This study examined how patients experience transitions to community from hospitals, inclusive of daily living problems and medical concerns. Analysing qualitative data from interviews with 36 individuals including 17 high-risk older adults with multiple chronic health conditions recently discharged from hospital, and 19 family members who provided the patients with ongoing care, we asked (1) What are the challenges that patients experience in transitioning home from the hospital, and (2) What are the system and policy solutions that can address the challenges these patients experience? Our findings reveal both short- and long-term challenges associated with transitions back home. Short-term challenges include preparing the dwelling for the patient and understanding the organization of care at home. Long-term challenges are associated with practical and emotional concerns. Reflecting on our findings, we suggest that patients’ social needs may be equally important to their medical needs during post-discharge recovery, and we discuss implications for policy.

The complex formed by chronic illness, episodes of acute illness, physiological disabilities, functional limitations, and cognitive problems is prevalent among frail elderly persons. These individuals rely on assistance from social and health care programs, which in Canada are still fragmented. SIPA (Services intégrés pour les personnes âgées fragiles) is an integrated service model based on community services, a multidisciplinary team, case management that retains clinical responsibility for all the health and social services required, and the capacity to mobilize resources as required and according to the care protocol. The SIPA demonstration project used an experimental design, with random allocation of the 1,230 participants from two areas of Montreal to an experimental and a control group. The costs of institutional services were $4,270 less for those in the SIPA group compared to the control group; the costs of community care were $3,394 more. The proportion of persons waiting in acute care hospitals for nursing home placement was twice as high in the control group as in the SIPA group. The costs of acute hospitalizations for persons in the SIPA group with ADL disabilities were at least $4,000 lower than those for persons in the control group. In conclusion, the SIPA trial showed that it is possible to undertake ambitious and rigorous demonstration projects in Canada. These results were obtained without an increase in the overall costs of health and social services, without reducing the quality of care, and without increasing the burden on elderly persons and their relatives.

This article uses the concept of continuity of care to examine the implications of health-system restructuring for workers and staff in the BC home support system. Home support primarily serves frail seniors living in poverty and has the potential to provide assistance with tasks like bathing, dressing, and toileting, as well as offer social support and relational care to isolated clients. Through presentation of qualitative data from focus groups and interviews with home support workers and clients in the Greater Vancouver area, we demonstrate how the casualization and intensification of work in a context of increasing client acuity levels has diminished both continuity and quality of care. This article discusses how restructuring in the home support sector in BC has reduced the overall number of persons under care in the system, disrupted continuity of care, and compromised quality.