Introduction
Interprofessional care in primary care settings is promoted as an effective and efficient model for health systems around the world (Wagner et al., Reference Wagner, Flinter, Hsu, Cromp, Austin, Etz, Crabtree and Ladden2017; WHO/UNICEF, 2018). Interprofessional collaborative practice occurs when ‘multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care’ (WHO, 2010). The collaboration of health and social care professionals is associated with positive patient health outcomes, including improved measures of physical and mental health, as well as other health markers (e.g., cholesterol, glucose, blood pressure) (Bouton et al., Reference Bouton, Journeaux, Jourdain, Angibaud, Huon and Rat2023; McCutcheon et al., Reference McCutcheon, Haines, Valaitis, Sturpe, Russell, Saleh, Clauson and Lee2020). For older adults, who are more likely to have multiple conditions requiring treatment, the demonstrated benefits of interprofessional care in primary care have included significant clinical improvements in psychosocial measures (quality of life, cognitive decline, depression) and cardiometabolic conditions (hypertension, heart failure, dyslipidemia, diabetes) (Dahlke et al., Reference Dahlke, Meherali, Chambers, Freund-Heritage, Steil and Wagg2017; Gougeon et al., Reference Gougeon, Johnson and Morse2017). Members of these interprofessional teams consistently feature physicians and nurses, and often include members of other health disciplines, including, but not limited to, dietitians, occupational and physiotherapists, social workers, and pharmacists (Johnson et al., Reference Johnson, Hermosura, Price and Gougeon2021). Worldwide definitions of interprofessional care also highlight the patient as the central member of these teams (CIHC, 2024; IPEC, 2023; WHO, 2010). Yet, how older adult patients actually view their role and participate in their interprofessional care is relatively understudied.
Patient perspectives about interprofessional care and their own position in the team configuration are essential for understanding how optimal patient-centred collaborative care can be enacted. Reviews of the small number of studies exploring patient experiences with interprofessional care in primary care outline several issues. Patients appreciated referrals between knowledgeable professionals with complementary expertise, but could feel like ‘bystanders’ when decisions were made for and not with them or when their values and goals were not considered (Gilchrist & Kholvadia, Reference Gilchrist and Kholvadia2024). These factors are reflected in other studies involving patients and their families who wish to be spoken with and not about among the health professionals and struggled with the role ambiguity of family members in interprofessional care (Sigmon et al., Reference Sigmon, Reis, Woodard and Hinkle2023). Unfortunately, older adults are not well represented in this literature examining interprofessional care in primary care, especially those who are community-dwelling and living independently. Just 11 studies could be summarized by Stray et al., who identified that many older adults were uncomfortable with the subject matter being discussed between health professionals, but they conversely felt poor communication marked a lack of professional concern and subsequently experienced anxiety (Stray et al., Reference Stray, Wibe, Debesay and Bye2024). Nevertheless, older adults possessed high levels of confidence and trust in their referring primary care provider (e.g., family doctor) (Stray et al., Reference Stray, Wibe, Debesay and Bye2024). Overall, the limited data indicate that older adults’ own role preferences in their interprofessional primary care team vary.
It is clear that there is more to understand about how community-dwelling older adults who do not require home care services engage with interprofessional care in primary care. Researchers (Dahlke et al., Reference Dahlke, Meherali, Chambers, Freund-Heritage, Steil and Wagg2017; Duhoux et al., Reference Duhoux, Dufour, Sasseville, Laroche and Contandriopoulos2022) point to deficiencies in reported processes and organization of interprofessional care in this population. Such details are relevant given distinct considerations required for interprofessional care for older adults of varying age (e.g., septuagenarians vs. octogenarians) or levels of frailty (Montano et al., Reference Montano, Cornell and Gravenstein2023). Factors around socioeconomic status and geography (e.g., rural vs. urban) are also anticipated to impact interprofessional care access of older adults (Gougeon et al., Reference Gougeon, Johnson and Morse2017). Expectations to better incorporate family and other caregivers into patient-centred collaborative care will continue to grow with the rising primary care needs for aging populations (Kim et al., Reference Kim, Wister, O’Dea, Mitchell, Li and Kadowaki2023), especially as the support and positive impact of family and social relationships on older adult well-being is incontrovertible. A longitudinal data of nearly 25,000 older adults in the United States found that those with quality family ties exhibited better mental health and social engagement than those who did not (Patterson & Margolis, Reference Patterson and Margolis2023). Similarly, positive caregiving experiences can be associated with higher cognitive performance (Wennberg et al., Reference Wennberg, Anderson, Cagnin, Chen-Edinboro and Pini2023), while having friends and strong social relationships (Haslam et al., Reference Haslam, Cruwys and Haslam2023; Kelly et al., Reference Kelly, Duff and Kelly2017) significantly benefits older adults by enhancing quality of life, preserving cognitive function, and reducing the risk of mortality and mental decline. Together, these findings highlight the vital role that medical and social care professionals, family, friends, and broader support networks play in promoting healthy aging. The purpose of our study was to explore the interprofessional care experiences of independent, community-dwelling older adults by examining their care networks and their perceptions of collaboration among different network members.
