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Reimagining aging in place through a holistic care lens
In support of Toronto Grace Health Centre’s evidence-based and collaborative research initiative to build an integrated transitional care model, HHF engaged older people and their caregivers, healthcare professionals, and leadership to reimagine how we support older people and their caregivers through transitions in care to promote aging in place.
Client
Toronto Grace Health Centre (TGHC)
Services
Service Design; Ethnographic Research, Co-Design Workshops, Pathway Mapping, Synthesis Mapping
Challenge
The Ontario healthcare system is currently under pressure due to ongoing human resource shortages and increasing demands for care from a growing and aging population. Adding to the pressure is an increasing number of older patients living with frailty (OPLF) who no longer require acute care but remain in hospital with no safe place to go. For OPLF languishing in acute care beds, there is an increased risk of physical and cognitive decline, which can later be exacerbated by poorly planned and supported hospital-to-home transitions. For hospitals, the inability to discharge OPLF to a safe environment leads to a lack of beds for incoming patients in need of acute level care.
Process
Discovery
Through a series of ethnographic interviews and group workshop sessions, the HHF team collaborated with the Toronto Grace Health Centre (TGHC) research team to explore the lived experience of older people living with frailty, their informal essential caregivers (ECPs), healthcare professionals (HCPs), and leadership from both hospital and community, mapping the gaps and challenges that currently exist and highlighting opportunities for innovation.
Research Insights
Healthcare is more than just physical care
Current care planning prioritizes physical health at the expense of psychological, social, and emotional care.
Home is more than a roof
More than a physical structure, home is familiar, safe, and filled with personal memories and emotional connections.
Patients and family need to feel they have a voice, a choice and a purpose
Clarity in path and purpose inspires action and builds motivation. Feeling included, acknowledged, and heard inspires confidence and connection.
The disconnect between hospital and community is challenging to navigate for everyone
The siloed healthcare system is impacting communication, consistency, and experiences.
Informal caregivers need greater support to continue in their role
The system requires informal care to fill the gap in emotional, physical, and financial support and advocacy in care, but is not adequately engaging or acknowledging the needs of those who fill this role.
Language and income impact care equity and experiences
Both financial constraints and an inability to communicate, whether a physical or language barrier, can impact a person’s ability to implement and maintain appropriate in-home support.
Design
The insights revealed during the exploration of lived experiences became the building blocks for a large in-person World Cafe style co-design session. OPLF, ECPs, HCPs and leadership came together to reimagine transitions in care and create digitally enabled and integrated pathways to home that support whole-person care.
A set of guiding principles served to bridge the gap between the insights and creative solutions developed during the co-design session, keeping the voice of contributors at the forefront and steering decision making.
5 Guiding principles:
- Take a whole person approach to care
- Include the full circle of caregivers (formal and informal/paid and unpaid)
- Be transparent in goals and expectations
- Plan care and transitions with an equity-based lens
- Provide open communication between people, hospital, and community
If patients do not receive an adequate amount of resources after getting discharged, they come back to acute/rehab care and start the process all over again.
Healthcare Provider
Outcomes
The Integrated Transitional Care Model (ITCM) provides pathways to support aging in the right place with the right level of care and support at the right time.
The ITCM spotlights whole person care for both OPLF and their ECPs, placing a primacy on collaborative and localized community care to support existing connections and foster new ones. Warm transitions in care are facilitated through community partnerships, extending hospital connections during transitional phases, and engaging community partners earlier in the acute and rehab care journey. An expansion of transitional care and the expansion of digitally-supported home monitoring fills noted gaps in care and provides an opportunity for anticipatory care and planning.
The HHF team is continuing to support TGHC and their partners as they implement ITCM features and build improved care pathways for OPLF and ECPs. Together, we hope to change how older people age in place with dignity and support.