Grant: Catalyst Grant: Partnering for Impact - General Pool

The number of people living in long-term care (LTC) homes in Canada is steadily increasing and their health and personal care needs have become more complex over time. While ideally LTC residents will have their health care needs met in their LTC homes, many will require hospital-based care. The transition from hospital back to LTC is a vulnerable time as residents face an increased risk of preventable problems including medication errors, unintentional changes in care plans, missed follow-up tests or appointments, and hospital readmission. A key contributor to this problem is suboptimal communication between hospital and LTC home teams. This study brings together LTC residents and family caregivers, researchers, clinicians and administrators from LTC and hospital settings, and health system planners, in Ontario, to strengthen partnerships and develop recommendations to ensure safe, high-quality care transitions for LTC residents. The project aims are: 1) Collaborate to develop an understanding of the experiences and quality of care (QOC) concerns associated with LTC resident transitions from hospital to LTC homes; 2) Co-create a list of opportunities for improvement and concrete strategies for how to achieve those improvements. We will achieve aim #1 by interviewing and observing people involved with care transitions and reviewing documents to explore experiences and QOC concerns from a range of perspectives. We will achieve aim #2 by bringing together residents, caregivers, and healthcare staff from hospitals and LTC homes for a series of co-design meetings to identify and prioritize ways to improve care transitions. Throughout, we will ensure that approaches are inclusive and transparent such that everyone shares in decision-making. Study results will help hospitals and LTC homes identify changes that can improve how care is organized and inform provincial policy to ensure that adequate resources are in place to support high-quality transitions for LTC residents.