Grant: Operating Grant: College and Community Innovation Social Innovation Fund

<html> <head> </head> <body> The long-term care (LTC) sector provides essential, ongoing care for some of Canada&#8217;s most frail and vulnerable citizens. With rising waitlists and a host of other health care system challenges, new residents are entering long-term care homes (LTCHs) sicker than ever, placing immense pressure on care teams to support them, and their families, with the transition process. When care transitions are not done well, the consequences can include medication errors, returns to hospital, declines in mental health, cognition and mood, and feelings of guilt, failure and stress amongst family caregivers. Together with our innovation partner, a non-profit LTCH in Southwestern Ontario, we project will measure the impact and support the scalability of an innovative, multicomponent care transitions model that is designed to support the health and wellbeing of residents and their family carers, both before and after a move to a LTCH. Internal pilot work has already shown that this care transitions support program, The Woodingford Way, produces better health outcomes, reduced caregiver stress, and cost savings. It is critical that all LTCHs have the opportunity to benefit from innovative and evidence-based models. Thus, we will use an implementation science approach, which we view as the ideal method for enhancing the reach and impact of social innovations. Working closely with our community partner and other LTCHs, our joint work will include: 1) a robust, mixed-method evaluation of the model, 2) data collection (e.g. interviews, document reviews) to understand how to implement the model (e.g. what are the barriers and facilitators, what inputs, capacity and resources are required, what lessons were learned during implementation). We will then 3) create an implementation guide, review and refine it with representatives from the sector, and 4) disseminate the guide and evidence to the LTC sector, decision-makers, clinicians and the community. The potential impacts for the broader sector are substantial, given that LTCHs struggle with care transitions and investments in such programs are very low. LTCHs are actively seeking proven transitional care models and approaches that are feasible and that function within current funding and staffing models. Demonstrating the impact of the model, and providing clear and practical implementation guidance, has the potential to improve the health of waiting/new LTC residents and their families regionally and nationally. </body> </html>