The terms used for the search strategy and criteria are presented in Table 1.

Table 1.

Terms for the search strategy and inclusion and exclusion criteria.

Terms use for search strategy
“case management" or "care management" or "disease management" or "patient navigation" or "integrated care" or "care coordinat*" or "patient-centred medical home" or "delivery health care, integrated"	AND	"primary care" or "primary health care" or "primary healthcare"	AND	"social work*"
Inclusion and exclusion criteria
General inclusion criteria	Specific inclusion criteria		Exclusion criteria
2004–2019	Intervention or model of care coordination		The care coordination activities are poorly described or not described
English or French	Care coordination led by a social worker
Empirical study	Adult patient with complex needs

The search strategy was conducted to cover articles from 2004 to 2020, written in English or French. Included articles present an empirical study describing the coordination of care among adult patients with complex needs in the primary care setting. The reported intervention was to be led by a social worker. Later in the search, articles reporting on an intervention led by a team including a social worker and a nurse with equal responsibilities were also kept for review. Articles that did not describe, or described poorly, the care coordination activities were excluded since their content could not meet this scoping review purpose.

Study selection and validation of the selected studies were conducted by two independent researchers through consensus-based discussion (SL & MG). The selected studies were then presented to the research team for further validation. The selection process is presented in Figure 1.

Figure 1.

Flow diagram detailing search and studies selection process.

Once the studies were selected, data extraction was accomplished by completing detailed analysis grids that reported the main characteristics of each study and the data required to answer the research questions. This process identified two supplemental studies that had not been identified by the initial literature search. These studies were added to the scoping review. The grids included specific data to describe each study: the study design, objectives, care coordination intervention, target population, and context. The grids also listed all care coordination activities reported in the articles (appellations and definitions). These grids were completed by one of the reviewers (SL) and further validated by a second reviewer (MG). Discrepancies were resolved by discussion between the two reviewers and the main researcher. As the purpose of this scoping review was to describe care coordination interventions and activities, a methodological quality appraisal was not performed.

The descriptive data were compiled to provide a portrait of the context and the population targeted by the care coordination interventions. Then a thematic analysis, using deductive and inductive approaches, was performed with the care coordination activities. First, using a deductive approach, this analysis considered the previous categorization of activity types made by Karam et al.¹¹ for nursing care coordination activities which were based on the American Nurses Association³³ framework and adapted for primary care and complex patient populations. Even though this categorization was developed for a different domain, the general activity categorization of primary care coordination seems similar to social work activities. Then, using an inductive approach, the analysis considers space to identify emergent subcategories for specific social work activities.

Results

As shown in Figure 1, 92 full-text articles were assessed for eligibility. Eighteen articles met all the criteria and were included in the final synthesis. The 18 studies included reported on 11 different care coordination interventions. For the analyses of care coordination activities, precautions were taken not to duplicate information. The content of each article was used to complete the information on the intervention. Table 2 describes all included studies.

Table 2.

Included studies that address social worker care coordination for patients with complex needs.

