The need for better care integration emerged from this scoping review. Integration has been described on a continuum (i.e. some components of the care system are better integrated than others), but was not always well-defined in the literature (Jackson et al., 2012). Common elements of integration included: comprehensive services across the care continuum, patient focus, geographic coverage, standardised care delivery through interprofessional teams, performance management, information systems, organisational culture and leadership, physician integration, governance structure and financial government. According to Jackson et al. (2012) four key change strategies were central to integration: providing people-centred care, reducing clinical variance, organising the care continuum, and process improvement. Factors affecting coordination,
patient navigators, and dividing time over different practices (Ferrante et al., 2010).
When examining health and social care delivery, it is essential to take the environment (in which patients seek and receive care) into consideration. From the challenges that came with navigation, the elements of integration as well as the rest of this scoping review it became clear that person-centred care was invaluable for patients. Involvement and partnership in care were key assumptions underlying the concept of person-centred care (also see Chapter One, section 1.1.3). However, based on Ravenscroft’s (2010) findings, participation seemed to be the result of active efforts from the patient and not the result of the system supporting patients in this idea of person-centred care. 3.3.3 Technological support for care navigation
The care system showed several commonalities with other public services. In business terms, service design (and delivery) is believed to have an impact on how services are perceived, experienced and even adopted. People with LTCs could be seen as consumers or users of care services. Service design of a hospital should not start at the point the patient enters the hospital, but at the point at which someone starts to feel unwell. As with other services, customer experience is at the core of care service design because of its direct impact on customer satisfaction. Experience-centric services (such as health care) need to enable the individual to connect with the service in a customised, personal, meaningful and memorable way (Bhandari and Snowdon, 2012).
The focus of several projects on patient navigation in this scoping review was on patient empowerment and patient assessment information. A few recent studies explored opportunities of technology to share, for example, up-to-date information (Manderson et al., 2012). Having an electronic tool to support
patients in the task of navigation, might indeed decrease the pressure on primary care. Although the numbers of digital use are increasing, they still tend to be lower amongst the current older-old (85 years and over) (Brossoie et al., 2010; Orlov, 2016). However, the baby boomer’s generation already show higher adoption rates (Brossoie et al., 2010; Green and Rossall, 2013). Looking at this more technological side and how this might support navigation, the design and accessibility of user interface was found to be a critical element. Regarding the adoption of technology in health care, most research has focused on the implementation and adoption of health information technology (Bhandari and Snowdon, 2012). Although these were important factors, evaluating the acceptance or rejection of technology applications by end-users would be critical. Without acceptance, adoption cannot take place. An experience-centric service design was expected to have positive impact on the user's acceptance and adoption of technology (Bhandari and Snowdon, 2012).
3.4 Conclusion
As the size of the older population increases and people are living longer, the demand for information on how to navigate and cope with issues faced in later life, is expected to increase even further (Brossoie et al., 2010). The idea of using care navigators to help patients with these aspects was initially introduced in the cancer setting (Huber et al., 2014; Willis et al., 2016). Efforts to address navigation challenges have been successfully implemented in other settings and care managers exist for specific diseases. Care navigation programmes have been shown to enhance patients care journeys, improve their satisfaction and potentially reduce costs in the long term (Albert, 2012).
Care navigation is now gaining traction in health systems, community-based health initiatives and primary care practices. Clinically skilled care navigators
provide a bridge between appointments with physicians. They try to meet patients' care needs and help them keep on track (Albert, 2012). Limited research is available on the use of care navigators in the primary care setting (Ferrante et al., 2010). The primary care setting is a unique environment in which a variety of health and social care issues form the reasons for encounter. With the changing population, the different care needs this brings along as well as evolutions in the care system (increase in specialisation), the role of care navigators in primary care tends to be challenging (Ferrante et al., 2010).
Projects have focused on ICT to help clinicians in the tracking and monitoring of patients. Less effort has gone to actually help patients navigate their care pathway (Ferrante et al., 2010); nonetheless ineffective navigation was reported to lead to poor outcomes and inefficiencies (Ferrante et al., 2010). Providing this support to patients, the tools to enable them to play an active role in their care plan, is fundamental to person-centred care (see Chapter One).
In his paper, Albert (2012) pointed out five elements that can help a system to change the care delivery process within the context of using care navigators. He detailed how one should determine areas of risk, identify a target population, find the right staff to support the model, outline protocols and expand the scale of the programme. Patients with multimorbidity are known to have multiple providers involved in their health and social care, all of which seem limited connected with each other (Jackson et al, 2012; Ravenscroft, 2010). The complexity of the care system and thus finding their way through these separate parts of the system (Ravenscroft, 2010) is a current problem for patients with multimorbidity.
To address these current gaps, three objectives were identified for this thesis (see sections 1.2.3.1 and 2.4.3). This chapter addressed the first objective of the thesis by synthesising the literature on care navigation among older people with multimorbidity from a patient perspective. Although the scoping review revealed
the types of support these patients need, it remains unknown in which way this should be delivered. Vague ideas on roles and tasks regarding care navigators exist, but it is unclear what patients prefer. In other words, the use of patient navigators or other support in navigating the care system has not been fully explored in the context of multimorbidity. Most research focussed on particular points on the care continuum (e.g. transition from hospital to home), specific conditions (e.g. COPD) and/or significant events (e.g. post stroke). The way in which the role of care navigators was fulfilled appeared to differ according to the goals of the study, the type and severity of the condition (Manderson et al., 2012). Implementing this role of care navigators in the primary care setting was challenging (Ferrante et al., 2010). Most positions and roles further seemed to be part of a larger (multidisciplinary) team (Manderson et al., 2012).
These difficulties, that might be peculiar to the setting of multimorbidity or primary care, fostered the idea to explore other options (i.e. ICT in this thesis). For example, whether ICT could support individuals in the task of navigating their way through a care system (i.e. a GPS for the care system). Such a ‘tool’ could be argued to be essential given that the care system is (and has been) characterised by dynamic changes that can occur quickly and often with little consultation (e.g., see Timmins 2012). Thus, the need for navigation is frequent, with some elements being dealt with in an automatic manner (e.g., prescription). Coleman (2003) identified technology as a route to, on the one hand capture such dynamic and rapid changes and on the other hand cope with parts that could be automated. As such, technology could be one way to mitigate the ongoing health and social care ‘churn’. However, implementing ICT systems to support care is also seen as costly and a balance between information needs and protection of privacy is required (Coleman, 2003).
for this group involves. All of these are conditions that need to be fulfilled and thus known before one can think about how to ‘support’ these patients. These elements are addressed in the second (analyse and visualise the structures of and interactions in the PCN of older people with multimorbidity and gain an understanding of their experience of navigating their PCNs) and third objective (identify elements for improvement in care navigation among older people with multimorbidity and deliver design requirements for the development of an ICT tool to support this population in their navigation through the care network) in Chapters Four and Five.