| Summary: | Introduction: Older adults tend to experience more chronic health conditions and disability and require a spectrum of supports to live independently in the community. A widely adopted approach to care coordination in both health care and social care sectors relies on case managers who work with individuals to help them access and coordinate services. As case management-based models continue to be key in many integrated care strategies, it is important to understand health and social care case management practices, including the factors that shape the work of coordinating across sectors. Methods: We used a case study approach to explore case management for older adults in two sectors in a large, urban health administration region in Ontario, Canada : i) home care (HC) case management, that coordinates publicly funded services (personal supports, nursing, professional therapists) and ii) community support services (CSS) case management, that deliver a range of subsidized and fee-for-service supports (housing with supports, meal delivery, socialization programs). Our findings are based on: i) a descriptive content analysis of regional and organizational-level strategies and guidelines for each sector’s case management programs, and ii) a descriptive and interpretive analysis of 33 qualitative interviews with case managers from HC and CSS. Results: In Ontario, the predominant narrative is the HC sector and the CSS sector occupy complementary roles in supporting older adults. Organizational efforts focus on inter-sectoral collaboration where HC case management is responsible for clients with higher medical acuity and CSS case management is responsible for clients with lower medical acuity. Overall, case managers from both sectors acknowledge a division of responsibility based on medical acuity. However, case managers from both sectors describe challenges in this arrangement. Case managers from HC describe working with clients who are ‘high’ needs but require types of supports that are not publicly funded and oftentimes these clients are referred to CSS. Case managers from CSS describe working with ‘high’ needs clients who need access to HC services. Discussion: This study illuminates the challenges to accessing and coordinating care in a policy context where individuals are entitled to medically-orientated services but lack the same entitlements for socially-orientated services. While practice models assume there is seamless collaboration between sectors, our study suggests this arrangement does not take into account clients with needs that fall outside a health care entitlement framework but are important to living independently in the community. Conclusions: Case management practice in community settings is highly influenced by the divide in health care versus social care entitlement policies. Meaningful integration between sectors can only occur when health and well-being imperatives drive policy rather than treating medical conditions. Lessons learned: Sectors and services should be organized around the needs of individuals rather than the need to delineate organizational roles and responsibilities. Limitations: The client and caregiver perspective was not studied; thus, limits triangulation of the findings. Future research: Futures studies on case management in the community could include other community based sectors, such as mental health and addictions and primary health care.
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