Authors, year of publication	Study design/Objectives	Care coordination interventions	Target population	Context, country*	Summary of Care Coordination activities
Cherry et al.³⁶	Longitudinal preintervention-postintervention study/Evaluate the effect of the intervention	Care management	Older patient with dementia and possibly other health conditions	Partnership between primary care clinic and community-based services, intervention from a social worker, California, USA	Assess patient; assess caregiver, family and support systems; assess caregiver needs; re-assess frequently, develop and implement treatment plan; follow up and educate on behavior management; educate and support caregiver in decision making; refer to community services; recommend needed services; facilitate connection with physicians and other health and social professionals
Counsell et al.³⁷	Randomized controlled trial/Test the effect of the intervention/Analyze cost	Care management	Older patient with social vulnerabilities (low-income) living in the community	Primary care clinics and home visits, intervention from a team of 2 care managers (1 social worker and 1 nurse), Indiana, USA	Conduct an initial assessment of the patient; follow up monthly to review the care plan; assess annually; encourage and teach goal setting, self-care, problem solving, health literacy, self-management; assist with transportation arrangements; link patient with health system and community services; share information with interdisciplinary team; develop a care plan; meet with the primary care physician to adjust care plan; activate care plan; review care plan regularly with interdisciplinary team; implement care plan with patient and primary care physician; provide coordination of care among all health professionals and sites of care; help and prepare patient to address problems with primary care physician; help communication with professionals; develop trusting and working relationships with patient and primary care physician; meet for weekly group supervision
Counsell et al.³⁸ (same study) (same intervention as in Ritchie et al.⁴⁹ and as in Schubert et al.⁴⁵)		Care management
Emery et al.³⁹ (same intervention as in Rothschild et al.⁴⁰)	Implementation evaluation/Evaluate the implementation of the intervention	Integrated care	Older patient with symptoms of depression and possibly other health conditions and social vulnerabilities	University medical center in partnership with primary care clinics, intervention from a social worker, Illinois, Chicago, USA	Assess patient; recommend treatment; review treatment; develop an individualized treatment plan; follow up via phone to maximize adherence; follow up to assure connection to services; share assessment result with interdisciplinary team, compile treatment recommendations; link participant to appropriate services
Iliffe et al.³⁴	Multiple case study and feasibility study/Explore the perceived value and benefit and feasibility and acceptability of case management practice	Case management	Patient with dementia and possibly other health conditions	Primary care clinics, intervention from social worker (1 site) or nurses (2 sites), London, Newcastle, Norwich, UK	Review medical records; target patient with dementia; complete medical records if needed; meet patient and caregiver to identify concerns or unmet needs; map support available; develop a personal care and support plan; help-seeking advice for finance, health and welfare decisions; liaise with other professionals; analyze information obtained from other practitioners; share the care plan with other professionals; liaise with the general practitioner about other health conditions reported by the patient; participate to regular supervision with a mentor.
Bamford et al.³⁴ (same study reported in two articles)		Case management	Patient with dementia and possibly other health conditions
Miller et al.⁴⁶	Multi-level study of intervention and implementation/Evaluate efficacy and implementation of the program	Care coordination	Veteran with health needs and social vulnerabilities who just visited an emergency department	Home visits, partnership between the veteran affairs medical center and the health care system, intervention from a social worker, Colorado, USA	Assess needs; review medical records; complete clinical interventions regarding social determinants of health; complete a warm handoff once the intervention is complete; transfer record to primary care team; collaborate with professionals involved with the patient; link patient and services (health and community); refer, if needed, to other case management services; use his or her professional judgment; use varying intervention techniques; educate collaborating partners for effective work with the program
Reeves et al.⁴⁷	Randomized, pragmatic, open, 3-group parallel design/Evaluate the outcomes of the intervention	Case management	Patient discharged after acute stroke who have identified unmet needs and functional limitations	Home visits, intervention from a social worker, Michigan state University project, Michigan, USA	Conduct a biopsychosocial assessment to identify patient and caregiver needs; develop service plan; implement service plan; promote and educate about the use of medication; facilitate patient and caregiver engagement; suggest solutions to specific problems and barriers; follow up weekly on progress; encourage patient self-management; ensure that the patient is seen by a primary care physician; refer patient to community services; facilitate access to social and community services; help coordinate services; maintain an interaction log; participate in bi-weekly group supervision; write close out report and share it with the patient and the primary care physician
Ritchie et al.⁴⁹ (same intervention as in Counsell et al.^37,38 and as in Schubert et al.⁴⁵)	Process evaluation/Evaluate the adaptation and implementation of the intervention	Care management	Patient with multiple chronic conditions or comorbid physical and mental health conditions	Academic medical center in partnership with Primary care clinics, intervention from a team of 2 care managers (1 social worker and 1 nurse), California, USA	Perform a comprehensive evaluation; follow up with the patient; discuss initial assessment with interdisciplinary team; develop an individualized care plan; discuss care plan with interdisciplinary team and primary care physician
Rose et al.⁵⁰	Interventional practice model/Evaluate the effect of the model	Collaborative care	Patient with social vulnerabilities and one or more uncontrolled chronic conditions	Home visits in partnership with primary care clinic, intervention from a social worker, Maine, USA	Meet with patient and physician to recruit the patient; assess the patient; work to increase patients’ capacity for participation; develop plan of care with patient; debrief with patient after medical visits; ensure that the patients’ basic needs are met; facilitate connection with community resources; help patient process complex medical information; discuss with primary care provider to create plan of intervention; contribute to extend primary relationship with multidisciplinary primary care teams; prepare a list of patient concerns and share it with the primary care team; integrate information from medical visits into care plan; help the primary care provider understand the patients’ reality; organise medical visit with the multidisciplinary care team; facilitate patient interaction with the professionals; accompany patient to specialist visits; develop a relationship with the patient to create a safe and empowering environment; help patient and professionals understand some concepts about service use
