Barriers to Care Coordination.

Care coordination is the deliberate organisation of patient care activities between two or more health care workers and other people involved in patient care (Mateo-Abad et al., 2020). Effective care coordination is made possible when there is teamwork and an open dialogue between clinical staff, allied health workers and families.  Coordination of care in nursing homes is centered around the creation of individualised care plans, with input from health care workers and families.  The policy in most care homes is that all care plans must be reviewed yearly and whenever there is a sudden unexpected change in resident’s functional status. The role of a Nurse in the resident’s journey through the health care system is to make sure that there are no gaps in access to care. It involves assessing the immediate and long-term care needs of the resident.

       The first major barrier to coordinating care is staffing issues, brought on, partly due to high staff turnover. This affects the general quality of care, as more time and money are spent on training new carers. This in turn reduces the response time to the care needs of residents and affects the continuity of care. (Amjad et al., 2016), found that low continuity of care was associated with higher rates of hospitalisation and emergency department visits, the study further found that the quality of care among dementia patients is often reactive  (O’Neill et al., 2017).  Care homes do not have staffing ratios and the number of nurses to resident ratio is dependant on the time of day and the acuity of residents. It is not unusual to find one RN in charge of 50 residents. Having the same staff in charge of residents care means that changes to the resident’s condition can be assessed early and interventions can be put in place (Marshall et al., 2016).

        Another major barrier to care coordination is poor communication between clinical staff and families. This is especially the case when the resident lacks the ability to communicate or advocate for themselves as is seen in individuals with dementia or aphasia (Brighton & Bristowe, 2016).  Poor communication between families and health care workers will often lead to poor assessment, planning and implementation of care. Studies indicate that having an open-ended dialogue between clinical staff and families in matters of care, not only improves the quality of life for resident but also reduces hospital transfers (Brighton & Bristowe, 2016). Other studies show that educating assistant nurses on effective ways of communicating with residents, improves care outcomes without increasing care time (Sprangers et al., 2015).

       Poor communication among nursing staff is also a source of frustration among families especially when there is a sharp decline in the functional status of the resident and the family where not informed  (Abrahamson et al., 2016).  Decision to send families to the hospital for treatment are normally done by the primary family representatives. Studies however show that when families are informed of resident’s condition on a regular basis, they are less likely to request for a hospital transfer when the resident suddenly deteriorates (Abrahamson et al., 2016). Most nursing homes have a policy of informing families of any changes to the resident’s care and condition. Another way communication issues can be mitigated is through having regular care conferences to discuss care issues and concerns.  Care conferences are a great way to meet families and find out their care expectations (Jobe et al., 2018).

      Care coordination is intended to provide holistic person-centred care that focuses on addressing the individual needs of each resident, through clear purposeful and open-ended communication between families and health care workers (Jobe et al., 2018). Person centered practice puts the individual at the centre of every decision-making process. Older people with specific communication needs have an increased risk of experiencing functional decline. Identifying communication issues when the elderly individual is admitted to the care facility and responding to these issues would improve the quality of life. Individuals that come from ethnically diverse minorities, face the added pressure of accessing care that is culturally and linguistically responsive.  Improvement in communication can be made by simplifying sentences and if they are unable to use speech, work with the resident and their family and carers to use an alternative form of communication (Horton et al., 2016).


Abrahamson, K., Bernard, B., Magnabosco, L., Nazir, A., & Unroe, K. T. (2016). The experiences of family members in the nursing home to hospital transfer decision. BMC Geriatrics, 16(1), 184. https://doi.org/10.1186/s12877-016-0359-2

Amjad, H., Carmichael, D., Austin, A. M., Chang, C.-H., & Bynum, J. P. (2016). Continuity of Care and Healthcare Utilization in Older Adults with Dementia in Fee-for-Service Medicare. JAMA Internal Medicine, 176(9), 1371–1378. https://doi.org/10.1001/jamainternmed.2016.3553

Brighton, L. J., & Bristowe, K. (2016). Communication in palliative care: Talking about the end of life, before the end of life. Postgraduate Medical Journal, 92(1090), 466. https://doi.org/10.1136/postgradmedj-2015-133368

Cashin, A., Heartfield, M., Bryce, J., Devey, L., Buckley, T., Cox, D., Kerdo, E., Kelly, J., Thoms, D., & Fisher, M. (2017). Standards for practice for registered nurses in Australia. Collegian, 24(3), 255–266. https://doi.org/10.1016/j.colegn.2016.03.002

Horton, S., Lane, K., & Shiggins, C. (2016). Supporting communication for people with aphasia in stroke rehabilitation: Transfer of training in a multidisciplinary stroke team. Aphasiology, 30(5), 629–656. https://doi.org/10.1080/02687038.2014.1000819

Jobe, I., Lindberg, B., Nordmark, S., & Engström, Å. (2018). The care‐planning conference: Exploring aspects of person‐centred interactions. Nursing Open, 5(2), 120–130. https://doi.org/10.1002/nop2.118

Marshall, E. G., Clarke, B., Burge, F., Varatharasan, N., Archibald, G., & Andrew, M. K. (2016). Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents. The Journal of the American Board of Family Medicine, 29(2), 201–208. https://doi.org/10.3122/jabfm.2016.12.150309

Mateo-Abad, M., González, N., Fullaondo, A., Merino, M., Azkargorta, L., Giné, A., Verdoy, D., Vergara, I., & de Manuel Keenoy, E. (2020). Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-05473-2

O’Neill, B. J., Reid-Searl, K., Dwyer, T., & Parkinson, L. (2017). The deteriorating resident in residential aged care: A focus group study. Collegian, 24(6), 563–570. https://doi.org/10.1016/j.colegn.2016.10.010

Sprangers, S., Dijkstra, K., & Romijn-Luijten, A. (2015). Communication skills training in a nursing home: Effects of a brief intervention on residents and nursing aides. Clinical Interventions in Aging, 10, 311–319. https://doi.org/10.2147/CIA.S73053

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