Long-term life care at home: a bottom up, community-driven model for long-term care reform in Canada

Introduction

Almost all Canadians want to live, age and receive care at home, yet long-term care (LTC) reform continues to narrowly focus on renovating and expanding residential care facilities that serve a small proportion of the aging population and are not well-integrated with the rest of the health care system. A broader system-wide perspective on long-term care should start with ensuring people at home have access to a wide range of community and home-based care and support services to meet their medical, functional and social ‘life care’ needs and delay or prevent their admission to a LTC facility.

Aims Objectives Theory or Methods

A bottom-up approach to re-imagining LTC in Canada was applied with people in their homes as the starting point. The objectives were: 1) to understand the long-term ‘life care’ needs of older adults; 2) to develop a new model of long-term life care at home; and 3) to assess the feasibility of the model. An explanatory, sequential mixed methods design was used. Phase 1 involved historical analysis of 2018-19 Canadian interRAI home care assessments (n=283,601). Phase 2 was a 6-week modified eDelphi process with interdisciplinary home care clinicians (n=42). Phase 3 involved initial comparisons of needs and daily care costs.

Highlights or Results or Key Findings

The home care population was segmented into 6 unique groups based on known risk factors for LTC admission including social frailty, caregiver distress, chronic disease management, cognitive impairment and behaviours, and geriatric syndromes. Almost all groups had ‘life care’ needs according to the 6 dimensions of the Pillars for Positive Health1. Sixty-five types of community-based services were considered in the development of integrated care packages to meet the life care needs of each group. The emerging model of long-term life care at home includes care packages ranging in daily care hours from 3.1-8.1 hours per day, including both direct home care by interdisciplinary providers and coordination time to integrate with other community services. There is significant overlap in the life care needs of older adults currently receiving home care and LTC in Ontario confirming potential to shift care to the community. Initial cost comparisons suggest possible short and long-term benefits.

Conclusions

Deep engagement of interdisciplinary home care clinicians provided a realistic and experienced lens for developing a new model of long-term life care at home. The 6 care packages represent an integrated continuum of LTC services that will give older Canadians more options to live, age and receive care at home.

Implications for applicability/transferability sustainability and limitations

Current steps involve focus groups with older adults, family caregivers, and interdisciplinary community-based clinicians beyond home care to validate and refine the new model and understand additional referral and integration channels. Next steps involve implementation and evaluation of the new model in the Ontario health care environment.