Seamless Transitions: The Path to Sustainable Health Care for Canadian Seniors

Improving the sustainability of health system depends in part on reducing demand for resource intensive acute care services by ensuring patients have access to high quality care at the most appropriate time and place. Access to the right care at the right time is especially critical for older adults experiencing complex healthcare needs, frequent healthcare visits, longer recovery times, and lack of appropriate and affordable housing to support aging in place. A significant health system challenge results from a lack of appropriate healthcare services to support older adults returning to community after a hospital visit, at which point in time they are designated “alternate level of care” and wait in hospital for an alternate location. Increasing proportions of older adults designated “alternate level of care” in hospital has detrimental impacts for costs of care, interruptions to patient flow, and worse health outcomes for older adults.

Transitional care services – interventions designed to ensure coordination and continuity of care as patients move between different locations or levels of care within the same location – show promise for supporting older adults’ needs and improving the sustainability of health systems. Transitional care programs globally show reduced health care service utilization, reduced costs of care, and improved functional status and health outcomes for older adults. Despite their importance, there is limited literature on the scope of such programs in Canada. A systematic review of grey literature was conducted to characterize the scope of transitional care programs that exist across Canada for older adults moving from hospital to home.

119 transitional care programs were identified from a systematic search of grey literature sources including Canadian organizational websites, reports, and news articles. Transitional care programs were categorized by model of care in community (n=42), hospital (n=45), and facility-based (n=32) settings. Programs were defined by goals, target populations, settings, duration, interventions, services, and healthcare team members. Outcomes for patients, caregivers, and the health system were reported for 18 programs. Most transitional care programs identified exist in Ontario (n=84), British Columbia (n=10), Manitoba (n=7), and Alberta (n=5), making them better equipped to scale up existing programs to meet the needs of an aging population. 

Characterizing transitional care programs is vital for health services planning, providing decision-makers with most up-to-date information about existing models of care across Canada.

W&W Strategy Lead, Dr. Brittany Barber and colleagues discuss the importance of improving availability of data and disseminating research findings to supporting uptake of effective healthcare interventions such as transitional care programs, leading the path towards sustainable health systems.