Table 2 Intervention characteristics
Study | What | Why | Who provided | How | Where | When and how much | Tailoring | Modifications | How well (Adherence/fidelity) |
|---|---|---|---|---|---|---|---|---|---|
Eight Guided Care services: - Home-assessment of patients’ needs and goals - Care planning - Proactive monitoring - Care coordination - Transitional care - SM coaching - Caregiver support - Access to community-based services | To combine effective chronic care interventions into a single delivery model for wide adoption within PC | RNs + 2–5 PC physicians trained in Guided Care model | 1:1, telephone (participants), group (caregivers and participants) | PC, home | Duration: 32mos Frequency: Individual care at least monthly; caregiver SM course 10 h over 6wks, monthly support group, ad-hoc calls | Care plan personalized to patient and caregiver preferences, priorities, and intentions | NR | NR | |
Burger 2019 [40] | Health coach facilitated communication with care team and promoted patient engagement to pursue provider-created care plans. Care plan, barriers and facilitators to goals were reviewed with patient, communicated to care team through daily huddles and electronic health record | PC physicians have limited time with patients. Including SM in patient care through health coaches may assist in more effective treatment for chronic conditions | Health coaches: Experienced medical assistants who completed a 16wk training course from local community college | 1:1, telephone | Community health centre, PC clinic | Duration: 6mos Frequency: Variable (Approx. 5–7 total sessions) | NR | NR | NR |
Carnes 2017 [47] | Meetings with SP coordinator and volunteer to develop and execute action plans, including goal setting and referrals to community organizations and services (e.g., exercise, cooking classes) | Commissioned pilot project to improve patient well-being and increase personal self-efficacy to reduce PC resource use | SP coordinators: Trained in social work, employed by a managing third sector organization Volunteers: Trained by coordinator to assist in service delivery and provide patient support | 1:1, in-person | PC centres | Duration: 8mos Frequency: Up to 6 sessions with SP coordinators; unlimited volunteer contacts | Goals developed in collaboration with patient and SP coordinator | NR | 13.9% no contact with services; 69.2% single consultation only |
Health TAPESTRY intervention: - Home visit with trained volunteer pair to collect information on intervention-designed “TAP-app” on goals, daily life activities and general health - Electronic report sent to clinical team - Clinic team reviews reports and connects with interprofessional healthcare team and PC physician - Care plan is collectively generated | Intervention developed to combine core elements of the Chronic Care Model (healthcare organization and leadership, linkage to community resources, client SM, coordination of delivery, clinical decision support and clinical information systems) into a coordinated approach to improve PC delivery and promote optimal aging | Lay-volunteers: Trained in 2 h in-person training session and ongoing online sessions Clinical intake team comprised of various healthcare team members and PC physician at PC clinic | In-person | PC, home | Duration: 6mos Frequency: Initial home visit with f/u ‘as needed’ | Care plan tailored to individuals’ goals and needs | NR | NR | |
Dye 2018 [48] | Health coach provided education on SM skills, coordination of health care services and referrals, links to community resources, medication management, appointment scheduling and treatment reminders, transportation arrangements, and facilitated communication between client, caregiver, service providers and PC. Digital blood pressure, scales or glucose monitor based on client needs, and patient Personal Health Diary for symptom tracking. Diary reviewed on subsequent visits | Evidence suggests gaps in transition to home health care following hospitalization. Following the Chronic Care Model can help patients meet SM needs | RNs linked patients with health coach Health coaches: Community members received 30 h training and must score ≥ 80% on knowledge test | 1:1, in-person, telephone | Home | Duration: 4mos Frequency: Approx/ 3.5 h/wk in mo 1; 3 h/wk in mo 2; 2.5 h/wk in mo 3; 2 h/wk in mo 4 | Tailored to the needs of the client and/or caregivers | NR | NR |
Franse 2018 [49] | Multidimensional health assessment of fall risk, polypharmacy, loneliness and frailty. Shared decision making to develop care plan and referral to care pathways to promote heathy aging, such as falls prevention (exercise, multifactorial programs), polypharmacy (self-monitoring, pharmaceutical care), loneliness (social activities/support), and frailty (medical management, exercise) | Integral, multidisciplinary conceptual model of frailty: physical, social and psychological components Intervention co-designed based on current evidence and stakeholder input via intervention mapping | Care coordinator: Trained assistant supervised by PC physician, social worker, community nurse or geriatric nurse practitioner (depending on site) | 1:1, in-person | Home or senior health centre | Duration: 12mos Frequency: Variable | Tailored to preferences of older adults, results of the short-standardized assessment form, and pathways available | Age was lowered to ≥ 70 in 2 cities Designed to use existing services, when limited/difficult to access new services developed | NR |
IMPaCT intervention consisted of goal setting with PC provider and connecting with a CHW for tailored coaching, social support, advocacy and navigation through 3 phases of action planning, tailored support and connection with long-term support | Intervention had previously been tested in hospitalized patients with positive effects and was then adapted to support outpatients with multiple chronic conditions | CHW from community organizations, underwent mo-long, college-accredited course and mentorship from a senior CHW | 1:1, in-person, telephone, text | Home, community | Duration: 6mos Frequency: At least 1x/wk (mean 38.4 h total) | Activities and resources tailored to patient goal | NR | 82% participants engaged in full 6mos Mean 4.6 action plans/participant created | |
