Sharing Info: One of the Biggest Care Coordination Challenges

Community care coordination is rarely, if ever, simple. As a coordinator or case manager, you know how much work goes into ensuring that at-home patients receive the care they need.

Communicating effectively with patients. Working through confusion between care professionals about areas of responsibility. Encouraging timely responses from practitioners. These are just a few of the many major challenges you deal with on a regular basis.

Of course, the fact that resources are limited makes every part of your job more difficult. But there’s one problem that can, to a large extent, be solved without major health care dollars. This challenge is persistent, and it lies at the heart of many day-to-day care coordination difficulties.

We’re talking about sharing health information. Practitioners can only provide reliable, patient-centred services if they have access to the information they need—when they need it.

Unfortunately, when many health professionals are involved in a patient’s care, sharing information gets complicated. Luckily, as a coordinator, you have the opportunity to make this process more efficient.

In this post, we’ll explore some of the coordination challenges associated with sharing information. We’ll also look at potential solutions.

A major obstacle to care coordination

Coordination is a persistent problem in home care, and it’s easy to understand why. In the care plan of any given complex patient, there are sure to be many moving parts.

Comprehending a patient’s medical history, health goals, and care preferences is a major undertaking. Then there’s the responsibility of ensuring this information flows to the right circle of care members in a timely manner. When various agencies, health care practitioners, and relatives are involved, the process is incredibly hard to manage.

If you’re a care coordinator in Ontario, you have your work cut out for you. It’s a time of transition in the province’s home care sector, and new questions are arising. There are bound to be times when it’s unclear who’s responsible for a given task. And sometimes, communication will break down.

To get an idea of how bad the problem is, consider this. Less than one-third of the province’s family physicians say they (or their staff members) routinely communicate with their patients’ community case managers or home care providers.

It goes without saying that you don’t want to be one of those coordinators who isn’t talking to your patients’ doctors. When you aren’t communicating, you aren’t sharing critical information. And the results are rarely pretty.

Inefficient service delivery is all too common. In some cases, home care workers repeat actions that have already been performed by others. Coordinators and health care practitioners spend more time than necessary assessing patients. Worst of all, patient outcomes aren’t what they should be—all because information isn’t passed along to the right care team members in a timely manner.

What makes sharing so hard?

Once a health organization is working with one or more skilled coordinators, care should be delivered 100 per cent smoothly, right? If you’re responsible for care coordination, you know things don’t work that way.

The health care system is complex—home care especially. Practitioners are often separated by geographic distance, which means steps must be taken to communicate a patient’s condition and health developments to relevant care team members.

Of course, information can be stored in image, video, or text formats. But documenting it is just one part of the process. In order to provide high-quality care, team members need a reliable way of sharing information.

Ontario’s care coordinators are making significant strides in this area. If you help develop coordinated care plans, you’ve been instrumental in making patient information more accessible to frontline practitioners. Still, when it comes to improving accessibility, there are a  lot of factors to consider.

At this point, we all know how much digital technology can speed up the transfer of data. It’s part of the reason the province is developing its digital health care infrastructures. But even when these solutions are implemented, barriers to efficiency arise.

Overcoming information-sharing challenges

When it comes to care coordination, not all digital information-sharing solutions are created equal. Here are just a few examples of issues that frequently come up.

Security issues

As a care coordinator, you’re probably enthusiastic about any solution that increases the likelihood that patient updates will be shared. That said, you’re also aware of the need for patient privacy. Important privacy legislation – such as Ontario’s Personal Health Information Protection Act (PHIPA) – can get in the way of quick and effective sharing.

Practitioner resistance

There’s no denying it: many health care practitioners are reluctant to adopt new technologies and processes. Perhaps you’ve found that the care practitioners you’ve worked with aren’t open to changing the way they do things. And in your ownrole as coordinator, it’s possible that your intuition has led to consistently better outcomes than the technology.

Technical or system complexity

When it comes to improving technology and workflow adoption rates, simplicity is crucial. Because in home care, it’s especially difficult to overcome learning curves, since practitioners often have nobody to turn to for help.

These issues (among others) make it difficult for care teams to share information in a way that enables high-quality, responsive care. But organizations can overcome them.

Choosing the right technology is key. Mobile apps are incredibly useful because they’re so convenient. Circle of care members don’t need to learn to use a new piece of hardware to benefit from them. Intuitiveness is also important—features such as touchscreen capability ensure that practitioners and patients alike know how to send and access relevant care information.

It’s also worth noting that there have been impressive security advancements in digital information-sharing platforms in recent years. Those involved in selecting a solution should always look for technology that goes above and beyond compliance of relevant legislation.

The Bottom Line

There’s no doubt that real-time care plan updates are good for care coordinators—not to mention home care practitioners and (ultimately) patients. In addition, supplementary updates in the form of text, visual, or video notifications can fill the gaps in circle of care communication.

Carefully-selected technology can make for quick, convenient, and secure sharing. But there’s one factor that’s even more important to improving care coordination than the specific platform you use. We’re talking about the attitudes of circle of care members.

When unfamiliar processes are introduced, it’s easy for practitioners to forget why they’re being implemented in the first place: to provide patient-centred care. As a coordinator, you’re in a unique position to help them remember.

Feature image courtesy of Michael Havens

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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