Transitional care programs or (TCPs) are a creative solution for providing older adults, who no longer meet the requirements for acute care but who cannot be discharged home, with an alternative level of care (ALC).
“TCPs are meant to be short term post-acute care programs,” says Kathy McGilton, a professor (status) at the Lawrence Bloomberg Faculty of Nursing, Senior Scientist at KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, and an expert in quality of care for older adults. “The goal of this model is to improve an individual’s functional status including their ability to eat, walk and dress themselves, so that they can eventually be discharged home or to another appropriate care setting.”
In a new systematic review led by Bloomberg Nursing PhD student Alexia Cumal, who is also a research trainee at KITE, the impact of facility-based transitional care programs on older adults with cognitive impairment such as dementia, was examined. Of the 22 studies included in the review, the majority suggested that TCPs resulted in a higher percentage of older adults with cognitive impairment being discharged home instead of being re-admitted to hospital or discharged to long-term care. While this also indicated an improvement in functional status, the percentage discharged home and improvements in functional status were greater for older adults without cognitive impairment.
“This is significant because it not only indicates that we need more transitional care programs but also that there is some fine tuning required to ensure these programs have the resources in place to assist older adults with cognitive impairment,” says Cumal.
Cumal who works as a registered nurse on an acute care for elders unit, has witnessed an increasing number of older adults who require alternate levels of care. According to a 2021 Canadian Medical Association report, 44 per cent of ALC patients are waiting for long-term care while 11 per cent are waiting for home care. Given the ongoing challenges in the health care system and long-term care sector, finding somewhere for these clients to go without having them stay in acute care settings for prolonged periods of time, means the need for TCPs is urgent. Utilizing TCPs that can be tailored to the needs of those with cognitive impairment is imperative McGilton adds, because a high percentage of those requiring alternate levels of care already have cognitive impairment such as dementia and/or delirium.
“This means that these individuals are already further behind in terms of function and cognition, they might need extra physiotherapy, occupational therapy, or other resources or interventions to gain back functional status in order to be discharged home,” says McGilton.
Additionally, involving caregivers of older adults and providing education to them to further aid in the older adult’s ability to be discharged and remain at home is needed. McGilton and her team’s earlier scoping review on TCPs found that the provision of caregiver education within TCP models of care was limited and that the intensity of therapy services provided to patients by each TCP varied.
“Without adequate resources in place for these TCPs, the rates of older adults with cognitive impairment who are re-hospitalized or are discharged to long-term care could increase,” adds Cumal.
Moving forward with this research, McGilton who received funding from the Canadian Institutes of Health Research (CIHR) earlier this year, has been working with the Ministry of Health to review eight of the TCPs currently in Ontario, learning which ones lead to the best outcomes for patients, which interventions are improving functional status for patients, and how different types of staff, including nurse practitioners, fit into this model of care. Cumal has also received a CIHR Doctoral Research Award to support her work in this area. For her PhD, she will be implementing a nurse-led intervention aimed at improving outcomes for older adults with cognitive impairment in TCPs.
For Cumal the results of their review, including the higher rates of readmission to hospital or transfer to long-term care for older adults with cognitive impairment, compared to those without cognitive impairment, means that further studies are needed to determine and address barriers that can have an impact on discharge destination and improve the percentage of older adults with cognitive impairment successfully discharged home.
“These models of care can make quite a difference for older adults in Ontario, it gives them a second chance to age at home and they could become a necessary piece of our health system going forward,” says McGilton.