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The population of older adults is projected to increase, potentially resulting in more older adults living with chronic illnesses or multimorbidity. Living with chronic illnesses increases the need for coordinated health care services. Older adults want to manage their illnesses themselves, and many are positive about using eHealth for care coordination (CC). CC can help older adults navigate the health care system and improve information sharing.
This study aimed to map the research literature on eHealth used in CC for older adults living at home. This study assessed CC activities, outcomes, and factors influencing the use of eHealth in CC reported by older adults and health care professionals.
We used a scoping review methodology. We searched four databases—MEDLINE, CINAHL, Academic Scoping Premier, and Scopus—from 2009 to 2021 for research articles. We screened 630 records using the inclusion criteria (older adults aged >65 years, primary health care setting, description of an eHealth program or intervention or measure or experiences with the use of eHealth, and inclusion of CC or relevant activities as described in the Care Coordination Atlas). The analysis of the included articles consisted of both a descriptive and thematic analysis.
A total of 16 studies were included in this scoping review. Of these 16 studies, 12 (75%) had a quantitative design, and the samples of the included studies varied in size. The categories of eHealth used for CC among older adults living at home were electronic health records and patient portals, telehealth monitoring solutions, and telephone only. The CC activity communication was evident in all studies (16/16, 100%). The results on patient- and system-level outcomes were mixed; however, most studies (7/16, 44%) reported improved mental and physical health and reduced rehospitalization and hospital admission rates. Observing changes in patients’ health was a facilitator for health care professionals using eHealth in CC. When using eHealth in CC, available support to the patient, personal continuity, and a sense of security and safety were facilitators for older adults. Individual characteristics and lack of experience, confidence, and knowledge were barriers to older adults’ use of eHealth. Health care professionals reported barriers such as increased workload and hampered communication.
We mapped the research literature on eHealth-enabled CC for older adults living at home. We did not map the gray literature as we aimed to map the research literature (peer-reviewed research articles published in academic journals). The study results showed that using eHealth to coordinate care for older adults who live at home is promising. To ensure the successful use of eHealth in CC, we recommend customized eHealth-enabled health care services for older adults, including individualized education and support.
It is estimated that the population of older adults aged >65 years will double between 2010 and 2050, and over half of them are expected to live with multimorbidity [
Health ITs (HITs), electronic health records (EHRs), and patient portals are important tools for CC that enable health care professionals and patients to share, access, and manage information [
Previous research has shown that many older adults want to manage their illnesses themselves [
Peterson et al [
A limited amount of research has focused on eHealth to support CC in older adults [
We followed the Arksey and O’Malley scoping studies framework [
The search was conducted in the MEDLINE, CINAHL, Academic Search Premier, and Scopus databases and included research articles published between 2009 and 2021. The last search was conducted in December 2021 by HMHF in collaboration with a university librarian. Search terms related to CC (
The selected studies were included based on a 2-step iterative process. First, we developed and tested a set of preliminary eligibility criteria, which we used to screen the titles. All authors met to discuss the preliminary eligibility criteria and did some final modifications (
Older adults aged >65 years
Primary health care setting; older adults living in their own home
Describing an eHealth program or measure or intervention or experiences with the use of eHealth
Including care coordination or relevant activities as described in the Care Coordination Atlas
Published after 2009
Reported in English
Peer-reviewed when possible to choose a limitation in the database
Older adults aged <65 years, next of kin, informal caregivers, and studies including different age groups when it was not possible to extract data on those aged >65 years
Older adults living in nursing homes or who were in a hospital
Studies with a primary focus on cost-effectiveness
Books, book chapters, literature reviews, study protocols, conference and poster abstracts and papers, editorials, and discussion papers
The EPPI-Reviewer (version 4; EPPI-Centre) software [
Descriptive data were charted from each article according to the following: authors; country of origin; study population (age group and number of participants); and type of eHealth program, intervention, measure, or experience with eHealth. For the articles that described patient or health care use outcomes, we extracted and charted these results when applicable. Data relevant to CC activities and factors influencing the use of eHealth in CC were also extracted. Data charting was conducted by HMHF with input from AMLH and MS.