Methods
Methodology
We employed a qualitative social network theoretical and analytical framework using an egocentric perspective. Social network analysis (SNA) is a relationship-mapping research approach to understand social phenomena in a group (network) (Scott & Carrington, Reference Scott and Carrington2011). SNA facilitates the identification of patterns of interaction, influence, and information flow within a network, offering insights into how social structures shape individual and group outcomes (Borgatti et al., Reference Borgatti, Mehra, Brass and Labianca2009). Egocentric SNA is a specific approach to both model and analyze an individual’s network and relationships as described from their perspective (Perry et al., Reference Perry, Pescosolido and Borgatti2018). Egocentric SNA captures the structure and function of an individual’s immediate social environment, which can reveal influential ties and pathways of information or support often overlooked in whole-network studies (Crossley et al., Reference Crossley, Bellotti, Edwards, Everett, Koskinen and Tranmer2015). Network-based data provide valuable insight into the composition, function, and impact of older adults’ relationships, as well as how these relationships influence attitudes, experiences, and behaviours, and ultimately patient care (Ho et al., Reference Ho, McGill, Malden, Wilson, Pearce, Kaner, Vines, Aujla, Lewis, Restocchi, Marshall and Guthrie2023).
Participants and setting
Community-dwelling older adults who were 65 years and older were recruited to participate. The study was promoted in the Canadian province of British Columbia through social media advertisements through the platforms (e.g., Twitter (X), Facebook, LinkedIn, Instagram, email) of the researchers and affiliated partners or other collaborators. In addition to the wider general public, recruitment was also conducted at specialized ambulatory clinics. Physical posters and pamphlets were shared at three ambulatory clinic sites where older adults receive geriatric care and medication management. Older adults were excluded if they had a diagnosis of a major neurocognitive disorder; were deemed incapable of making medical decisions and were not actively involved in management of their own health; or could not communicate in English without the support of a translator. A researcher (AA) screened interested potential participants by telephone.
Data collection
The data collection interview was designed to explore the composition and nature of relationships in the participants’ networks of care. We collected social network data using a two-stage participant-aided concentric circle technique for network visualization (Hogan et al., Reference Hogan, Carrasco and Wellman2007). Pairing interviews with a visual layout of responses helps older adults concretely represent their social worlds by placing people or connections in spatial relation to themselves, making network characterization more manageable and engaging. In the first stage, participants were asked to name individuals (or organizations) who support their care and well-being. Participants were encouraged to consider both health care and non–health care personnel and to describe their roles. The interviewer (AA) wrote each network member’s name on a label. In the second stage, the participant placed the labels within a concentric circle diagram. Participants were advised that they were at the centre of the concentric circle diagram (‘ego’) and to position their network members (‘alters’) in the circle rings according to the relative strength of their relationship, with one being the closest relationship and four being the most distant relationship (Figure 1). Participants were allowed to freely interpret the ranking of relationship strength and where to place the labels. Participant rationale for alter placement was elicited with subsequent interview probes in the topic guide (Supplementary Materials S1). The data collection encounter (topic guide and concentric circle) was piloted with a volunteer older adult to check clarity, coherence, and confirm the estimated data collection encounter length to communicate to participants. When interviews were conducted virtually, this two-stage process of label making and positioning was carried out by the researcher who was directed by the participant to create alter labels and where to position them in a concentric circle displayed on-screen.
Concentric circle network visualization tool.
