Impact of nurse-led care coordination in a regional Australian hospital system: A case study

Thesis Abstract

This study investigates how nurse-led care coordination influences patient outcomes, care continuity, and system efficiency within a regional Australian hospital network, addressing the persistent challenges of fragmented care, delayed discharges, and elevated readmission rates in rural health settings. The aim is to evaluate whether nurse-led care coordination improves patient experiences, reduces length of stay, decreases 30-day readmissions, and enhances interprofessional collaboration and discharge planning. Specific objectives include (1) describing the care coordination model employed by nurse coordinators across three regional sites, (2) quantifying changes in patient outcomes such as hospital length of stay, 30-day unplanned readmissions, and patient satisfaction, (3) exploring nurse coordinators’ roles, workload, and perceived barriers and enablers to effective coordination, (4) examining interprofessional collaboration and discharge planning processes, and (5) identifying contextual factors within the regional system that influence implementation and sustainability. A mixed-methods design is employed, integrating a quasi-experimental component with a longitudinal pre-post analysis and a qualitative interpretive strand. The population comprises admitted adult medical-surgical patients across three regional hospitals within the network over a 24-month period, with a sample target of 1,200 patients for the quantitative phase (600 pre-implementation and 600 post-implementation) and purposive sampling of 24 nurse coordinators, 30 ward managers, and 40 discharge planners for interviews. Data collection instruments include (a) electronic medical record data extraction for outcomes (length of stay, 30-day readmission, discharge disposition), (b) patient experience surveys using a validated instrument (short-form Patient Experience Questionnaire), (c) structured time-and-motion logs to quantify nurse coordinator involvement, and (d) semi-structured interviews guided by a theoretical framework. Validity and reliability are addressed through triangulation, pilot testing of instruments, inter-rater coding checks for interview transcripts, and Cronbach’s alpha assessment for the patient experience scale. Analytical approaches combine quantitative and qualitative methods. Descriptive statistics summarize demographic and clinical characteristics; inferential analyses employ difference-in-differences regression to estimate the impact of the nurse-led coordination on length of stay and 30-day readmissions, controlling for case mix, comorbidity (Charlson index), and site effects. Multilevel modeling accounts for clustering at ward and hospital levels. Patient experience scores are analyzed via generalized estimating equations to handle repeated measures. Time-motion data are analyzed using ANOVA to compare workload allocations pre- and post-implementation. The qualitative component utilizes thematic analysis framed by the Normalization Process Theory to examine implementation, integration into routine practice, and sustainability, with coding verified by intercoder agreement (>0.80). Expected findings anticipate reductions in average length of stay by 0.8–1.5 days and a 12–18% reduction in 30-day unplanned readmissions in post-implementation periods, alongside improvements in patient experience scores and discharge readiness. The qualitative analysis is expected to reveal enhanced interprofessional communication, clearer delineation of responsibilities, and increased confidence among patients and families in care transitions, while also identifying barriers such as staffing variability, technology interoperability, and rural workforce constraints. The study contributes to knowledge by providing robust, context-specific evidence on the effectiveness and mechanisms of nurse-led care coordination in regional health systems, integrating Normalization Process Theory with practical metrics of care transitions and patient-centered outcomes. It informs policy and practice by outlining scalable structural and process changes, including standardized handover protocols, telehealth-enabled liaison functions, and targeted training for nurse coordinators to sustain improvements in continuity of care. The main conclusion posits that nurse-led care coordination, when embedded within a supportive regional system with clear roles, adequate staffing, and interoperable information systems, yields meaningful gains in efficiency and patient-centered outcomes, while highlighting the necessity of ongoing organizational commitment to sustain gains. Recommendations include adopting standardized care coordination pathways across regional hospitals, investing in user-friendly electronic discharge planning tools, fostering interprofessional education to reinforce collaborative practice, and implementing continuous monitoring using the embedded metrics to ensure long-term sustainability. The study also suggests avenues for further research, such as comparative analyses across urban–regional networks and exploration of patient subgroups most benefited by nurse-led coordination.