A COMPREHENSIVE DATA-DRIVEN, EVIDENCE-BASED ROADMAP FOR ENHANCING OLDER ADULTS’ TRANSITIONS THROUGH CONTINUING CARE SYSTEMS

Abstract

Global populations are aging rapidly, with the number of individuals aged 65 and older projected to double to 1.6 billion by 2050. This demographic shift is increasing chronic conditions, escalating the demand for clinical, social, and personal care services. To meet these needs, healthcare systems rely on continuing care systems encompassing institutional services such as long-term care (LTC) and complex continuing care (CCC) alongside home care. However, surging demand has outpaced institutional capacity, leading to severe patient flow congestion. While expanding institutional bed capacity is a potential solution, resource constraints make it financially unsustainable. A more viable approach is to enhance care transitions, directing individuals with lower resource-intensive needs toward home care. This strategy may not only alleviate institutional strain but also support older adults’ preference for independence. Two critical transition pathways drive most capacity challenges: (a) post-acute care transitions from hospitals to LTC, CCC, or home care and (b) community reintegration transitions from LTC or CCC to home care. Enhancing these pathways requires understanding the factors influencing transitions and assessing the risk of adverse post-transition, including hospital readmission and mortality. Accordingly, this dissertation addresses the overarching research question: “What role can empirical analysis play in potentially determining more efficient and effective placement of older adults in LTC, CCC, and home care settings while considering the risk of adverse outcomes?” Study 1 presents a scoping review of 103 OECD-based publications (2015-2023), synthesizing evidence on transition determinants and identifying research gaps. Study 2 employs a multi-million-record dataset spanning 2001-2023 to analyze factors influencing post-acute care transitions and assess readmission and mortality risks. Findings underscore the potential for improved outcomes in home care for many LTC-placed individuals while cautioning against substituting CCC with home care for those with complex needs. Study 3 examines community reintegration, revealing how personal habits, autonomy, and social support influence transition success. It also highlights that for selected individuals, moving to home care might not significantly heighten the risk of adverse outcomes. Collectively, these studies provide a data-driven, evidence-based roadmap for enhancing care transitions and strengthening the sustainability of continuing care systems amid the challenges of an aging population.