We prepared a descriptive summary of the study characteristics (country of origin, methods used, overview of included participants, and year of publication). We were inspired by a thematic analysis to thematically organize and present the study results [
The study selection process is illustrated in
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
Of the 16 included articles, 4 (25%) were from 2 research studies and had the same first authors: Makai et al [
Overview of study designs and participant characteristics (N=16).
Authors, country of origin | Type of study design | Participant characteristics | Perspectives represented in the study |
Sheeran et al [ |
Quantitative pilot study |
55 participants 48 patients with depression 7 health care professionals |
Patients Health care professionals |
Logue and Effken [ |
Quantitative pilot study |
38 patients with chronic illnesses |
Patients |
Gokalp et al [ |
Quantitative pilot study or technical review |
36 patients; frail older adults with at least one chronic disease Service team including health care professionals (number not specified) |
Patients Health care professionals |
Lewis et al [ |
Quantitative observational study |
54 patients; frail older adults with comorbidities such as dementia, cardiovascular disease, hypertension, cerebral vascular disease, or COPDa |
Patients |
De Jong et al [ |
Quantitative observational study |
96 patients with a dementia diagnosis |
Patients Health care professionals |
Makai et al [ |
Quantitative controlled before-and-after study |
682 patients; frail older adults 290 patients in the intervention group 392 patients in the control group |
Patients |
Biese et al [ |
RCTb |
120 patients who were discharged from the EDc; no requirements of chronic condition or diagnosis 39 patients in the intervention group 35 patients in the placebo group 46 patients in the control group |
Patients Health care professionals |
Mavandadi et al [ |
RCT |
1018 patients with depression or anxiety 509 patients in the intervention group 509 patients in the control group |
Patients |
Gurwitz et al [ |
RCT |
3661 patients who were discharged from the hospital (some had no diagnosis or chronic conditions, and others had diabetes, myocardial infarction, heart failure, COPD, cancer, stroke, cerebrovascular disease, or renal disease) 1870 patients in the intervention group 1791 patients in the control group |
Patients |
Gellis et al [ |
RCT |
115 patients with either heart failure or COPD and screened for depression 57 patients in the treatment group 58 patients in the control group |
Patients |
Gellis et al [ |
RCT |
115 patients with either heart failure or COPD and screened for depression 57 patients in the treatment group 58 patients in the control group |
Patients Health care professionals |
Cutrona et al [ |
Mixed methods; descriptive quantitative study and qualitative focus group study |
799 patients who were discharged from the hospital (diagnosis not mentioned in the article) Focus group with 5 physicians |
Patients Health care professionals |
Makai et al [ |
Mixed methods; quantitative study and qualitative individual interviews |
290 patients; frail older adults 23 of these patients and their informal caregivers were included in semistructured individual interviews |
Patients Health care professionals |
Mateo-Abad et al [ |
Mixed methods; quantitative and qualitative study |
200 patients with two or more chronic conditions (at least one of them being COPD, chronic heart failure, or diabetes mellitus) 101 patients in the intervention group 99 patients in the control group 9 qualitative interviews with patients, carers, clinicians, nurses, and managers |
Patients Health care professionals |
Dent and Tutt [ |
Longitudinal qualitative study |
44 IT and health care professionals’ experiences with implementation and integration of an IT-supported care pathway for frail older adults |
Health care professionals |
Freilich et al [ |
Qualitative study |
42 participants 12 patients with multimorbidity (one chronic condition was either heart failure or diabetes mellitus) 3 registered nurses 20 physicians 7 family caregivers |
Patients Health care professionals |
aCOPD: chronic obstructive pulmonary disease.
bRCT: randomized controlled trial.
cED: emergency department.
In total, 44% (7/16) of the studies were conducted in the United States [
Most studies (12/16, 75%) had a quantitative design [
The included patients had a variety of chronic illnesses or multimorbidity, such as heart failure, chronic obstructive pulmonary disease, diabetes, cancer, dementia [
We identified three categories of eHealth in CC for older adults living at home in the included studies: (1) EHRs and patient portals, (2) telehealth monitoring solutions, and (3) telephone only. In the EHRs and patient portals category, electronic journals, personal health portals, and electronic personal health plans were used in CC [
A total of 44% (7/16) of the studies [
In
Overview of Care Coordination Atlas activities in the electronic health records (EHRs) and patient portals category.