The combination of nominated alters and concentric circle positions with associated narrative allowed for a ‘thick description’ of the relationships in the participants’ networks of care. Such summaries permitted examination of the network roles of different health care professionals (medical care providers), family and friends (non-medical care providers), and interactions among and between the two. Personal names of alters were removed from final concentric circles and replaced with role (e.g., the family doctor, the spouse). Certain participant demographic data were also gathered (age, self-identified gender and ethnicity, marital and living status, prior occupation, and medical history). De-identified interview recordings were transcribed verbatim by artificial intelligence software (Otter AI™) and re-read and verified by the interviewing researcher (AA).
Data analysis
Quantitative
Each participant’s social network was summarized according to (1) the number of alters in each concentric circle ring and (2) the total number of alters overall. These were aggregated to describe the sample population data set as a whole. Counts of each alter role (e.g., family doctor, spouse), their characterization (medical or non-medical care providers), and their concentric ring positions in the data set were also performed.
Qualitative
We conducted a conventional content analysis using an inductive approach to derive categories directly from the data, enabling a detailed understanding of older adults’ perspectives without applying predetermined frameworks (Hsieh & Shannon, Reference Hsieh and Shannon2005). Interview transcripts were coded and analyzed in an iterative process throughout the data collection period (Bazeley, Reference Bazeley2020). Preliminary codes were generated by open coding of text and further refined through an inductive process, including re-reading and discussion with all authors (AA, JC, KW). Broader categories consolidated from codes were identified through pattern recognition and constant comparison. The interviewing research assistant (AA) maintained reflective memos throughout the interview and coding process to document analytic decisions, developing insights, and potential biases, which can enhance dependability and confirmability (Lincoln & Guba, Reference Lincoln, Guba, Denzin and Lincoln2005). Repeated dialogue among the three authors and presentation to other academic and public audiences guided the interpretation of the data and the categories we formed to represent participant network relationships. The research team were all pharmacists bringing different perspectives to the analysis: the trained research assistant (AA) is a graduate student who practiced for a short time in Nigeria; JB is a clinical pharmacist and educator who sees older adults for medication management in an outpatient clinic; and KW is an educator and researcher of interprofessional care who previously worked on an acute care for elders’ hospital unit.
The research was reviewed and approved by the University of British Columbia Behavioural Research Board (#H23-01174).
Results
Twenty-three participants community-dwelling older adults were recruited and interviewed (Table 1). Interview length varied from 22 to 76 minutes, with a mean of 49 minutes. Two were conducted in person. The mean age was 75.3 years (66 to 91), and most were women (15). The 16 participants who were married or in common-law relationships lived with their partner, while the other seven participants who were divorced, widowed, or never married were living alone. The majority self-identified as white. All participants were retired from the workforce, and five had previously been practicing health professionals. Participants each listed several medical conditions (median 2, 1 to 6); these were then categorized by the researchers into acute conditions (e.g., self-limiting, resolved past surgical or medical issues) or chronic conditions requiring ongoing management. Fifteen (65.2%) patients had conditions requiring specialist physician care.
Participant demographics, n = 23
* Self-identified.
** All participants were retired. Former occupations were classified according to the Government of Canada National Occupational Classification (NOC) www.noc.esdc.gc.ca.
Network composition
Participant network sizes ranged from 4 to 17 alters, with a mean network size of 11. Closest relationships (alters positioned in concentric ring one) counted on average 3 (2 to 6). These were followed by concentric ring 2 (mean 1, 1 to 9) and concentric ring 3 (mean 2, 1 to 5). The least close relationships, while still assuming a network position (alters positioned in concentric ring 4), counted on average 1 (1 to 3). Relatively more non-medical members (specifically a spouse or a child) were positioned in concentric ring 1 (59%) compared to medical members (41%). The most prevalent medical network member was the family physician (usually positioned in concentric ring 1), followed by the pharmacist and the dentist (Figure 2).
Participant care network membership and relationships.
Network relationships
Relationship features of the closest network members include near physical proximity and frequent interactions. These network positions heavily favoured family members, especially a spouse. Participants living with a spouse or common-law partner consistently emphasized the invaluable functional and emotional support they provided. Children (and their spouses) who participants saw often were also positioned closest in the network; participants also described close relationships with children living elsewhere and with whom they communicated regularly. While the contribution to participant well-being was less instrumental (e.g., not practically supporting day-to-day living due to distance), physically distant non-medical members were a source of support through remote provision of advice and comfort. Meanwhile, participants’ day-to-day living benefited from neighbours and friends who could be relied upon to pitch in with household tasks and socialize. These relationships (as well as pet-ownership) were especially important for those living alone.
