Abstract
Background: To remain in their community, a person’s combination of self-care abilities, family support and formal care must match their level of need. When this does not happen, the individual can experience negative outcomes such as unmet needs, caregiver burnout, or increased use of facility-based care. Having an accurate understanding of care needs is critical not only at an individual level, but also at a program or population level for organization and system leaders to understand and plan for the types, amounts, and combination of services required. To facilitate provision of holistic, integrated health and social care, this understanding must be based in a broadened definition of health, moving beyond the traditional dimensions of daily functioning and bodily functions, to consider aspects of societal participation, quality of life, meaningfulness, and mental well-being.
Approach: In this study, routinely collected health assessment data was leveraged to conduct a retrospective, cross-sectional analysis of the dominant medical, functional, cognitive and psychosocial ‘life care’ needs of 205,405 older adults assessed for home care in Ontario, Canada. Individuals were first categorized into distinct groups using a hierarchical service level algorithm and then care needs of each group were examined to create comprehensive profiles of the groups’ clinical needs. These data-informed care profiles were then translated into six research-based toolkits with accompanying narrative personas, care calendars, and scenarios to support the applied use of the information for participatory research, workforce development and training initiatives, operational and human resource planning and new model design.
Results: Six unique home care client groups representing 162,523 home care clients were identified. The dominant care needs of each group were examined in depth to create data-informed care profiles aligned with known predictors of long-term care facility admission including Geriatric Syndromes, Medical Complexity, Cognitive Impairment and Behaviours, Chronic Disease Management, Caregiver Distress and Social Frailty. While each group had a distinct clinical profile, there were several common ‘life care’ needs identified across the home care population including challenges related to daily functioning, experiencing daily pain and living with incontinence. Furthermore, clients in all six groups had care needs spanning multiple dimensions of a broadened definition of health, emphasizing the need for a holistic approach to assessment, care planning and delivery in home care.
Implications: The care needs of older adults assessed for home care are heterogenous and complex, requiring a shift from siloed health and social care towards integrated, people-centred home and community care. Comprehensive clinical profiles developed from routinely collected assessment data, can support data-informed design of tailored integrated care models which attend to population health needs. However, just designing these programs will not be sufficient to move the needle. To shift existing practice patterns and culture to a more holistic approach, updated education and training along with clinical and system leadership will be required. Workforce development initiatives designed to grow interprofessional and collaborative care competencies can leverage these data-informed profiles as the foundation for workplace case-based training programs to support delivery of integrated care.