Research & theory

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

Authors:

Kerry Kuluski
Email Kerry Kuluski
Julia W. Ho
Parminder Kaur Hans
Michelle L.A. Nelson

Kerry Kuluski, Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System; and Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Canada
Dr. Kuluski is an Investigator at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System (Bridgepoint Hospital site), Assistant Professor at the Institute of Health Policy, Management and Evaluation (University of Toronto) and Research Affiliate at the Centre for Education and Research on Aging and Health (Lakehead University). She is an Applied Health Services Researcher and a Social Worker by training. She received her PhD in Health Services and Policy Research from the University of Toronto in 2010 followed by a Prestigious Postdoctoral Visiting Fellowship at the University of Oxford where she worked with the Health Experiences Research Group. She is the recipient of several extra-curricular leadership awards, a Literary Award in Health Services Evaluation, Co-Investigator on over 7.5 million dollars in externally funded research, has given over 50 invited talks and has over 20 publications in peer-reviewed journals. Her current research focuses on quality and health system performance through the eyes of people with multimorbidity and their caregivers in the contexts of community based primary health care, homecare, hospital care, delayed discharge and transitions between care settings. She draws on both quantitative and qualitative methods to uncover population level trends in care utilization as well as patient and caregiver experiences in the health care system. Her ultimate research goal is to use the patient and caregiver experiences to inform quality improvements in the health care system including approaches to care delivery that are more family centred. At the University of Toronto she teaches a foundational course on Canada’s Health Care System and supervises a number of Masters and PhD students.
Julia W. Ho, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Canada
Parminder Kaur Hans, Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada
Michelle L.A. Nelson, Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto; and Daphne Cockwell School of Nursing, Ryerson University, Canada

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:

multimorbidity homecare transitions social care social determinants of health integrated care

Volume: 17
Page/Article: 2
DOI: 10.5334/ijic.2944

Submitted on 8 Dec 2016
Accepted on 12 Jul 2017
Published on 21 Jul 2017

Peer Reviewed