Rothschild et al.⁴⁰ (same intervention as in Emery et al.³⁹)	Randomized controlled trial/Test the effects of a 12-month multidisciplinary team intervention in primary care	Integrated case	Older patient from minority background with symptoms of depression and social vulnerabilities	Academic medical center in partnership with primary care clinics, intervention from a social worker, Illinois, USA	Conduct an assessment; share recommendations with the patient; develop a patient-centered action plan; provide ongoing care management as needed; facilitate referrals to community services; share assessment results with the interdisciplinary virtual team; analyze and synthesize recommendations from each professional in the team; coordinate primary care services; connect patient with services; facilitate referrals to health care providers; participate in weekly group supervision
Rowe et al.⁴¹ (same intervention as in Rowe et al.⁴² and as in Rowe et al.⁴³)	One group exploratory retrospective study/Explore links between intervention and utilization of care services	Care coordination	Older patient presenting social vulnerabilities and 3 or more chronic conditions	Primary care clinics associated with academic medical center, intervention from a social worker, Illinois, USA	Ensure that the patient understands the need for care coordination; identify immediate nonmedical goals; conduct a comprehensive biopsychosocial assessment; develop a mutually agreed-upon care plan; assist with care plan implementation; provide information; link patient with community resources; encourage patient to independently implement goals; maintain weekly follow up; ensure community-based resources are in place to support the patient; encourage the patient to contact the social worker if needed; link the patient to services and supports; establish rapport and trust; use problem-solving and motivational interviewing techniques
Rowe et al.⁴² (same intervention as in Rowe et al.⁴¹ and as in Rowe et al.⁴³)	Case study/Illuminate the unique contributions of social workers in a team-based care coordination model	Care coordination	Older patient presenting social vulnerabilities and 3 or more chronic conditions	Primary care clinics associated with academic medical center, intervention from a social worker, Illinois, USA	Ensure that the patient understands the need for care coordination; identify immediate needs; conduct a comprehensive psychosocial assessment; tailor a care plan; assist with care plan implementation; provide information or education or psychoeducation; provide behavioral health counseling; coordinate activities; link patient with community resources; monitor care plan progress; reassess patient needs if necessary; modify care plan if necessary; acknowledge goal achievement and reinforce patient strengths; prepare the patient ongoing care; ensure community-based resources are in place to support the patient; encourage the patient to contact the social worker if needed; transfer information to the primary care physician; use empathy, positive interpersonal skills, motivational interviewing and cognitive-behavioral techniques, stress and coping and problem-solving strategies; establish trust and promote a collaborative working relationship; use counseling strategies; encourage goal achievement
Rowe et al.⁴³ (same intervention as in Rowe et al.⁴¹ and as in Rowe et al.⁴²)	One-year longitudinal quasi-experimental study/Examine social workers’ time contribution to the management of patients’ nonmedical needs	Care management	Older patient presenting social vulnerabilities and 3 or more chronic conditions	Primary care clinics associated with academic medical center, intervention from a social worker, Illinois, USA	Confirm the patients’ need for care coordination; identify immediate needs; provide immediate intervention if necessary; complete a comprehensive multi-dimensional psychosocial assessment; develop a coordinated intervention care plan; assist with care plan implementation; provide information or education or psychoeducation; coordinate care plan activities; connect the patient to neighbourhood resources; perform wrap-around and follow up task; acknowledge goal achievement and reinforce patient strengths; prepare the patient ongoing care; ensure community-based resources are in place to support the patient; encourage the patient to contact the social worker if needed; connect the patient to services and supports; establish rapport and trust; provide psychoeducation and motivational interviewing; use problem-solving and cognitive behavioral therapy strategies; encourage change
Ruikes et al.⁴⁴	Two-arm nonrandomized cluster-controlled trial/Report on effectiveness of trial	Case management	Older frail patient with multiple health and social needs	Primary care clinic, intervention from a social worker or a nurse, Nijmegen, the Netherlands	Ensure patients’ acknowledgement of the care plan; encourage patients’ involvement in setting goals; maintain treatment contact; organize the multidisciplinary team meeting; coordinate and monitor care
Schubert et al.⁴⁵ (same intervention as in Counsell et al.³⁷^,³⁸ and as in Ritchie et al.⁴⁹)	Comparative cohort study and implementation study/Describe lessons learned, and outcomes observed during implementation of the intervention	Care management	Older veterans with geriatric syndromes	Primary care clinics in partnership with the Veteran Affairs medical center, intervention from a team of 2 care managers (1 social worker and 1 nurse), Indiana, USA	Contact patient promptly after discharge; conduct a comprehensive geriatric assessment; participate collaboratively and as needed in the implementation and follow-up of care; present and discuss the case with interdisciplinary team; develop a care plan; collaborate with the primary care physician to review, modify and implement the care plan; ensure appropriate clinic follow up; build rapport with the patient
Wetta-Hall et al.⁴⁸	Implementation study/Assess both the process of case management as well as outcomes of the process	Case management	Low-income uninsured frequent users of emergency services	Hospital-based intervention from a team of 2 care managers (1 social worker and 1 nurse), Kansas, USA	Assess eligibility and needs; conduct follow up progress and goal assessment; assess readiness for change; identify barriers; help resolve barriers; help patient formulate a plan; assist patient goal setting and prioritization of needs; discuss resources; encourage patient to make appointments; help patient develop new care-seeking behaviors; support patient in scheduling medical appointment; assist with transportation; identify and educate patient on available choices; link patient to informal and formal supports; develop a therapeutic rapport; provide information, education and counseling; provide necessary orientation, training and consultation to caregiver; identify relevant service resources; organized resources’ information for the patients’ use; link patient with health professional services; support the client with service coordination and navigation; provide emotional support during visits with health care providers; advocate for the patient; help access to services; assist with paperwork; help communication with care providers; use effective listening and interviewing skills; encourage patient to drive decision-making processes; model new and appropriate behavior when interacting with health care providers.
Williams et al.⁵¹	Retrospective cohort study/Describe to inform the development of targeted, centralized care management programs	Care management	Patient with low income, frequent utilization and multiple medical, mental health and social needs, who have significant impairments in at least two of five domains	Independent program in partnership with University of Michigan faculty group practice, intervention by social workers, Michigan, USA	Visit the patient if hospitalized; identify and remove barriers; coordinate with community service agencies; serve as patient advocates for community resources; coordinate recommendations of multiple care providers; collaborate with primary care physicians and their staff; accompany patient to schedule appointments; accompany patient during visits with their primary care providers or other professionals; assist in medication reconciliation