The family physician was positioned as the closest medical member in almost all participant networks of care. Instead of proximity or frequency, family physicians and the next closest medical network members (e.g., dentists, pharmacists) shared a level of accessibility to the participant. Specialist physicians, in contrast, were often positioned in distant network positions due to infrequent interactions and difficulties securing appointments.
These three features of closest relationships (proximity, frequency, accessibility) are common characteristics in network structures (Berkman et al., Reference Berkman, Glass, Brissette and Seeman2000). Participants also described how other aspects of network composition and member relationships affect their health.
Longevity
Longstanding relationships were considered close and positioned accordingly by participants in their networks of care. For example, the health of many participants was overseen by the same family physician for several years. At this time, participants felt the family physician was not only well acquainted with their medical needs but also their life experiences. These relationships were marked by comfort, trust, and even mutual familiarity.
That’s the advantage of having defined providers over time; you build relationships so you’re not just the guy with the cold or line number three; you are ‘[name], how are you? How’s the dog? Do you still do this?’ That kind of thing. (Participant 17)
I get along with my family doctor pretty well; he’s polite enough to laugh at my jokes! (Participant 19)
[The family physician] makes me feel supported in that I feel they treat me as a human being. It’s not so much straightaway, what is the health issue, but you know, talking about how I have been doing? How have I been feeling overall? (Participant 22)
Impact
Conversely, several participants described short-term, yet deeply meaningful relationships with certain medical network members. The care of specialist physicians when participants were in medical peril carried a residual positive impact many months and years later. Similarly, specialist physicians who were perceived to take time with participants and even take an interest in other issues were recognized and positioned as near-network members.
My neurosurgeon saved my life. So you know, I’m just really grateful. He maintains his communication with me on a very supportive level. (Participant 13)
The nephrologist is new to his job. Man, this doctor is a young guy! I’m an old and decrepit guy. He has lots of energy. He cares about the fact that I have difficulties with Parkinson’s Disease too. And he will listen to me and express human emotions to me about that situation. He doesn’t have do that. He cares about me. (Participant 5)
A number of participants prioritized preventative care and positioned providers as close members in their network of care. The impact of visits and treatments related to oral health and physical mobility, in particular, was reflected in participant relationship descriptions.
The osteopath was really good to help me prepare for my hip replacement and helping me with the beginnings of osteoarthritis this past year. (Participant 20)
The dental hygienist is in a close position in my network…I understand the importance of good dental care for people for their health, and even their self-esteem by keeping their teeth in a certain condition if they can afford to. (Participant 17)
Dissolution and expansion
Participants described prior relationships with members who were now less close or even no longer part of their network of care. Usually, the dissolution of medical network member relationships involved the conclusion of necessary care, retirement (the health professional), or relocation (participant). In a few instances, relationships with medical network members frayed due to conflict, miscommunication, or misunderstanding. Some such members may have remained in the network of care due to medical necessity, but a positive relationship was lost due to some negative impact on the participant.
The [specialist] that I had at the clinic, he would be with me for 20 minutes… but I take all of his behaviour as almost when can I get out of this appointment? (Participant 5)
He [specialist] was harsh, cold, dismissive, impatient. He was quite arrogant. (Participant 13)
Death and drift in relationships with non-medical network members were similarly destabilizing to participants. Sudden losses weighed on some participants, and others expressed regret about distances between them and their siblings and old school friends and colleagues.
My best friend died and that was very difficult – she was a nurse as well so we always had that in common. (Participant 4)
I found the man that I love dead on his apartment floor unexpectedly… and it broke my heart and so it was trauma and grief. (Participant 13)
The development of new relationships with individuals who then assumed a position in the network of care was infrequent. These members might be from the neighbourhood or social groups and were welcomed for companionship.
The dog walkers we’ve met walking our dog in the same place who we run into so often that we’ve actually developed a relationship with two recently that we’re now going to each other’s homes every couple of weeks to play cards! (Participant 17)
Expansion of medical network membership was necessary when participants required care for emerging conditions or needed to secure a family physician replacement. Some participants anticipated increased support requirements from their family members as their needs grow in the future.
Looking into the future, if I’m not able to advocate for myself, I would hope that my sibling would be able to help, as well as my daughter and of course, my son.
(Participant 21)
Collaboration and information exchange
Participants were limited in their abilities to describe collaboration and information exchange with and among members in their network of care. Many were confident that there was reciprocal communication between their family physician and the specialist physicians to whom they were referred, but this seemed to be inferred by observation alone.
