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

TLDR

A growing number of people live with complex care needs characterized by multimorbidity, mental health challenges, and social deprivation, requiring integration of health and social care beyond traditional services to address social determinants. The study investigates key care components to support complex patients and their families in the community. Expert panel focus groups with 24 care providers across Toronto, Ontario, Canada were conducted, presenting patient vignettes illustrating significant health and social care needs. The study identified three categories to support complex patients: foundational relationships, desired processes and structures, and barriers with workarounds.

Abstract

<p class="p1"><strong>Introduction: </strong>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.<span class="Apple-converted-space"> </span> <p class="p2"><strong>Methods: </strong>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.<span class="Apple-converted-space"> </span> <p class="p2"><strong>Results: </strong>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.<span class="Apple-converted-space"> </span> <p class="p2"><strong>Discussion and Conclusions: </strong>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.<span class="Apple-converted-space"> </span>