Underlined organizations indicate where the care coordinators are located.

Complex target patient populations

Diverse populations were targeted by the interventions described in the 18 studies. These patient populations are mostly characterized by social vulnerabilities (e.g., low income, uninsured, living alone, housing or employment insecurity, etc.) combined with multiple health needs (e.g., multiple chronic diseases, depression, dementia, stroke, etc.). The majority of interventions (12/18 articles) targeted older patient^34–45 with different health conditions. The population's age is not specified in three of the articles^46–48 and other care coordination interventions are not age specific.^49–51

Organizational context of the care coordination

The care coordination interventions presented in the articles were carried out through different organizations. The majority of interventions involve primary care clinics,^{34–46,49,50} however, as shown in Table 2 (underline organizations), these clinics are not always the care coordinator's home organization. Other organizations involved in the interventions are academic or university medical clinics,^{39–43,47,49,51} the department of Veteran Affairs (USA),^45,46 hospitals,⁴⁸ community-based organization,³⁶ and one intervention seem to be provided by an independent organization.⁵¹ Several articles (12/18 articles) report on an intervention that involved a partnership between two different organizations.

The majority of articles reported intervention led exclusively by a social worker (10/18 articles).^{36,39–43,46,47,50,51} In addition, articles reported on two different interventions where care coordination was led interchangeably by a social worker or nurse, regardless of the role or activities of these professionals.^34,34,44 It is to be noted that those two interventions are the only ones from outside of the United States. Lastly, since we expanded the criteria to include studies reporting on interventions involving a team of care coordinators, five articles report on two different interventions where a team of one nurse and one social worker work together to coordinate care.^{37,38,45,48,49} Even though parts of the assessment of the patient are reported as specific to the social worker or the nurse, all other activities are not specific to one professional.

Care coordination activities

Considering in this analysis that some interventions are reported in more than one study, the care coordination activities were synthesized into four categories as presented by Karam et al.¹¹ In the following, we briefly present the four categories and related activities. A more detailed description and content specifications are provided in Appendix A.

Activities that target the patient, family, and caregivers

Target and recruit patients who will benefit most from the intervention. The care coordinator identifies patients with complex needs by reviewing records or with the help of referring general practitioners and partners.^34,35,46 The care coordinator introduces the intervention and makes sure he or she is interested in participating.^{41–43,45,50}

Assess patient, family and caregivers. The care coordinator conducts a comprehensive biopsychosocial assessment of the patient^{36,38–43,45–50} and an assessment of the patient, family and caregivers’ needs,^{34,35,42,43,48} readiness to engage in the treatment plan,⁴⁸ and decision-making process.³⁶ The care coordinator conducts an initial comprehensive and transdisciplinary assessment of needs and formal or informal follow-up assessment throughout the intervention duration. This initial assessment is supported by disciplinary assessments, including those of the physician or nurse, and provides additional information for patient care coordination.

Develop, present, discuss, and assist in implementing a tailored care plan. The care coordinator develops the care plan in collaboration with the patient^{34,34,39–43,47,48,50} and shares and discusses the care plan with the patient.^36,39,40,44 The care coordinator also assists in implementing the care plan.

