Abstract Objectives To address the rising burden of dementia, China has prioritized the integration of cognitive care frameworks within primary care (PC). However, a functional gap persists: while screening has expanded, subsequent clinical management remains fragmented. This study investigates the structural and behavioral discontinuity contributing to the post-screening care gap in community-based geriatric care. Methods Adopting a qualitative exploratory design, this study was conducted across PC facilities in Guangdong, China, between February and August 2022. Through purposive sampling, 104 key stakeholders – including frontline clinicians (n=55), program coordinators (n=21), and health administrators (n=28) – were recruited. Data collected via semi-structured interviews and focus groups underwent rigorous thematic synthesis to map systemic bottlenecks in the care pathway. Results Theme analysis revealed a tripartite architecture of service discontinuity. First, individuals’ behavioral choices during screening process, characterized by procedural fragmentation, disrupt the transition from initial detection to definitive diagnosis. Second, multiple institutional governance dilemmas – stemming from chronic resource scarcity and governance constraints – undermine the delivery of sustained interventions. Finally, cultural resistance creates a stalemate where deep – seated stigma fuels family avoidance and provider reluctance. Collectively, these forces fracture the management loop, preventing the realization of a continuum of care. Conclusions Closing these gaps requires more than expanding screening coverage. To bridge these multi-layered gaps, policy interventions must foster intersectoral synergy, transforming isolated diagnostic encounters into unified, longitudinal care pathways.
Huang et al. (2026) studied this question.