Care Coordination Atlas activities | EHRs and patient portals |
Establish accountability or negotiate responsibility |
Patients were responsible for who they wanted to add to their electronic health portal [ Patients had to give permission to begin a record and invite health care professionals to sign up. However, patients themselves did not use the eHealth portal [ |
Communicate |
Health care professionals and patients, or professionals and other health care professionals communicated with the help of electronic messages [ Contact with the patient through telephone or in person [ Health care professionals received automatic digital alerts about relevant patient health information [ |
Facilitate transitions |
Primary care health care professionals received automated alerts when a patient was discharged from the hospital regarding discharge information, new drugs, medication warnings, and notification to schedule a follow-up appointment [ |
Assess needs and goals |
Patients could register care-related goals in the electronic care plan and initiate a change in the plan when a goal was reached [ |
Create a proactive plan of care |
By using and accessing an electronic personal health plan, patients were more involved and responsible for their health [ |
Monitor, follow up, and respond to change |
Health care professionals followed up on clinical information that was registered in the health portal [ |
Support self-management goals |
Patients received education and guidance on managing their chronic illness over the telephone or in the health portal [ |
Link to community resources |
Not evident |
Align resources with patient and population needs |
Health care professionals in primary care experienced an increased workload with the new eHealth model [ |
The category of telehealth monitoring solutions, such as sensor technology and virtual wards, was evident in 44% (7/16) of the studies [
CC activities such as communicating and exchanging information, facilitating transitions, monitoring, following up, and responding to change were evident in all studies (7/7, 100%), as described in
Overview of Care Coordination Atlas activities in the telehealth monitoring solutions category.
Care Coordination Atlas activities | Telehealth monitoring solutions |
Establish accountability or negotiate responsibility |
A telehealth nurse was assigned to be a care manager for the patient and contacted other health care professionals when necessary [ A senior nurse was appointed as the clinical care manager and was responsible for patient care [ Some patients reported not knowing if primary health care professionals or hospital specialists communicated with each other [ |
Communicate |
Education or counseling sessions were conducted over the telephone [ The studies used a variation of home visits, video meetings, or telephone calls to patients or health care professionals [ Patients’ health data were registered in a portal and reviewed by a nurse [ |
Facilitate transitions |
Information about the patient was sent to primary health care when the patient was transferred between specialist and primary health care or needed a change in treatment [ Telehealth nurses contacted and referred patients to primary care health care professionals when they observed changes in patients’ health data [ Different health care professionals were located together, and a care manager followed up with the patient across specialist and primary care [ If a patient was discharged from hospital to home, a community nurse received an alert in an electronic portal and would ensure early discharge of the patient [ |
Assess needs and goals |
A telehealth nurse provided goal setting over the telephone with patients [ |
Create a proactive plan of care |
Not evident |
Monitor, follow up, and respond to change |
Health care professionals monitored and assessed patient health data that were registered in an eHealth portal [ Some patients felt secure knowing that a nurse kept track of their health parameters and would contact them if changes were observed [ |
Support self-management goals |
Patients received education or counseling sessions over the telephone or via an eHealth portal [ Patients could ask questions or discuss a problem with a telehealth nurse when needed [ |
Link to community resources |
Not evident |
Align resources with patient and population needs |
A virtual ward model with telehealth monitoring was set up with existing resources [ |
A total of 12% (2/16) of the studies belonged to the third category, telephone only [
Establish accountability or negotiate responsibility: not evident
Communicate: health care professionals contacted patients over the telephone [
Facilitate transitions: a nurse telephoned patients 3 days after discharge from hospitals and helped patients who needed it navigate the health care system by reviewing discharge instructions and making appointments with or referrals to physicians [
Assess needs and goals: not evident
Create a proactive plan of care: not evident
Monitor, follow up, and respond to change: health professionals monitored response to treatment and facilitated treatment over the telephone with patients [
Support self-management goals: a study nurse conducted symptom monitoring, education, and problem-focused therapy with patients over the telephone [
Link to community resources: not evident
Align resources with patient and population needs: not evident
Overall, 56% (9/16) of the studies measured the effect on patient- or system-level outcomes when implementing, piloting, or testing an eHealth solution [
The patient- and system-level outcomes were mixed. Of the 9 studies, 7 (78%) showed improved physical or mental health [
Overview of interventions and identified patient-level and system-level outcomes.