Kangovi 2018 [34] | CHWs developed action plan for goals set with PC physician, provided tailored coaching, social support, advocacy, and navigation to appropriate clinician for health education or clinical care. Long-term supports (e.g., neighbours, family, church, support groups) identified for post-intervention SM. Link Worker connects patient to relevant third-sector groups for f/u | As many clinicians are unable to address social issues, evidence suggests lay CHWs can perform various roles to support and improve chronic disease management | Lay CHWs with at least a high school diploma, undergo behavioural interviews and mo-long training. Supervised by a manager, typically master’s degree in social work, for ongoing support, training and clinical integration | 1:1, in-person | PC | Duration: 6mos Frequency: Monthly | Tailored to each patient care plan, and relevant to each site using a structured approach | NR | 91% completed intervention Mean 5.5 (SD 2.0) action plans per person 60.3% action plans completed |
Kellezi 2019 [41] | SP pathway: - Initial needs assessment with health coach - SM or referral to link worker for connection with relevant third-sector groups - Health coach and link worker regularly check patients’ progress | SP pathway implemented within GP practices to increase SM, improve health and reduce PC usage amongst individuals with chronic illness experiencing loneliness | Initial program referral from PC physician Health coach: Unspecified health professional Link worker: Unspecified community-based worker | 1:1, in-person | NR | Duration: 8wks, Frequency: Initial meeting plus variable f/u based on patient needs | Tailored to patients’ needs | NR | NR |
Loftus 2017 [42] | SP pathway: Home visit conducted to select programs (e.g., social clubs, Men's Shed, counselling, arts, falls prevention, exercises, crocheting, personal development, crafts, befriending, computer courses) | In the UK, all PC physicians are encouraged to consider SP, but many do not. This has the potential to decrease PC workload, but this has not been confirmed | PC physician referred to program SP coordinator: Qualified social worker in community health care | 1:1, in-person | Home, community | Duration: 12wks Frequency: 1 home visit; frequency of programs variable | NR | NR | Mean 92 days from referral to starting SP activity 59% of patients did not join any programs |
Loskutova 2016 [43] | PNs assessed patients’ needs, barriers, limitations, and stage of readiness to change with diabetes management, and offered support and encouragement to link to 2–3 appropriate community programs. Follow-up letters and reminders were used to encourage participation and monthly feedback reports were provided to PC and community programs | Evidence indicates that PN can improve health outcomes. Many of the services needed for diabetes care can be provided by community organizations and navigation could be provided by non-health workers via telephone | Referral from PC physician 2 × 0.5 FTE lay PNs: non-health professional community members familiar with local resources, backgrounds in community programming or research, underwent 2 × 1.5 h online training sessions | 1:1, telephone, email, mail | Home, community | Duration: Variable (mean 120.4 ± 50.5 days, range 1–260) Frequency: Variable (mean 6.1 calls/patient, range 2–15) | NR | 69.1% of calls successful 7.8% of patients never reached | Project manager participated in ongoing review and feedback sessions |
Mayhew 2009 [44] | Integrated Care Coordination Service provides initial home assessment, ongoing follow-up, and coordination health and social care (e.g., home assistance, living arrangements, financial advice, referrals to health and social care provider in public, private, volunteer sector) based on identified needs | Many hospital admissions could be prevented by early treatment of social factors. This initiative aims to reduce costs through prevention | PC physicians, family/friend, or self-referral Lay care coordinator (not described) | 1:1, in-person | Home | Duration: 3mos Frequency: Initial in-home visit, unspecified number of f/u contacts | Tailored to patients’ needs | NR | NR |
Mercer 2019 [36] | Link Worker Program - Community links practitioner identifies patients’ needs - Links to local community organizations (e.g., walking groups, finance, welfare, addiction support, socialization) - Support to encourage attendance, if needed - PC staff supported to set up referral systems | Drawing on a theory of community-based PC, patients in deprived areas often have multiple issues not amenable to medical intervention. Community organizations offer many resources but are inaccessible to many. Closer links between PC and community organizations may support better access | PC physicians and nurses refer Community links practitioner: Experienced in community development and working with community organizations | 1:1, in-person, some telephone | PC, home, community | Duration/Frequency: Variable; as many times and when necessary | Flexible and dependent on patient needs, wants and professional judgement | NR | NR |
SP pathway: - Assessment of patients’ non-medical needs - Motivational interviewing - Personalized support - Link to non-medical support and referrals to third sector programs (e.g., finance, housing, employment, physical activity, gardening, social activities, stress management, creative activities) - Re-assessment and exit interview | A biopsychosocial model is needed because of wider determinants of health, integration of care across professionals, and changing needs of populations | PC physicians refer to program PNs: Non-clinicians employed in primary care practices, received targeted training to perform navigation and refer patients to third sector organizations | NR | PC | Duration: NR Frequency: Variable (based on individual needs), approx. 12 | Referred to services based on patients’ needs | NR | 70% lost to f/u or did not engage with SP service after initial assessment | |
