Exploring long-stay seniors’ transitions from home care services to self-management

As a result of longer life expectancies and below-replacement fertility rates, the Canadian population is aging. Approximately 14.8% of the Canadian population was aged 65 years or older in 2011. The senior population is faced with co-morbidities and polypharmacy. The result is a significantly higher usage of healthcare resources by seniors. Homecare services allow seniors to stay at home and manage their complexity by providing home support services and care coordination. However, limited resources for homecare have led to long waitlists and prioritization of short-stay, acute clients at the expense of long-stay seniors. As a result, long-stay seniors are often discharged faster, leading to transitions. Appropriate transitional care ensures the coordination and continuity of care and may help seniors avoid poor health outcomes. \nThis study used a qualitative approach, more specifically Grounded theory, to explore the transition from homecare to self-management and had 3 objectives: 1) describe the preparation of long-stay seniors for self-management at discharge from home support services in the Waterloo-Wellington CCAC, through the perspectives of seniors and/or their caregivers, as well as care coordinators; 2) assess the quality of transition from the perspectives of long-stay seniors and their caregivers, including successful actions and challenges, from homecare services to self-management; and 3) examine the senior’s and caregiver’s experience of the transition and subsequent unmet needs for homecare services. \nThree seniors, two dyads of seniors and caregivers, and one caregiver were interviewed, as well as six care coordinators from the Waterloo-Wellington Community Care Access Center (WW-CCAC) using a semi-structured interview guide. Interviews with Seniors and/or their caregivers were used to address all three objectives, while interviews with care coordinators helped address the first objective.. \nResults showed that the preparation for discharge lacked a discussion between care coordinators and seniors/caregivers on medication management, limited knowledge of health conditions and limited information of health service providers of seniors and caregivers. However, seniors and caregivers were aware of available community supports. Subsequently, the transitional care after discharge form homecare services lacked a mechanism to ensure follow-up with primary healthcare professionals as well as a formal process for medication though a large support network was available to the seniors. The seniors and caregivers reported a positive experience with managing their own care after discharge with limited perceived need of homecare or formal help and capability to manage and cope without homecare services. Overall, there was a poorly informed discharge and limited transitional care but a positive subjective experience and avoidance of adverse health issues. A theoretical framework for the perceived transition from homecare services to self-management after discharge from WW-CCAC was generated from the findings. The framework presents a disconnect between actual needs and perceived needs for transitional care. Seniors are hesitant in seeking out care or information while care coordinators expect seniors to take initiative if any issues or concerns need to be addressed. These findings suggest room for improvement when preparing seniors for discharge from homecare services to avoid poor health outcomes that may result. There seems to be an absence of many important elements of successful transitional care in this specific transition. Seniors’ and/or their caregivers’ lack of proactively seeking information and resources may contribute to the lack of preparation by care coordinators. \nThis study provides an important first step in understanding the transition from homecare service to self-management after discharge. Further research should further test the results of this study by implementing an intervention based on the theoretical framework presented in this study. The result also have the potential to contribute to discharge planning at WW-CCAC to improve the transition.

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