Intervention description | Patient-level outcomes | System-level outcomes |
Mateo-Abad et al [ |
Health data levels (BMI, blood pressure, blood glucose, and oxygen saturation) were significantly reduced in the intervention group compared with the control group [ |
There were lower hospitalization rate and increased appointments with general practitioners and nurses in the intervention group compared with the control group [ |
Makai et al [ |
The researchers observed no differences in physical or mental health between the intervention and control groups [ |
N/Ab |
The study by Gurwitz et al [ |
N/A | The study did not demonstrate an increase in follow-up visits with primary care health care professionals or a reduction in rehospitalization [ |
The quantitative pilot study by Sheeran et al [ |
19 older adults had severe depression after the intervention, and 16 of them reported a mild depression score after the intervention [ |
N/A |
Gellis et al [ |
Patients in the intervention group showed a greater increase in general health and social functioning than patients in the control group after 3 months [ |
The control group in their RCT study had significantly more visits to the EDd than the intervention group after 3 months [ |
Gellis et al [ |
Results showed that the intervention group had greater problem-solving abilities, and their depression symptom scores improved significantly compared with those of the control group at the 3-month survey [ |
N/A |
Lewis et al [ |
N/A | The study demonstrated a reduction in ED visits and unplanned hospital admissions [ |
Mavandadi et al [ |
The older adults in the intervention group reported greater improvement in overall mental health functioning and reduced anxiety and depressive symptoms compared with those in the control group [ |
N/A |
Biese et al [ |
N/A | The older adults in the intervention group were more likely to see a physician within 5 days compared with the control and placebo groups [ |
aEHR: electronic health record.
bN/A: not applicable.
cRCT: randomized controlled trial.
dED: emergency department.
In the analysis of the articles, we identified two factors—facilitators and barriers—describing the use of eHealth in CC. A total of 8 facilitators and barriers were identified (see the overview in
Available support to the patient
Relation continuity between the older adult and health care professional
A sense of security and safety
New and valuable way to observe changes in patients’ health
Individual characteristics
Lack of experience, knowledge, or confidence regarding how to use eHealth
Increased workload
Hampered communication because of limited access to the electronic health records or patient portals
Available support to the patient was an important facilitator for older adults’ use and management of eHealth technology [
Relational continuity between the older adult and health care professional was important to facilitate the older adult’s use of eHealth. In total, 12% (2/16) of the studies [
The use of eHealth in CC among older adults was also facilitated when they felt a sense of security and safety. A total of 19% (3/16) of the studies [
Health care professionals’ use of eHealth to coordinate care was facilitated when it was experienced as a new and valuable way of observing changes in patients’ health [
Individual characteristics such as being an older adult and having health problems such as hearing impairment and memory loss were barriers to the use of eHealth [
The use of eHealth by older adults was also limited by a lack of experience, confidence, and knowledge of how to use it [
Increased workloads limited health care professionals’ use of eHealth. Some health care professionals experienced a heavier workload when implementing a new eHealth tool such as a patient portal [
eHealth used for CC communication was hampered by limited access to the EHRs and patient portals for the health care professionals. De Jong et al [
This review mapped the research literature on eHealth in CC for older adults living at home. We included 16 articles in the scoping review and identified three categories of eHealth: EHRs and patient portals, telehealth monitoring solutions, and telephone only. Communication was the CC activity reported in all the articles (16/16, 100%). Patient- and system-level outcomes were mixed. Most studies (7/16, 44%) showed that improved mental and physical health, reduced rehospitalization and hospital admissions, available support to the patient, relational continuity with health care professionals, and a sense of security were facilitators of older adults’ use of eHealth in CC. Having new and useful tools for observing a change in patients’ health facilitated health care professionals’ use of eHealth in CC. Individual characteristics and lack of experience, confidence, and knowledge were barriers to older adults’ use of eHealth in CC. Barriers reported by health care professionals were increased workload and hampered communication because of limited access to the EHRs and patient portals.
