The Par-Aînés project, part of the PATIenTS program, which aims to improve the trajectory of seniors in the transition between home and residential care in the RUISSS Université Laval territory, has documented a list of improvements to facilitate the transition between home and Long-term care facilities (CHSLD).
Owner : Maude Laberge, Associate Professor, Department of Social and Preventive Medicine, Université Laval
Authors : Maude Laberge, Fanny Leblanc
Collaborators : Manon Cody, CISSS de la Côte-Nord
Recipients : Unité de soutien SSA Québec, Centre intégré de santé et services sociaux de la Côte Nord (CISSS-CN), Réseau universitaire intégré de santé et services sociaux – Université Laval (RUISSSUL)
Process for identifying improvements
The team pooled and compared the following elements:
- Recommendations identified in the grey literature;
- Best practices identified in the scientific literature;
- Recommendations and suggestions from interview analysis;
- Field observations;
- Current practices documented in interviews.
The improvements thus identified were divided into two categories and eight sub-categories.
The improvements
The table presented in the document is classified by type of strategy:
- Strategies related to the structure of care and services
- Personalized and adapted living environment :
- Have a different architecture and layout from hospitals to reduce the feeling of being hospitalized and create a sense of familiarity.
- Facilitate the personalization of the room by giving access to it before moving in, and helping people who don’t have relatives to do this with them.
- Take people’s culture and beliefs into account when designing private and communal spaces
- Stability of human resources and continuity of care and services:
- Have stable teams to enable relational continuity
- Foster collaboration with residents and their families
- Hold weekly team meetings to follow up on files and case discussions.
- Management and administrative processes:
- Provide managers with tools to address the issues experienced by seniors and their loved ones during the transition to a CHSLD: training, online toolbox and forum, procedures guide, co-development workshops, etc.
- Integrate life history questionnaire into electronic file
- Adopt a continuous improvement approach in which facilities draw on evidence to make improvements
- Staff preparation and support:
- Ensure that staff understand all stages of the transition process and its effects on the individual.
- Allow staff time to help people settle in and acclimatize to their new environment
- Provide a practical guide outlining best practices to be adopted during the transition.
- Personalized and adapted living environment :
- Strategies for quality of care and service processes
- Housing access mechanism:
- Establish a unique transition mechanism that respects resident preferences
- Admission and welcome procedures:
- Whenever possible, conduct a pre-move-in visit to familiarize the resident with the premises and the people, otherwise conduct a virtual visit.
- Draw up a life history in advance, so that it is available at the time of admission.
- Support the person and family in completing the life story
- At reception, staff introduce and welcome residents; they are welcoming, the center is visited, the experience must be positive for the person.
- Pair all residents with an attendant so that they have a resource person, someone who will act as an advocate for the facility.
- For the first week, identify other employees who can respond to residents when the attendant is not available.
- Life history :
- Add an introduction to the life history questionnaire to explain its relevance and use to the person and family.
- Complete the questionnaire before the person moves into the CHSLD.
- Complete the questionnaire with the person and family
- Have the life history completed by a person with training in helping relationships, so as to have the skills to discuss more sensitive or painful subjects.
- Make staff aware of the importance of the life story through training: how to fill it in and use it.
- Make the information available in the rooms
- Make greater use of the person’s life story
- Create a concise, easy-to-read format (summary)
- Aspects related to interpersonal relations :
- Develop tools/interventions to improve communication and reception of indigenous people
- Use the person-centered approach and shared decision-making
- Respect residents’ values, preferences, tastes and consent
- Facilitate the creation of new social relationships and participation in activities
- Housing access mechanism:
Improving the pathway of seniors in the transition from home to residential care: RUISSS Université Laval activates the PATIenTS program
As part of the PATIenTS program, the RUISSS Université Laval launched its project to improve the trajectory of seniors, from the declaration of loss of autonomy at home to the integration of a housing environment, within the Centre intégré de santé et de services sociaux (CISSS) de la Côte-Nord (Par-Aînés Project).