Using routinely collected assessment data to understand the diverse care needs of clients across the long-term care continuum

Background:There is growing evidence that long-term care in Canada -- defined as an array of health and social care services provided to individuals at home or in home-like settings -- should be structured as an integrated system capable of meeting clients’ holistic needs in an equitable manner. To better understand variation across the long-term care continuum, this project aimed to describe and compare the characteristics and care needs of older adults across four long-term care contexts in Ontario, Canada, including publicly funded home care, home care accessed through a private insurance model, community-based transitional care, and facility-based long-term care.

 

Approach: Leveraging routinely collected data from the interRAI Home Care — a standardized assessment tool used internationally to evaluate the health and social care needs of individuals — we applied a three-step segmentation process to categorize clients across each of the care settings into a range of eight Life Care Needs Groups including Geriatric Syndromes, Medical Complexity, Cognitive Impairment and Behaviours, Chronic Disease Management, Caregiver Distress, Social Frailty, Daily Support and Other Needs.

 

We then examined each group’s demographic, medical, functional, cognitive, and psychosocial characteristics to create comprehensive clinical profiles. Profiles were compared across care settings to understand the similarities and differences across long-term care contexts. Consultations with care providers, older adults, caregivers, and health system leaders were conducted to validate findings and inform interpretation to ensure practical relevance.

 

Results: While clients representing each of the eight life care needs groups were identified across each of the care settings, the prevalence of groups varied by setting. For instance, facility-based long-term care had the greatest proportion of individuals within the Cognitive Impairment and Behaviours group. There were also differences and similarities in individual care needs across settings. For example, between public and private-pay home care, the population accessing private-pay services had a greater prevalence of medical issues such as dehydration and social concerns including loneliness. Mental health concerns, such as depression, were flagged as critically important issues across multiple care settings. More detailed findings will be available at ICIC26.

 

Implications: This study supports an improved understanding of the complexity of client needs across the long-term care continuum. Our results support the call to shift from task-oriented, location-based long-term care models that focus primarily on physical health and functional status toward holistic, equitable and integrated care with strong collaboration across health and social care providers. A more integrated model of long-term care such as this would better support equitable, people-centered care tailored to clients’ diverse needs.