Coordinated care benefits outpatient home care treatment, study suggests

The Canadian Patient Safety Institute recently conducted a study to better understand the patient experience for individuals who require outpatient home care services. The CPSI, which was established by the federal department, Health Canada, in 2003 works with the government, health organizations and healthcare providers to improve patient safety and quality. For the study, the CPSI use numerous sources to establish and analyze data. These included secondary health databases from multiple territories, audits of 1,200 charts in Manitoba, Quebec and Nova Scotia, interviews with clients with chronic illnesses, among others, as focus groups of home support workers and nursing staff.

What the researchers found, however, was more than just what the patient experience for home care individuals was like. As EHRIntelligence noted in an analysis, some of the most important information provided by the study shed light on the best ways to communicate with stakeholders within a patient’s continuum of care.

The coordinated care model is catching on across all areas of healthcare, including behavioral and mental health, which was one focus of the CPSI study. The advent of new health information technology – from mental health to discharge management software – has helped facilitate dialogue and a greater degree of information sharing between caregivers. As EHRIntelligence put it, the patient experience now extends well beyond the walls of the clinic or hospital.

Based on their results, the CPSI study authors broke down a series of suggestions for three major stakeholders in patient experience: healthcare organizations, policymakers and researchers.

Healthcare organizations

The first tip for organizations specializing in home care was to offer training to unpaid caregivers, whether that be family, friends or volunteers. These non-professionals also need ongoing support in their role, as well as counseling and health assessments.

Second, organizations should find ways to better manage medication for home care patients.

Third, each home care client should have a case manager who can work as the cross-sector authority. This individual should be responsible for maintaining the dialogue between members in a patient’s continuum of care.

EHRIntelligence also noted that a key part of coordinated care is sharing data from EHRs. Electronic reporting and communicating is an efficient way to keep every member of the continuum updated.


For policymakers, the researchers had a number of suggestions that could improve patients’ experiences.

Policymakers could work toward creating standards for home support workers and encouraging interdisciplinary healthcare teams. Furthermore, standardizing mental health EHR for greater accessibility among caregivers would aid information sharing. The same standardization of medication packaging and any outpatient medical equipment would also ease transition and make untrained caregivers’ jobs easier.


Interestingly, the CPSI team also sounded the horn for other researchers to tackle the quality of outpatient experiences. And to help future studies along, the authors spelled out two tasks.

First: “Researchers should develop and pilot a national set of reportable [home care] adverse events with common definitions, forms and processes.”

This would create a standard and vocabulary for the discussion at hand. What troubles are home care patients most frequently running into? How can these effectively be reported and dealt with?

Second: The Canadian team asked that future researchers encourage the use of tools currently available in the country to assess and reduce the risk of adverse events in home care.

Similar tools are available to researchers in the U.S. to analyze the patient experience after discharge. By analyzing the benefits or pushing for greater demonstration of meaningful use of mental health EHR software and coordinated care models, researchers can make their own mark.

According to EHRIntelligence, healthcare workers – whether physicians, nurses, physicians assistants or other designations – have earned their titles through education and training. But there’s no reason for them to be the only ones who have access to patient data.