I think the records go back to the family physician so that seems to be the hub. I get a sense that they read those reports because when I go back, I get some feedback. (Participant 15)
The family physician, I guess, in some ways they are collaborating with the pharmacist, the lab for bloodwork and that type of thing, that seems to be working well. (Participant 18)
Other pseudo-apparent communication between medical network members involved the pharmacist who participants knew contacted the family physician when prescriptions needed clarification or correction. Other examples did not occur to participants. The only participant who believed that their different care providers ‘just seem to know everything’ (Participant 6) was attending an interprofessional geriatric clinic. Nevertheless, most participants seemed satisfied with this level of collaboration and information exchange. Described shortcomings were instead related to their own collaboration with individual medical network members. While many participants appreciated the convenience of virtual appointments, others preferred to attend in person: ‘you can’t see what’s wrong with anyone on a telephone’ (Participant 3). A handful of participants described discouraging interactions with their specialist or family physicians who did not seem to have time to appreciate all medical concerns. These participants were frustrated when unaddressed symptoms then turned out to be signals of significant impending illness.
I feel like sometimes you would like to see a specialist more often, but they don’t want to send you unless it’s for real. It took me a long time to get attention for my bowel issues, until I lost so much weight that they had to take notice. (Participant 12)
I’m beginning to have memory problems, but he [family physician] won’t do anything about it. He’s not paying attention when I tell him that…so I was doing some Googleing yesterday to see what my next step is. (Participant 23)
Participants indicated interactions or coordination between their non-medical and medical network members was negligible. When the household included a spouse or common-law partner, they were inevitably updated with the participant’s medical concerns and may even attend appointments. However, children, other family members, neighbours, and friends were largely uninvolved in direct collaboration or information exchange with medical network members, and this was also true for networks of participants who lived alone.
Patient as a team member
Most participants felt strongly about their responsibilities and participation in their medical network of care. Many expressed convictions around self-advocacy behaviours and encouraged this behaviour among friends and peers. Different forms of ‘system vigilance’ were described, including following up on the execution of referrals and the results of ordered bloodwork and tests, as well as processes to keep information organized.
I think that a person, no matter what their age, has to be looking after themselves. And a lot of people don’t do that, they don’t know how to, or who to call, or what to say. (Participant 3)
I keep my computer running to report on most every appointment I have, like I’ll come home and enter what happened, which one it was, because it can get confusing. So then I have better questions. I’m more organized. (Participant 12)
With few exceptions, no participant network member was expressly part of any one unified or predetermined team providing their care. Nevertheless, participants felt central to the care they were receiving, irrespective of the configuration or collaboration among their various health care providers.
Oh, yeah, I’m part of this team. I mean, after all, you’re inside looking out, right?
(Participant 19)
I am certainly part of this team. I should be the main person responsible for my health. (Participant 22)
A number of participants derived a sense of belonging or ‘team’ among members of their non-medical network of care. Family members aside, participants who were somehow part of a community (e.g., church, recreation, or social group) described enhanced well-being.
[the] Retiree association has monthly social events like luncheons and that kind of thing. So there’s personal contact. And should someone be out of touch for a long period of time, they’ll make a phone call… to see how things are. (Participant 17)
Through Covid there were five of us women who formed a bubble. We have lunch at least every three weeks together at one of our houses. And we laugh and we honestly, we survived and thrived. (Participant 15)
Discussion
Our study of the networks of care of community-dwelling older adults has yielded insights about the composition of medical and non-medical members and relationship ties with and between these members. Closest relationships were typically with family members, accounting for the physical proximity and frequency of interactions, yet other features were apparent. Older adults described strong ties with network members who shared longstanding relationships or whose care had a significant impact on their wellbeing. Family physicians appeared in all participant networks and were the medical network members the participants positioned closest most often.
