Health and Social Care as Complex Adaptive Systems: Application of Relational Network Theory to Care for Older People

Background: Building on concepts from Complex Adaptive Systems (CAS), this paper proposes an overarching social science framework for addressing the fragmentation that exists in health and social care systems worldwide. The focus is on how relational networks might be strengthened to deliver more coordinated, integrated, whole person-centered care. The framework examines a major planned social experiment occurring in New South Wales, Australia: “All-Inclusive Care for the Elderly” (ALICE). Approach: Existing research on integrated care has largely focused on structural elements of care with mixed results (Goodwin, 2004; Burns et al., 2022). This approach has largely ignored the complex, emergent, ever-changing relational dynamics of how care is delivered. To address this gap, we merge social network theory (Granovetter, 1973; Kadushin, 2022) and relational coordination theory (Gittell and Weiss, 2004) to develop a relational network theory that addresses the complex ecosystem of health and social care delivery. Network ties involving strength, centrality, density, embeddedness, and structural holes are made “social” by the extent to which the network actors share common goals, trust, mutual respect, and engage in frequent, specific, accurate, and problem-focused communication. These relational processes both influence and are influenced by the structural network properties and impact outcomes. ALICE is an emerging, neighborhood-based, relational model of care for older people on the Central Coast of New South Wales. Traditionally, healthcare for older people has been complex, fragmented and not focused on social needs. A Relational Network Theory (RNT) framework highlights three core principles of ALICE: 1) the promotion of integrated care delivery through the use of “link workers” who conduct holistic care assessments and coordinate access to care across providers; 2) the development of integrated care communities that leverage social connections and networks through use of kiosks and community engagement officers to support older person care; and 3) a commitment to healthy place-making with local governance and engagement forums to create healthy built and natural environments to support older people in living heathy and active lives. Results: The ALICE initiative has been co-designed with residents and stakeholders from different sectors to implement an agile approach that will work in different community contexts. This is a foundational step in spreading and scaling outcomes. The relational work in creating new roles (linkage staff, engagement officers) is building the required connections and trust to meet the whole-person needs of older people. A key finding is the need to assess and map the complex social and relational network properties carefully to facilitate successful spread and sustainability. Implications: Two important implications for providers, managers, and policymakers are: 1) Recognize health and social care delivery as a complex adaptive system (CAS). 2) Co-design new care models following a framework of Relational Network Theory (RNT), building social reciprocity among all actors to reduce the current fragmentation and promote more socially connected care.