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. 2017 Jul 21;17(4):2.
doi: 10.5334/ijic.2944.

Community Care for People with Complex Care Needs: Bridging the Gap between Health and Social Care

Kerry Kuluski  1   2 , Julia W Ho  2 , Parminder Kaur Hans  1 , Michelle LA Nelson  1   2   3
Affiliations

Community Care for People with Complex Care Needs: Bridging the Gap between Health and Social Care

Kerry Kuluski et al. Int J Integr Care. .

Abstract

Introduction: A growing number of people are living with complex care needs characterized by multimorbidity, mental health challenges and social deprivation. Required is the integration of health and social care, beyond traditional health care services to address social determinants. This study investigates key care components to support complex patients and their families in the community.

Methods: Expert panel focus groups with 24 care providers, working in health and social care sectors across Toronto, Ontario, Canada were conducted. Patient vignettes illustrating significant health and social care needs were presented to participants. The vignettes prompted discussions on i) how best to meet complex care needs in the community and ii) the barriers to delivering care to this population.

Results: Categories to support care needs of complex patients and their families included i) relationships as the foundation for care, ii) desired processes and structures of care, and iii) barriers and workarounds for desired care.

Discussion and conclusions: Meeting the needs of the population who require health and social care requires time to develop authentic relationships, broadening the membership of the care team, communicating across sectors, co-locating health and social care, and addressing the barriers that prevent providers from engaging in these required practices.

Keywords: homecare; integrated care; multimorbidity; social care; social determinants of health; transitions.

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Figures

Figure 1
Figure 1
Key Categories Identified by Health and Social Care Providers in the Care of People with Complex Care Needs.
See this image and copyright information in PMC

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