Monitor and follow up on the patient and the care plan implementation. The care coordinator maintains contact with the patient to monitor implementation of the plan, progress, adherence, service use, etc.^{36,37,39–45,47–49}

Offers support and psychosocial intervention to the patient, family, and caregivers. The care coordinator, when relevant, offers support and specific psychosocial intervention to help the patient, family, and caregivers meet their needs. Support and psychosocial intervention mainly aim to answer needs related to the social determinants of health,^{46–48,50,51} to ensure empowerment of the patient, family, and caregivers,^{36,41–43,46–48,50} and help in understanding and managing behavioral problems.³⁶

Activities that target health and social care professionals and services

Share and receive information about the patient, the assessment, or the treatment recommendations. The care coordinator is active in various exchanges of information with other professionals involved with the patient. Information sharing aims to support assessment,^{37,39,40,49,50} to coordinate recommendations of treatment plan provided by an interdisciplinary or multidisciplinary team,^{34,35,39,45,46,50,51} or to communicate or discuss patient's needs to service providers.^{34,35,42,47,50} The care coordinator also sometimes provides logistic support to team meetings,^44,50 promote the care coordination intervention,^46,50 help provider's understanding of concepts of care coordination,⁵⁰ and link professionals together.⁴⁰

Develop the patient's care plan or share the patient's care plan with the professionals involved. The care coordinator often develops the care plan with the patient (see category above), but often he or she develops the care plan with a team of professionals^38,45,49 or both the patient and a team.^34,35,50 This team is also responsible to follow up on implementation and adapt the care plan to answer emerging or changing patient's needs.

Activities that link the patient and family with health and social care professionals and services

Link the patient or provide referrals to health and social services. The care coordinator assists in identifying or recommending relevant resources and services^34–36,48 and refer, link, facilitate access, or assure connection to services.^{39–43,46–48,50} These referrals can be within health services, specific to social services, and across multiple public or community-based sectors such as school, work, and housing.

Coordinate services and support interactions between patient, caregiver, family, and providers. The care coordination sometimes directly assists in coordinating services (scheduling, brokering, engagement of resources, follow-up with providers).^{34,35,41–43,45,47,48,51} In some interventions, the care coordinator also coordinates actions between professionals to provide services or implement the care plan.^37,47,48 They also in some cases assist during medical visits and appointments during which, if needed, they facilitate interactions with the professional and advocate for the patient.^36,48,50,51

Cross-cutting activities that support and enhance other activity

Build a relationship with the patient, caregiver, and professionals. The care coordination uses different strategies to ensure he or she develops a relational connection with every person involved which contributes to the efficacy of the intervention.^{37,41–43,45,48,50}

Participate in professional supervision and continuous education. The care coordinator takes part in activities to support the quality of care coordination, the implementation of the intervention of care, professional disciplinary development, and interdisciplinary team development.^{34,35,37,40,47}

Discussion

Our results showed a variety of interventions, led by social workers, in primary healthcare settings and used to coordinate care around patients with complex needs. This heterogeneity confirms that coordination of care means different things to different people in different healthcare systems, depending on locations, targeted populations, and the intervention's objectives.⁵² This variety also depends on the diversity of the characteristics of the clients with whom they work and on the quality of their integration into primary health care organizations.

The terms and concepts used to identify the care coordination intervention (care management, case management, care coordination, integrated care, collaborative care) do not appear to define the content of the intervention or the activities of the care coordinator. They seem to vary within the same kind of intervention type as well as multiple similarities can be noted between different appellations of care coordination intervention. For example, studies that identify with care coordination all have activities related to the systematic linkage of the patient with community resources, but only one study⁴⁶ presents activities regarding the medical record of the patient (reviewing, completing, and transferring), which are also activities reported in studies using the term “case management”.^34,35 Moreover, three studies reporting on the same intervention^41–43 do not use the same terms to identify the care coordination intervention. Two of them use care coordination^41,42 and one uses care management.⁴³ As reflected previously in the introduction, terms used to designate care coordination intervention vary and these different terms might need further clarifications. Yet the term case (as in case work) has a historical audience in this discipline. This probably shows how the idea of coordination came back into the world of social work via the world of health.

Single care coordination activities do not seem associated with the target populations. Interventions targeting the same kind of population have similar activities as well as activities that are different. For example, in articles reporting on interventions targeting older patients, not all interventions conduct an assessment (articles that do not report conducting an assessment in the care coordination activities),^34,35,44 but all have activities related to the development and implementation of a care plan. In addition, when comparing different population types, it is also noted that activities are sometimes similar, sometimes different. For example, the same intervention is studied in four articles, three targeting older patient^37,38,45 and one targeting none age-specific patients (Ritchie et al., 2016).⁴⁹ Therefore, care coordination activities do not seem to depend on the target population but are more related to the intervention itself.

Observations are similar when considering the organizational context in which the care coordination activities take place. No specific activities seem related to the localization of the care coordinator. The involvement of a partnership in the project versus the initiative of a single organization also does not appear to determine the nature of the care coordinator's activities. It also seems that there are no significant differences in the care coordination whether it is led by a social worker, a nurse, or a bidisciplinary team.

The interventions are what seem to influence the most the care coordination activities. Unfortunately, the articles included in this review rarely specify or specify with too few details, the rationales behind the choice of the included care coordination activities. Therefore, it is harder to discuss the specific similarities and differences between interventions. Still, similarities between interventions are frequent. Some activities appear less often than others, but no activity is associated with only one intervention. For example, Assess patient, family and caregivers appears in 15 of the 18 articles while participate in professional supervision and continuous education appears in five of the 18 articles.

