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. 2020 Apr 23;21(1):69.
doi: 10.1186/s12875-020-01143-8.

Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study

Ruta Valaitis  1 , Laura Cleghorn  2 , Jenny Ploeg  3 , Cathy Risdon  2 , Derelie Mangin  2 , Lisa Dolovich  2 , Gina Agarwal  2 , Doug Oliver  2 , Jessica Gaber  2 , Harjit Chung  4
Affiliations

Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study

Ruta Valaitis et al. BMC Fam Pract. .

Abstract

Background: There are gaps in knowledge and understanding about the relationships between primary care and community-based health and social services in the context of healthy aging at home and system navigation. This study examined provider perspectives on: a) older adults' health and social needs; b) barriers to accessing services; c) the nature of relationships between primary care and health and social services; and d) ways to facilitate primary care and health and social services navigation to optimize older adults' health.

Methods: Four focus groups were conducted involving providers (n = 21) in: urban primary care clinics and health and social services organizations serving older adults in Hamilton, Ontario, Canada. Purposive sampling was employed to recruit community health and social services managers, directors or supervisors and primary health care providers in a Family Health Team via email.

Results: Health and social services needs were exacerbated for community-dwelling older adults with multiple chronic conditions. Strong family/caregiver social support and advocacy was often lacking. Access barriers for older adults included: financial challenges; lack of accessible transportation; wait times and eligibility criteria; and lack of programs to address older adults' needs. Having multiple providers meant that assessments among providers and older adults resulted in contradictory care pathways. Primary care and health and social services linkages were deficient and complicated by poor communication with patients and health literacy barriers. Primary care had stronger links with other health services than with community-based health and social services; primary care providers were frustrated by the complex nature of health and social services navigation; and care coordination was problematic. Health and social services referred older adults to primary care for medical needs and gathered patient information to gauge program eligibility, but not without challenges.

Conclusions: Results point to strategies to strengthen primary care and health and social services system navigation for older adults including: using a person-focused approach; employing effective primary care and health and social services communication strategies; applying effective system navigation; building trust between primary care and health and social services providers; advocating for improved program access; and adapting services/programs to address access barriers and meet older adults' needs.

Keywords: Community services; Health and social services; Multiple chronic conditions; Older adults; Primary care; Social care; System navigation.

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Conflict of interest statement

The author(s) declare no conflicts of interest with respect to the authorship and/or publication of this article.

References

    1. Beard JR, Officer A, de Carvalho IA, Sadana R, Pot AM, Michel J-P, et al. The world report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145–2154. doi: 10.1016/S0140-6736(15)00516-4. - DOI - PMC - PubMed
    1. Mossabir R, Morris R, Kennedy A, Blickem C, Rogers A. A scoping review to understand the effectiveness of linking schemes from healthcare providers to community resources to improve the health and well-being of people with long-term conditions. Health Soc Care Community. 2015;23(5):467–484. doi: 10.1111/hsc.12176. - DOI - PubMed
    1. Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Aff. 2014;33(12):2247–2255. doi: 10.1377/hlthaff.2014.0947. - DOI - PubMed
    1. Ploeg J, Matthew-Maich N, Fraser K, Dufour S, McAiney C, Kaasalainen S, et al. Managing multiple chronic conditions in the community: a Canadian qualitative study of the experiences of older adults, family caregivers and healthcare providers. BMC Geriatr. 2017;17(1):40. doi: 10.1186/s12877-017-0431-6. - DOI - PMC - PubMed
    1. Sturmberg JP, Botelho RJ, Kissling B. Integrated multimorbidity management in primary care: why, what, how, and how to? J Comorbidity. 2016;6(2):114. doi: 10.15256/joc.2016.6.95. - DOI - PMC - PubMed

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