ArticleAfrican journal of primary health care & family medicine2020
The three-stage assessment to support hospital-home care coordination in Tshwane, South Africa.
Article in African journal of primary health care & family medicine, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers, 1 of them a synthesis that pooled it.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
3 citing papers in PubMed, 1 synthesis or guideline pooled it, 12 citations in OpenAlex.
- Dimensions and components of hospital-at-home care: a systematic review.BMC health services research · 2024Pooled it
- Article
- Perceived quality of primary healthcare post-National Health Insurance pilot implementation.Health SA = SA Gesondheid · 2021Article
Corrections and comments
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Authors and funding
6 authors at 1 institution in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundIn complex health settings, care coordination is required to link patients to appropriate and effective care. Although articulated as system and professional values, coordination and cooperation are often absent within and across levels of service, between facilities and across sectors, with negative consequences for clinical outcomes as well as service load.
aimThis article presents the results of an applied research initiative to facilitate the coordination of patient care.
settingThe study took place at three hospitals in the sub-district 3 public health complex (Tshwane district).
methodUsing a novel capability approach to learning, interdisciplinary, clinician-led teams made weekly coordination-of-care ward rounds to develop patient-centred plans and facilitate care pathways for patients identified as being stuck in the system. Notes taken during three-stage assessments were analysed thematically to gain insight into down referral and discharge.
resultsThe coordination-of-care team assessed 94 patients over a period of six months. Clinical assessments yielded essential details about patients' varied and multimorbid conditions, while personal and contextual assessments highlighted issues that put patients' care needs and possibilities into perspective. The team used the combined assessments to make patient-tailored action plans and apply them by facilitating cooperation through interprofessional and intersectoral networks.
conclusionEffective patient care-coordination involves a set of referral practices and processes that are intentionally organised by clinically led, interprofessional teams. Empowered by richly informed plans, the teams foster cooperation among people, organisations and institutions in networks that extend from and to patients. In so doing, they embed care coordination into the discharge process and make referral to a link-to-care service.
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Registered trials
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