Integrating health and social care in the community to support a new model of Long-term Life Care at home

Background: Long-term care (LTC) reform was an international priority well before the COVID-19 pandemic. While strategies to promote de-institutionalization, rehabilitation, caregiver support and enhanced home and community care have varied by country in terms of implementation and success, the pandemic universally reinforced existing system-specific barriers and weaknesses. In Canada, heightened access issues and silo-ed delivery of community-based medical, functional and social care and support services contributed to increased caregiver burnout and growing residential care waitlists. Aims: This study aimed to develop an alternative model to residential LTC that would enable older adults to live, age and receive care at home long-term. The specific objectives were to: 1) describe variation in medical, functional and psychosocial ‘life care’ needs of community-dwelling older adults; 2) develop a model of needs-based care with packages to support variation in needs; and 3) to assess preliminary feasibility of the model using the Ontario, Canada (population 15 million) health care market. Approach: An exploratory, sequential, mixed methods design was applied (5). Phase 1 involved historical analysis of 2017-18 Ontario interRAI home care assessments (n=283,601) and 2018-19 Ontario service utilization data (n=115,000) to develop unique patient vignettes. Phase 2 was a 6-week modified eDelphi process with interdisciplinary home care clinicians (n=42) to develop care packages for the model, including types and dose of care and services. Six focus groups (n=67) were then conducted with older adults, caregivers and health and social care providers across Ontario to validate and refine the model. Phase 3 explored feasibility of the emerging model through comparison of the home care patient vignettes with the needs of the residential LTC population using 2017-18 Ontario interRAI data (n=115,000). Preliminary costing of the model was based on existing system per diems and direct care costs in comparable transitional care models. Results: A model of ‘Long-term Life Care’ at home (LTLifeC model) includes care packages to meet the dominant life care needs of 6 unique patient groups representing known predictors of LTC home admission: social frailty, caregiver distress, chronic disease, cognition/ behaviours, medical complexity, and geriatric syndromes. Overlap in care needs of home care and LTC populations confirms potential to shift care to the community; yet current