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Since its first issue in 1986 the Social Services Research Group’s journal Research Policy and Planning has been one of the key research journals in the personal social services.

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Quality of Life of Older Persons: The Role and Challenges of Social Services Providers

Mihaela ghenţa.

1 National Scientific Research Institute for Labour and Social Protection (INCSMPS), 010643 Bucharest, Romania; [email protected] (A.M.); moc.liamtoh@nedalmesiul (L.M.-M.)

Aniela Matei

Luise mladen-macovei, simona stănescu.

2 Research Institute for Quality of Life (ICCV), 050711 Bucharest, Romania; moc.oohay@acinov_anomis

Associated Data

Not applicable.

Considering the growing number of older persons, ensuring the quality of life of them, as well as the social services designed for this population category, has become more and more important. Especially in the case of dependent older persons, social services are essential components, as they contribute to a better quality of life. The aim of this paper was to examine the perspectives of social services providers for older persons with respect to their role and the challenges encountered in ensuring the quality of life of older beneficiaries. In order to answer our objectives, we employed a qualitative methodology, using the focus group method to collect information from social services providers (both residential and home care). Multiple factors are related to a good quality of life in old age: some are related to individual characteristics, while others are related to the provision of services. The provision of quality social services that adequately respond to the needs of beneficiaries contributes to increasing the degree of independence and maintaining the physical and mental health of dependent older persons.

1. Introduction

The share of the population aged 65 and over has continuously increased in recent years in Romania, from 17% in 2015 to 19.3% in 2021, and that of people aged 80 and over has increased in the same period from 4.1% to 4.8% [ 1 ]. Romania is expected to have 4.1 million people 65 years or older by 2035 and 4.5 million by 2050, accounting for 23.3% and 27.7% of the total population, respectively [ 2 ].

In 2019, life expectancy in Romania at age 65 for men was 14.9 years (compared to 18.3 years in the European Union) and 18.6 years for women (compared to 21.8 years in the European Union). However, in 2019, healthy life expectancy at age 65 was lower for both sexes: 6.7 years for men (10.2 years in the European Union) and 6.5 years for women (10.4 years in the European Union), resulting in a greater need for adequate social services to meet higher care needs [ 1 ]. At the European level, almost 50% of people 65 years or older reported long-term restrictions in daily activities, whereas more than two-thirds reported physical or sensory functional limitations [ 3 ]. Nevertheless, Romania allocates only 0.31% of its GDP to long-term care, compared to the 1.6% EU average [ 1 ]. Providing long-term, good quality care services that are integrated, people-centered, and properly managed is the right step for ensuring healthy lives and well-being in old age [ 4 ]. The difficulties older persons experience have been exacerbated due to the COVID-19 pandemic. Older persons have been recognized as the most vulnerable category of the population, and the need for policy measures directly targeted to them has thus became more necessary in this period [ 5 ].

Considering the current situation, the aim of this article is to examine the perspective of social services providers with regard to their role and the challenges encountered in ensuring the quality of life of older beneficiaries. The objectives of the research were: (1) to explore the opinions of social services providers with regard to their contribution to the quality of life of beneficiaries; (2) to highlight the views of social services providers in terms of their contribution to quality of care (autonomy and independence of older persons, freedom of decision, control, sense of security and respect for privacy, communication, and social interactions); and (3) to identify the difficulties experienced in the services delivery process.

1.1. Social Services for Older People Living in Romania

In Romania, social services addressed to older people are provided by both public and private social services providers (associations, foundations, cults recognized by law), and are offered on a residential or non-residential basis. The first category of services includes care and assistance centers for older people, such as nursing homes, respite/crisis centers, and sheltered housing, as well as residential care and medical-social assistance centers. The second category of services includes home care units and day centers for older persons, such as day and recovery centers and day centers for socializing and leisure.

Within the current social protection system, older people have the right to social assistance in relation to their social and medical status and the economic resources (income, assets, etc.) they possess. The legal framework stipulates that decisions regarding admitting an older person to a residential center are made considering the following priority criteria: if the person requires special permanent medical care, which cannot be provided at home; if the person cannot manage on his/her own, is without legal supporters, or is unable to fulfill their obligations due to their health or economic situation and family responsibilities; if the person has no home and no income of his/her own. However, home care and keeping older people in their living environments are much more suitable for those in difficulty, with these measures having a multitude of benefits [ 6 ].

The field of social services is still poorly developed at the national level, with the number of accredited providers and licensed services being quite small compared to existing needs. The geographical coverage of these services is not balanced, with a higher concentration of providers in urban areas and in more developed counties [ 5 , 7 ]. The main source of funding for social services is the local budget, so the number and quality of social services for the elderly are highly dependent on the financial capacity of the administrative-territorial units [ 8 ]. The financing of social services is also derived from the contribution of the beneficiary and/or their family, from the state budget, as well as from other sources. The local public administration authorities finance the public social services under their authority. The rest of the social services are financed by contracts awarded through public procurement or by grants or subsidies. The standard cost of personal home care services varied in 2020 between 3225 EUR (15,600 RON) and 6450 EUR (31,200 RON) per year, and of residential social services for the elderly between 5321 EUR (25,738 RON) and 10,451 EUR (50,554 RON) per year, according to the degree of dependence in which the person is included [ 9 ]. In the same year (2020), the annual average pension for old age was 4061 EUR (19,644 RON) [ 10 ], and 24.5% of older persons aged 65 and over—22.3% of pensioners—were at risk of poverty [ 1 ].

Access to social services for older people is essential due to their specific needs, and offers them a dignified life. The quality of social services provided to these people is reflected in their quality of life. It can be stated that the quality of life of older people is closely linked to the social protection system and the quality of social services they receive [ 11 ].

1.2. Quality of Life of Older Persons in Home and Residential Services

Quality of life is a complex, multifaceted concept, having several components that interact simultaneously: objective, subjective, macro-societal, micro-individual, positive and negative components [ 12 , 13 , 14 ]. The macro- (societal, objective) component refers to the roles of income, employment, housing, education, and other living and environmental circumstances, while the micro- (individual, subjective) component considers perceptions of overall quality of life, individuals’ experiences and values, and related proxy indicators such as well-being, happiness, and life satisfaction [ 15 ].

Despite the growth in scientific inquiry regarding quality of life, there is no generally accepted definition of the concept or a way to measure it [ 12 ]. Quality of life in old age and well-being are more often associated with good health and functional ability, a sense of personal adequacy or usefulness, social participation, intergenerational family relationships, the availability of friends and social support, and socioeconomic status [ 16 , 17 , 18 ]. However, quality of life in old age often differs between various groups of older people [ 19 , 20 ]. For example, there are differences in perceptions between older people living in the community and older people in institutional care. The former values more social integration and the latter, the quality of the environment. Additionally, for older people in institutional environments, their significant priorities are in control over their lives, the structure of the day, a sense of self, activities, and relationships with staff and other residents [ 21 ].

A number of studies have focused on diverse quality of life issues of older people in residential care homes. The body of literature reveals that quality of life of these persons is greatly determined by their independence, individuality, and autonomy. It is also influenced by the quality of residential care and facilities [ 22 ]. Duncan-Myers and Huebner [ 23 ] identified a strong positive correlation between improved quality of life of older people and increased frequency of choices available to them in self-care and leisure activities. An important aim is to help older people in residential care to maintain self-control of their lives and care. People who have more independence in performing activities of daily living (ADL) and instrumental activities of daily living (IADL) have reported better quality of life [ 24 ]. Studies have also found a significant impact of social health on the quality of life of older people in residential care homes. Social factors, including socio-economic status, perceived social support from caregivers, and frequency of interactions with family have been reported as predictors of quality of life of older people in residential care facilities [ 25 ]. Institutionalization is a stressful experience for older people, having a detrimental impact on their physical and psychosocial well-being. Environmental modification in the sense of promoting a home-like physical and social atmosphere, autonomy, and individuality is seen to be beneficial for older people in residential care homes [ 22 ].

Research has also focused on the analysis of the quality of life of older people receiving community-based care. Large-scale studies indicate that the level, maintenance, and development of high-quality social support networks contribute to improved quality of life [ 26 , 27 ]. Older adults’ social networks could provide access to support and assistance from family members, neighbors, friends, and service providers. This type of support is essential and is related to older adults’ perception of control and improved well-being [ 27 ]. Studies detail that social participation opportunities and provision of care services that meet older adults’ needs are associated with higher quality of life [ 28 ].

The growth in the older population has contributed to an increased demand for social services that are cost neutral and that maximize the quality of life of beneficiaries [ 29 , 30 , 31 ]. Quality of life has become a standard measure of long-term care services outcomes [ 29 , 30 , 31 , 32 , 33 ]. Care homes could be an important part of caring for older dependent people. Despite this, across all cultures, up to 90% of older adults prefer to remain in their own homes for as long as they can [ 34 ]. The trend at the European level is to move from an institutional care system to a system that provides care for older people in a more familiar environment, i.e., at home. Existing studies have found that older people enjoy a higher quality of life if they remain in their home receiving the care they need than if they live in a residential care institution [ 22 , 35 , 36 , 37 , 38 ].

Other studies have not found differences in the quality of life between institutionalized older people and non-institutionalized ones [ 39 ]. At the same time, some studies have shown positive aspects of institutionalization, such as adherence to pharmacotherapy, improvement in social life, easing of depressive symptoms, and participation in leisure activities that benefit locomotion [ 40 ].

Irrespective of the type of social services, the quality of life of dependent older people is a difficult issue to manage, especially where there is no family support in the physical proximity of the older person, as in the case of transnational families [ 41 ], which changes the paradigm of understanding the family based on the idea of co-residence and physical unity [ 42 ]. Migration causes the spatial separation of families, with the care of dependent elderly people left behind in their home countries being a real challenge for members of transnational families, as shown by the studies conducted on this topic [ 43 , 44 , 45 , 46 , 47 ]. Although migration does not make mutual care obligations and expectations disappear, members of transnational families usually involved in different types of transnational care of relatives who remain in their countries of origin encounter difficulties in fulfilling their roles in the absence of a well-developed long-term care system in the home country. The forms of care provided by members of transnational families for dependent relatives left behind also depend on cultural norms that define the duties of the younger generation towards senior family members.

