This timely book offers a range of practical and applied insights, and a research agenda directed towards improving the quality of care for vulnerable older persons as they experience transitions in long-term care. In health care, although a great deal of research has focused on service utilization patterns and predictors within specific, siloed service sectors (e.g., acute care, home care, residential care), only limited attention has been directed to understanding patterns and pathways across these sectors in a broadly conceptualized health care system.
Although the book’s content focuses on the United States, most of the issues and solutions have relevance in the Canadian context. The volume’s authors concede that real, positive system change to meet the needs of older individuals will require a paradigm shift in how we think about and implement their health care. A primary thesis advanced in the book is the need to focus on the individual patient, placing them at the heart of the care equation, rather than overemphasizing the system (both constraints and institutional efficiencies). The book’s 12 chapters are organized into five sections: (a) setting the stage for transitions; (b) health issues; (c) legal, ethical, and decision-making issues; (d) educating the workforce; and (e) policy and planning implications for transitions in care. While the authors highlight a broader range of issues that need to be addressed, this review focuses on six of these.
In section one, attention is drawn to the transitions themselves when it is asserted that successful experiences require paying attention to the medical, cognitive, functional, and psychosocial needs of individuals, in alignment with their personal goals, cultural norms, and financial means. To this end, patient-centred care orientations should never lose touch with who the older adult patient is. This can be achieved by focusing on the importance of their individual characteristics (e.g., race, gender, socioeconomic status), the broad health care context in which they receive care (e.g., considering cultural values, beliefs and worldviews, configurations of services, the broader political system, geography), and their combined influence on the care experience.
In the second section, the increasingly complex needs of older persons are highlighted. The care that they need requires the skills of multiple providers and clinicians. Older persons also need more basic help with the activities of daily living to foster self-reliance, identity and independence. The heterogeneity of older adults, viewed through their increasing diversity and frailty relative to co-morbid conditions and other life circumstances, again underscores the need to be patient-centred and suggests that this orientation stands a better chance of meeting patients’ real needs.
At the larger scale, ecological models, the patient-centred medical home, and the Program of All Inclusive Care for the Elderly (PACE) are three examples that the volume’s authors provide to emphasize more holistic views of patient care from the system perspective. These models acknowledge the complexities within the system and within individual experience. They are geared towards resolving tensions between them largely by recognizing the need for broad partnerships in care, and for integration and coordination at multiple scales (i.e., local, provincial, national), within sectors (e.g., acute care, residential care) and communities, and among families and individuals. In the models’ operationalization – and in the provision of care more generally – transparency and accountability must be foundational principles across the care continuum so that older adults and their families know who is in charge and accountable at all times.
With improvements in coordination and integration, the fragmentation that exists and that hampers continuity in service provision, can be addressed. Of tremendous importance in addressing this problem, is the need to move away from a “discharge mentality” in care provision and towards a “continuous management philosophy”. Patients should not be considered to be leaving one system and then engaging with another, separate system; instead, they should be seen as transitioning through a larger system in which their care continues to be managed, coordinated, integrated and tied to their needs and wishes. In practice, such continuity in care provision has been an elusive goal, impeded by a host of structural constraints (e.g., resources, capital, management philosophy, and workforce wages, training and retention). However, the need to overcome some of these constraints has never been more pressing given that individuals are most vulnerable to negative health outcomes and to acute hospital readmissions at these transition points.
A third issue relates to interdisciplinary teams. Researchers need to explore the composition, functioning, and communication within these teams. Family members must be recognized as full, contributing members of the care team, and not rendered invisible or considered only as nuisances, or even as mere peripheral informants to the ‘medical’ team. In similar and also unique ways, direct care workers must also be considered integral to the care team. Although their viewpoints can be overlooked by higher level managers and administrators, they possess the most extensive knowledge of and experience with the individuals receiving care. This remains the case throughout the care trajectory.