We identified 3 eHealth categories when coordinating care for older adults. Despite the fast development of eHealth and technology, our results indicate that the telephone should still be considered necessary for older adults. A total of 12% (2/16) of the articles were classified under the category of telephone only [
Our results showed that communication was the dominant CC activity in all 3 eHealth types, a finding supported by other studies using the Care Coordination Atlas as a framework [
A CC activity that appeared often was establishing accountability or negotiating responsibility [
In total, 56% (9/16) of the studies measured the effect of the eHealth interventions. Some of the studies focusing on patient outcomes (5/6, 83%) showed greater social functioning and improved mental and physical health [
We identified that older adults’ characteristics, such as being very old and having health problems and memory loss, were barriers to eHealth use. Anderson and Perrin [
The digital divide can be explained in relation to eHealth literacy [
A barrier that health care professionals reported was increased workloads and having new work tasks assigned related to the use of eHealth in CC. Gill et al [
The lack of interoperability across health systems hampers information exchange and communication when using eHealth in CC [
Our results showed that CC activities, including identifying community resources, establishing accountability, and negotiating responsibility, have a future potential for inclusion in eHealth research and practices. We recommend that community resources such as volunteer work, food delivery services, and support groups [
To narrow the digital divide and take into account the variety of older adults’ individual characteristics, future researchers, practices, and policy makers need to consider using the telephone or in-person visits as a supplement or backup when conducting virtual visits or telehealth monitoring in CC. To meet the individual needs of older adults, customized support to the patient and education can be helpful to the successful use of eHealth in CC. Knowledge, confidence, and support are needed to ensure patient involvement when using eHealth to coordinate care. Therefore, future practice should have health care professionals with dedicated responsibility and time to individually follow up on older adults. This can ensure sufficient allocation of resources in CC when using and introducing eHealth. As previously mentioned, interoperability is still an issue. Policy makers and practices should continuously focus on ensuring access for all health care professionals to common CC eHealth solutions such as EHRs or patient portals.
In this scoping review, several limitations need to be addressed. First, we did not critically appraise the included studies as scoping reviews are flexible in their methodology [
Second, we searched 4 databases and used several search terms relevant to CC, eHealth, home care, and older adults. Our searches were conducted with the assistance of an experienced librarian. Despite our efforts to map the research literature on eHealth and CC for older adults living at home, we may have missed some studies.
Third, we included studies with participants aged ≥65 years and excluded several studies because the participants were younger (eg, aged 60 years). The World Health Organization [
The number of older adults will continue to increase well into the future. Older adults with chronic illnesses must navigate fragmented health care services, and eHealth in CC may be a way to prevent this fragmentation. The use of eHealth in CC for older adults is promising, although the outcomes so far have been mixed. eHealth in CC may improve older adults’ mental and physical health and reduce hospital admissions and readmissions. A barrier was hampered communication because of the lack of interoperability of the EHRs and patient portals, which seems to be an ongoing issue worldwide.
To ensure the successful use of eHealth in CC for older adults living at home, the eHealth used needs to be customized to each individual’s care needs. Education and patient support should be individualized. The telephone is still important for some older adults, and future research and practice should consider using the telephone or in-person visits to close the digital divide. However, it is essential to ensure that older adults interested in and capable of using HIT can be offered eHealth in CC. This calls for individualized eHealth-enabled health care services for older adults. eHealth in CC has an immense potential for the future organization and development of health care services. Thus, more in-depth knowledge of eHealth at the crossroads of CC for older adults living at home is needed.
Example of a search.
Overview of the included papers and care coordination activities.
blood pressure
care coordination
emergency department
electronic health record
health IT
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews
randomized controlled trial
Funding was provided by the University of Stavanger, Norway.
All authors contributed to designing and developing the study topic, research questions, and literature search. HMHF conducted the literature search and charted the data with input from AMLH and MS. The data analysis was led by HMHF in collaboration with AMLH and MS. All authors contributed to the screening of articles and reading of the included articles, which was led by HMHF. HMHF was responsible for drafting the main text. All authors took part in reading, providing input, reviewing and editing the text, and approving the final manuscript.
None declared.