2. Materials and Methods

2.1. conceptual framework.

Studies in the field have identified, as the main determinants of quality of life in old age, psychological/emotional aspects (life expectations, acceptance of physical dependence), health (mobility, functional autonomy), social participation and social support (involvement in social, cultural, religious activities), social capital (relationships with family, friends, other residents), and the feeling of security [ 18 , 48 , 49 , 50 , 51 , 52 , 53 ]. A qualitative methodology was developed starting from this conceptual scheme that refers to general determinants of quality of life in order to generate information on the specific determinants of the quality of life of dependent elderly people in Romania. The qualitative methodology offers a research tool that enables the understanding of the complexity of the phenomenon of quality of life of dependent elderly people in Romania, measured from the perspective of social services providers involved in managing the phenomenon [ 54 , 55 ].

2.2. Study Area

The qualitative methodology developed by the research team was applied in eight focus groups organized in each of the eight development regions of Romania, participants in these focus groups being public and private providers of social services with and without accommodation for dependent older persons. According to the nomenclature of social services in Romania, accommodation services include social services provided in homes for the elderly—8730 CR-VI; respite centers—8730 CR-V-II; sheltered housing—8730 CR-V-III; services without accommodation, which include social services provided in day care and recovery centers—8810 CZ-VI; and home care units—8810 ID-I. The situation of participation in regional focus groups is presented in Appendix A .

2.3. Method, Recruitment, Data Collection, and Analysis

The authors developed a focus group guide within this qualitative methodology, with the conceptual dimensions of the research tool relying on scientific literature in the field. The focus group technique enables, through interactions with respondents, the development of a discussion about a topic [ 48 , 52 , 53 ]. Analysis of the information gathered enables the identification and study of the social meaning of the studied topic [ 7 , 56 ].

The study was carried out between May and June 2019. As the data collection occurred before 2020, the analysis provides a picture of the determinants of the quality of life of older persons in social services just before the COVID-19 pandemic. The sample size took into account the aim of the research, the sample specificity, and analysis strategy [ 57 ] (p. 402). Theoretical sampling was used in the selection of participants in the focus group, the main selection criterion being the relevance of the investigation unit for the research objectives. In the case of our research, the relevance of the investigation units was given by the information they have about the quality of life of the elderly [ 58 ]. The public and private providers that participated in the focus groups were selected from those included in the Single Electronic Register of Social Services provided by the Romanian Ministry of Labor and Social Justice (MMJS) in January 2019.

The tool used (focus group guide) addressed the following topics: (1) quality of life of dependent older people in Romania; (2) autonomy and independence, quality assurance of care; (3) freedom of decision, control, sense of security, and respect for privacy; (4) communication and social interactions, social participation/activities carried out ( Table 1 ).

Dimensions and indicators operationalized in the focus group guide.

Source: developed by authors.

Each focus group session lasted 60–90 min, was conducted by a moderator and an observer, and was digitally recorded with the participant’s oral consent [ 53 , 55 ]. All the social services providers for the elderly received an e-mail with an invitation to participate in the research. Social services providers willing to participate in the research appointed a person to participate in a focus group. Following this, informed consent was obtained from all participants of each focus group, and this consent was audio recorded.

The research team used the qualitative research software NVivo12Pro to record and manage the data ( Table 2 ). After all the focus groups’ data were transcribed, the transcripts were analyzed following the principles of thematic analysis, which reveals the content of and meanings behind patterns (themes) present across entire data sets [ 59 ]. The coding was conducted in two phases. In the first phase, two researchers assigned independently all the responses to each theme of the focus group guide. Inconsistencies in text coding between the two researchers were reviewed and refined after another revision of the transcripts and audio recordings. In the second phase, analyses of results were jointly conducted by all authors. As the participants of the focus group discussions were professionals nominated by each nationally accredited social services provider for the elderly that agreed to participate in the research; therefore, a good degree of credibility of the results can be assumed. Text passages are presented in the Results section by type of service and development region (Bucharest Ilfov, BI; Centre, C; East, E; Nord West, NW; South Muntenia, SM; South East, SE; South-West, SW; West, W).

Phases of data analysis.

3.1. Quality of Life of Dependent Older People in Romania

3.1.1. factors (positive/negative) that influence the quality of life of dependent older people.

The quality of life of dependent older people was defined by social services providers as meeting the daily needs of dignified care and proper access to various forms of support or to social services. Quality of life implies the ability of each person to satisfy his/her needs and to have access to medical services and social activities adequate to their health status.

“In general, the quality of life requires at least a satisfactory degree of fulfillment of a person’s specific needs, in our case semi-dependent or dependent older people.” (Residential care provider, BI.)

“First of all, the older person must have a permanent connection with the family doctor, the caregiver must take care of the older person’s scheduling and medical assistance. At home, personal hygiene is needed as much as possible, the older person must have a social life, if possible.” (Home care provider, SE.)

Social services providers considered that the main positive factors with an influence on the quality of life of older dependent persons that are receiving home or residential care were related mainly to income level, health status, and access to healthcare services, while the negative factors were related to health status, the ability to move independently, and relationships with family members ( Table 3 ).

Factors influencing the quality of life of older dependent persons.

In the case of home care services, the social services providers mentioned the risk of inadequate care despite the good intentions of the caregiver. Residential care was considered to be able to contribute to a better quality of life for dependent elderly people, as it facilitates access to adequate medication, staff, and medical care despite the social stigma associated with the institutionalization of older family members. The main disadvantage mentioned for home care services was the inability to respond positively to all the needs that an elderly person in home care has.

“ I think that the whole of society needs an education in this regard, which is why those who are at home suffer. Because of some mentality, a poor education, to do things in such a way as to reconcile society more than the older person in need. They come and say: I can’t take my mother or my father to a nursing home! What will my neighbors say?” (Residential care provider, C.)

“ They should have access to quality medical services, including an ambulance that fails to arrive.” (Home care provider, BI.)

In the case of residential social services, occupational therapy can positively contribute to a better quality of life for the elderly. It involves the provider access to different types of activities that give the beneficiary a feeling of freedom and sense of utility, and that fosters connections with the previous life and occupations of the beneficiary.

“ Occupational therapy helps a lot. The vast majority of the elderly who, at some point, end up accessing residential social services, want to continue the activities that they were taught and used to do.” (Residential care provider, SM.)

Communication and the involvement in different social activities improve the quality of life of older dependent persons and reduce social isolation in old age, but the scarcity of occupational therapists, physiotherapists, and psychologists is common with both residential and home care providers, and it is felt especially in small towns and rural areas.

For beneficiaries that have good relationships with family members, the effects are positive in regard to their emotional status and sense of belonging.

“ There were cases where grandchildren, uncles, and aunts came. The fact that they came is good. Older persons may have dementia, but you can talk to most of them and they know they have a family. It’s something that improves their daily mood.” (Residential care provider, W.)

Intergenerational activities provide the opportunity for older dependent persons to feel part of the community again, to exchange experiences and knowledge and to feel valued.

“Collaboration between generations is very important. Older people enjoy exchanging information with younger people, children, and teenagers.” (Home care provider, C.)

In terms of negative factors, the quality of care is limited by the available resources of providers and the time that human resources have at their disposal.

“And the services are not easy to provide, the nursing job is hard, difficult … it requires a lot of physical effort and mental consumption … and you end up being over-saturated in all respects … burnout.” (Residential care provider, NW.)

Last but not least, bureaucratic requirements directly diminish the ability of providers (irrespective to where the services are provided) to respond to the needs of beneficiaries.

“ I have to be available if the institution hires me and has 300 beneficiaries. I, a social worker, have to be available to prepare the files and you don’t want to know what a medical-social file means to be prepared, right? Or, when the ministry comes for an inspection and controls the paperwork, it’s extremely messy. A bunch of documents that from my point of view, forgive me … are made in vain. I don’t see the point … except that we cut down trees and throw them away, and the beneficiary receives what? My frustrations, his unresolved frustrations … […] The time allotted to the beneficiary is then shortened.” (Home care provider, BI.)

Other negative factors pointed out by the social services providers were related to the difficulty of meeting the quality requirements set in the national standards of quality for social services, the lack of adequate financial resources, the lack of specialized staff, and the changes to the legal framework in the field of social assistance.

3.1.2. The Impact of Social Services on Quality of Life

The provision of appropriate social services that adequately respond to the needs of beneficiaries, directly contribute to an increased degree of independence and maintenance of their physical and mental health was reported as being beneficial.

“The existence of the social service itself is beneficial for dependent and semi-dependent older persons.” (Home care provider, BI.)

Cases of significant improvement in health following residential care were reported. Meanwhile, for home care provided by untrained informal carers or family members, cases when the beneficiary’s level of dependence was accentuated despite good intentions were noted.

“We had positive results when they came on a cart or in bed and then they managed to walk without a cane.” (Residential care provider, SM.)

In the case of home care, the lack of human resources and services (e.g., personal hygiene), difficulties in complying with medication on time by the beneficiary, and the positive impact of social visits to the dependent elderly person were also mentioned.

Social services providers emphasized the importance of assessing the quality of social services provided in order to improve, diversify, and adapt them as best as possible to meet the needs of beneficiaries. Consultation with both beneficiaries and their relatives were taken into account. However, the bureaucracy related to admission into social services was cited as a barrier. Another problem faced by residential centers is the difficulty of managing the presence in the same home of dependent but mentally healthy elderly people and those with dementia (including persons over 20 years old diagnosed with autism).

Social services providers appreciated that a first direction is the continuous improvement of the quality of social services offered through individualization instead of diversification. Financial incentives for existing staff and the identification of ways to attract a young and skilled labor force could cover the necessary human resources.

