Integrating supportive housing into the continuum of care in Ontario

Background: An essential component of managing the health care system effectively as the population ages is to provide care to seniors in the care setting that can best meet their needs. The majority of seniors wish to remain at home, to maintain their independence. Informal caregivers (family, friends and neighbours) provide as much as 80% of care to seniors who reside at home. The absence of or loss of an informal caregiver and/or a decline in a senior’s health may necessitate a change in care setting. Supportive Housing (SH) is a rapidly emerging alternative care setting for seniors who can no longer have their needs met at home. \nObjective: The objectives of this dissertation were: to provide a comprehensive description of the profile of SH clients in Ontario; to determining the role of SH in the continuum of care; to develop an algorithm to support care placement decisions; and to explore the longitudinal outcomes of SH clients including quality of life, and long-term care placement. The following four research questions were addressed: What are the socio-demographic and clinical characteristics of persons currently residing in SH units in Ontario? How do the profiles of current SH clients differ from the profiles of persons residing in other care settings? What changes occur in the appropriateness of SH to meet care needs over time? What factors are associated with discharge from SH to a long-term-care facility (LTC)? \nMethodology: The research questions were answered primarily using two Ontario interRAI data sets: A pilot sample of 1,720 SH clients collected using the interRAI Community Health Assessment and a sample of 29,790 Community Care Access Centre (CCAC) clients collected as part of normal clinical practice from clients residing in residential care setting, including SH. Data from LTC (N=832) and complex continuing care (CCC; N=425) clients in the Mississauga-Halton (MH) LHIN were also used. Data on care placement decisions were collected using a Staff Rating Form (N=332 in SH). \nResults: SH clients are a relatively light-care population who require support with instrumental activities of daily living (IADLs) and tend to lack an informal caregiver. SH clients who receive care from a CCAC are in the minority but represent a much more clinically complex sub-population. According to staff members, the majority (80%) of SH clients are appropriately placed; of the remaining 20%, 17% were prematurely admitted to SH and would be best cared for at home, a further 3% require LTC placement. Moreover, about 10% of seniors who receive care in the MH LHIN, have been inappropriately placed and would be best cared for in a SH unit. A Decisions Support Algorithm for SH (DASH) was developed to inform care placement decisions in Ontario. The algorithm was based on both resource availability and client care needs. Level of impairment in: IADLs, cognition, continence and score on the MAPLe algorithm (an interRAI prioritization algorithm; see Figure 11), were found to be significant predictors of care placement. Poor QoL was relatively rare (~5%) among SH clients and regression analysis was used to determine the variables associated with a decline in QoL. Finally, survival analysis determined that 20% of SH clients are discharged to LTC within one year. Age, dependence on others to perform IADLs, bladder incontinence, cognitive impairment, and higher MAPLe scores were associated with this discharge. \nConclusions: Analyses in this dissertation have clearly indicated the need for a standardized assessment instrument in this sector. Arbitrary decisions around eligibility and discharge criteria for supportive housing have led to inappropriate placement of clients and confusion over the role supportive housing is to play in the continuum of care. Evidence-informed care placement decisions should consider client care needs as well as both the availability of formal and informal support. An integrated health information system, such as the interRAI instruments, facilitates a culture of evidence and improves communication across the care continuum. SH is a rapidly emerging alternative care setting for seniors. If managed carefully, SH has the potential to help address many health system level concerns as the population ages. It is hoped that this dissertation has answered some key questions and also inspired further research into an important and growing field.

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