{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T07:53:56Z","timestamp":1791964436358,"version":"4.3.4"},"reference-count":39,"publisher":"North Carolina Institute of Medicine","issue":"5","license":[{"start":{"date-parts":[[2024,8,1]],"date-time":"2024-08-01T00:00:00Z","timestamp":1722470400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-sa\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"\n Background<\/jats:title>\n There has been a growing interest in integrating social and function-focused care into health care settings. Little is known about what older adults perceive as the needs that impact their lives, and the resources to address patients\u2019 social and functional needs often exist outside of traditional health care settings.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Our objective was to understand frail older adults\u2019 and community organizations\u2019 perspectives on what social and functional needs impact older adults\u2019 health, the support they receive, and how organizations and health systems could partner to address these needs. We conducted semi-structured interviews with patients and community-based organizations. Patients were aged 65 years or older, frail (electronic frailty index greater than 0.21), and at an increased geographic risk of unmet social needs (Area Deprivation Index greater than or equal to the 75th percentile). Staff were from organizations that provided social and\/or functional resources to older adults. We used an inductive content analysis approach and the constant comparative method to analyze the data and identify themes.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n We interviewed 23 patients and 28 staff from 22 distinct organizations. We found that social, financial, and functional needs were common and highly intertwined among older adults with frailty, but the support they received at home, from their health care providers, and from community organizations was highly varied.<\/jats:p>\n <\/jats:sec>\n \n Limitations<\/jats:title>\n Our sample was limited to participants from one county, so the results may not be generalizable to other areas. We only inter\u00adviewed organizations and patients with frailty.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Health systems and community organizations have distinct areas of expertise, and purposeful collaboration between them could be important in addressing the needs of frail older adults.<\/jats:p>\n <\/jats:sec>","DOI":"10.18043\/001c.121369","type":"journal-article","created":{"date-parts":[[2024,8,1]],"date-time":"2024-08-01T09:15:57Z","timestamp":1722503757000},"source":"Crossref","is-referenced-by-count":2,"title":["The Complex Relationship Between Social and Functional Needs in Frail Older Adults"],"prefix":"10.18043","volume":"85","author":[{"given":"Elena","family":"Wright","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathryn E.","family":"Callahan","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haley","family":"Park","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Corrinne","family":"Dunbar","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Gabbard","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristin","family":"Lenoir","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaime M.","family":"Hughes","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Renee","family":"Woodard","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deepak","family":"Palakshappa","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/0207ad724","id-type":"ROR","asserted-by":"publisher"}],"name":"Wake Forest University","department":["School of Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"7507","published-online":{"date-parts":[[2024,8,1]]},"reference":[{"key":"ref1","article-title":"Developing national social care standards","author":"L. 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Berry","year":"2019","journal-title":"Am J Accountable Care"},{"issue":"1","key":"ref8","doi-asserted-by":"publisher","first-page":"171","DOI":"10.1111\/1468-0009.12491","article-title":"Money moves the mare: The response of community-based organizations to health care\u2019s embrace of social determinants","volume":"99","author":"L. A. Taylor","year":"2021","journal-title":"Milbank Q"},{"issue":"11","key":"ref9","doi-asserted-by":"publisher","first-page":"1771","DOI":"10.1093\/gerona\/glz017","article-title":"Frailty screening using the electronic health record within a Medicare Accountable Care Organization","volume":"74","author":"N. M. 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De Marchis","year":"2019","journal-title":"Ann Fam Med"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"101705","DOI":"10.1016\/j.arr.2022.101705","article-title":"Associations between loneliness and physical frailty in community-dwelling older adults: A systematic review and meta-analysis","volume":"81","author":"G. Kojima","year":"2022","journal-title":"Ageing Res Rev"},{"issue":"2","key":"ref22","doi-asserted-by":"publisher","first-page":"407","DOI":"10.1111\/1468-0009.12390","article-title":"Meanings and misunderstandings: A social determinants of health lexicon for health care systems","volume":"97","author":"H. Alderwick","year":"2019","journal-title":"Milbank Q"},{"issue":"4","key":"ref23","doi-asserted-by":"publisher","first-page":"303","DOI":"10.1016\/j.amjmed.2014.01.002","article-title":"Treat or eat: Food insecurity, cost-related medication underuse, and unmet needs","volume":"127","author":"S.A. 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