Other areas mentioned were collaboration with medical staff, the local community, and volunteers (including older persons) and the development of national public information and awareness campaigns about the social services available for dependent older people. The possibility to visit residential centers and access direct information could allow for the overcoming of stereotypes related to the abandonment of older family members in residential settings. The development of such national education programs would allow for the provision of social services in residential centers or at home in time, preventively not at the moment when a person’s health status is far too deteriorated to be remedied.

The impact of social services on the quality of life of dependent older people is constantly measured through questionnaires, observations, activities carried out, and discussions whenever necessary. Measuring the influence of the quality of care on the quality of life of beneficiaries is requested within the national quality standards. In the present study, social services providers were concerned with overcoming the formal level of completing the questionnaire and identifying those issues that may contribute to a better quality of life of beneficiaries. In this respect, the information obtained from the beneficiaries was correlated with that obtained from the assigned staff and subjected to discussions in the team meetings.

3.2. Autonomy and Independence; Quality Assurance of Care

Within this dimension, the beneficiary’s ability to carry out basic activities of daily living, dependency, and mobility and their level of vitality were taken into account.

3.2.1. The Role of Social Services in Maintaining the Independence of Older People

Social services providers reported that concerns for the preservation of the functional autonomy of beneficiaries was the main aim of their activity. A first obstacle in this regard is the number of and the training of the human resources involved.

Social services contribute to the improvement of the quality of life of older person, as they cover activities of daily living that can no longer be carried out by the person. Moreover, in the case of residential centers, an older person has access to adequate health care and specialized staff trained to support the older person in maintaining a level of autonomy and independence.

“ I have found that at home, even if people are hired to take care of them, they are untrained. We have seen cases in which they have turned a semi-dependent person into a completely dependent person. Why? Because it’s very convenient to change a diaper. That person should stay in bed, calm, quiet and why waste time with mobilization?! And so it turns a semi-dependent people into a totally dependent people, through the care they provide. Their degree of independence has increased because we do physical therapy, we do treatment, we monitor, plus they socialize very well and there are also rules that they would not follow at home. At home they are very comfortable, at home they are used to taboos. Here, they are willing to accept rules that we are aware of and convinced that are to their advantage.” (Residential care provider, SW.)

In the case of residential services, due to the advanced state of dependence at admission, in many cases, the provider does not necessarily aim to improve the autonomy of the person through the services they offer, but rather to lower the process of physical or mental degradation, while taking into account the pathology of each person.

“When they get to a residential center, they find themselves cared for, nothing bad can happen to them. After a certain period of time of accommodation, they enter into a certain routine and everything is okay for them, no matter how sick they may be, especially in cases of dementia. They feel protected that nothing can happen to them, there is immediately someone next to them who helps them when needed, they enter a certain stage, the evolution is very slow, with the exception of the compensations that appear later due to other reasons.” (Residential care provider, SW.)

The involvement of beneficiaries in maintaining a degree of functional autonomy depends on their mental state, their degree of awareness with regard to their health status, the accessibility of the living environment, their feelings of trust in their care staff and their existence, as well as the involvement of family members.

Social services providers reported that the majority of beneficiaries were concerned with maintaining functional autonomy, especially in the case of home care beneficiaries where there are not always people available to help. These beneficiaries were characterized as healthier, more open to interaction, balanced, smiling, well-disposed, and able to decide on their own whether to move to a residential center.

Residential social services providers mentioned a number of autonomous activities that the elderly carry out: personal hygiene, serving meals, caring for plants, participating in various activities within the residential center (library, meetings) and community (church). In the case of those cared for at home, the following were mentioned: small walks in the park, shopping, and going to the market.

In addition to the social services provided, participants mentioned other types of services, which the beneficiaries request in order to maintain functional autonomy: prostheses, orthoses, hearing aids, and dental services and implants.

3.2.2. The Role of Dependent Older People/Legal/Conventional Representatives in Improving the Quality of Care

Beneficiaries, their families, or other legal representatives may influence the quality of care. In some cases, family involvement has positive effects on the well-being of the dependent older person, and these benefits were pointed out by both home care and residential services providers.

“The efforts of the team no longer lead to the same result, to the same quality of service, to the same degree of satisfaction for the beneficiary and the same quality no longer reaches the beneficiary.” (Residential care provider, SM.)

Participants in focus group discussions reported that semi-dependent older people are more interested in maintaining their level of autonomy. In the case of people with various cognitive pathologies, their interest in maintaining good physical health was reported as being rather low.

“It depends on the disease and how aware they are of this. Often there are certain relatives who make the decision on their behalf, especially in cases of dementia…. Many do not have the necessary will. It matters a lot! If they don’t get involved, you have no results. You need to find the ways to show them that what you are doing is for their own benefit! It takes a lot of patience and involvement!” (Residential care provider, SW.)

Maintaining the autonomy and independence of beneficiaries is a major concern among older people who are in a better emotional state, whether they receive home care or residential care. The participants mentioned that those persons who have a daily life schedule, with regular activities, are more interested in maintaining their autonomy and independence. The involvement of family members in providing services helps to improve the older person’s emotional state and is often essential.

“I say that it is very important to involve the family in everything you do. I had people who were in bed and benefited from this collaboration between the family and the organization.” (Residential care provider, C.)

3.3. Freedom of Decision, Control, Sense of Security, and Respect for Privacy

3.3.1. freedom of decision regarding the type of care.

Freedom of decision is limited by the degree of dependence (physical and mental) of each person, the social services available, the area of residence (rural or urban), and last but not least, the available financial resources.

“And mental health, depending on each individual, the social situation in which they are… And secondly, the range of social services within the region or within the community. In rural areas they are non-existent.” (Residential care provider, SM.)

Freedom of decision is also limited by the lack of information about available services that an older person can access.

“Unfortunately, this freedom of decision does not exist as it should, because even if they want a specific service, they want a specific care … they can’t find it or don’t know where to look for it.” (Home care provider, BI.)

Family members also perform an important role in choosing the social services for dependent older people, as the costs associated with such services are often supported by them.

“There are extraordinary differences and the family says: up to here, up to the money.” (Residential care provider, SM.)

According to social services providers, the decisions of beneficiaries are respected, and they take into account the characteristics of the social services provider. However, the spectrum of services from which dependent older people can decide is limited.

According to the social services providers, collaboration with beneficiaries and family members is vital in ensuring the quality of care, irrespective of where the social services are provided (at home or in a residential setting). Reduced understanding of the limits of social services provision both by beneficiaries and relatives leads to unrealistic expectations and even tensions.

The quality of life of beneficiaries is also influenced by the way in which connections with the human resources involved in care are built. The skills reported as necessary to perform the tasks of care were professional skills and the ability to manage difficult situations. Due to the specific nature of caring for dependent elderly people, some employees decide not to stay (even after care experiences abroad) and some volunteers do not continue their activity. Another problem is the ageing of the care staff, which reduces their physical capacity to manage certain situations that appear during the care process.

3.3.2. Safety of Social Services Provided

According to social services providers, when beneficiaries consider that their personal safety is endangered, written complaints are addressed to the authorities in charge. Social services providers also emphasized their compliance with standard protocols and procedures (strict guidelines for medication and care, evaluation, and monitoring visits). A positive image of care staff in the eyes of beneficiaries is important in a good care process.

“Procedures should be followed ad literam. If you have a procedure, you follow it. […] Where there is a lack of procedure, there is chaos.” (Home care provider, BI.)

With regard to the security felt by beneficiaries during the provision of services, the order and the daily routine of care can provide them with a feeling of security. Safety in the provision of social services requires the existence of qualified staff, continuous collaboration between the members of the provider’s team, and control and supervision over the way in which the care is provided by the staff.

“First of all, continuous surveillance. They keep going to the sick persons and observe them. I don’t know how home caregivers cope because the condition of an elderly person can be so misleading. They might be fine now and then fall on their feet in five minutes.” (Residential care provider, C.)

3.3.3. Respect for Privacy

Respect for the privacy of a dependent elderly person is important regardless of where the services are provided, the provider having the responsibility to ensure the training of staff in this regard. A first step in this delicate process is to understand the meaning of privacy for a dependent person. The patience and training of the care staff influence the way in which beneficiaries perceive that their privacy is respected.

“You shouldn’t ask him more than he wants and can give you as information. You have to have some limits. If he doesn’t want to tell you more, you don’t insist upon asking annoying questions.” (Home care provider, BI.)

Representatives of residential social services and home care providers reported that care for the safety of a beneficiary is ensured by following the standard procedures of caregivers. Respecting the privacy of an elderly person implies respect for his/her religious beliefs, and in the case of home care services, it is important to respect the wishes of and restrictions imposed by the person during the provision of services.

“The person’s privacy package, the bedside table where the person has their personal belongings, in the immediate vicinity of the bed there are icons or photos from their youth, indicating their desire to arrange their own corner.” (Residential care provider, SM.)

3.4. Communication and Social Interactions, Social Participation/Activities Carried Out

3.4.1. the importance of social interaction activities.

Providers of social care services for dependent elderly people reported that they appreciate that communication and involvement in social activities are important. In the case of residential social services, the frequency of social activities depends on a number of factors, such as the availability of human resources, the occasion for which they are organized, available income, the health state of beneficiaries, and their willingness to engage. In the case of home care services, involvement in social activities depends on the level of autonomy of each person. Carrying out such activities changes the mood of beneficiaries and maintains good emotional well-being.

“They want to have someone to talk to, to have someone to socialize with. Not to feel alone, not to fall into a depression, not to feel insignificant in this world.” (Residential care provider, NW.)

Social services providers noted that care staff are ready to support elderly beneficiaries’ involvement in social activities. The involvement of human resources depends on the level of professional training and of personal skills. Compliance with internal regulations supports the development of care. From this perspective, the high load of care staff and the involvement of volunteers were mentioned.

