Original Title: État des pratiques - Portrait sommaire des indicateurs en transitions de soins et services des aînés vivant dans la communauté avec un trouble neurocognitif majeur (TNCM) au Québec

Authors' objectives: Major neurocognitive disorders (MNCDs) are clinically characterized by acquired, progressive and persistent declines in abilities in one or more cognitive domains, sufficiently pronounced to lead to a loss of autonomy in daily living activities. MNCD etiology is multifaceted and the risk of developing such a disorder increases rapidly with age. Given that people living with diagnosed MNCD have chronic, multiple, complex and evolving needs, the care and services they receive consume a large portion of the resources of the health and social services system and the community. These people also experience numerous transitions in terms of the care and services they receive. These transitions are defined as the physical relocation of a user between care settings, a change in the level of assistance required within the same setting, or a transfer of responsibility to a different health professional in order to accommodate changes in a user’s state of health or needs for care and services. As vulnerable areas in the care and services continuum, these transitions can notably interfere with home support for affected seniors. Transition care and services comprise a set of actions that are implemented to ensure the continuity of care and services. It is vital to have a better understanding of community-dwelling Quebec seniors who have been diagnosed with MNCD, i.e., those who are not residents of long-term residential facilities.3 We also need a better understanding of the care and service transitions they experience. This mandate is in line with INESSS’s goal of providing stakeholders in the health and social services network and their partners with the tools they require to carry out continuous improvement activities based on care and service indicator results. With this in mind, INESSS is currently drafting a practice guide for care and service transitions. These two knowledge products will enable teams to use their “field” knowledge to better analyze results, share a common vision of the strengths of the care and services offered and ways to make them better, and ultimately, enhance them for the benefit of users and their informal caregivers.

Authors' results and conclusions: RESULTS: The 15 indicators provided the following results: • a summary description of the targeted population; • front-line care and service transitions for this population; • care and service transitions for this population between hospitals and the front line. (#1 COMMUNITY-DWELLING PEOPLE AGED 65 AND OVER LIVING WITH DIAGNOSED MNCD): In 2021, 20,500 people aged 65 and over and living in the community were newly diagnosed with MNCD, giving an incidence rate of 1.3%. This rate had been stable for six years. Also in 2021, nearly 92,000 people aged 65 and over – i.e., 5.5% of this population – were already living with diagnosed MNCD. This disorder is proportionally more common in women, people over 75 and those living in more socially vulnerable environments. Among community-dwelling people aged 65 and over who had been diagnosed with MNCD, 62% had more than five health conditions, and 60% were prescribed 10 or more different medications during the year. (#2 FRONT-LINE TRANSITIONS): In 2021, 8% of people aged 65 and over living with diagnosed MNCD were not registered with a family doctor. These are people with complex needs, and access to a family doctor is an essential part of the care and service pathway. Moreover, it was noted that in the case of people in this age group diagnosed with MNCD and having a Family Medical Group (FMG) family doctor, 97% of front-line visits were made to the registered FMG. Local community service centre (CLSC) mission services also played a key role in the care pathway for these people. In 2021, nearly three-quarters (74%) of people aged 65 and over living with this diagnosis received services from a CLSC. We also noted in 2021 that 70% of this population used at least one CLSC mission service provided by a professional for more specific needs. Finally, we observed that 58% of communitydwelling people aged 65 and over with diagnosed MNCD were assessed or reassessed during the year by the CLSC. (#3 TRANSITIONS BETWEEN HOSPITALS AND THE FRONT LINE): In 2021, 51% of people aged 65 and over living with diagnosed MNCD went to the emergency department, including 27% who did so two or more times. Of these emergency visits, 43% were categorized as low or non-urgent (P4 or P5).4 In some situations, CLSC mission monitoring may be necessary after an emergency department visit to ensure that the transition is appropriate. In 2021, more than one in four emergency visits (28% combining all priorities) made by people with diagnosed MNCD were followed by a professional CLSC mission service within three days of discharge. In 2021, a third of people aged 65 and over with diagnosed MNCD were hospitalized for acute care at least once. Moreover, data analysis revealed that 15% of short-term hospitalizations were followed by hospital readmissions within 30 days. Because the return home after a short-term hospitalization represents a period of vulnerability, it is advisable for this population to be monitored by a doctor or the CLSC during the transition. In 2021, 19% of short-term hospitalizations were followed by a medical visit with a general practitioner or a front-line specialized nurse practitioner (FLSNP) within 14 days of discharge. This proportion rose to 41% for short-term hospitalizations that were followed by a CLSC mission within three days of discharge. (#4 OTHER FINDINGS): The various waves of the spread of COVID-19 produced fluctuations in the accessibility of health and social service resources and changes in how they were used. The pandemic had a significant impact, as reflected by the fact that certain indicators sometimes followed opposite trends. For example, there were more follow-ups after a short-term hospitalization and fewer emergency department visits. CONCLUSION: Community-dwelling seniors living with diagnosed MNCD are using various services provided by a number of organizations to meet their needs. Their care and service pathway necessitates frequent transitions, such as changes in the physical delivery location (CLSC, hospital, FMG); changes in the level of assistance needed within the same environment; or transfers of responsibility between required healthcare professionals. These transitions are areas of vulnerability in terms of coordination and continuity of care and services, and it is important to pay particular attention to them. The results of the transition indicators are provided here as support for ongoing improvement initiatives regarding care and service transitions for community-dwelling seniors who have been diagnosed with MNCD. This data needs to be analyzed and interpreted using the knowledge and expertise of local stakeholders. This document also provides avenues for reflection on practices intended to better address these seniors’ needs, prevent avoidable hospitalizations and deterioration of their condition and facilitate living at home for as long as it is possible.

Authors' methods: Three sources of information were used to draw up this overview. • (#1 An analysis of clinical-administrative data): The 15 indicators used are the same ones that were constructed as part of the Collectif pour les meilleures pratiques et l’amélioration des soins et services+ (CoMPAS+) (Collective for Best Practices and Improvement of Care and Services+) project. This pilot project was designed to implement reflective practice activities for users and their caregivers, clinicians, managers and stakeholders working in various organizations in the province, with a view to improving transition care and services for people living with MNCD. This overview focuses on these indicators, which are broken down by year for Quebec as a whole, by region and according to certain socio-demographic variables. • (#2 A summary review of the literature): The research strategy, criteria and data selection and analysis process were defined in advance to document best practices in transition care and services among communitydwelling seniors and support the interpretation of the results provided by the indicators. • (#3 Expert consultations): Consultations took the form of individual interviews with four key informants and a consultation with an advisory committee composed of researchers, managers, network professionals and informal caregivers. They were provided with the indicator outcomes so that they could contextualize these results, discuss their limits and inform their interpretations in line with their respective expertise.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/amelioration-des-transitions-de-soins-et-services-des-aines-vivant-dans-la-communaute-avec-un-trouble-neurocognitif-majeur-tncm-au-quebec-pratiques-exemplaires-et-indicateurs.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/amelioration-des-transitions-de-soins-et-services-des-aines-vivant-dans-la-communaute-avec-un-trouble-neurocognitif-majeur-tncm-au-quebec-pratiques-exemplaires-et-indicateurs.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)