Closing the Knowledge Care Gap for Seniors and Community Care Collaborative

To develop capacity to measure, at a population level, transitions in seniors' health and requirements for care in order to evaluate (a) the effects of these transitions on seniors’ health outcome, quality of life and their utilization of health services and (b) the effects on service providers’ work life.

To develop capacity to measure, at a population level, transitions in seniors' health and requirements for care in order to evaluate (a) the effects of these transitions on seniors’ health outcome, quality of life and their utilization of health services and (b) the effects on service providers’ work life.

Profile and Purpose

Many seniors lead healthy and active lives. However, a significant number live with multiple chronic health problems requiring a wide range of social and health services across multiple settings including home support, respite care, clinical nursing and rehabilitation services and palliative care. These individuals may experience sudden and substantial changes in their health status, leading to changes equally sudden and substantial changes in service providers and settings of care.

While there are various ways of measuring health status and quality of care, none of the currently available methods adequately captures the unique and changing needs of seniors. The measures are not population based. They do not address the challenge of delivering care across the continuum of services that seniors require nor do they capture the health care needs of clients with complex, chronic and unstable conditions.

The aim of this investigative team is to create a sustained collaboration among decision makers, knowledge brokers and researchers across all five health authorities and the Ministry of Health to support ongoing measurement and evaluation of transitions in health and service delivery within the continuum of home and community care for seniors. Their plan is to:

• Develop capacity within BC’s Home and Community Care sector to measure, at a population level, transitions in seniors’ health and in requirements for health services
• Evaluate the effects of these transitions on seniors’ health outcomes, quality of life and patterns of service utilization on service providers’ work life
• Enhance the capacity of the Home and Community Care sector and stakeholders to conduct health system research and to use the findings to support timely, effective evidence-based decisions to improve seniors’ health and health services.

The team will address these issues by identifying and developing a core set of valid and reliable community indicators that will enable regions and the MOH to evaluate, compare and benchmark home and community care in a consistent and comprehensive manner. This will include evaluating the sensitivity and appropriateness of the indicators in three areas of transition research: assisted living, people with dementia and seniors at risk. Ultimately, these indicators, linked to census data for BC, could be used to develop appropriate benchmark analysis procedures and reports both within and across Health Authorities that can be rolled up to the provincial and national levels. To ensure uptake and use of research to support evidence-based policy and practice change, the team will also work with Home and Community Care stakeholders to identify facilitators and to mitigate systemic and other barriers that impede knowledge translation.