New RISE evidence syntheses on care coordination and system navigation

RISE recently finalized two rapid syntheses, the first of which focuses on care coordination in the home- and community-care sector, while the second examines what is known about system navigation.

The rapid synthesis on care coordination found that coordination strategies using multidisciplinary teams and disease-management programs consistently reported improved outcomes across populations. We did not identify an optimal population size for care coordination nor were we able determine what demographic is most likely to benefit from care-coordination interventions. We identified 12 components from care coordination frameworks that should be considered when designing care-coordination approaches, as well as additional supports that are needed, including those for designing and adapting care-coordination strategies (e.g., data reviews, workflow maps and role-planning matrices), implementing care coordination strategies (e.g., templates and checklists for providers and local service directories), and the technological supports that can underpin coordination (e.g., EMRs, medical record alert systems, email and messaging services).

The second rapid synthesis on system navigation did not find a consensus in the literature for the definition of system navigation, but did find that it differed from other concepts through a unique focus on reducing barriers to care and may be included as a component of care coordination. We found that system-navigation efforts focused on populations for whom care is already complex (e.g., those who see multiple specialists) or who are at rising levels of risk. Navigation services were frequently provided by staff within primary care or community care organizations by a range of providers and often included providing patients with resources and guidance, identifying service needs, identifying barriers to care, facilitating communication between providers, confirming eligibility, and tracking progress on care plans. Finally, we identified structures (e.g., ensuring the right legislation is in place, clearly defining roles and responsibilities, and providing dedicated funds) and processes (e.g., gathering evidence on the benefits of the innovation, undertaking a baseline assessment to understand the context for implementation, and communicating a why that frames the innovation) that could support the scale up of approaches to system navigation.