Key factors in patient-centered care coordination in ambulatory care: Nurse care coordinators' perspectives

Background: Care coordination within Health Care Homes (HCHs) is an evolving registered nurse role. The purpose of this study was to identify factors influencing nurse care coordination. Aims: The aims are to 1) describe the characteristics of patients perceived by nurse care coordinators (NCCs) to benefit from care coordination and to 2) describe interventions judged by NCCs to be most effective in caring for patients with complex chronic care needs. Methods: This study was an analysis of existing data using a qualitative descriptive design. Experienced NCCs from various practice settings participated in a focus group. Data were analyzed using content analysis. Results: Findings indicate the importance of the cumulative impact of complex health problems, limited social support, culture and language on patients needing care coordination. Effective interventions are focused on providing holistic, relationship-based care. Conclusion: The identification of contextual factors juxtaposed to complex chronic health conditions holds promise as a powerful indicator of individuals needing targeted, individualized interventions.