Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study

Area of Science:

• Gerontology
• Health Services Research
• Patient Care

Background:

• Older adults with complex needs frequently transition between care settings due to health fluctuations and fragmented services.
• The Geriatric Evaluation and Management (GEM) model aims to improve care transitions and outcomes through multidisciplinary, coordinated care.

Purpose of the Study:

• To describe care transition experiences of older adults moving between subacute and primary care.
• To identify factors influencing these transitions.
• To suggest enhancements for the GEM model and improve local service coordination.

Main Methods:

• Exploratory, longitudinal case study design.
• Repeat interviews with 19 patients and carers.
• Patient chart audits and three focus groups with service providers.
• Thematic synthesis of interview transcripts.

Main Results:

• Care transitions were perceived as dislocating and unpredictable within a complex service environment.
• Patients and carers faced precarious self-management, unmet needs, and challenges with holistic care.
• Factors influencing experiences included help-seeking attitudes, communication quality, information exchange, and system pressures.

Conclusions:

• Enhanced policy and practice are needed, focusing on early intervention, prevention, and strengthened links between care levels.
• Educative and self-help initiatives for patients and carers are recommended.
• Optimizing the GEM model requires improved system linkages and proactive care across all settings.