Perspectives of Community Organizations on Clinical-Community Partnership to Address Social and Functional Needs of Older Adults

Background: Collaboration between health systems and community-based organizations is increasingly incentivized and adopted to address patients’ social determinants of health. The role of these partnerships, however, in addressing the social and functional needs of frail, older adults, is not well characterized.

Hypothesis: The primary objective of this qualitative study was to gain a greater understanding of community organizations’ perspectives in collaborating with health systems to address frail, older adults’ needs.

Methods: All organizations that provide social services to older adults (>60 years old) in Forsyth County, NC were eligible to participate in this qualitative study. We used snowball recruitment to identify additional eligible organizations. Organization representatives who completed an interview included staff members who were involved in the organization leadership and/or involved in organization programming. All interviews were digitally recorded, audio taped, and transcribed. We developed a coding scheme and used the constant comparative method to identify themes. We used a modified grounded theory approach to analyze the data.

Results: We invited 43 organizations to participate, of which 28 representatives from 22 distinct community organizations completed an interview. Of the interviewed organizations, 11 provide social services only, 5 provide functional/mobility assistance, and 6 provided both social and functional services. We identified 3 primary themes with additional subthemes. The 3 primary themes included:  1. the social and functional needs of frail, older adults are intertwined; 2. availability of community-based services does not translate into access; 3. intentional clinical-community partnerships could help address older adults’ needs. 

Conclusions: For frail, older adults, social and functional needs are often intertwined, as limitations in mobility can impact adults ability to address basic needs (e.g. food, social interaction) and limited economic resources can make it challenging to improve function (e.g. transportation). Health systems and community organizations have distinct areas of expertise, and purposeful collaboration between them could be important to meeting the social and functional needs of older adults.