Outcomes of Home and Community-Based Care Coordination Programs: A Review of Interventions, Measures, and Impacts

Background: Care coordination is essential for managing complex needs and serves as a key element of integrated care for older adults who receive health and community care services. However, despite growing reliance on home-based care coordination models, there remains limited consensus on how care coordination outcomes are defined and measured. This review synthesized outcomes of care coordination that have been defined and measured in quantitative studies.

 

Approach: We conducted a rapid realist-informed review to examine how home and community-based care coordination programs influence patient, provider, and system outcomes. A systematic search of EMBASE, MEDLINE, CINAHL, and AgeLine was conducted in 2024. Empirical, peer-reviewed studies published between 2000 and 2024 were identified and screened for relevance to care coordination in home care settings.

 

Data extraction was completed by the research team, and synthesis was advanced collaboratively through two team workshops. This secondary analysis categorized reported outcomes at the patient, provider, organizational, and system levels, summarizing the measures used and key findings across studies.

 

Results: Thirty-three studies were included, with most focused on older adults with chronic or complex conditions. Twenty-two of the studies were conducted in the United States. The interventions reported included telehealth or remote monitoring, nurse-led models, home-based primary care, disease management programs, and interprofessional interventions. Outcomes were assessed across different domains, with healthcare utilization and patient health and well-being most commonly measured.

Healthcare utilization measurement subdomains include hospitalization/admission, prim

ary care visits, clinic visits, and emergency department (ED) visits. Hospitalization was the most frequently reported outcome (11 studies), with most studies showing reductions in hospitalization. Seven studies reported on ED visits, and three of these reported increased ED visits. Physical functioning (7 studies), mental well-being (4 studies), and cognitive functioning (4 studies) with mostly positive and some mixed results reported. Mortality was assessed in a few (five) studies, with evidence of reductions in some cases. Economic outcomes (one study) and patient satisfaction (three studies) were rarely reported.

 

Implications: Care coordination interventions in home care have been shown to reduce hospitalizations and improve health outcomes. However, only a few studies reported important dimensions such as economic impact and patient satisfaction. This review highlights the wide range of outcomes used to evaluate the impact of care coordination interventions implemented in home care and community settings. However, there is a need for standardized evaluation frameworks to enhance the evaluation of care coordination and contribute to the broader goal of achieving integrated, person-centered care.