Aging, Community and Health Research Group (ACHRU)

McMaster University


Newly Released: Improving Hospital-To-Home Transitions for Older Adults with Complex Health and Social Needs in Ontario

We collaborated with the McMaster Health Forum on a stakeholder dialogue summary, evidence brief, and video interviews on ‘Engaging Older Adults with Complex Health and Social Needs, and Their Caregivers to Improve Hospital-to-home Transitions in Ontario’.

The stakeholder dialogue summary, evidence brief, and video interviews were funded through the ACHRU study ‘Community Assets Supporting Transitions (CAST)’, which was supported by funding from the Ontario SPOR SUPPORT Unit, the Labarge Optimal Aging Initiative, and the CIHR Signature Initiative in Community-Based Primary Healthcare.

The study was led by Drs. Maureen Markle-Reid and Carrie McAiney and involved ACHRU researcher Dr. Rebecca Ganann and our Caregiver Research Partner Gail Heald-Taylor.

Participants of the stakeholder dialogue emphasized:

• that hospital-to-home transitions should be reframed to consider the full continuum of care, starting with trying to keep people from going to hospital in the first place

• the need for key performance indicators that are person-centred and consider their social context for optimal hospital-to-home transitions

• having funding arrangements that enable the key performance indicators to be achieved; and

• new indicators and funding arrangements require different types of leadership, for example from community-based organizations, frontline staff, and patients and families. Nimble leadership will enable dynamic matching of supports to changing patient needs  

The evidence brief aims to inform deliberations that could help to improve the quality and experience of hospital-to-home transitions for older adults with complex health and social needs (and their caregivers) in Ontario.

Click here to view the Stakeholder dialogue summary

Click here to view the Evidence brief 

Click here to watch the Video interviews

Published on: June 21, 2021

By Study