The majority of older adults prefer to live at home and age in place for as long as possible [1], yet evidence indicates that older people who are hospitalized may be admitted to long-term care (LTC) homes unnecessarily [2]. LTC homes are intended for older adults that are not able to live independently in the community due to complex needs that require full-time assistance with activities of daily living and access to 24-hour nursing care. However, some older adults with mild or moderate health conditions or physical limitations may be entering LTC unnecessarily, instead of returning home with enhanced supports [3]. Within Canada, approximately 1 in 9 newly admitted LTC residents could have potentially been cared for at home with added support [3]. There are many factors that can contribute to older adults entering LTC homes earlier, such as difficulty navigating the health care system (e.g., being unaware of available home care services), financial barriers (e.g., significant out-of-pocket expenses and resources required to care for someone at home), health system responsiveness (e.g., finding reliable and consistent home care services), and access to specialized services (e.g., need for services tailored to specific geriatric health care needs and social or emotional support for family or friend caregivers) [3]. Older adults that live in rural areas in comparison to urban areas are twice as likely to be admitted to LTC [3, 4]. Additionally, older adults that live alone compared to those living with family members are twice as likely to be admitted to LTC when they potentially could have been cared for at home [3, 4].
Health services used by older adults and their family or friend caregivers involve an array of public and private services that tend to operate in ‘silos’ independent of each other including home and community-based services, acute care, primary care and social services [5, 6]. Within Canada, home health care services involve a range of public and privately funded organizations that provide skilled nursing services in the home, combined with a range of other home services such as personal care, housekeeping duties, physical therapy and rehabilitation, counselling, occupational and vocational therapy, dietary and nutritional services, speech therapy, audiology, medical equipment and supplies, medications, and intravenous therapy [7]. The provision of home care services in Nova Scotia are funded and organized provincially between Department of Health and Wellness (i.e., governing public health policy), Nova Scotia Health (i.e., governing delivery of health services and programs), and delivered locally through Nova Scotia Health and Continuing Care coordinators that work with contracted agencies to provide home care services [8]. Home care services include skilled nursing care (i.e., dressing changes, catheter care, intravenous therapy and palliative care), home support (i.e., personal care, respite, and essential housekeeping) and additional supports for caregivers (i.e., respite stay, hospital-type bed loan, specialized health equipment) [8]. There are no costs for receiving skilled nursing care services however, home support fees are based on income and family size, and additional supports for caregivers may include costs such as specialized equipment loans [8].
Often, older adults and their caregivers are required to navigate within and between these services to sustain their health, yet they experience inherent challenges in doing so, which are detrimental to themselves and the healthcare system [9]. It is often during transitions between types of health services along the continuum of care that issues arise, such as long wait-times in hospital [10]; poor communication of care needs and loss of information related to care plans [11–13]; care that is delayed, unnecessary, not evidence-based, potentially unsafe, fragmented and poorly coordinated [11, 14]; inappropriate placement in LTC facilities [15]; exacerbated mental health issues [15]; issues in accessing transportation [15]; and additional burden placed on caregivers [10, 15]. Essentially, older adults and their caregivers are the common element moving across different types of healthcare services. Transitional care programs are designed to support them through this process by providing supports such as discharge care planning, patient education, coordination and continuity across health settings, early identification and response to health changes, facilitating access to the right services at the right time, and planning for future health needs [9, 17–19]. When older adults do not receive adequate support from transitional care programs, they may lack access to appropriate services when they are needed, which can ultimately lead to an increased burden of care on acute care services and increased healthcare costs, such as earlier and unnecessary placement into residential LTC homes [20, 21].
Acute care services in hospital are primarily designed to deliver short-term inpatient care and necessary treatment for a disease or severe episode of illness, with the goal to discharge patients as soon as they are medically stable [22]. The purpose of acute care hospitalization is to address acute health conditions and acute exacerbation of chronic conditions (fall-related injuries, stroke, infection, surgical interventions). However, older adults often have a complex array of health considerations and are being admitted to acute care in hospital with multimorbidity and geriatric syndromes (e.g., frailty, impaired cognition, continence, gait and balance problems) [23–27]. The increasingly complex health care needs of older adults mean they may require greater care and rehabilitation services focused on multiple conditions and support needs, which acute care settings do not typically provide during a hospitalization [23, 29]. Rehabilitation within acute care hospital settings involves care from a multidisciplinary team (e.g., occupational therapists, physical therapists, psychologists, social workers, speech and language therapists, dietitians, nurses, and physicians) to evaluate, diagnose, and deliver therapeutic interventions for the purpose of restoring functional ability or enhancing residual capabilities for older adult patients [30].
