Grant: Travel Awards - Institute Community Support

Transitions from hospital to the community for older adults are often accompanied by a deterioration of physical and mental health, increased mortality and hospital readmissions, and dissatisfaction with care. Efforts to improve care transitions have focused on improving hospital service delivery, but poor outcomes of care have persisted. Supporting older adults in care transitions requires not only the integration of care within the hospital (ex. coordination between multidisciplinary providers), but also between hospital and community services (ex. timely sharing of discharge recommendations to the community), and within the community (ex. capacity to meet health and social needs). The goal of this research is to determine how integrated care is currently being implemented to support older adults transitioning from hospital to the community. This will be accomplished using two primary methods. First, hospital and community health care professionals from associated with a large Canadian teaching hospital will be interviewed about integrated care strategies currently being implemented, and the challenges and benefits inherent in these strategies. Second, 300 charts of individuals 65 and over who were hospitalized in the same teaching hospital, and discharged with continuing care services will be reviewed. This chart review will result in an understanding of relationships between the specific health and social needs of these older adults, what kinds of integrated care strategies are being used to promote their care transition back to the community from the hospital, and the efficiency of the discharge process. This study will generate highly descriptive 'real-world' information that will improve capacity for providing high quality care transition services that tailor to specific patient needs.