Residential social services providers mentioned a wide range of activities: art courses (painting on canvas and glass), sports activities (dancing, table tennis, cycling in the yard), activities organized within the center (folk performances, marching bands, songs and poetry, counseling on various topics, meeting with the priest, visits to the chapel, and involvement in culinary activities), other leisure activities (choir, karaoke, rummy, chess, backgammon, watching movies, prayer in the chapel of the residential center), and trips outside the home (walks, pilgrimages, going to church, watching shows or movies, short visits to home or relatives). Participation in mountain or sea trips depends both on a beneficiary’s ability to travel independently and logistical aspects specific to transport (e.g., covering the costs involved). In the case of beneficiaries cared for at home, they may be accompanied to carry out various activities. Within the focus group discussions, there were representatives of social services providers who stated that they managed to collaborate with different private organizations in organizing trips for dependent older people.

Regarding the interaction of dependent elderly people with other categories of people outside the organization, social services providers mentioned: relatives, friends, community members, and neighbors (in the case of rural areas).

3.4.2. Factors Limiting the Social Participation of the Elderly

In the opinion of social services providers, the factors that limit the participation of dependent elderly people in social activities are: the existence of different health problems (including depression), their limited physical capacity, their previous social status, their previous lifestyle, their interest in involvement in social activities, the characteristics of those with whom they would interact, the attitude of the community towards them, their income level and, last but not least, solving the various logistical aspects related to the organization of such activities (ensuring private transportation means, difficulties in accessing accessible public transport means, availability of staff, etc.). Representatives of social services providers emphasized the importance of permanent supervision when traveling outside the center in order to avoid walking difficulties and falls. Often, the authorized attendant is a family member or a trusted person who can ensure the physical safety of the elderly person while traveling.

3.4.3. The Attitude of the Elderly towards IT Technology

Regarding the attitude of dependent elderly people towards modern means of communication, social services providers reported that beneficiaries are interested in using the Internet and electronic devices related to the field of information technology. Communication and social applications (e.g., Skype, Facebook, email, WhatsApp) are used on various devices (e.g., smartphones, tablets, laptops, and computers). Beneficiaries’ families perform a major procurement and learning role in older people’s accessing and using modern means of communication. Older persons communicate with family members (especially when their children are abroad), receive photos, read the press, search for various information on the Internet, and shop online. Computer rooms are available in some centers. However, not all elderly people are technologically connected in this way. Those who have various mental illnesses are neither interested in nor able to access IT technology. One of the beneficiaries of social services at home interviewed had only a landline phone. Difficulties were also mentioned regarding the use of mobile phones (e.g., abandonment or blocking of telephones, loss of chargers, etc.), cases in which relatives call the care staff for help.

4. Discussion

4.1. limitations of the research.

Some limitations of the present study can be highlighted. The main limitation was that it explored the meaning and the determinants of the quality of life of older persons from the perspective of providers, reflecting only one facet of the issue. Another limitation of the study was that providers of residential services were greater in number compared to home care providers, and thus a less comprehensive picture for understanding the influences of social services on the quality of life of beneficiaries resulted. However, this study contributes to a better understanding of the role of social services providers in ensuring the quality of life of dependent older beneficiaries of social services, and these results could also serve as an evidence base to improve policies regarding older persons.

4.2. Suggestions for Services and Policy

This study presents the roles involved and challenges encountered in ensuring the quality of life of older beneficiaries. Our findings revealed aspects related to the objective quality of life of older dependent persons, quality of care, freedom of decision, control, sense of security, respect for privacy, the role of communication and social interactions, and social participation/activities.

With respect to the quality of life , previous studies [ 60 ] outlined objective measures of quality of life that support social policies and programs (and thus a better adequacy of the social services to meet the needs of older beneficiaries), as they capture the effects of such interventions. Other studies [ 61 ] argued that objective measures do not reveal the individual perspective. However, the assessment of quality of life cannot remain a purely subjective matter, especially when it is used in a particular social policy context [ 12 , 56 , 62 ], being one of the most important objectives in caring for older persons [ 63 ]. Quality of life of dependent older persons is related to the ability of each person to be able to satisfy their needs and have access to social and health services; it also includes attention to their emotional state.

Multiple positive factors were pointed by the participants as being related to a good quality of life in old age: an adequate level of income, a healthy lifestyle, access to necessary and affordable healthcare services, good relationships with family members, and involvement in social activities. Participants highlighted certain advantages of residential care compared to home care, for instance, despite their good intentions, family caregivers do not possess the knowledge to provide adequate care. These findings suggest the need for the training and education of caregivers and family members using various methods (video, the Internet, etc.) to inform and train them on how to perform caring tasks, as other studies related to older persons have concluded [ 64 ]. Existing studies have highlighted that the COVID-19 pandemic increased the care burden of older people’s family members [ 65 , 66 ]. In our study, residential care was found to contribute to a better quality of life for dependent elderly people, as it facilitates access to adequate medication, staff, and medical care. In other studies, the results suggested that elderly residents are more likely to experience a deterioration in quality of life due to changes in their living conditions, impaired health, reduced functional autonomy, and decreased social interactions [ 22 , 67 ].

Factors with a negative impact on the quality of life relate to the physical and mental health of older persons, the characteristics of their environment, and the limited availability of social services, especially in small towns and rural areas. Adequate and trained social and healthcare professionals are essential to ensure the quality of care and to prevent the risk of burnout or abusive care practices in caring for the elderly. Our findings are consistent with studies that suggest the negative impact of burnout on the level of stress of staff [ 68 ], as well as the quality of care [ 8 , 69 ].

The providers’ preservation of the functional autonomy of beneficiaries was reported as the main aim of their occupation, and this implies both the effort of professionals, beneficiaries, and family members. The influence of the quality of care on the quality of life of beneficiaries is under constant monitoring, and the involvement of older persons and families in the care process is a constant measure for the quality of services delivered (at home or in a setting), as well as for the quality of life of beneficiaries. The process of service delivery becomes an important indicator for outcomes in terms of satisfaction with quality of life of beneficiaries [ 11 , 70 ].

Communication and social participation improve the quality of life of older dependent persons and reduce social isolation in old age, but the scarcity of occupational therapists, physiotherapists, and psychologists is common to both residential and home care providers. The results in this study are consistent with previous national and international studies [ 11 , 63 ], according to which social participation has proven to be an important explanatory factor for the quality of life of the elderly. Providers argued that social interactions with family and the community maintain and improve the emotional well-being of older persons, as other studies proved [ 71 , 72 ].

5. Conclusions

This study shows that quality of life of older beneficiaries of social services is an important aspect that gives sense and meaning to social services provision for older persons. Our results point to the convergent opinions of providers with respect to the understanding of the quality of life of older dependent persons. Multiple positive factors were pointed out by the providers as being related to a good quality of life in old age: some of the factors are related to individual characteristics, while some of them are related to services provision. Access to necessary and affordable healthcare services is a factor that positively impacts the quality of life. The provision of quality social services that adequately respond to the needs of beneficiaries, increase their degree of independence, and maintain their physical and mental health is also vital. Quality assurance is an important aspect that providers take into account in the provision of social services, and the participants in the qualitative research pointed to some factors that negatively affect this provision (lack of human resources, bureaucracy, etc.). Social services play an important role in maintaining the autonomy of older beneficiaries, and the participating providers stressed that the involvement of beneficiaries and families is very important in this regard. Different opinions in regard to the impact of social services on quality of life of older persons were revealed by home care and residential providers.

The results of our research conducted among social services providers highlight the need for a fundamental change in the construction and governance of the national system of social services for older persons. This change must take into account the existence of multidisciplinary teams, continued investment in the workforce, better public allocation of resources for social services, finding innovative ways to attract and to maintain the young and specialized workforce (beyond financial motivation, and especially by providing concrete prospects for professional development and increasing professional prestige of the social work profession), and development and diversification of the available social services, especially in rural areas and in communities with high migration rates. All these factors could improve the overall functioning of the social assistance system for older persons and, most importantly, the quality of life of beneficiaries. However, further research should evaluate, on a periodic basis, the quality of life of older persons receiving social services, as well as the effects of high migration flows of labor forces on the older population left behind, and the results should substantiate subsequent improvements of the social policy for this age group.

Situation of social services providers who participated in the regional focus groups.

Funding Statement

Part of this work was developed and funded under The Research and Development Programme of the Ministry of Labour and Social Justice for the period 2018–2020, project number 3676/2018, and part under the Nucleu Programme, supported by the Ministry of Research, Innovation and Digitalization (PN 19130401 and PN 19130203). (Această lucrare a fost realizată prin Planul sectorial de cercetare—dezvoltare al Ministerului Muncii și Justiției Sociale pentru perioada 2018–2020, proiect nr. 3676/2018 și prin Programul-nucleu, derulat cu sprijinul MCID, proiect nr. PN 19130401 și proiect nr. PN 19130203). The APC was funded by the Nucleu Programme, supported by the Ministry of Research, Innovation and Digitalization (MCID) (PN 19130401 and PN 19130203).

Author Contributions

Conceptualization and design: M.G., A.M., S.S. and L.M.-M.; Investigation: M.G. and L.M.-M.; Literature review, discussion: M.G. and L.M.-M.; Methodology: A.M.; Analysis and interpretation of data: M.G. and S.S.; Validation: M.G., A.M., S.S. and L.M.-M.; Writing—original draft preparation: M.G., A.M., S.S. and L.M.-M.; Writing—review and editing M.G., A.M., S.S. and L.M.-M.; Funding acquisition M.G. and A.M.; Project administration M.G. and A.M. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the Code of Ethics and Integrity of the National Scientific Research Institute for Labour and Social Protection— INCSMPS, and approved by the Internal Approval Commission of the Scientific Board of National Scientific Research Institute for Labour and Social Protection—INCSMPS document number 268 from 28 March 2019.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study, according to the sociological methodology used. All the social services providers for the elderly received an e-mail with an invitation to participate in the research. Social services providers willing to participate in the research appointed a person to participate to focus group discussions. Following this, informed consent was obtained before each focus group from all participants, and this consent was audio recorded.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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• Published: 08 September 2022

Social service providers’ perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study

• Nicole D. Gehring 1 , 2 ,
• Kelsey A. Speed 1 , 2 ,
• Kathryn Dong 2 , 3 ,
• Bernie Pauly 4 ,
• Ginetta Salvalaggio 2 , 3 &
• Elaine Hyshka 1 , 2  

BMC Health Services Research volume  22 , Article number:  1138 ( 2022 ) Cite this article

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People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers’ perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care.

