Integration matters
<strong>Seniors</strong> <strong>in</strong> <strong>need</strong>, <strong>caregivers</strong> <strong>in</strong> <strong>distress</strong> 39 Integrat<strong>in</strong>g home care <strong>in</strong>to the larger health care system can ensure that seamless transitions are created for patients, their families, and providers <strong>in</strong> a way that leads to higher quality care, greater efficiency, and susta<strong>in</strong>ability. Integration is particularly important <strong>in</strong> home care to ensure that there are strong connections and good communication between home care, hospitals, and 56, 57 primary health care. Reviews of Canadian and <strong>in</strong>ternational studies show that <strong>in</strong>tegrated systems of care for seniors can lead to ma<strong>in</strong>ta<strong>in</strong>ed health, well-be<strong>in</strong>g, <strong>in</strong>dependence, and <strong>in</strong>creased satisfaction, as well as reduce the demand for more expensive care <strong>in</strong> hospitals and long-term care homes. 12, 58, 59 Better <strong>in</strong>tegration would also help to identify seniors who <strong>need</strong> home care services but who are currently fall<strong>in</strong>g through the cracks of the system. In this section, we profile some practices and programs that are successfully <strong>in</strong>tegrat<strong>in</strong>g home care with other parts of the health care system, both <strong>in</strong> Canada and abroad. Two <strong>in</strong>ternational examples, from Australia and Denmark, demonstrate system-wide <strong>in</strong>tegration of care for seniors. Integrat<strong>in</strong>g home care with hospitals <strong>Seniors</strong> are referred to home care services by a variety of sources, but they are most likely to be referred through a hospital. There is an <strong>in</strong>creased sense of urgency to discharge patients out of hospitals as soon as possible, preferably to their homes rather than to long-term care facilities. This policy direction has meant that many more patients who are still vulnerable are be<strong>in</strong>g discharged home. 29 Smooth transitions are essential to ensure that patients are discharged safely and will be appropriately supported at home. Families sometimes question whether their loved ones should leave the hospital while they are still vulnerable, but prolonged hospitalization can expose seniors to problems such as harmful drug <strong>in</strong>teractions or hospital-acquired <strong>in</strong>fections, and can delay their access to the therapy they <strong>need</strong> to rega<strong>in</strong> mobility and strength. In addition, an unfamiliar and conf<strong>in</strong><strong>in</strong>g hospital environment can lead to depression and delirium, particularly among people with dementia. 20, 21 Prolonged hospitalizations can jeopardize a senior’s ability to return home. Many hospitals have established geriatric teams to prepare patients for their eventual return home and to help build their capacities to rema<strong>in</strong> <strong>in</strong>dependent. However, shortterm, hospital-based geriatric care without follow up is not as effective at prevent<strong>in</strong>g patients from return<strong>in</strong>g to the emergency department as are home- or community-based 60, 61 programs, and those coord<strong>in</strong>ated with primary care. The role of the case manager is crucial to help ensure smooth transitions and ongo<strong>in</strong>g coord<strong>in</strong>ated care. PROMISING PRACTICE * Partner<strong>in</strong>g for Patients, Alberta In Red Deer, Alberta, home care case managers work <strong>in</strong> hospital emergency departments to assess patients to determ<strong>in</strong>e the best care path for the patient, whether it is hospital admission, home care, or a long-term care facility. The case manager works with the emergency department staff and patients to do this plann<strong>in</strong>g and to ensure that it is safe to discharge the patient home with home care supports and referrals to community-based services, <strong>in</strong>clud<strong>in</strong>g the transfer of pert<strong>in</strong>ent health <strong>in</strong>formation. This Partner<strong>in</strong>g for Patients home care program is also aligned with primary care, allow<strong>in</strong>g appropriate transitions and follow up. The case manager also visits with general patients <strong>in</strong> the emergency department to educate them about home care options. This pilot project allowed nearly half (46%) of the patients to avoid hospital admission by be<strong>in</strong>g directed to home care. 62 * The Health Council of Canada has established criteria to categorize <strong>in</strong>novative practices as emerg<strong>in</strong>g, promis<strong>in</strong>g, or lead<strong>in</strong>g (www.healthcouncilcanada.ca/<strong>in</strong>novativepractices)
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