Consistent, close relationship ties between older adults and family physicians are unsurprising given the vital role they play in delivering services across the spectrum of primary care (Kolber et al., Reference Kolber, Korownyk, Young, Garrison, Kirkwood and Allan2023). Our study population of older adults had relatively stable medical conditions with little routine encounters with other specialty physicians; the next noteworthy network relationships with medical care providers were with dentists and pharmacists. Regular appointments with dentists were made to maintain oral health and avert acute problems. While interactions with pharmacists were also frequent, our participants characterized these relationships as transactional: generally, the dispensing of medications and not ongoing or preventative health management. Conversely, family physicians offer a reassuring continuity of care for changing health conditions over time, which instills patient confidence in medical decision making (Nowak et al., Reference Nowak, Sheikhan, Naidu, Kuluski and Upshur2021). The loss or inability to access a family physician represented network instability owing to disruptions in primary care, specialty physician referral, and follow-up. Evidently aware of the national health care workforce shortages (Lavergne et al., Reference Lavergne, Bodner, Allin, Christian, Hajizadeh, Hedden, Katz, Kephart, Leslie, Rudoler and Spencer2023), the older adults repeatedly expressed deep gratitude for having a family physician. Paradoxically, our participants then made concerted efforts not to ‘overburden’ their family physician with their issues at any given visit.
While the relationship with the family physician was central to older adults’ medical care, several other professional members contributing to health and well-being were represented in the networks. Examples included chiropractors, exercise instructors, kinesiologists, nutritionists, physiotherapists, and psychologists. Older adults self-selected these services outside any family physician recommendation or referral and usually incurred the costs personally. Such practice highlights troubling issues around health equity and effectiveness for older adults. First, older adults without socioeconomic privileges, that is, the knowledge of what these providers can contribute to health and the financial means to pay, will not benefit from this type of care. Indeed, community-dwelling older adults incur out-of-pocket expenses to support aging in place (Moody et al., Reference Moody, Ganann, Martin-Misener, Ploeg, Macdonald, Weeks, Orr, McKibbon and Jefferies2022), with current estimates as high as $6,000 annually in Canada (Arcand & Herschel, Reference Arcand and Herschel2019). Secondly, these care relationships practically function in isolation from one another. What these professionals may document locally is not recorded on a common electronic platform for others to view, a well-known and seemingly intractable barrier to collaborative care across multiple physical settings (Wei et al., Reference Wei, Horns, Sears, Huang, Smith and Wei2022). Instead, the patient is responsible for remembering and volunteering relevant information if the need arises. In fact, older adults in our study were only vaguely aware of communication between specific medical network members and reported almost none between their medical and non-medical members, findings previously borne out in other studies (Gilchrist & Kholvadia, Reference Gilchrist and Kholvadia2024; Sigmon et al., Reference Sigmon, Reis, Woodard and Hinkle2023; Stray et al., Reference Stray, Wibe, Debesay and Bye2024). An adamant expressed sense of responsibility for their own health information may in part account for an indifference towards interprofessional communication. However, such agency is not necessarily possible for all older adults or even sustainable by our participants over time, especially if they develop further multimorbidity or cognitive decline (Chi et al., Reference Chi, Wolff, Greer and Dy2017; Mattos et al., Reference Mattos, Gibson, Jepson, Ahn and Williams2022).
Many older adults in our study felt they were on a team and even leading it; however, the network data suggest there is actually no real team. Instead, patients are part of multiple dyadic relationships whereby care is provided to them by one individual working independently of all others. Infrequently, the older adult and family physician might engage with a third network member (specialty physician, pharmacist, family member) in some form of information exchange. By and large, the care of independent community-dwelling adults is provided by many professionals, but it is not integrated or collaborative in nature. Only two participants had access to a conventional interprofessional care team: one former organ transplant recipient who was receiving specialized team follow-up and one older adult who had been referred to an interprofessional outpatient senior health and wellness centre, staffed with gerontologists. Otherwise, these older adults were not benefiting from the safety and effectiveness outcomes of interprofessional care (Dahlke et al., Reference Dahlke, Meherali, Chambers, Freund-Heritage, Steil and Wagg2017; Gougeon et al., Reference Gougeon, Johnson and Morse2017; Johnson et al., Reference Johnson, Hermosura, Price and Gougeon2021). Although our participants had family physicians who could conceivably conduct comprehensive geriatric assessments and make early interventions and referrals related to domains such as mobility, cognition, mood, or nutrition (Mueller et al., Reference Mueller, Monod, Locatelli, Büla, Cornuz and Senn2018; Tatum III et al., Reference Tatum, Talebreza and Ross2018), such coordinated care is unavailable to older adults without a primary care provider.