Many of the reported activities may be perceived by social workers and researchers as disciplinary. However, they are often shared with colleagues from other disciplines, such as nurses, forming a common core of transdisciplinary coordination activities. Moreover, as shown in the introduction, the definition of the contribution of social work to coordination in primary health care is young and still being defined. Case management seems characteristic of social work and most times is undifferentiated from standard social work practice, which can be illustrated by the frequent use of the term “case work” to define their practice. It is a professional function mainly dedicated to the multidimensional evaluation of the needs of people with complex problems, to the planning of all the multidisciplinary interventions that result from it, and then to their coordination over a long period, regardless of the territory under the responsibility of the organizations involved in the overall response to the user's needs.⁵³ Therefore, care coordination also concerns patients with complex needs that go beyond the medical response. It is the professional component of service integration at the core of reforms in the organization of health and social services for clients with complex clinical situations.⁵⁴

This scoping review proposes many essential components of care coordination that should be found in interventions for patients with complex needs. Assess patient, family, and caregivers seem inevitable in healthcare interventions and even though it is an important activity that guides the entire intervention, it is not specific to care coordination. More specific to care coordination is activities related to share and receive information about the patient, the assessment, or the treatment recommendations. Collaboration based on interprofessional and sharable records with the general practitioner seems to be the foundation of every activity involving social workers working with patients with complex needs. The exchange of information between the people involved in the different components of care is recognized as an effective strategy for the organization of care.^55,56 Collaboration is encouraged by the World Health Organization⁵⁷ and has become a priority for healthcare systems over the past decade. Other studies have stressed the importance of communication based on good working relationships between professionals to respond to the complex needs of patients.^52,58–62

The care coordinator's action must therefore deal with an interprofessional function focused on the organization and coordination of services⁶³ and a disciplinary professional function focused entirely on the relationship with the patient.⁶⁴ At the junction of those two functions lies a specifically well-known action of case management: advocacy⁶⁵ which is the action of supporting the patient in an always more complex system. In this way, care coordinators manage to establish a relationship of trust with their patients, advocate on their behalf and make themselves available which are two other essential categories of activities (Coordinate services and support interactions between patient, caregiver, family, and providers and Build a therapeutic relationship with the patient, caregiver, and professionals).

Also, Link the patient or provide referrals to health and social services is of great value in care coordination. Various coordination models share some common goals, including facilitating access to social resources,⁶⁶ and increasing interorganization services coordination,⁶⁷ one of the traditional functions of social work.⁶⁸ Home visits, as well as the involvement of community resources, seem of particular importance when coordinating the care of patients with complex needs. This is largely in response to the vulnerability and some cases functional decline of the target patient populations.⁶⁹ Creating a relational continuity of care with the patient and family, and relevant members of the community emerge as central to the coordination of care with complex needs populations. For these patients, integrated care means a single point of entry and privileged contact with a dedicated care coordinator.⁶²

This scoping review has several implications for future research, policy, education, and practice. We have shown that the success or failure of integrated care interventions, including care coordination,^70,71 depends on the context and the quality of their implementation.⁶ It is generally recognized that complex interventions frequently encounter obstacles in their implementation.⁴⁴ However, the studies included in our review present little, or no information related to the quality or fidelity of interventions. There is also no clear indicator of the frequency of social workers’ activities, nor of their need to develop skills or competencies for certain activities that are atypical to their field. It would be interesting to explore these factors further to explain, at least in part, the limited effectiveness of some interventions.

The extent and purpose of coordination depend in part on the coordinator's area of practice. The scope of social work is characterized by linkages with nonmedical services, including life skills support, community resources, and nonhealth intervention areas (school, work, housing, etc.). Social workers share a care coordination contribution with families and caregivers with nurse care coordinators. Interprofessional coordination between these two disciplines remains to be better understood.

From a policy perspective, our results highlight the following challenge for health care systems: to identify employment and remuneration models for primary health care that would facilitate multidisciplinary teamwork and promote collaborative rather than hierarchical practice. This involves facilitating the transfer of information between providers through effective communication technologies, and the integration of social work in the information tools used by physicians, otherwise, the two parallel modes will continue, on a disciplinary level, but also in care coordination activities.

At the organizational level, our review highlights the need for coordinating social workers to have a clear role and to “meta-coordinate” with all professionals in and around primary health care involved in the patient's care. In addition, they must be supported by the health care system through funding, clinical and communication tools, and other means. Especially in certain contexts where social workers intervene on two levels, the one belonging to their discipline and the one involving their coordination activities. This is particularly difficult when their place in primary care organizations is uncertain.

