Hidden Structure of Care Coordination in Heart Failure Care Transitions: A Mixed-Method Network Analysis of Clinical...

Patients with heart failure, especially those with lower socioeconomic position, are vulnerable to adverse outcomes of care fragmentation. Care coordination mitigates care fragmentation; however, a comprehensive assessment of relationships among all relevant clinicians that enable it is lacking. This explanatory sequential mixed-methods study explores how patients' clinician network characteristics relate to their social context and clinical outcomes following heart failure care transitions.

We conducted a bipartite social network analysis to describe clinician networks for 1269 patients first hospitalized with heart failure in a southeastern US health system. Networks were constructed using electronic health record notes 1 year before, during, and 1 year after the index hospitalization (January 2015-February 2020). We then used stratified purposive sampling to select 11 adults with diverse socioeconomic positions but similar illness severity and comorbidity. For these patients, we conducted qualitative chart reviews of their clinical notes. Each patient's clinician network size, density, and centrality were integrated with qualitative findings to explore clinician networks' relationship to patients' social context and outcomes.

Patients with higher socioeconomic positions used fewer acute care services and lived longer. Their clinicians, particularly outpatient clinicians, tended to have denser and more centrally located team networks before the index hospitalization that persisted after the index hospitalization. Their telephone notes indicated more regular and reciprocal communication patterns between patients and clinicians.

Early involvement and better communication among clinician networks with greater density and centrality may help to explain better care transition outcomes observed among patients with higher socioeconomic positions.