Preliminary Field-Note Observations on Referral Uptake Among Community-Dwelling Older Adults: A Qualitative Pilot Study in Tarrant County, Texas

Older adults with complex health and social needs are frequently referred to community-based services, yet follow-through remains low. Motivational barriers and misalignment with personal values may undermine engagement. This qualitative descriptive pilot study explored barriers to referral uptake and the role of relational engagement within the Age-Friendly Integrative Mobile Services (AIMS) model, using thematic analysis of field notes from a pilot implementation. Seven adults aged ≥65 in Tarrant County, Texas received in-home assessments and referrals across five domains. Quantitative measures included Mini-Cog, TUG, PHQ-9, and the Older People’s Quality of Life scale. Field notes were thematically analyzed. Participants had substantial needs—43% screened positive for cognitive impairment, 67% had mobility limitations, and all reported depressive symptoms—yet uptake was limited. Barriers included mistrust, emotional fatigue, and preference for independence. Despite this, participants deeply valued the interpersonal experience, emphasizing the importance of being visited, heard, and treated with respect. Findings support integrating a Values Support Specialist to build trust and align care with personal values.