Abstract
Canada’s population is rapidly ageing. Its life expectancy, now among the highest in the world, exceeds 82 years. This rapidly ageing population contributes to the unprecedented strain on the health care system. Toronto's seniors have additional challenges with equitable access to preventive health promotion services.
SPRINT Senior Care, a small Community Support Service agency and Sunnybrook Health Sciences Center, a large academic hospital, have a long history of working in partnership with the consistent goal to improve the ability of seniors to live in our community. This long-standing relationship is foundational for what has become a strong partnership for integrated care.
A suite of collaborative initiatives between SPRINT Senior Care and Sunnybrook Health Sciences Centre have aimed to advance integrated healthcare and support seniors in living independently. This partnership evolved over many years, building on trust, and demonstrating the impact of community services as an integral part of the healthcare system. This innovative and multi-faceted relationship includes a co-location of the community Meal on Wheels program within the Hospital, integration of community social workers into the hospital, the development of co-run transitional care sites serving alternative level of care (ALC) patients, and the cross pollination of senior staff in strategic planning, hiring, accreditation and governance. Initiative co-design and evaluation leveraged surveys were used to obtain both acute and community provider and patient/client input.
To optimize the delivery and sustainability of these program, we partnered with researchers with expertise in implementation science to support the delivery and evaluation of our transitional care programs. All of these qualitative studies have been informed by the Consolidated Framework for Implementation Research (CFIR), which involved using the CFIR to develop interview guides and analyze data collected through semi-structured interview and focus group data with hospital- and community-based healthcare professionals and decision-makers engaged in these programs. As well, we have collected data from patients and family members to inform program development and refinement.
The collaboration between SPRINT Senior Care and Sunnybrook Health Sciences Centre has significantly improved senior care by reducing avoidable ED visits and ALC days, enhancing healthcare efficiency, and ensuring safer transitions from hospital to home. This partnership has decreased readmissions and provided essential caregiver support, showcasing the effectiveness of integrated healthcare models.
The success is due to strong executive leadership backing, trust, and collaborative decision-making between both organizations. The partnership thrives on flexibility and a commitment to continuous improvement, supported by qualitative and quantitative research demonstrating positive patient outcomes.
This partnership showcases the power of integrated healthcare to achieve a common vision. The success underscores the importance of trust and courage of engaging healthcare professionals, client, patients, and caregivers to collaborate for a better health care system.
Next Steps:
- Expand the Model: Scale this integrated healthcare approach to other regions, optimizing senior care.
- Increase Engagement: Enhance involvement of seniors, caregivers, and community members in co-design.
- Evaluate and Innovate: Collect and assess data, refine programs, and explore new interventions to reduce hospital use and improve senior independence.