Grant: CIHR Fellowship

Older adults report better quality of life when they are able to live and receive support in their preferred setting of care. In British Columbia's Northern Health Authority (NH) long term care facilities (LTCFs) all residents need support and services, however, a large number of these residents may not need the intensive services the LTCFs provide, and may be happier being cared for in the community. These residents potentially could be discharged to community settings. It is hypothesized that some but not all of these residents in LTCFs will desire to return to a community setting, and that varied supports will be required. An analysis of assessment data will provide a snapshot of how many of these residents in LTCFs there are across NH and describe their characteristics. These residents and their families and caregivers will be interviewed individually to find out more about their preferences and needs. Through small group interviews with regional, facility, and community care providers the requirements and resources for successful transition will be identified, along with what needs to happen in order to have the needed resources in place. The research will describe person and community contextual features, barriers, and facilitators that would help this group of LTC residents to transition safely back to the community. What is identified through this research will be used to develop and test a plan that can be used to safely transition this group of residents to their desired place of care in the community. Such a plan has the potential to identify critical community support services that can be put into place to help older persons move out of LTCFs back to the community and as a result to receive care in the right place, in ways that improve the satisfaction of older persons and their families while reducing health care costs. The knowledge created in these rural settings will also inform how to improve the Knowledge-to-Action model.