Mapping the way: functional modelling for community-based integrated care for older people

Area of Science:

• Geriatric Medicine
• Health Services Research
• Systems Engineering

Background:

• Healthcare systems face sustainability challenges, particularly with an ageing population requiring complex, coordinated care.
• Current episodic care models are inadequate for frail older adults, necessitating integrated health and social services accessible within communities.
• Fragmented community-based care delivery, characterized by professional silos and disparate systems, hinders comprehensive geriatric assessment.

Purpose of the Study:

• To analyze the community-based comprehensive geriatric assessment process in an urban Canadian setting.
• To identify challenges and opportunities for developing a more integrated care delivery model for older adults.
• To inform the redesign of health and social care services for improved patient outcomes.

Main Methods:

• Functional Resonance Analysis Method (FRAM) and dynamic FRAM (DynaFRAM) modelling were employed.
• A hypothetical patient journey scenario was created to represent community-based health and social care system operations.
• Data collection involved document review, focus groups, and semi-structured interviews with healthcare professionals.

Main Results:

• Key challenges and opportunities for integrated care implementation were identified within the local context.
• FRAM and DynaFRAM analysis provided insights into system operations and professional workflows.
• Co-designed, multi-level process improvement recommendations were developed to enhance geriatric assessment integration.

Conclusions:

• Transformative redesign of community-based health and social care is crucial for addressing the needs of an ageing population.
• Understanding professional practices and patient care dynamics is essential for successful system redesign.
• FRAM and DynaFRAM modelling offer valuable insights for decision-makers aiming to implement integrated care models.