Qualitative Case Study: A Pilot Program to Improve the Integration of Care in a Vulnerable Inner-City Community.

Introduction: There is a strong correlation between vulnerable populations and poor health outcomes. Growing evidence suggests that person-centred interventions using 'link workers' can support communities to navigate and engage with health and community services, leading to improved health service access. We describe the initial phase and qualitative evaluation of a Healthy Living Program, supported by a link worker role. The Program aimed to improve health service access for residents of an Australian inner-city suburb. Methods: To inform future program development, semi-structured interviews were conducted with clients and stakeholders (n = 21). The interviews were analysed thematically to understand program impact, success factors, constraints and potential improvements. Results: Key themes relating to impacts were a new model of working with community, improved access to services, and responsiveness to community need. Key factors for success included being a trusted, consistent presence, having knowledge of the community and health system, and successful engagement with the community and stakeholders. The constraints included difficulty influencing health system change and lack of community input. Suggested improvements were expanding the service, enhancing health system change and increasing community involvement. Conclusion: Knowledge gained from this study will inform future integrated approaches in health districts to address health inequities in areas of need.