In this study, primary health care stakeholders shared their perspectives and experiences about barriers and facilitators to accessing resources in the community. This provided a unique viewpoint to understand access at a client, practice, and local level. The primary access themes identified in our findings helped to inform the ARC navigation model and corresponding intervention activities. These will be described in the study implications section.
PCPs discussed challenges in addressing the social determinants of health for their patients and possible solutions to inequitable access. The interviews revealed that approachability, availability, and appropriateness of community resources at a system level, significantly impacted patient access to care. Community-based organizations need to be approachable to providers and patients to be utilized. PCPs desired information that is relevant and practical, to enable them to effectively act on patients’ health and social needs.[31, 32] It is recommended that organizations maintain and promote complete and current information about their services including the location, hours of operation, eligibility criteria, appointment mechanisms, and associated fees. A user-friendly digital repository of information about community resources [33] can help to reduce barriers to approachability and ability to perceive. Participants advised that information should be indexed to priority health topics such as mental health, to facilitate the finding of relevant resources.
Adequate literacy levels are a large predictor of individuals’ ability to understand and navigate the health care system, which includes being able to act on PCP referrals and reach community resources.[34, 35] Patients require information that is current and relevant, and written in language that meets health literacy standards to enable an understanding of the material. Programs that provide health information online should be easy for patients to use and navigate to prevent additional barriers related to digital literacy.
Consideration is also needed for outreach initiatives to vulnerable groups that may not have access to the computer, internet, or a primary care provider. Support groups such as those for addictions and mental health, can be a venue to promote awareness of available resources for health and social needs. It is challenging for PCPs to remain up to date with available community resources for their patients, as found in previous studies. [16, 21] Participants recommended training PCPs on how to access information on local HERs and embedding a referral process in the electronic medical record, as strategies to increase providers’ knowledge about available community programs, promote referral, and track patients’ outcomes related to HERs. PCPs also recommended increasing the transparency of HERs by placing informational pamphlets in a primary care practice waiting room to promote awareness among patients.
Focus group participants identified that culture and language barriers influence individuals’ ability to seek and access community resources. Language discordance extends beyond the patient-provider interaction and may impact quality of care and patients’ ability to access services for health and well-being needs.[36] Currently, Ontario health care plans do not cover translation services, and cultural interpretation is allocated to poorly funded community health centres. Finally, participants identified that access to health care services can be facilitated when operating hours accommodate the the needs of its target population (e.g. being open on weekends and weeknights to accommodate persons that are working or providing child care or elder care).
Participants’ discussions surrounding the potential scope and role of a navigator helped provide insight into the ARC navigation model and how it could be embedded in a primary care setting. At a provider level, a navigator may promote awareness of available HERs for their patient needs. This would help to address the concerns of many PCPS who identified the challenge of being knowledgeable about resources to address their patients’ social determinants of health. The findings suggest that navigators need to be individuals with the knowledge and skills to support and connect patients to resources, allowing providers to devote their limited time to other patient priorities. Study participants emphasized that navigators should assume non-clinical roles in which they do not offer medical advice or care to patients. At a patient level, a navigator situated in primary care, could help foster acceptability in an environment that they trust.[37] A navigator could help identify appropriate HERs to meet individuals’ needs and priorities, assist in overcoming barriers such as location of the service, transportation, and funding, and provide emotional and social support to facilitate access.[38] Patient navigation is conceived as a person-centered approach to empower individuals, promote patient engagement, and address health disparities.[39–41] In summary, navigation services have the potential to support continuity of primary and community care, and increase approachability, availability, and accommodation as well as appropriateness of community resources.
Study implications
The conceptualization of access based on the framework of Levesque et al.,[8] enabled an understanding of the facilitators and barriers to access care from the perspectives of PCPs and community stakeholders. Based on the findings, the following innovations will be leveraged to facilitate access to HERs for primary care patients in the ARC study:
1) PCPs and their staff will be oriented to the breadth of available health and social resources to which they can refer their patients. Clinic processes that fit into the routines of daily practice will be developed to support providers to refer to these resources including a standardized referral form to identify patient needs and navigation services to support patients’ access to resources.
2) Available community resources will be promoted to patients in the practice waiting room through informational brochures and videos. Patients will also be taught how to use existing online and telephone directory of information services [33] so that they are empowered to identify, and access needed resources.
3) A lay patient navigator will be integrated within the primary care practice to help patients address and overcome barriers to access. The navigator will serve as a link between patients, primary care, and community care through collaboration and effective exchange of information to promote navigation services and leverage community resources to address patients’ social determinants of health.
Study Limitations
We advance four limitations to this study: 1) The PCPs participants were recruited from a similar demographic; those practicing in an urban setting and serving a patient population that were predominantly middle to high socioeconomic status. 2) The access dimension of Affordability and Ability to Pay did not emerge as primary barriers. The five dimensions of access as defined by Levesque et al.,[8] can be thought of as a continuum that ranges from the early stages of access to the later stages of access. Focus group members reported barriers to the earlier stages of access much more frequently than the later stages. Our assumption is that if patients cannot successfully perceive, seek, and reach community resources, they may have not yet been faced with barriers concerning services’ affordability. Another potential explanation is that the study was conducted in a resource-rich region with many low costs or no cost community health and social resources. Data collection methods, participants, and/or patient population served, may also have contributed to this finding. 3) The composition of the focus groups and the nature of the PCPs’ patient population may have not reflected the social complexity seen in primary care patients. The study was a single center study, interviewing PCPs only in one health region, whose experiences may not be representative of other PCPs or other primary care providers such as nurses, nurse practitioners or social workers. Increasing the sample size and diversity in terms of physician demographics, and the patient populations served (socioeconomic areas, geographic regions), would enable a broader understanding of the challenges in caring for primary care patients with social barriers and how to support them in accessing community-based primary health care. 4) Finally, the robustness of the study is limited using purposive sampling to recruit interview and focus group participants. Further consultation with key stakeholders in the health region including patients, primary care providers, community service providers and health planners was therefore undertaken to inform the design of the ARC intervention.