Poorly executed transitions between health care settings can lead to poor outcomes and greater use of health care resources for older adults. Older adults with complex needs often receive care from many health care providers in multiple care settings, and face greater risk of experiencing fragmented care. System navigation roles have been suggested as an innovative strategy to address these challenges, yet there is a lack of consensus on the desired characteristics and effectiveness of the role. The goal of this research is to develop a framework for a system navigation role to enhance coordination of formal and community-based services to older persons with chronic disease through health care transitions. This research gathered information from multiple perspectives and a variety of data sources, including a systematic literature review, focus group interviews and in-depth interviews with a variety of health care consumers and providers. A critical analysis of collected data, using a frame derived from content analysis, sought to understand how older adults navigate the health care system, and subsequently to explore the potential of a “system navigator” role to facilitate successful transitions across care settings. Finally, following a grounded theory approach, a model was empirically derived to reflect what role system navigators may have on the experience of older adults navigating the health care system in Waterloo Wellington. This research study aimed to describe optimal care coordination practices across the continuum of care for complex, high-risk individuals, such as those with chronic disease or hip fracture. Ultimately, this study may lead to improved patient care coordination, safety and satisfaction during transitions and in accessing community services, which may assist patients to achieve a higher quality of life.

Poorly executed transitions between health care settings can lead to poor outcomes and greater use of health care resources for older adults. Older adults with complex needs often receive care from many health care providers in multiple care settings, and face greater risk of experiencing fragmented care. System navigation roles have been suggested as an innovative strategy to address these challenges, yet there is a lack of consensus on the desired characteristics and effectiveness of the role. The goal of this research is to develop a framework for a system navigation role to enhance coordination of formal and community-based services to older persons with chronic disease through health care transitions. This research gathered information from multiple perspectives and a variety of data sources, including a systematic literature review, focus group interviews and in-depth interviews with a variety of health care consumers and providers. A critical analysis of collected data, using a frame derived from content analysis, sought to understand how older adults navigate the health care system, and subsequently to explore the potential of a “system navigator” role to facilitate successful transitions across care settings. Finally, following a grounded theory approach, a model was empirically derived to reflect what role system navigators may have on the experience of older adults navigating the health care system in Waterloo Wellington. This research study aimed to describe optimal care coordination practices across the continuum of care for complex, high-risk individuals, such as those with chronic disease or hip fracture. Ultimately, this study may lead to improved patient care coordination, safety and satisfaction during transitions and in accessing community services, which may assist patients to achieve a higher quality of life.