Spoorenberg 2018 [37] | Embrace person-centred integrated care service, SM support and prevention including: - Community meetings - Links to local healthcare and welfare organizations (health maintenance, physical and social activity, diet) - Individual support from a case-manager to develop care plan targeting health-related problems | Following the Chronic Care Model and a Population Health Management model (Kaiser Permanente Triangle) to support older adults to age in place through person-centered, integrated, proactive, and preventive support and care | PC physicians refer Elder Care team includes PC physician, nursing home physician and two case managers (nurse and social worker), all take part in intensive training program | 1:1 and group, in-person | Home and community | Duration: 12mos Frequency: NR | Tailored to participants’ risk profile of robust, frail or complex needs | NR | NR |
Taube 2018 [38] | - Assessment of lifestyle, functional and cognitive status, monitoring and evaluation, care coordination and encouragement of social activities - General health system information and specific information to address participants’ needs and psychosocial aspects - Continuity and safety | There is evidence that comprehensive case management can benefit a client’s perception of psychological support in terms of providing reassurance, feelings of security and social support | 2 case managers: RN focused on health, medications, and psychosocial aspects; physical therapist focused on fall prevention and physical functioning | 1:1, in-person, telephone | Home | Duration: 12mos Frequency: At least monthly | Based on patients’ care needs, goals of care | Pilot phase only include RN case manager, PT added | NR |
Tung 2020 [50] | CommunityRx intervention: All participants receive a “HealtheRx” including location, hours, and fees for 2 resources closest to patient’s home - Interventions focused on basic needs, physical and mental wellness, and disease management including smoking cessation, weight loss, and counseling based on an evidence-based algorithm - Contact information for community health information specialist also provided | Most referral interventions rely on costly staff to implement such as case managers or CHWs, which can be difficult to implement within routine clinic workflow. An IT solution may reduce cost and healthcare burden | Nurse in ED or administrative staff in PC refer Community health information specialist available (details not provided) | Electronic | PC, ED | Duration: NR Frequency: One time referral | Resource referrals individually tailored | NR | NR |
Community Connections Program: - Initial strengths assessment including identification of priority needs and development of an action plan, crisis prevention plan, and circle of support - Ongoing f/u provided to problem solve, strengthen supports and coordinate with community services - Nurse care coordinator, patient and support person using “Wraparound” to coordinate the use of comprehensive community-based services | Based on the Chronic Care Model developed in response to widespread inefficiencies of chronic illness care and the need for a multi-faceted, evidence-based model. The Chronic Care Model proposes that effective partnerships between health and community providers are a key element to support patient SM | Nurse care coordinator. Training included strategies for conducting strengths assessments, identifying holistic care needs, and developing care plans to address concerns | 1:1, in-person | Home | Duration: 3mos Frequency: Initial meeting, unspecified ongoing f/u | Plan of care tailored to patients’ needs | NR | NR | |
Wang 2015 [52] | PNs delivered patient-centered education about f/u care, appointment scheduling, assessing needs for specialist referral, identifying challenges to accessing healthcare and aiding to overcome challenges | Evidence of effectiveness of in-person and telephone-based PN in improving access to cancer screening, diagnosis, and treatment in racial/ethnic minority populations. The role of the patient in chronic disease management is not well understood | 3 lay PNs: community members trained by the healthcare team and completed CHW training program | 1:1, primarily telephone, follow-up via letter or home outreach | Home | NR | NR | NR | Only 31% eligible reached by navigator, and 21% scheduled appointment |
Woodall 2018 [46] | SP service: Well-being coordinators assess user needs, offer support, and provide advice on local groups and services (e.g., mental health and counselling, fitness classes, support for physical or emotional difficulties, finance advice and creative groups) | Despite suggestion that SP can reduce burden on PC services, evidence is lacking, and most current programs lack evaluative components or show mixed results | Wellbeing coordinator: Diverse ages, ethnicities, and professional experiences, understood working in marginalized communities | 1:1, mostly telephone but in-person for complex cases | NR | Duration: Mean 10wks (most < 16wks) Frequency: Up to 6 sessions | Involvement of specific services/ programs tailored to participants’ needs | NR | NR |
Zhang 2018 [39] | Older person-centred and integrated health management model, includes SM, individual health management, community health management (e.g., classes to encourage healthy behaviours), and family management | Few studies have investigated and evaluated effective interventions for multiple healthy lifestyle factors, but many have shown promising results | Community health service centre staff, multidisciplinary team | In-person, telephone, individual, group | Hospital or community centre | Duration: 24mos Frequency: Once every 2mos, all participants were visited at 12 and 24mos | Individual interventions based on health assessment and counselling | NR | NR |