A fourth issue that arises in Pathways through the Transitions of Care for Older Adults related to team functioning is in the area of technology. There is a hope that technology can be used more effectively to facilitate patient transitions and continuity of care for individuals. As one example, timely updates to electronic medical records that travel with patients across systems could facilitate improvements in continuity of care, particularly in the realms of medication and symptom management. Ideally, this will reduce negative outcomes and readmissions. Additionally, technology may be used to deliver other products and services more safely and effectively to promote quality of care (e.g., as in the case of telehealth consultations between practitioners and clients in rural and remote settings).
A fifth issue taken up by the authors is in the realm of legal and ethical concerns. It is in the best interests of patients if there is discussion among family members and care teams about care planning. Families are encouraged to talk about preferences and concrete actions that can be taken to protect patients as they navigate difficult care transitions and health status changes. Ideally, all processes, particularly the consent process, should be fluid and dynamic, needing to be revisited at regular intervals or when changes in health or care setting occur. The heterogeneity of the older adult population, dictates that care plans must also feature built-in flexibility, sensitivity, compassion, and creativity if they are to best serve the interests of older adults within current health system limitations. In this regard, at least two special subpopulations are noteworthy among vulnerable older adults receiving long-term care services: persons living with dementia and persons at the end of life. In the realm of advance directives and care planning, these groups often present particular challenges: those with dementia because they may be unable to express their needs for care directly, and end-of-life life patients because of challenges with their illness trajectories that require plans to change with greater regularity and shorter notice. These challenges draw attention back full circle to interdisciplinary team functioning and communication mechanisms, and the relationships between family members, direct care workers, administrators, and decision-makers in long-term care facilities.
A sixth area of importance in this volume concerns the long-term care workforce. Many policies and practices in the present health care system influence education, wages, “turf”, and scope of practice for those providing care for vulnerable older adults. Direct care workers require better training and education. The relationships between professionals and these para-professionals is an area in need of further study and policy development to encourage seamless transitions and continuity of care for individuals. Better training, along with better remuneration, will go some way towards addressing the gaps and supporting quality of life for individuals and families. On a related note, families often take on tasks that they are not trained for (such as wound care). Measuring the quality of care provided across the care continuum is challenging but necessary to inform research, policy and practice around transitions and trajectories work.
Pathways through the Transitions of Care for Older Adults provides useful and illustrative case examples. A main strength of this volume is that it is both issue- and solution-focused, although the authors don’t have all the answers in this rapidly growing area of need. Further, while their findings are situated in the American health context, there are consistent parallels here to inform research and policy and practice in Canada.
This book will be useful for clinicians, decision-makers, and academics, and secondarily for direct service workers, family members, and recipients of long-term care. In the near future, more holistic, comprehensive and integrated models of care are needed. Patient-centred care offers a model that appears far better suited to meeting older adults’ needs. Aligned with this approach is the need to acknowledge the support of families and direct service workers as the workforce with the most significant involvement and knowledge of patient needs. Beyond this inner care circle, the broader interdisciplinary team made up of physicians, nurses, oncologists, counsellors, pharmacists, allied therapists, homemakers, friends and neighbours can work together more effectively in a coordinated and integrated fashion supported by comprehensive and timely information flows. Technology, in myriad forms (like electronic patient records), is a means to facilitate better care as individuals experience transitions.
For practitioners and policy makers, the insights from this book can contribute to the development of effective interventions to address many of the recognized gaps in the system to date. For family members, greater awareness of the issues raised may assist them in helping loved ones to navigate the present system. For academics, key strengths of the text are its ability to: (a) draw attention to the complexity of the current system; (b) emphasize the need to reduce the silos in care that have existed for many decades; (c) recognize the need for the continuous management of patient care across a unified health system (rather than the discontinuous care of a ‘discharge planning mentality’ within fragmented sectors); and finally (d) create a vision for change and empower others to act on this vision aimed at improving the quality of life of vulnerable older adults and their families receiving care.