We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model.

Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients’ ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs.

Conclusions

Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care’s ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management.

Peer Review reports

Structural vulnerability is the manifestation of intersecting political, socioeconomic, and cultural hierarchies that impact the health of individuals and populations [ 1 , 2 ]. People who use drugs are often structurally vulnerable due to severe socio-political disparities that amplify stigmatization, discrimination, and cultural oppression. Structurally vulnerable patients who use drugs, particularly those experiencing unstable and/or lack of housing, disproportionately access acute care compared to the general public [ 3 , 4 ]. Hospitalized patients who use drugs are more likely than other hospitalized patients to experience unstable/lack of housing and report acute care as their primary point of healthcare access [ 5 , 6 ]. Structurally vulnerable patients rely on acute care more often for several reasons, including access barriers (e.g., no identification, health insurance), lack of primary care continuity, and/or prior experiences of stigma and discrimination in healthcare settings [ 7 , 8 ] that can result in delayed care seeking until health conditions require urgent medical attention. These factors often reinforce acute care as the most accessible and convenient healthcare option.

Conventionally, hospitals provide short-term diagnostic assessment and acute medical treatment. Although structurally vulnerable patients often present to acute care with unmet social needs (e.g., inadequate housing, food insecurity, unemployment, safety concerns, difficulty affording basic needs) [ 9 , 10 ], acute care systems and providers may not be able to effectively address these determinants of health during hospitalization [ 6 , 11 ]. Instead, structurally vulnerable patients are frequently discharged back to emergency shelters or onto the street, further compounding health inequities [ 12 ]. This is concerning because addressing social needs can improve post-discharge outcomes, decrease readmissions, and shorten the length of hospital stays amongst structurally vulnerable patients who use drugs [ 13 , 14 ]. For example, provision of housing after hospital discharge is associated with improved health outcomes and sustained housing [ 15 ].

The integration of social services within acute care settings is one potential strategy to address the broader social needs of patients. While social service providers in acute care hospitals have specialized training to help meet basic and complex needs of patients, they receive little guidance on how to care for patients who use drugs [ 16 ] or those with unstable and/or lack of housing [ 17 ], let alone patients experiencing both substance use and unstable/lack of housing. There is also limited literature regarding effective social service provision specific to structurally vulnerable patients who use drugs. The majority of research examines addressing social needs for general acute care patients, or for those experiencing unstable and/or lack of housing or those who use drugs, exclusively. This is problematic given the high prevalence of substance use disorders and unstable and/or lack of housing amongst structurally vulnerable populations [ 18 , 19 ] and the unique challenges associated with supporting this patient population effectively.

Patients who use drugs and experience unstable and/or lack of housing report feeling judged and unwelcomed within hospital settings, and describe futility in the care they are provided [ 20 , 21 ]. Hospitals also often enforce formal or informal bans on illegal drug use [ 22 , 23 ]. As a result, patients can hesitate to disclose their drug use or housing status [ 24 , 25 ]. Nondisclosure leaves these important aspects of health neglected, while disclosure can lead to stigmatized clinical encounters [ 24 , 26 ]. Effective care for this patient population requires tailored and coordinated interventions that address both housing and drug use simultaneously. However, little research has explored how to respond to barriers impeding the delivery of social services in hospitals, and extant studies focus on the perspectives of social workers only. The views of other professionals who address social needs (e.g., peer support workers, transition coordinators) have received little attention, resulting in a narrow perspective on social service delivery within acute care. We explored the perspectives of social service providers at a large urban acute care hospital on: 1) the barriers and facilitators they face in addressing the social needs of structurally vulnerable patients who use drugs; and 2) if they identified any possible strategies for improving care for this patient population. Our overall aim was to generate knowledge on social service provision that could lead to better integration of social services within acute care to improve health outcomes for this patient population.

Study design

We adopted a focused ethnographic design. Compared to traditional ethnography, focused ethnography is more targeted and time-limited [ 27 , 28 ]. Focused ethnographies are characterized by: focusing on a distinct issue, problem, or experience within a discrete community or organization; being problem-focused and context-specific; involving a limited number of participants who hold specific and specialized knowledge; developing practical recommendations or solutions; and spanning a limited or episodic period of time [ 27 , 28 , 29 , 30 ]. Focused ethnography commonly employs semi-structured interviews and often limits or omits participant observation in order to generate rapid data [ 27 , 28 , 29 ]. This method is frequently used to study highly fragmented or specialized areas, and has been widely used in a variety of healthcare settings [ 30 ]. Given our focus on a specialized healthcare setting with a distinct issue (i.e., social service provision), population (i.e., structurally vulnerable patients who use drugs), and community (i.e., social service providers at an urban acute care hospital) this method was well-aligned with our objectives, and helped to quickly generate practical information directly relevant for improving this patient populations’ social needs. Further, this method allowed us to protect the privacy of a structurally vulnerable patient population by not necessitating direct observations of clinical care on hospital units. We report this study using the consolidated criteria for reporting qualitative research (COREQ; see Additional file 1 ) [ 31 ].

Study setting

The study was conducted at a large, urban acute care hospital located in Edmonton, Canada. While the hospital serves patients from all over Northern and Western Canada, many reside within the local health services catchment of Edmonton-Eastwood. This catchment area is associated with poorer socioeconomic status compared to the provincial average [ 32 ], high drug poisoning deaths [ 33 ], and the hospital has a high number of emergency department visits and hospitalizations related to substance use [ 33 ].

The hospital offers access to an addiction medicine consult team (AMCT). At the time of the study, the AMCT included addiction medicine physicians, a nurse practitioner, social workers, an addiction counsellor, and peer support workers. The team provides in-hospital consultation services for patients experiencing substance use and unstable/lack of housing, including specialized pain and withdrawal management, substance use treatment, harm reduction, access to personal identification, and income and housing support [ 34 , 35 ]. Social service providers outside of the AMCT (i.e., unit social workers, transition coordinators) work throughout different areas of the hospital to address social needs, where indicated, to the general patient population. While unit social workers provide a range of social services (e.g., psychosocial assessment, advanced care planning, case management and coordination, discharge planning), transition coordinators are focused on facilitating patient discharge and provide resources and services that promote post-discharge planning. Social service providers are also employed by the provincial Department of Community and Social Services who liaise with hospital staff and patients to provide access to client records from across different ministry income support programs.

This study received ethics approval from University of Alberta’s Health Research Ethics Board as part of a larger evaluation of the AMCT.

Data collection and participants

The AMCT helped identify potential participants through personal invitations, flyer distribution, and presentations at hospital staff meetings. Interview participants also referred colleagues who might be interested in participating. Of 28 potential participants who were referred to, or contacted by, the study team, 10 were lost to follow-up and 18 provided informed consent and participated in a semi-structured interview. The semi-structured interviews were completed between August 8, 2018 and January 24, 2019. AP was the lead interviewer and had no previous relationships with any of the participants. EH joined AP in three earlier interviews. Given the close collaboration between our research group and the hospital, EH was previously acquainted with two participants. However, EH did not hold any influence over these participants or their employment status, and they were advised that their interview would be confidential. In cases where participants' unique roles might incidentally reveal their identity to readers with knowledge of the hospital, participants were given the option of reviewing and approving their transcript prior to inclusion in the analysis. The interview guide (see Additional file 2 ), which was pilot tested, explored staff experiences providing social services to patients experiencing substance use and unstable and/or lack of housing. It also explored staff views on bridging patients between hospital and community supports. Interviews were held in a private area of the hospital, audio-recorded, lasted approximately one hour, and were de-identified and transcribed verbatim using pseudonyms for participants.

Participants were social workers (SW; n  = 8) and other social service providers (SSP; n  = 10), including peer support workers and transition coordinators. The ‘other’ category was used to protect participant anonymity for social service providers occupying otherwise identifiable positions. Participants were affiliated with the AMCT, the inner-city acute care hospital, and the Ministry of Community and Social Services. Participant recruitment and data collection continued until the research team agreed that the transcripts provided rich data, no new ideas or concepts were emerging from interviews, and preliminary analysis showed thematic saturation [ 36 ].

Data analysis

We used NVivo 12 to manage the data. Consistent with focused ethnography and given the descriptive nature of our qualitative study, we performed content analysis [ 28 ]. Content analysis uses a descriptive approach to coding and interpretation [ 37 ]. Specifically, we conducted latent content analysis. As opposed to manifest content analysis which typically codes and tallies specific words or ideas, latent content analysis emphasizes coding the underlying meaning of text passages and reviewing data within the context of the entire dataset to categorize patterns in the transcripts [ 27 , 28 ]. This analytical approach was particularly important given the context-specific nature of our study. Examples of how latent content analysis was applied are described below.

The main analyst (NG) reviewed all transcripts and field notes to generate in-depth familiarity with the data and cultivate a general understanding of emergent ideas, words, phrases, and concepts. The data were then coded inductively (i.e., allowing codes emerge from the dataset [ 28 ]) using latent content analysis (i.e., coding the meaning and underlying context of text passages [ 27 , 28 ]). For example, rather than simply coding for instances of discharging patients back onto the street (e.g., ‘discharging to homelessness’), we coded the context in which participants’ described discharging patients back onto the street (e.g., ‘no medical needs to stay in hospital’, ‘pressure to discharge’, ‘patient not receptive’, ‘patient chooses homelessness’). Field notes for each participant were reviewed again during coding to provide additional context. Considerations and deliberations on emerging codes were detailed in a central document. The preliminary codes and codebook were iteratively refined based on several rounds of feedback from KS and EH. Once the codebook had been established, KS reviewed the coding of a subset of the transcripts for coherence and accuracy, paying particular attention to how the codes considered the context of the text passages, and coding was further refined by NG. The final codebook included contextualized accounts of barriers and facilitators to providing social services to this patient population, participants’ perceptions of potential strategies to improve social service provision, and the influence of the social determinants of health and structural vulnerability in social service provision.