Our findings indicate that team-based interprofessional care in primary care is not readily accessed by independent-living, relatively healthy, community-dwelling older adults. Depending on the Canadian jurisdiction, provincial governments support home and community care visits for acute and chronic illnesses, and these services can be multidisciplinary in nature, although also subject to collaborative challenges (Manns et al., Reference Manns, Hastings, Marchildon and Noseworthy2024; Song et al., Reference Song, Jung, Park, Hasnain and Gruss2023). As independent living becomes untenable, individuals admitted to assisted-living facilities or nursing home care may receive institutionalized team-based interprofessional care (Doornebosch et al., Reference Doornebosch, Smaling and Achterberg2022). Short of these channels, independent community-dwelling older adults are reliant on the multidisciplinary configuration of their family physician’s practice (e.g., embedded nurses, pharmacists) or referral to available special geriatric programs to access team-based interprofessional care (Aggarwal, Reference Aggarwal2022). In the meantime, certain older adults possess the means and motivation to act as self-advocates for their care and custodians of associated information. However, the absence of interactions between these non-medical and medical network members, especially the family physician, is concerning. While non-medical network members contribute significantly to older adult well-being, they were not typically involved in formal care at this stage of our participants’ lives. Non-medical caregivers, especially family members (Davidson et al., Reference Davidson, Zigori, Ball, Morgan, Gala and Reidlinger2023), are inevitably faced with assuming advocacy roles on behalf of the older adult, coupled with shifting relationship dynamics around their changing health and required support.
These findings underscore the importance of strengthening partnerships between formal care providers and the informal networks that surround older adults. For policy makers and care planners, the knowledge offers a reminder that aging-in-place often relies on the resources and capacities of families – resources that may not be equitably distributed across all populations. While existing literature has examined models of integrated care, few studies centre the everyday experiences of relatively healthy, community-dwelling older adults. Importantly, our sample reflected a degree of socioeconomic privilege that likely shaped participants’ ability to access both care and informal support. Future research would benefit from intentionally recruiting a more diverse participant base – across income levels, cultures, geographies, and caregiving structures – to better understand how systemic barriers may affect access. In the meantime, care systems must consider how to meaningfully engage health and social care professionals with one another, as well as families as collaborators in care. Mechanisms to communicate and share meaningful information beyond conventional professional dyads (e.g., family physician with the specialty physician or pharmacist) are necessary (McGregor et al., Reference McGregor, Ronald, Pollock, Berta and Curran2021). Health professional engagement with non-medical network members (Ho et al., Reference Ho, McGill, Malden, Wilson, Pearce, Kaner, Vines, Aujla, Lewis, Restocchi, Marshall and Guthrie2023) can include proactive conversations with older adults to identify and understand the contributions of these sources of network support and consideration of how they can be appropriately incorporated into information-sharing and decision making. Incorporating non-medical network members into care planning must be balanced with respect for older adults’ autonomy and confidentiality (Kim et al., Reference Kim, Wister, O’Dea, Mitchell, Li and Kadowaki2023). It is essential that any information-sharing or collaborative decision making processes are guided by the explicit consent of the older adult, ensuring that their preferences, privacy, and independence remain central to care coordination efforts.
Our study characterizes the networks of care in a relatively homogeneous population of older adults: mostly white, former professionals of middle-class socioeconomic status. We did not recruit older adults who could not communicate in English without a translator, and so, individuals of varied cultural backgrounds and networks are not represented. These individuals may have network members who engage differently in caregiving roles, potentially playing more active or culturally distinct roles in supporting older family members. Readers are encouraged to consider the descriptions of our setting and participants as well as procedures for data collection in order to make judgments regarding the transferability of our findings to their own particular contexts. Although the interviewing author was not in pharmacy practice, the study was conducted by researchers in a Faculty of Pharmaceutical Sciences, which could have had unknown effects on participant descriptions of pharmacist network relationships and roles.
Conclusion
Our study provides insight into the composition and characterization of independent community-dwelling older adults’ networks of care. While showcasing the important role of family members and the family physician, our findings highlight the dyadic relationships older adults form with health professionals in the absence of accessing formal team-based interprofessional care in primary care. Older adults reported little known collaboration between medical network members providing care and practically none between medical and non-medical network members. The independent community-dwelling older adult feels part of their team, but they were in fact referring to the discrete interactions with multiple individuals providing care in their network. A gap in accessing interprofessional care in primary care for independent community-dwelling older adults is evident, and the development and evaluation models of integrated care enabling collaboration between health care providers and non-medical members of the older adult support network are needed.
Acknowledgements
This project is one output of a larger collaborative work supported by a UBC Health, Health Innovation Funding Investment (HIFI) Award.
Open access