Finally, some interventions in our review necessitated preimplementation training for social workers. Though we cannot confirm that it is the case in other countries, in Québec, care coordination, and primary care, are not present in social work education even though activities of coordination seem to be a crucial part of social work history. This synthesis provides a foundation for the development of specific professional competencies that would target the skills needed for effective coordination and improve care coordination interventions. It also supports the need to develop systematic documentation of care coordination activities of social workers to secure appropriate financial and societal recognition of their contribution to high-quality integrated care.

Research that describes the intensity of care coordination services for different populations is still needed.⁵² In medical clinics, there are three coordinators, the doctor who coordinates with specialists, the nurses who coordinate some nursing interventions, and the social workers for services to support functional capacity, family mobilization, intersectoral coordination, etc. From pair to pair (doctor–nurse, nurse–social worker), the coordination overlaps. The articulation of these coordinations and their effects are still to be understood.

This scoping review has several strengths and limitations. To our knowledge, there are currently no other reviews to synthesize social worker care coordination activities for patients with complex needs in primary health care settings. Findings could contribute to the development of a framework for care coordination and opens the door to several future research projects.

The review used only parts describing the processes of care coordination and the specific activities of care coordinators as provided in the included studies. Therefore, aspects such as system-level mechanisms, structural aspects that support care coordination and the organization of primary care in each country were not addressed. For example, this article does not consider the diversity of primary care between countries and their influence on the practice of social workers. More studies should be conducted on this topic.

Also, descriptions were sometimes poor or lacking details, so we may have missed specific features of some activities. To minimize missing information, we reviewed the available theoretical articles presenting the interventions studied in the included empirical articles.

In conclusion, despite the heterogeneity of care coordination interventions, one common thread remains: they aim to reduce the fragmentation of care by bridging the gaps between the patient needs and the system capacity. Social workers, because of their disciplinary skills, can make a significant contribution to care coordination in primary health care, in collaboration with nurses. This interprofessional collaboration is common in practice but is rarely supported by training that meets the need of professionals. The practical and conceptual heterogeneity shows that further attention needs to be given to the education and training of social workers to enable them to act effectively in care coordination and team-based care delivery. The integration of essential and transversal skills into the training program for social workers would optimize the coordination of care.

This same heterogeneity illustrates the diversity of needs that care coordination aim to meet. Behind this observation lies the narrow information provided about the implementation of a care coordination intervention, insufficient by itself to foster strongly integrated care and meet the needs of targeted patients. Challenges remain and care coordination interventions should be linked to a continuum of strategies at all levels to achieve effective and efficient care.⁷² Finally, the intersectoral part of coordination of care, around the primary health care setting, closely concerns social workers.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Maxime Guillette

Appendix A.

Care Coordination activities and their description.