Finally, codes were grouped in relation to the socioecological model outlined by McLeroy et al. (1988) to generate themes. The socioecological model considers the complex interplay between individual (e.g., knowledge, attitudes, skills), interpersonal (e.g., families, friends, social networks), organizational (e.g., social institutions, formal and informal rules and regulations), community (e.g., relationships between organizations), and public policy (e.g., local, state, and national laws and policies) features which influence health behaviours [ 38 ]. It is particularly helpful for understanding multiple and interacting determinants of health and developing recommendations for multi-level interventions. Once codes were grouped according to the socioecological model, we examined negative cases (i.e., perspectives that contrasted with more commonly occurring perspectives). Negative cases were reviewed to understand the source of their discrepancy, detailed within the audit trail, and groups were revisited and refined [ 39 ]. KS and EH reviewed the groupings to ensure each code fit within assigned categories. Each theme was defined and named to provide a descriptive overview, after which participant quotes were selected to complement each theme description. This consisted of revisiting codes and excerpts in each category in their entirety and choosing participant quotes that were representative of the theme description and broader nuance of each theme. As such, each theme heading includes a participant quote and descriptive overview (i.e., “participant quote”: theme description) for transparency on how the two relate to one another and showcase that the single quote captures the context of the theme description. For example, a participant quote highlighting a holistic approach to social service provision represented the sentiment of participants in that theme who proposed comprehensive socio-structural policy. In addition, participant quotes chosen for theme names were not pre-determined and did not guide any part of the analysis.

Themes were ultimately organized in relation to four of the five context-specific levels of the socioecological model: 1) individual; 2) organization 3) community; and 4) policy levels of influence, based on consideration of the entire dataset. For example, codes that contextualized discharging patients back onto the street, were not necessarily categorized together; ‘patient not receptive’ and ‘patient chooses homelessness’ were categorized at the individual level, whereas, ‘no medical needs to stay in hospital’ and ‘pressure to discharge’ were categorized at the organizational level. While the individual level of the socioecological model typically refers to the individual receiving services personally, this level of influence was adapted to describe how social service providers view individual-level patient barriers. While some interpersonal dynamics between social service providers emerged from our analysis they were not prominent in the main findings of our inductive analysis, and thus no related themes are presented here.

Throughout the analytic process, maintaining and reviewing an audit trail of analytic thoughts, decisions, and reflexivity (i.e., iterative positionality statement in relation to the research topic) helped the main analyst identify and engage with potential investigator bias. In addition, we engaged in ongoing discussions with the research team members and consulted members of a community advisory group of people with lived/living experience of substance use, structural vulnerability, and hospitalization, who confirmed our main findings were in line with their own interactions with social service providers.

As shown in Fig.  1 , four main themes emerged from our qualitative analysis, corresponding to levels of the socioecological model. The main themes are described below from micro- to macro-level of influence: 1) individual; 2) organization; 3) community; and 4) policy.

Main themes organized within the socioecological model (figure adapted from [ 40 ])

“There are people [who] unconsciously or consciously subscribe to an individualist orientation”: conflicting views on patient-level barriers to care

How social service providers conceptualize patient-level barriers to care determines, in part, their approach to addressing needs in practice. Participants in our sample had divergent views, with most emphasizing perceived deficits in patient motivation as the main factor determining unsuccessful social service provision, and a minority highlighting the centrality of structural factors that impede individual patients’ ability to secure income, housing, and other social needs.

Participants attributing patients’ unmet social needs as due to individual factors suggested that some patients “choose” to be houseless, or lack motivation to address their financial circumstances or substance use, and as a result often fail to “follow through” on offers of support. This view was particularly common amongst transition coordinators in our sample. These participants described structurally vulnerable patients who use drugs as “blocking beds” for others with more “legitimate medical needs,” or as “noncompliant” with care plans or hospital rules. These views were often cited as rationale for discharging patients back onto the street. Participants voicing this perspective downplayed the importance of building rapport and trust with structurally vulnerable patients, often expecting patients to access supports on their own, e.g., “put a bunch of papers down…here you go let me know if you need any help” [SSP15]. Another participant explained:

At the end of the day, patients make their own decisions and make their own choices. And if they choose not to help themselves, no matter how much stuff you give them it’s not going to be enough, because they’re still not going to do it. [SSP4]

In contrast, other participants described how patients’ ability to follow through with supports was limited by factors outside of patients’ control. Participants voicing this perspective were largely affiliated with the AMCT. Some participants expressed how post-discharge or outpatient follow-up was challenging because other urgent needs such as “where am I getting my next meal, where am I sleeping tonight” [SSP5] often take priority over keeping scheduled social service appointments. These participants noted that following-up with supports that address social needs could be further hindered by a lack of a phone or transportation and the need to continually focus on securing drugs and avoiding withdrawal. Beyond material challenges, participants outlined how patients find the hospital “inhospitable” and are often discharged when away from the unit for too long, even when they had logical reasons for leaving (e.g., looking for housing, collecting belongings, income generating activities, consuming substances, interacting with peers). Many participants therefore detailed having to allocate a lot of time to building rapport with patients and advocating for patients to stay in hospital in order to adequately address their social needs. For example, a social worker said:

[T]hey may be off the unit because they’re looking for a place…They may have a [substance use] issue that is bringing them off the unit…I’ve had a lot of people be really worried about their stuff and where they’ve stashed their stuff. And they’ve got to go and move it…going and connecting with their peer group out in the smoke pit or things like that…because they’re plus, plus, off unit they kind of get pushed out…So, we have to try and advocate for them to stay in hospital so we can actually help them. [SW6]

The combination of follow-up challenges and the “inhospitable” hospital environment were described as the main reason individual patients “fall through the cracks” [SW7], and ultimately do not get their social needs met.

“If we view health from a medical model, we’re not understanding the social determinants of health”: the contested role of the hospital in social service provision

At the organization level, participants described tensions in addressing social needs for structurally vulnerable patients given the traditional biomedical approach to acute care. In particular, they discussed the need to frequently turn over available beds and feeling constant pressure to discharge patients back onto the street if patients no longer have acute medical needs. As one social worker shared:

Traditionally hospitals are based on a very medical model…The old school saying that you still hear sometimes on the units is that we’re not here to solve social issues, we’re here to solve medical issues…Being [houseless] is not a medical issue, having no income is not a medical issue so it should not warrant or require that they need to stay in hospital to address this. So, hence, why patients once they’re medically stable, are discharged. I think that social issues are addressed if they impact the hospital stay or the hospital discharge. [SW1]

As a result, most participants outlined how they struggled to provide more than “band-aid” approaches to address patients’ social needs, and being able to only “do something really quick, because they’re being discharged in two days” [SW10].

A few participants were comfortable with the limited range of social services provided in hospital and felt that hospitals should not be responsible for addressing social needs. However, all participants accepting the biomedical model still acknowledged that without providing adequate social services within the hospital, patients will continue to have adverse health and social outcomes. A social worker told us:

I don’t necessarily think that everything needs to be dealt with in an acute care setting. But I think there needs to be some understanding of here’s all these other things that are actually impacting their health and if we don’t address them in some way…overall their health and their wellbeing as a person is not going to get better. [SW8]

In contrast, many participants stressed that hospitals should be responsible for social services because if “we just look at the medical part we are going to wait for them to come back in another week or two” [SW2]. These participants noted that inequities in health and social service access in the community can be alleviated through the hospital because admissions provide an opportunity to reach structurally vulnerable patients who otherwise have limited access to care.

Similarly, participants outlined how the hospital provides a relatively stable environment, which creates an opportunity to comprehensively address social needs. As detailed by a social worker:

It’s actually more productive when they’re in hospital because they have a safe and stable place that they are staying right now that I can find them when I go up to the unit and be able to make progress while they’re in hospital. [SW6]

Others noted that the hospital provides a window to build relationships with patients who otherwise face barriers connecting to care, especially because acute care is often where structurally vulnerable patients access healthcare. For example, one participant told us:

It’s a great time to say here’s an opportunity…especially for [substance use]…so sometimes that window of opportunity is really small, and when they hit that window of opportunity in a hospital, if there’s an opportunity for housing and all those wrap-around services to kind of capitalize on that opportunity. Some people might say it’s a captive audience. [SSP14]

Overall, while some participants felt that acute care was not an appropriate setting to address social needs, most felt that the hospital provides a unique opportunity to provide both medical and social needs to improve outcomes for structurally vulnerable patients who use drugs.

