Community care for people with complex care needs: Bridging the gap between health and social care

International Journal of Integrated Care

Volumn 17, Issue 4, 2017, Pages

  Kuluski, Kerry ^a,b   Ho, Julia W ^b   Hans, Parminder Kaur ^a   La Nelson, Michelle ^a,b,c  

^a MOUNT SINAI HOSPITAL   (Canada)

^b UNIVERSITY OF TORONTO   (Canada)

^c RYERSON UNIVERSITY   (Canada)

Author keywords

Homecare; Integrated care; Multimorbidity; Social care; Social determinants of health; Transitions

Indexed keywords

EID: 85026319510     PISSN: None     EISSN: 15684156     Source Type: Journal    
DOI: 10.5334/ijic.2944     Document Type: Article

References (34)

1. Moineddin, R, et al. Measuring change in health status of older adults at the population level: the transition probability model. BMC Health Serv Res, 2010; 10: 306. DOI: https://doi.org/10.1186/1472-6963-10-306
2. Tinetti, ME, Fried, TR and Boyd, CM. Designing health care for the most common chronic condi­tion–multimorbidity. JAMA, 2012; 307(23): 2493–4. DOI: https://doi.org/10.1001/jama.2012.5265
3. Lyons, R, et al. Chronic illness research: Translating what we know into what we do. Kralik, D, Paterson, B and Coates, V (eds.), In: Translating chronic illness research into practice, 2010; 163–197. Oxford: Blackwell Publishing Ltd.
4. Barnett, K, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet, 2012; 380(9836): 37–43. DOI: https://doi.org/10.1016/S0140-6736(12)60240-2
5. Abu Dabrh, AM, et al. Minimally disruptive medicine: the evidence and conceptual pro­gress supporting a new era of healthcare. J R Coll Physicians Edinb, 2015; 45(2): 114–7. DOI: https://doi.org/10.4997/JRCPE.2015.205
6. Gilmour, H. Social participation and the health and well-being of Canadian seniors. Health Reports, 2012 [cited 2016 October 29]; Available from: http://www.statcan.gc.ca/pub/82-003-x/2012004/ article/11720-eng.htm.
7. Humphries, R. Integrated health and social care in England-Progress and prospects. Health Policy, 2015; 119(7): 856–9. DOI: https://doi.org/10.1016/j.healthpol.2015.04.010
8. Vrijhoef, H and Thorlby, R. Developing care for a changing population: supporting patients with costly, complex needs, 2016; London, England.
9. Challis, D, et al. An examination of factors influencing delayed discharge of older people from hospital. International Journal of Geriatric Psychiatry, 2014; 29(2): 160–168. DOI: https://doi.org/10.1002/gps.3983
10. Chopard, P, et al. Predictors of inappropriate hospital days in a department of internal medicine. Int J Epidemiol, 1998; 27(3): 513–9. DOI: https://doi.org/10.1093/ije/27.3.513
11. Falcone, D, Bolda, E and Leak, SC. Waiting for placement: an exploratory analysis of determinants of delayed discharges of elderly hospital patients. Health Serv Res, 1991; 26(3): 339–74.
12. Hwabejire, JO, et al. Excessively long hospital stays after trauma are not related to the severity of illness: Let’s aim to the right target! JAMA Surgery, 2013; 148(10): 956–961. DOI: https://doi.org/10.1001/jamasurg.2013.2148
13. Tan, WS, et al. Factors associated with delayed discharges after inpatient stroke rehabilitation in Singapore. Ann Acad Med Singapore, 2010; 39(6): 435–41.
14. Hendy, P, et al. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clinical Medicine, 2012; 12(4): 320–323. DOI: https://doi.org/10.7861/clinmedicine.12-4-320
15. Jeffs, L, et al. The perspectives of patients, family members and healthcare professionals on readmissions: preventable or inevitable? J Interprof Care, 2014; 28(6): 507–12. DOI: https://doi.org/10.3109/13561820.2014.923988
16. Fuji, KT, Abbott, AA and Norris, JF. Exploring care transitions from patient, caregiver, and health-care provider perspectives. Clin Nurs Res, 2013; 22(3): 258–74. DOI: https://doi.org/10.1177/1054773812465084
