Six key elements for effective coordination in home-based care for older adults with cancer in Japan: A qualitative...

As Japan's population ages, home-based care has become increasingly important for older adults with cancer. Many patients experience functional decline, multimorbidity, and psychosocial challenges, making continuity of care across medical and long-term care services essential. However, coordination between hospital-based and community-based providers remains fragmented. This study aimed to explore the perspectives of healthcare and long-term care providers to identify key elements for effective coordination in home-based care for older adults with cancer.

We conducted semi-structured interviews with healthcare and long-term care providers from designated cancer care hospitals, home-visit medical institutions, and long-term care agencies. Institutions were purposively selected based on prior reports or expert recognition of structured coordination practices, and additional participants were recruited through snowball sampling. Interviews were conducted online between September 2024 and January 2025. Transcripts were analyzed using conventional content analysis, and themes were synthesized to capture essential components of coordination.

Seventy-seven participants from 48 institutions were enrolled. Six key elements were identified for effective coordination: (1) system infrastructure, (2) information exchange, (3) communication, (4) timeliness, (5) human resource development, and (6) information dissemination. Institutions with structured referral protocols, designated coordinators, and information and communication technology platforms demonstrated smoother transitions from hospital-based treatment to home-based care. Timely, patient-centered information sharing was emphasized as more important than technology. Beyond medical details, functional status, psychosocial information, and patient goals were considered essential. Real-time, bidirectional communication ensured goal alignment across care settings. Early initiation of coordination-ideally during treatment or even at diagnosis-was considered critical for advanced care planning and symptom management. Cross-training, interprofessional workshops, and multidisciplinary conferences were perceived as effective strategies to increase hospital providers' awareness of community resources, foster mutual understanding, and strengthen workforce capacity. Proactive education and outreach were considered essential to addressing the limited understanding of home-based care systems among patients and caregivers.

Six key elements, including structural, procedural, and educational components, were identified as essential to strengthening transitional and longitudinal care. Effective coordination in home-based care for older adults with cancer requires appropriate tools or systems along with proactive, timely, and multidimensional engagement across medical and long-term care sectors.