“It’s almost like they’re set up for failure”: gaps in community health and social systems

Participants noted several gaps in community health and social systems that further challenged their ability to care for this patient population. Most participants discussed a lack of affordable and available housing supports compared to the number of patients in need, resulting in waitlists lasting “close to a year” [SSP4]. Participants noted several other challenges in connecting patients with housing supports, including finding suitable housing, accommodating patient preferences, and patients’ histories with housing supports. Participants outlined how the unique needs of structurally vulnerable patients with current substance use were particularly poorly addressed within mainstream housing programs. For example, one participant said:

Substance use is a huge issue. Even in some of the lodges, for some of our patients who are [houseless], there's only a handful that will take them. Which they’re fantastic but any other lodge that finds out that there’s substance use, is not likely going to take them…[It’s] great to have that [option allowing substance use] but then again, we have a waitlist. [SW8]

Participants further expressed that housing options were restricted for particular groups of structurally vulnerable patients who use drugs, such as women: “Trying to find a…domestic violence women’s shelter who will take somebody with [substance use] issues. I don’t know that that exists” [SW9]. Others described that current shelter and rental housing options for structurally vulnerable patients are typically “rough”, often leaving patients with no viable options. As one participant said:

There are times that because of the existing resources for [houseless] individuals, and how they’re not set up properly, they’re not considered safe, they don't have regulations, if you are somebody who is very vulnerable; it’s not an ideal place. You have people that will refuse to go to them and would rather sleep in a lean-to in the river valley. Like what does that tell you about the way that we treat [this population]? [SSP15]

Finally, participants noted that restrictive and frequently changing criteria for housing supports are a barrier to successfully housing patients. One participant described this challenge by saying:

[Housing] agency’s criteria always change. So, we have to call the same agencies over and over and over again because we never know. So sometimes you get lucky. And somewhere else will have room or make an exception, but there’s nothing easy. [SW9]

Several gaps in financial supports were also identified. Participants noted that income support benefits were insufficient to cover cost of living, requiring patients to have to “choose between…food…or…shelter.” [SSP15]. Participants further added that “if you have a substance [use] problem on top of that, then how do you pay for that?” [SW8]. Participants also described numerous barriers to obtaining and maintaining income support benefits. For example, participants mentioned a cyclical relationship between needing a current address to apply for income support, but also requiring income support to obtain housing. The contradictory nature of obtaining income support was highlighted by two participants who described:

[They] have to have an address so that we can establish residency [to obtain income support]…that’s the piece for individuals that maybe are experiencing homelessness; they do not have an address. [SSP11] You have to start with their finances. If I don't want to discharge to the street, finances need to be done because in order to get housing you need income. [SW10]

Other barriers to obtaining and maintaining income support benefits included restrictive and convoluted criteria and payment schedules, and unrealistic reporting requirements. For example, one participant said:

[I]t is a lot for people to remember, I mean, my goodness, there are three of us sitting around the table who are educated and articulate and we have a hard time understanding it. So, people with complex needs that are going through [substance use], mental health, trauma, homelessness, whatever it might be, that’s a lot to remember. Even if you’re incredibly…knowledgeable in a lot of different things, when you’re going through a time of crisis, it’s hard to remember those things. [SSP14]

Perhaps most concerning, some participants said that patients residing in shelters are often ineligible for income support, because the provincial government considers their basic needs (e.g., shelter, food) to be met. One participant explained:

The Government…is only responsible for food, shelter, clothing…So, if they’re receiving food and shelter at one of our shelters that the province funds already, to provide a [person] money additionally it could be perceived by some as double dipping. [SSP14]

Gaps in community health and social systems, particularly in housing and income support, were seen as creating intense barriers in providing comprehensive and applicable care for structurally vulnerable patients who use drugs, ultimately exacerbating health and social inequities.

“We need to look at this from a very holistic perspective”: the need for comprehensive socio-structural interventions and policy change

Several potential policy changes were suggested by participants to help improve acute care experiences, as well as health and social outcomes for structurally vulnerable patients. Many participants said “we would like to have a Housing First team based out of the [hospital]” [SW6] that “would provide a central access point that would prioritize patients leaving acute care” [SW6]. Housing First programs are non-abstinence-based housing initiatives which provide housing to people as quickly as possible, with no preconditions [ 41 ]. Participants described several potential benefits to having an in-hospital Housing First team, including: 1) promoting consistency and continuity of care (e.g., mitigate duplication of service offerings, create an easy point of access for inpatients, increase follow-up capacity, enable progress on housing to be made over multiple hospital admissions and/or ambulatory visits); and 2) facilitating the creation of new specialized housing options for patients who use drugs and have co-occurring health conditions. For example, a social worker told us that a Housing First team could start working with acute care patients immediately and allow for better follow up, especially for structurally vulnerable patients with complex health needs:

A Housing First team…that would be aimed towards a specific population that is more vulnerable, with complex health needs…And then leave a small caseload for people that could be easily housed as well so that we’re not missing the whole spectrum right?...there would be an actual team that could go up to the units, grab them and bring them out to look for housing and actually work on that immediately…have that relationship and continue to follow that patient while they’re in housing to help them maintain their housing. [SW1]

Many also described a need for appropriate sub-acute care spaces where patients with medical, social, and substance use needs could wait during hospital-community transitions, because many existing sub-acute facilities often “refuse…inner-city [houseless] patients because of behaviours, because of their substance use, because of mental health” [SW8]. Opening a transitional hospital unit or a community-based sub-acute care facility with a mandate, tailored services, and staff with expertise in the management of patients who use drugs, was seen as one way to prevent discharging medically complex patients back onto the street or keeping them in-hospital while they wait for a space. One social service provider said:

[I]f someone is really ill, it’s hard to find them housing if they’re using [substances]…Even though there is housing for people that use [drugs]. They’re not for people that are also really sick…these are the ones that are stuck in the cracks. [SSP12]

Finally, participants described the need to better identify social determinants of health and substance use within acute care. Not only was this described as a way to enhance existing statistical data on the need for in-hospital Housing First teams and subacute care facilities, but also as a way to identify broader social needs required within acute care and the community. This was particularly important as multi-level interventions addressing broader social needs within existing or proposed housing supports were seen as necessary to better support structurally vulnerable patients who use drugs. Participants told us that multi-level interventions would address personal care skills and support systems since structurally vulnerable patients who use drugs have often lived in extreme poverty for long durations which may limit their ability to maintain housing or income support. For example, a social worker said:

I am talking about people who…have been so entrenched for so many years that they don’t understand how to make a budget, they don’t understand how to grocery shop, they don’t understand how to meal prep…if you take somebody who’s…[used drugs] pretty much most of their life…they have some barriers…come from an unhealthy family system, they don’t have supports and then we finally do get them housed…how are they going to function…They’re not going to know how to maintain this lifestyle now because they’ve never been exposed to it. [SW16]

Taken together, more comprehensive policies and interventions were seen as necessary to address medical, income, and substance use needs concurrently.

To our knowledge, this study is the first to explicitly examine social service providers’ perspectives on addressing the needs of patients who use drugs and are experiencing unstable and/or lack of housing within an acute care setting. Specifically, we described the barriers and facilitators to addressing the social needs of structurally vulnerable patients who use drugs and are experiencing unstable and/or lack of housing at the individual, organization, community, and policy levels of influence. Our findings highlight tensions regarding the appropriate scope of social services for structurally vulnerable patients who use drugs, but also the potential for hospitals to play a larger role in providing and advocating for social service provision for this patient population.

Participants had divergent views on patient-level barriers that affected social service provision. Similar findings were reported by Fleming et al. (2017) who found that acute care providers grappled with the complex interplay between structural and individual-level factors, sometimes explaining behaviours as a response to structural conditions, and other times as the result of individual choice [ 42 ]. Our study adds to this literature and suggests that when caring for structurally vulnerable patients who use drugs, attributing patients’ unmet social needs as due to individual factors contribute to suboptimal social intervention. People who use drugs and are experiencing unstable and/or lack of housing often have personal histories and social circumstances which require social needs to be balanced with limited time and resources [ 43 , 44 ]. The complexity of patients’ structural barriers can result in difficulties in providing compassionate care [ 45 ], which may in part explain the varied quality of social services provided to structurally vulnerable patients who use drugs. Participants in our study who were affiliated with the AMCT often held more structural views. This may be, in part, because the AMCT was established to provide care for patients who use drugs [ 34 , 35 ]. AMCT staff may therefore be more familiar with structural barriers specific to this population compared to social service providers outside of the AMCT who provide care to a broader spectrum of patients and may spend less time working with patients who use drugs. Increasing recognition of systemic factors that shape substance use and unstable/lack of housing to broader groups of social service providers may help counter provider burnout and negative clinical interactions by increasing appreciation for patients’ circumstances [ 46 , 47 ]. It may therefore be beneficial to provide formal structural competency training (i.e., training health professionals to recognize and respond to the impact of upstream, structural factors on patient health) [ 2 , 48 ] for social service providers, especially for those with a more reductionist view (e.g., attributing patients’ unmet social needs due to individual factors such as motivation). While this type of training may increase understanding of structural factors and how to practically intervene on them, it is only a partial response to improving the overall care for this patient population. Structural competency training should be complemented with additional training on substance use and unstable/lack of housing, as well as rapport building and cultural safety [ 26 ].

While social service providers have identified constraints to addressing social needs within hospitals (e.g., limited resources, hierarchies, pressure to discharge) [ 45 , 49 , 50 ], our findings emphasize that the hospital environment is an opportunity to provide social services that are often difficult to access and maintain for structurally vulnerable patients. Hospitalization can temporarily alleviate some of the immediate structural vulnerabilities faced by patients (e.g., lack of shelter, food insecurity, acute withdrawal) [ 51 , 52 ] and therefore provides a comparatively stable environment where social needs can be attended to without competing with other patient priorities. To take advantage of this brief window of opportunity, improvements need to be made to streamline social service provision. Neglecting to identify social needs limits the quality of care provided to patients [ 53 ], yet documentation of housing status [ 54 , 55 ] and substance use [ 56 ] in acute care settings is inconsistent. Active case finding and tracking data on social determinants of health or using Bourgois et al.’s (2017) structural vulnerability assessment tool for clinical encounters may be an important first step in strengthening acute care’s role in social service provision. Screening for social needs and structural vulnerability should be complemented with broader culture change and care coordination. Doing so may ultimately increase quality of care, efficiency, prevent readmissions, improve successful discharges, and provide cost savings [ 57 ].

