Table 2 Managers' and healthcare professionals' current practices and perceived issues

Challenges created by the complex and multidimensional chronic conditions of older persons

Primary Care Physician (PCP) as the key clinician

   • Essential role of the PCP

   • Older persons' loyalty to their PCPs

Inadequate needs assessment process within primary care

   • Medical-centered. Lack of multidimensional needs assessment.

   • Dichotomy between medical needs assessment/other assessments

Inadequate coordination of primary care services

   • No one is responsible for coordinating services. PCPs' lack of time. Poor knowledge of services.

   • Lack of communication between professionals.

   • Fee-for-service remuneration

Inadequate coordination of primary and secondary care

   • Poor planning of services at discharge

   • Little continuity of care. No information on hospitalization provided to PCP

   • Unavailability of direct hospitalization or geriatric expertise

Perceived Consequences:

   • Unmet needs

   • Inappropriate use of services. Unwanted institutionalization

   • High family burden