Communication between office-based primary care providers and nurses working within patients' homes: an analysis of process data from CAPABLE.

Aims and Objectives. To examine themes of communication between office-based primary care providers and nurses working in private residences; to assess which methods of communication elicit fruitful responses to nurses' concerns. Background. Lack of effective communication between home health care nurses and primary care providers contributes to clinical errors, inefficient care delivery and decreased patient safety. Few studies have described best practices related to frequency, methods and reasons for communication between community-based nurses and primary care providers. Design. Secondary analysis of process data from 'Community Aging in Place: Advancing Better Living for Elders (CAPABLE)'. Methods. Independent reviewers analysed nurse documentation of communication (phone calls, letters and client coaching) initiated for 70 patients and analysed 45 letters to primary care providers to identify common concerns and recommendations raised by CAPABLE nurses. Results. Primary care providers responded to 86% of phone calls, 56% of letters and 50% of client coaching efforts. Primary care providers addressed 86% of concerns communicated by phone, 34% of concerns communicated by letter and 41% of client-raised concerns. Nurses' letters addressed five key concerns: medication safety, pain, change in activities of daily living, fall safety and mental health. In letters, CAPABLE nurses recommended 58 interventions: medication change; referral to a specialist; patient education; and further diagnostic evaluation. Conclusions. Effective communication between home-based nurses and primary care providers enhances care coordination and improves outcomes for home-dwelling elders. Various methods of contact show promise for addressing specific communication needs. Relevance to clinical practice. Nurses practicing within patients' homes can improve care coordination by using phone calls to address minor matters and written letters for detailed communication. Future research should explore implementation of Situation, Background, Assessment and Recommendation in home care to promote safe and efficient communication. Nurses should empower patients to address concerns directly with providers through use of devices including health passports.