Complicating improvements to hospital care, however, are gaps in community-based supports for patients who use drugs and are experiencing unstable/lack of housing and have medical needs. Participants explained that the majority of community housing programs lack specialized medical care. This care gap is concerning because: 1) it can delay discharge or result in patients being turned away by housing supports, [ 12 ]; and 2) substance use is associated with higher odds of chronic and acute medical illnesses [ 58 ] which require tailored and often ongoing medical care. Our findings suggest that appropriate transitional housing programs, hospital-based Housing First teams, and substance use oriented sub-acute care facilities tailored for structurally vulnerable patients who use drugs and have other complex medical needs, could better meet the needs of patients experiencing hospital-community transitions. Providing patients experiencing unstable and/or lack of housing and medical illness with respite transitional housing and then rapidly moving them to permanent supportive housing has shown reductions in emergency department visits and hospital stays [ 59 ]. Moreover, a Housing First pilot project that provided integrated medical, psychiatric, and substance use care for people experiencing unstable/lack of housing, medical illness, and substance use found reductions in acute care and medical respite service utilization, and cost benefits [ 60 ]. While this pilot was not hospital-based per se , hospital-based Housing First teams may increase acute care efficiency as collaboration between Housing First teams and social service providers could occur on site. It is important to note, however, that successfully implementing in-hospital Housing First teams will require a simultaneous increase in availability of appropriate community housing supports.

Our study also outlines the potential utility of minimizing complex and restrictive eligibility criteria for income support policies. Previous research has also found that such policies function to compound existing structural vulnerabilities and ultimately create avoidable harms [ 61 ]. Increasing the amount of income support is also likely to be of benefit, especially since substance use creates additional subsistence needs beyond food and shelter (e.g., securing substances, medication, transportation costs). Importantly, our study highlights that while housing and income are necessary social needs, they are only one component of addressing structural vulnerability. Multi-level interventions that address intersecting factors are necessary to improve post-discharge outcomes and reduce admissions. For example, interventions that address other contextual factors (e.g., personal care skills, support systems) may help to mitigate structural factors that affect social service provision as well as patient outcomes once discharged and/or housed [ 62 ]. Increasing the availability of service models that couple provision of independent housing with on-site and community-based supports for intersecting issues (e.g. low-barrier, permanent supportive housing) may also be effective in improving long-term residential stability and health and social wellbeing [ 63 , 64 ]. It is imperative that these initiatives ensure that substance-related health needs are addressed (e.g. through harm reduction, treatment and/or other support) along with housing and other structural factors.

Limitations

To our knowledge, this study is the first to explicitly examine acute care social service providers’ perspectives on addressing the needs of structurally vulnerable patients who use drugs. This study included a novel mix of participants, incorporating the perspectives of social workers, peer support workers, and transition coordinators, ultimately broadening understanding of social service delivery within acute care hospitals. However, our study is not without limitations. Our focused ethnography targeted one large urban acute care hospital that operated a specialized team dedicated to caring for patients who use drugs and are experiencing unstable and/or lack of housing, which may not be representative of other acute care hospitals and constricts the relevance of our findings for other hospital settings. Our study was also time-limited and omitted participant observation. While this helped produce rapid data to generate practical recommendation, it limited the extent to which we could understand the full scope of social service provision from an observer standpoint. To protect participant confidentiality, we did not collect participant demographics and were unable to further break down ‘other social service providers’ into peer support workers and transition coordinators. Moreover, the small sample sizes between participant role types were not sufficient to conduct formal comparative analyses. As such, we were not able to provide further context on the participants themselves, which limits the transparency of the contrasting views presented in the theme ‘Conflicting views on patient-level barriers to care’. While we attempted to reduce potential investigator bias through several strategies (e.g., audit trail; reflexivity; team member review of coding, codebook, transcripts, and categorization; community advisory group consultation), latent content analysis requires coding the underlying context of participants’ accounts which requires subjective examination of the data. Moreover, coded transcripts were reviewed and not double coded by another team member. As such, it is still possible that investigator bias influenced our interpretation of the data, and in turn, our findings. Nevertheless, this study offers notable contributions. It produces new insights on how social services are provided to a patient population typically underserved in a setting not traditional to social services, and provides new insights to improve social service provision within acute care and post-discharge outcomes.

Our findings revealed several barriers that limit the successful provision of social services within acute care for structurally vulnerable patients who use drugs, and suggest a number of acute care and broader policy changes that could potentially improve this population’s health and social wellbeing. While ambivalence over the role of the hospital and the reductionist views held by some social service providers themselves act as potential barriers to effective care, the hospital has the potential to serve a coordinated role in social service delivery. We suggest that acute care facilities augment their role as providers of social services and advocate for multi-level policy and interventions that address structural vulnerability, medical needs, and substance use.

Availability of data and materials

The dataset analysed for this study are not publicly available in order to protect participant anonymity. Additional information may be provided upon reasonable request to the corresponding author.

Abbreviations

Addiction medicine consult team

Consolidated criteria for reporting qualitative studies

Social service provider

Social worker

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Acknowledgements

We respectfully acknowledge that this work took place on Treaty 6 Territory, a traditional gathering place for diverse Indigenous Peoples including the First Nations, Métis, and Inuit. The authors are thankful to the participants who shared their time and expertise, the Inner City Health and Wellness Program’s community advisory group of people with lived/living experience of substance use who provided feedback on the findings, and Arlanna Pugh (AP) who conducted the interviews.

This project was funded by Policywise for Children and Families. NG received funding from the University of Alberta and the Canadian Federation for University Women. EH’s faculty receives salary support from the Royal Alexandra Hospital Foundation and Alberta Health Services. KD receives a medical leadership salary from Alberta Health Services and has received committee honoraria from the College of Physicians and Surgeons of Alberta and the Edmonton Zone Medical Staff Association. The views expressed are those of the authors and do not necessarily represent the views of the funders.

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Nicole D. Gehring, Kelsey A. Speed & Elaine Hyshka

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Nicole D. Gehring, Kelsey A. Speed, Kathryn Dong, Ginetta Salvalaggio & Elaine Hyshka

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EH, KD, and GS acquired funding for the study. NG and EH conceptualized the manuscript with input from BP and GS. NG conducted the analysis. KS validated the analysis. NG drafted the manuscript with input and contributions from all authors. All authors read and approved the final version of the manuscript.

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Additional file 1..

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

Additional file 2.

Semi-structured interview guide.

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Gehring, N.D., Speed, K.A., Dong, K. et al. Social service providers’ perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study. BMC Health Serv Res 22 , 1138 (2022). https://doi.org/10.1186/s12913-022-08498-x

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Last week, the Iowa Board of Regents approved a new name and scope for the University of Iowa’s prominent hub for social science research. The Public Policy Center, and its subsidiary unit the Iowa Social Science Research Center, are being replaced by a new Center for Social Science Innovation . The reimagined center will serve as a central hub where social scientists including faculty, staff, and PhD students, can find a community of research support and resources.

Mark Berg , director of the unit since January 2023, will continue to lead the center’s operations. Berg is a professor and collegiate scholar in the Department of Sociology and Criminology in the College of Liberal Arts and Sciences.

“The social sciences have long been an important and highly regarded pillar of the teaching, research, and community outreach missions at the University of Iowa,” said Kristy Nabhan-Warren, associate vice president for research. “Under Professor Berg’s leadership, the refocused Center for Social Science Innovation will provide the research infrastructure needed to support social scientists as they explore 21 st century issues affecting human welfare.”  

The center’s restructuring was guided by an independent internal review committee and a transition team staffed by four faculty, including two associate deans for research.

“The reviewers identified several opportunities to reduce redundancies with other campus units and provide end-to-end resources for scholars to address longstanding and emerging societal challenges,” said Berg. “This new structure allows us to focus our energy, and deploy strategic resources to advance, support, and celebrate interdisciplinary social science research across our campus.” 

As part of its mission to function as a dynamic community for social scientists, the center will implement a faculty affiliate program to create a diverse network of social science scholars on campus. 

Four new core priority areas support the center’s mission: research incubation, survey and multimethodology research services, grant development, and dissemination. 

Research Incubation

The center will host several major fellowships, consortium groups, workshops, and residency programs to catalyze research ideas. The programs are open to faculty, scientific staff, and graduate students. 

A Researcher-in-Residence Program provides dedicated time and support for faculty and scientific staff to research topics of significant public interest. Participants in each cohort meet regularly to share updates, discuss roadblocks and resources, and give and receive feedback. 

Megan Gilster, associate professor in the School of Social Work, participated in the program in summer 2024. “I think external accountability is always super helpful for faculty, and the structure that’s been created here in the program is fabulous for really making sure that we get the work done that we’re trying to do.”  

Through a new Dissertation Completion Program , the center provides space and structure for doctoral students to complete their dissertation projects among a   community of scholars. A Grant Writing Residency Program helps scholars advance their research projects through dedicated time to apply for and secure external funding.  A new Summer Fellowship for Qualitative Research provides support to faculty and scientific staff developing qualitative research projects, including ethnography, historical and archival research, content analysis, case studies, action research, and mixed-method designs. 

The center will also host research incubation workshops on topics such as the process of developing research questions, manuscript writing, and interdisciplinary collaboration.

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As a part of its mission to serve the needs of campus, the center will continue to provide a full suite of research services . This includes survey and multimethodology research services and free workshops, grant development support , and for the first time, an in-house IRB liaison to help researchers navigate the complex regulatory environment.

“Our team is excited support clients on campus and beyond with a variety of high-quality services that include survey data collection and focus group moderation,” said Cassidy Branch, interim manager of research services. “We’re particularly looking forward to rolling out new data collection initiatives, one of which will offer faculty, research staff, and students access to a nationally representative survey panel on a recurring basis.”

A team led by Kristopher Ackerson, grant development manager, is available to review and edit grant proposals, provide budget management, host grant writing groups, and coordinate the submission of proposals with other institutional offices such as the Division of Sponsored Programs.

A fourth priority of CSSI is to communicate and disseminate the practical knowledge of social science research to the wider community which will be accomplished through a variety of mechanisms, including research symposiums, regular newsletters, collaborative connections to peer universities and outreach events.  “These resources are strategically designed to cultivate a vibrant community for social scientists at the University of Iowa,” said Berg.

For more information about the Center for Social Science Innovation’s programs, visit their new website, cssi.research.uiowa.edu and sign up for their newsletter . The center reports to the Office of the Vice President for Research.

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