An overview of care coordination elements for older adults with long-term care needs: A narrative review

Care coordination is crucial in long-term care (LTC) as it contributes to patient-centered, high-value, and high-quality care. This review presents an overview of how care coordination for older adults with long-term needs is described in the literature.

This narrative review focused on older adults receiving LTC in institutional settings and the community. A comprehensive and structured search was conducted in PubMed in January 2025 using a combination of key and indexed terms related to care coordination, long-term care, and older adults.

We retained 56 articles published between 1988 and 2024. Most of the information was from North American programs designed for community-dwelling older persons. Description of care coordination is lacking in middle and low-income countries, with limited information on institutional settings. Coordination is commonly performed by a designated health or social worker, responsible for assessing, developing, and monitoring the care plan with the support of a multidisciplinary team (not always including a geriatrician) and electronic health records. Care coordination can be challenging to translate into practice, mainly due to limited time availability and a lack of specific training. Communication across care settings and among the staff is frequently fragmented, partial, and unstandardized.

Care systems for older persons living in the community seem to apply fundamental elements of care coordination. However, their implementation in real life is challenging. The current information on care coordination is not well-documented at the global level, especially in LTC facilities, highlighting the need for more attention to this aspect of care.