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.
Highlights
A growing number of people are living with complex care needs characterized by multimorbidity, mental health challenges and social deprivation
Despite the growing numbers of people who present with complex health and social care needs, health systems continue to deliver care that predominantly focuses on one illness at a time or prioritizes medically oriented care over socially oriented care
In this study we presented health and social care providers with composite patient vignettes characterized by significant health and social care needs, nearing hospital discharge
Summary
A growing number of people are living with complex care needs characterized by multimorbidity, mental health challenges and social deprivation. 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. Despite the growing numbers of people who present with complex health and social care needs, health systems continue to deliver care that predominantly focuses on one illness at a time or prioritizes medically oriented care (management of disease and symptoms) over socially oriented care (attention to quality of life and social support). There is widespread consensus that improving care for people with complex care needs requires integration of health and social care services [7, 8]. Failing to mobilize health and social care in the community may result in a hospital discharge delay [9,10,11,12,13,14], and once discharged home could result in hospital readmission [15, 16]
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