A Hidden Dependency Compromising Complex Healthcare Systems

In complex systems, outcomes emerge from the interaction of many interconnected parts rather than the performance of any single component. If a critical component, frequently described as a hidden dependency, is not formally recognized or designed into workflows, problems show up indirectly—as defects, delays, workarounds, and inconsistent performance (1). Human organizations are vulnerable to this problem. When an individual’s contributions are invisible, managers misjudge risk, overestimate reliability, and struggle to improve outcomes (2)(3).

What Makes Family Caregivers a Hidden Dependency

Typically, hidden dependencies share three characteristics (4) (5) (6). First, they are not explicitly visible in system design. Their work rarely appears in pathways, organizational charts, reimbursement models, or quality metrics. Yet when actual clinical workflows are traced beyond the clinic or hospital, patient relatives are the ones coordinating appointments, monitoring symptoms, transporting patients, administering medications, enforcing instructions, and responding to problems in real time.

Second, they create indirect coupling. For example, medical teams may develop goals of care plans directly with the patient. But success relies on family caregiver availability, capacity, understanding, and follow-through for implementation—inputs that are rarely assessed or negotiated. Outcomes are then attributed to providers and healthcare systems, even though implementation occurs largely outside their direct control.

Third, they are critical to performance and safety. Systems routinely assume their competence, consistency, and compliance, but rarely train, support, or measure them as part of the therapeutic team. These assumptions fail habitually under real-world conditions—not due to a clinical error, but an operational breakdown: missed medications, delayed follow-up, preventable crises, and avoidable readmissions.

From this perspective, it is not surprising that value-based care programs struggle to deliver consistent improvements. America’s elder care system depends on a workforce it does not fully see and control.

Why “Informal” Is a Misleading Label

Language matters because it shapes strategy. The term “informal” suggests something optional, casual, or peripheral (7). That framing does not match reality. Today, nearly 90 percent of older adults receive most of their daily support from relatives, friends, and neighbors (8).

Family caregivers routinely perform tasks that would be considered skilled if delivered by paid professionals. In fact, 70 percent monitor conditions, 64 percent communicate directly with clinicians, and 58 percent advocate across providers, community services, and government agencies (8). Additionally, they help manage activities of daily living, multiple chronic conditions, cognitive impairment, functional decline, and complex transitions between hospitals, skilled nursing facilities, home health agencies, and outpatient settings (9). Together these responsibilities make them uniquely positioned in ways the system is not because caregivers are often the only ones experiencing the entire trajectory of aging and end of life progression.

Further, as patients are discharged earlier and with greater acuity than in the past, families are expected to absorb increasing complexity with little preparation. Research consistently shows family caregivers feel undervalued, unrecognized, and uncertain about how—or whether—their knowledge (or lack thereof) can be incorporated into planning (10). Calling this work informal diminishes its scope and consequence. It also makes it easier for systems to rely on caregivers without building appropriate support structures around them.

The Missed Paradigm Shift

More than a decade ago, the Institute of Medicine (IOM) explicitly called for a broader definition of the healthcare workforce—one that includes informal caregivers alongside professionals (11). Still unresolved is how—and under what conditions—informal caregivers should be incorporated into the process.

Sources:

1. Organizational Structure, Subsystem Interaction Pattern, and Misalignments in Complex NPD Projects. Songhori, Jafari M., and Nasiry, J. https://doi.org/10.1111/poms.13102, 2020, Production and Operations Management.

2. The Human Side of Strategy: Employee Experiences of Strategic Alignment in a Service Organization, Organizational Dynamics. Schneider, Benjamin, Ellen G Godfrey, Seth C Hayes, Mina Huang, Beng-Chong Lim, Lisa H Nishii, Jana L Raver, and Jonathan C Ziegert. https://doi.org/10.1016/S0090-2616(03)00014-7, 2020, Production and Operations Management.

3. The integration of human and non-human actors to advance healthcare delivery: unpacking the role of actor-network theory, a systematic literature review. Ryan, T., Ryan N and Hynes B. https://doi.org/10.1186/s12913-024-11866-4, 2024, BMC Health Serv Res.

4. Considering complexity in healthcare systems. Kannampallil, Thomas G., Guido F. Schauer, Trevor Cohen, Vimla L. Patel. https://doi.org/10.1016/j.jbi.2011.06.006, 2011, Journal of Biomedical Informatics.

5. Systems modeling to support the complex nature of healthcare services. Engelseth, Per, E B White, Ingunn Mundal, Trude Flostad Eines, and Duangpun Kritchanchai. https://doi.org/10.1007/s12553-020-00504-8, 2021, Health and Technology.

6. Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science. Leykum et al. http://www.implementationscience.com/content/9/1/165 , 2014, Implementation Science.

7. Bridging Troubled Waters: Family Caregivers, Transitions, and Long-Term Care. Levine, Carol, Deborah Halper, Ariella Peist, and David Gould. 10.1377/hlthaff.2009.0520, 2010, Health Affairs.

8. AARP and National Alliance for Caregiving. Caregiving in the U.S. 2025. 2025.

9. Providing Physical Assistance for Family or Friends: An Overview for the Home Health Care Professional–Part 1. Weir, Rodney L and Donald L Hoover. 2021, Home Health Care Management & Practice.

10. Roles and experiences of informal caregivers of older adults in community and healthcare system navigation: a scoping review. Wister, Kim B, A, O'dea E, Mitchell BA, Li L, Kadowaki L. doi: 10.1136/bmjopen-2023-077641, 2023, BMJ Open.

11. Institute of Medicine (US) Committee on the Future Health Care Workforce for Older Americans. Retooling for an Aging America: Building the Health Care Workforce. Washington DC : National Academies Press, 2008.