Needs and expectations for improving management of chronic conditions in a multi-ethnic and low socio-economic community

Background: Managing chronic conditions such as diabetes or long COVID requires an integrated primary care approach due to its complexity which is exacerbated for culturally diverse and low socioeconomic communities.

Approach: We gathered information about needs and expectations for managing chronic conditions from  stakeholder and  community participants in a culturally diverse community in a low socioeconomic urban area in Australia. We engaged with 35 people living with or caring for people living with chronic conditions, as well as with 16 healthcare providers and stakeholders from the Community Primary Health Network through focus groups and semi-structured interviews. We undertook a thematic analysis and used a systems thinking lens to make sense of the themes.

Results: We identified five key activities associated with integrated primary care, and determined how these activities relate to one another to perform optimally and improve integrated care for managing chronic conditions. The five key activities were managing chronic conditions (by consumers and carers), providing medical care, social prescribing, supporting care, and coordinating care. By mapping needs to and from key activities, we identified gaps and barriers in the provision of community services. We found that the activity of coordinating care was centred around personal liaising between the different services to deliver care that met the needs and circumstances of the patient; the profile of the liaison person varied depending on the medical and social needs. A key finding was the need for coordinating primary care with welfare and wellbeing services, which involved identifying organisations serving the community and developing collaborative relationships with primary care health services. Another salient need identified by patients was sufficient time for being heard or listened to. One avenue for increased collaboration might be to co-design a space within an integrated health care centre for community, welfare organisations and support services to augment the centre and enhance the consumer experience of belonging to a community. Another key finding was the need for cultural matching between the consumer and the providers, whether clinicians or welfare and wellbeing services. This might be achieved by adding information about culture, language and modality of care preferences to the patient health record, together with service providers, and creating a matching recommendation system.

Implications: Improving integrated primary care for managing chronic conditions is a team endeavour which requires teaming within primary health care services and beyond with community welfare and wellbeing organisations. This requires a collaborative mindset and participatory leadership.