A Novel Use of Social Network Analysis and Routinely Collected Data to Uncover Care Coordination Processes for Patients with Heart Failure

Effective patient care transitions require consideration of the patient’s social and clinical contexts, yet how these factors relate to the processes in care coordination remains poorly described. This dissertation aimed to describe provider networks and clinical care and social contexts involved during longitudinal care transitions across settings. The overall purpose of this dissertation is to uncover the longitudinal patterns of utilization and relational processes needed for effective care coordination in transitional care, so we can redesign interventions that focus on informational and relationship networks to improve interaction patterns and system performance for people living with heart failure (HF) as they undergo transitions across settings and over time. This dissertation was a retrospective exploratory study. Chapter 2 is an integrative review examining coordination processes in transitional care interventions for older adults with HF by integrating a social network analysis framework. We subsequently selected a cohort of patients aged 18 years or older (n = 1269) with an initial hospitalization for HF at Duke University Health System between January 1, 2016 and December 31, 2018 based on encounter, sociodemographic, and clinical data extracted from electronic health records (EHR). In Chapter 3, a latent growth trajectory analysis was used to identify distinct subgroups of patients based on the frequency of outpatient, as well as emergency department (ED) and inpatient encounters 1 year before and 1 year after the index hospitalization; multinomial logistic regression was then used to evaluate how outpatient utilization was related to acute care utilization. Based on findings (described in Chapter 3), we purposively sampled 11 patients from the Chapter 3 cohort for a second empirical study (described in Chapter 4) with a mixed-methods sequential explanatory design. These 11 patients had a full spectrum of experience in socioeconomic disadvantages based on three strata (race, insurance, and Area Deprivation Index), but they had similar levels of comorbidity and average severity of illness and displayed the same change in the severity of illness during the study period. We used quantitative and qualitative data available from clinical notes in the EHR, and integrated results from quantitative and qualitative analysis to better understand the social and clinical context and social structure essential for care coordination. High variability in transitional care is likely because care coordination processes are highly relational. The relational structure of transitional care interventions varied from triadic to complex network structures. Use of a network analysis framework helped to uncover relational structures and processes underlying transitional care to inform intervention development. Chapter 3 revealed that high heterogeneity exists in patients’ utilization patterns. A small subgroup of high users utilized a substantial amount of the resources. Patients with high outpatient utilization had more than 4 times the likelihood of also having high acute care utilization, and change in the severity of illness had the highest level of significance and strongest magnitude of effect on influencing high acute care utilization. Chapter 4 demonstrated the feasibility of using clinical notes and social network analysis (SNA) to assess the provider networks for patients with HF in care transitions. People who were experiencing more socioeconomic disadvantages and social instability were less likely to have densely connected provider teams and providers who were central and influential in the system network. Lacking consistent and reciprocal relationships with outpatient provider teams, especially primary care provider and cardiology teams, was precedent to poor care management and coordination. Turbulence in care transition can result from sources other than transitioning between settings. This dissertation demonstrated the (a) importance of understanding relational processes and structure during patients’ utilization of acute and outpatient care services and (b) potential to capture structural inequalities that may influence the efficiency of care coordination and health outcomes for patients with HF.