Activities that target the patient, family and caregivers	Description
Target and recruit patients who will benefit most from the intervention	Target patients with complex health and social needs Introduce the program to the patient and ensure the patient's understanding of the program and the need for care coordination Make sure the patient is interested in participating
	Strategies to target and recruit patients include: Reviewing medical records or GP lists (assess for program eligibility) Referral from the GP or other program's partners (hospital, primary care clinic, etc.)
Assess patient, family and caregivers	Conduct a comprehensive biopsychosocial assessment of the patient ○ Conduct by phone, in a clinic setting or home visit ○ Conduct follow-up assessments as needed or depending on the program's procedures ○ Use validated and standardized tools and protocols ○ Use various counseling strategies ○ Discuss the assessment's outcomes with the patient
Assess patient, family and caregivers	Assessment may include: Patient's history (medical history, personal history, social history) Physical health (general health, vital signs, cardiovascular risk, gait and balance, vision et audition etc.) Mental health (mental and cognitive status, depression, psychotic symptoms, dementia, behavioral problems, etc.) Social determinants of health (social support, home safety, living arrangements and conditions, family interactions, available resources, financial situation, etc.) Functional status (medication management, daily function, feeding, dressing, mobility, etc.) Readiness to engage in the program (motivation, values, readiness for change, barriers, goals, decision-making process, strengths, etc.) Family and caregiver needs
Develop, present, discuss and assist in implementing a tailored care plan	Share and review care recommendations with the patient Develop (collaboratively) and review the care plan Assist the patient in implementing the care plan—coordinate the care plan activities
	The care plan: Is patient-centered Is individualized Is mutually agreed (with patient and caregivers) Is based on priorities and mutually agreed goals Is evolving Is revised as needed
Monitor and follow-up on the patient and the care plan implementation	Maintain contact with the patient ○ By phone, home visits or clinic appointments ○ Weekly, monthly, twice per year or as needed (depending on the program)
	Monitoring and follow-ups aim to: Re-assess the patient (progression or decline) (see Assess patient, family, and caregivers) Assess ongoing implementation (relevance and achievability) of the care plan Assess goal attainment Review or modify the care plan Facilitate adherence to care plan Ensure support is available Ensure services are obtained—address barriers to the use of services Provide further information and resources (if needed)
Offers support and psychosocial intervention to the patient, family and caregivers	Support and psychosocial interventions aiming at the social determinant of health (SDOH) Clinical intervention regarding SDOH to improve health outcomes Practical education on housing, finances, parenting, employment, etc. Identification and removal of barriers (e.g., transportation issues, financial burdens, complexities of multiple providers, etc.) Collaborate to ensure basic needs (e.g., safe and affordable housing, food security, clothing, etc.)
	Support and psychosocial interventions aiming at empowering the patient Encourage and educate in self-care and self-management Encourage and reinforce goals setting, goal implementation and goal achievement Facilitate decision-making ○ Encourage decision making ○ Educate, give information, and discuss available choices and resources ○ Give relevant information about disease and treatment options Educate and assist in learning problem-solving skills Use behavioral counseling and psychoeducation to reinforce self-efficacy, personal strength, self-focus, and a sense of control
	Use psychoeducation to help with understanding and managing behavioral problems and mood disorders (environmental modification, task simplification, appropriate activities, etc.)
	*The provision of support and psychosocial interventions, when relevant, depends on the patient's needs as well as family and caregiver's needs.
Activities that target health and social care professionals and services	Description
Share and receive information about the patient, the assessment, or the treatment recommendations	Present the assessment results to an interdisciplinary or multidisciplinary team (virtually or in a meeting) Provide information about the patient to the professionals involved Receive information about the patient from the professionals involved Make sure the medical record or the patient's file are up to date, write a close-out report (so that the information is shared with the professionals involved) Discuss the patient's case with the interdisciplinary team and the primary care provider Prepare a list of the patient's concerns and needs to present them to the professionals involved to prepare for the patient's visit
	To share information, the care coordinator: Compile recommendations Coordinate recommendations of multiple care providers Integrate suggestions into the care plan Analyze and synthesize information (from assessment, medical records, providers, etc.) Complete medical records if needed
	With the information-sharing activities, the care coordinator sometimes: Plan and organize the interdisciplinary or multidisciplinary team meeting Promote the program or provide education about care coordination and the program to professionals and service providers Help providers’ understanding of concepts Link professionals (health services and community-based services) together to help coordinate services between other providers and the patient primary care provider (physician)
Develop the patient's care plan or share the patient's care plan with professionals involved	Develop an individualized care plan for the patient ○ Based on assessment results, interdisciplinary team suggestions, and protocols Review care plan with the interdisciplinary team (regular team meetings) Adapt the care plan with the primary care provider (present, review, modify, prioritize)
Activities that link the patient and family with health and social care professionals and services	Description
Link the patient or provide referrals to health and social services	Identify resources (indexing, organizing, mapping) that may provide services to the patient and caregiver Recommend resources to the patient and caregiver Refer the patient and caregiver to services Link the patient and caregiver to services Facilitate connection and access Assure connection to wanted services (if needed and agreed upon)
	Linkage and referral may include: Health services (physical and mental health) Community-based services Neighbourhood resources (formal and informal)
	Linkage and referral aim to: Ensure the patient is informed of available services to help achieve care plan goals Assist the patient in seeking needed services Help create a system of support (natural helping network)
Coordinate services and support interactions between patient, caregiver, family and providers	Directly assist in coordinating services between the patient and providers ○ Support scheduling (set up appointments and visits) ○ Assist with transportation ○ Assist in brokering services, obtaining services ○ Ensure resources are in place and engaged (ongoing care) ○ Ensure follow-up with providers Coordinate actions of all professionals involved in implementing the patient's care plan Help to navigate the health system Assist during medical visits (clinic or home visits) and appointments with other providers ○ Facilitate interaction and communication ○ Support patient in presenting concerns and needs ○ Provide emotional support ○ Advocate for patient ○ Assist with paperwork ○ Model appropriate behaviors
Cross-cutting activities that support and enhance other activity	Description
Build a relationship with the patient, caregiver, and professionals	Develop a relational connection based on: ○ Trust ○ Collaborative working ○ Creating a safe and empowering environment ○ Empathy ○ Positive interpersonal interactions ○ Active listening
Participate in professional supervision and continuous education	Participate in a supervision meeting ○ In group or individually ○ Regularly (weekly or bi-weekly) Undertake training and continuous education ○ Specific training, co-development, professional updating (as needed)
	This activity aims to: Support professional development Support quality of care coordination (improvement of care) Help and support implementation of the program

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Social workers coordination in primary healthcare for patients with complex needs: A scoping review

Abstract

Introduction

Methods

Results

Discussion

Keywords

Introduction

Methods

Results

Complex target patient populations

Organizational context of the care coordination

Care coordination activities

Activities that target the patient, family, and caregivers

Activities that target health and social care professionals and services

Activities that link the patient and family with health and social care professionals and services

Cross-cutting activities that support and enhance other activity

Discussion

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

References