Abstract

Introduction:
The health and social care environment is being transformed by the needs of the aging population, higher levels of multimorbidity, and shifts in the care landscape, such as specialisation, ‘privatisation’ and fragmentation. Health and social care systems were not designed to appropriately support individuals with multimorbidities; primarily evolving to cater for single diseases and acute events. Nevertheless, there is now an urgent need to redesign existing structures and care delivery to address the needs of the population, ensuring individuals can access the right care at the right time and in the right place. If patients or users are unable to adequately navigate health, social and third sector care, there is likely to be an increase in expenditure through use of non-appropriate services and a reduction in patient satisfaction and well-being.
Multimorbidity requires patients to seek care from different clinicians and professionals, within and beyond primary care. However, little is known about how these patients interact with the complex health and social care systems, and particularly how this impacts on effective care navigation. This study aimed to scope the literature on how older people (aged 55 years and over) with multimorbidities effectively navigate the care system.

Methods:
A scoping review was conducted to address the research question: ‘What information is available in the literature regarding care system navigation in the setting of older people with multimorbidity?’. A detailed search strategy was developed, including the following inclusion criteria: literature published between 2003-2014 in English, Dutch, French or German, holding the key terms of navigat* AND multi*morbid*. Papers were initially selected based on title from five electronic databases together with a review of ten grey literature sources. The selection was further refined through abstract reading. The final selection of full text papers was analysed through the use of a data extraction tool.

Results:
In total 3,171 papers were found. After title and abstract reading, 367 papers were extracted. These were subject to more in-depth abstract and full text reading, which resulted in a final selection of 46 papers. These papers were reviewed in depth and analysed. Only 12 papers addressed the research question, suggesting that limited literature is available on the experience of older people with multimorbidities navigating the care system. Overall, the studies demonstrated that patients perceived they were expected to find their own way, learning from experience, rather than being able to rely on a particular service or system that could support them to navigate their different care needs. The scoping review further revealed the necessity of providing patients with practical, information and social support to help them navigate the system. Where care navigation programs were in place across primary and secondary care, demonstrable benefits were shown for patients with single diseases (e.g. cancer, chronic lung disease). In contrast, although promising results were seen for those patients with multimorbidities there was a lack of implementation.

Conclusion:
Older people with multiple morbidities face a daunting task navigating the care system. In order to maximise health and wellbeing, increase patient empowerment and satisfaction, and limit inappropriate costs due to inappropriate navigation better systems are needed to support people to navigate the care system. Although there is clarity as to the type and extent of support patients perceive they need, there is little evidence around the most effective method of delivering such support.