Rehabilitation is critical for older adults with multimorbidity and geriatric syndromes, given they have a higher risk for hospitalization and adverse outcomes, such as hospitalization-associated disability and inability to live independently upon discharge [23, 24, 28]. Rehabilitation has become increasingly important within acute care hospitalizations to address older adult complex conditions and has been found to have a positive impact on health outcomes such as improved functioning and mobility [30], transition of patients from hospital to home [30], reduced length of stay in hospital [31], and reduced risk for nursing home admission [29, 31]. Unfortunately, there are wide health system discrepancies in the availability and delivery of rehabilitation for older adults within acute care hospital settings [29, 32], oftentimes resulting in a lack of meaningful activity and limited rehabilitative care for older adults with complex medical conditions during hospitalization [29, 33, 34]. In addition to challenges of meeting complex health care needs of older adults during a hospitalization, there are immense economic burdens from high use of acute care hospital services [35]. A national study examining high-cost users of acute care hospital services indicated high hospital use among Canadians aged 50 or older was associated with extended length of stay before discharge to long-term care [35]. Finding appropriate placement and moving older adults out of acute care hospital settings as soon as possible is ideal [23–25]; not only to ensure complex health care needs can be met with appropriate rehabilitative services, but also to prevent worsening health conditions due to extended length of stay waiting to be discharged to long-term care [31, 35].
Prior to the COVID-19 pandemic in the province of Nova Scotia, Canada, about 40 to 50 percent of patients staying in hospital for extended periods of time are deemed alternative level of care (ALC) due to the fact they are medically stable and no longer require acute medical care in hospital but are not discharged to return home [36, 37]. The majority of patients that are assessed as ALC are older adults who are waiting in hospital for more appropriate settings such as placement in LTC [8, 38]. Provincial Nova Scotia Health data showed that in 2017–2018 the median wait time for older adults to be admitted to LTC from their homes was 350 days, and the median wait time in hospital for LTC placement was 54 days [39]. Long wait times for LTC may be attributed to an increasing demand for LTC, in part intensified by an increasing proportion of older adult populations with chronic conditions that require specialized support services [40, 41]. Existing research has identified that older adults are often unnecessarily placed into LTC due to the need for physical assistance and unmet home care needs [40–43]. Yet, there is a need to understand the experiences of various stakeholders involved in the care of older adults, and older adults themselves, to investigate contextual factors involved in the decision-making process that indicate why older adult ALC patients in hospital are potentially inappropriately assessed as requiring long-term care when they could return home with enhanced home care services. Although there are common issues and challenges that arise during transitions between types of health services [10–16], it is critical that research identifies barriers to returning home for older adults including factors that are specific to local community contexts and acute care hospital settings. Increasing the uptake of home care services by older adults and their family or friend caregivers has the potential to reduce pressure on acute care hospital services and improve quality of care by ensuring older adults are receiving the most appropriate care, at the right time and place [11, 14, 16].
Investments towards home care supports have recently been made in Nova Scotia through the development of the Home First Philosophy [44] and Home Again enhanced services within Central Zone (pilot region). The Home First Philosophy, originally initiated in Ontario, Canada [44], involves a shift in thinking where the focus is on giving older adult patients the chance to go home first with enhanced home services after an acute episode in hospital, instead of assuming a LTC home is the only option [44]. Home Again enhanced supports provide transitional care and additional hours of support or services beyond what is normally provided through the provincial government’s home care program to facilitate a smooth transition home after a hospital admission [40]. Nova Scotia Health has identified challenges with current practices used to determine whether hospitalized patients will transition back to the community versus being placed in LTC. First, the current acute care assessment process may not appropriately identify hospitalized patients who would benefit from Home Again enhanced services. Currently, too many hospitalized older adults are assessed prematurely as needing LTC who could go home with enhanced supports. Second, additional time is needed to plan for early mobilization of patients while in hospital to optimize independence and functioning, and to organize critical community supports the patient needs post-discharge. Earlier identification of Home Again patients could provide healthcare professionals additional time to ensure community-based supports are in place and coordinated with the existing resources patient may have without delaying hospital discharge. Lastly, to ensure patients effectively transition from hospital to home, at least one family or friend caregiver needs to be involved throughout the whole process, so the needs of family or friend caregivers are met in the care plan. Oftentimes the unpaid family or friend caregivers provide significant care to patients transitioning home, making it critical to address their needs and resources within the care plan so they can continue providing care to patients at home. The challenges identified by Nova Scotia Health provide an opportunity to improve acute care in hospital processes by identifying what critical information needs to be gathered on patients and caregivers so health care professionals can effectively communicate with them about enhanced home care services and the potential for older patients to transition from hospital to home. The purpose of this study was to gain an in-depth understanding of characteristics and experiences of ALC patients, their family or friend caregivers, and health care professionals during an acute care hospital episode to identify factors influencing whether a patient returns home with enhanced home care services or is assessed as requiring LTC. These results contribute to understanding challenges and barriers facing ALC patients, factors influencing why they are potentially assessed prematurely for LTC placement, and how identified challenges and barriers could be addressed to support more older adults to return home with enhanced home care services.