Abstract
The Ontario healthcare system is currently under pressure due to ongoing human resource shortages and increasing demands for care from a growing and aging population. Adding to the pressure is an increasing number of older patients living with frailty who no longer require acute care but remain in hospital with no safe place to go. For these older people languishing in acute care beds, there is an increased risk of physical and cognitive decline, which can later be exacerbated by poorly planned and supported hospital-to-home transitions. For hospitals, the inability to discharge these patients to a safe environment leads to a lack of beds for other incoming patients in need of acute level care.
Through ethnographic interviews and group workshop sessions, we collaborated with older people, their informal essential caregivers, healthcare professionals, and leadership from both hospital and community to explore their individual lived experiences, mapping the gaps and challenges that currently exist and highlighting opportunities for innovation. Through this human-centred approach we built a comprehensive understanding of the diversity of needs that exist for older people and their informal caregivers as well as the systemic factors that impact current decision making and policies.
The insights uncovered during the exploration of lived experiences became the building blocks for a large in-person World Cafe style co-design session. All of our key stakeholder groups came together to work collaboratively and reimagine transitions in care and create digitally enabled and integrated pathways to home that support whole-person care.
A set of guiding principles served to bridge the gap between the insights and creative solutions developed during the co-design session, ensuring the voice of older people, their caregivers, and hospital and community care providers led decision making.
This presentation will explore our unique approach to research and how it informed the development of an Integrated Transitional Care Model (ITCM) providing pathways to support aging in the right place with the right level of care and support at the right time.
The ITCM spotlights the need for whole person care for both older people and their informal caregivers, placing a primacy on collaborative and localized community care to support existing connections and foster new ones. Warm transitions in care are facilitated through community partnerships, extending hospital connections during transitional phases, and engaging community partners earlier in the acute and rehab care journey. An expansion of transitional care and the expansion of digitally-supported home monitoring fills noted gaps in care and provides an opportunity for anticipatory care and planning.
Participants will learn about the unique needs of older people living with frailty and their informal caregivers and how they affect the design of care pathways and digital solutions. Including collaboration with older people and their caregivers when we reimagine how we might better promote aging in place. Successes, values, and barriers encountered throughout the project when integrating qualitative and quantitative data. Methods used, such as in person ethnographic interviewing, and virtual one on one discussions, as well as in-person, virtual, and hybrid workshop sessions.