17. Watt, S, Browne, G and Gafni, A. Community care for people with chronic conditions: an analysis of nine studies of health and social service utilization in Ontario. Milbank Q, 1999; 77(3): 363–92, 275.
18. Creswell, J. Choosing a Mixed Methods Design, in Designing and conducting mixed methods research, Creswell, J and Plano Clark, V (eds.). Thousand Oaks: Sage Publications; 2007; 58–88.
19. Kuluski, K, et al. The care delivery experience of hospitalized patients with complex chronic disease. Health Expect, 2013; 16(4): 111–23. DOI: https://doi.org/10.1111/hex.12085
20. Nelson, M, et al. “Working the system”: The experience of being a primary care patient. Patient Experience Journal, 2014; 1(1): 37–42.
21. Miller, D, et al. Beyond Multi-morbidity: Patient Perceptions of the Impact of Illness. Evidence Brief, 2015 [cited 2017 April 21]; Available from: http://hsprn.ca/uploads/files/Beyond%20Multimorbidity_Evidence%20Brief_April%202015.pdf.
22. Sandelowski, M. Whatever happened to qualitative description? Res Nurs Health, 2000; 23(4): 334–40. DOI: https://doi.org/10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G
23. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academic Press 2001.
24. Kuluski, K, et al. What Gets in the Way of Person-Centred Care for People with Multimorbidity? Lessons from Ontario, Canada. Healthc Q, 2016; 19(2): 17–23. DOI: https://doi.org/10.12927/hcq.2016.24694
25. Hirdes, JP, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC Health Serv Res, 2008; 8: 277. DOI: https://doi.org/10.1186/1472-6963-8-277
26. Kontos, PC, Miller, KL and Mitchell, GJ. Neglecting the importance of the decision making and care regimes of personal support workers: a critique of standardization of care planning through the RAI/MDS. Gerontologist, 2010; 50(3): 352–62. DOI: https://doi.org/10.1093/geront/gnp165
27. Turcotte, PL, et al. Participation needs of older adults having disabilities and receiving home care: met needs mainly concern daily activities, while unmet needs mostly involve social activities. BMC Geriatr, 2015; 15: 95. DOI: https://doi.org/10.1186/s12877-015-0077-1
28. Woo, J, et al. Identifying service needs from the users and service providers’ perspective: a focus group study of Chinese elders, health and social care professionals. J Clin Nurs, 2011; 20(23–24): 3463–71. DOI: https://doi.org/10.1111/j.1365-2702.2011.03702.x
29. Foust, JB, Vuckovic, N and Henriquez, E. Hospital to home health care transition: patient, caregiver, and clinician perspectives. West J Nurs Res, 2012; 34(2): 194–212. DOI: https://doi.org/10.1177/0193945911400448
30. Davis, MM, et al. “Did I do as best as the system would let me?” Healthcare professional views on hospital to home care transitions. J Gen Intern Med, 2012; 27(12): 1649–56. DOI: https://doi.org/10.1007/s11606-012-2169-3
31. Repper, J and Carter, T. A review of the literature on peer support in mental health services. J Ment Health, 2011; 20(4): 392–411. DOI: https://doi.org/10.3109/09638237.2011.583947
32. Gray, LC, et al. How effective are programs at managing transition from hospital to home? A case study of the Australian Transition Care Program. BMC Geriatr, 2012; 12: 6. DOI: https://doi.org/10.1186/1471-2318-12-6
33. Mitton, C, et al. Moral Distress among Healthcare Managers: Conditions, Consequences and Potential Responses. Healthc Policy, 2010; 6(2): 99–112. DOI: https://doi.org/10.12927/hcpol.2010.22036
34. Maruthappu, M, Hasan, A and Zeltner, T. Enablers and Barriers in Implementing Integrated Care. Health Systems & Reform, 2015; 1(4): 250–256. DOI: https://doi.org/10.1080/23288604.2015.1077301