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Co-Designing An Integrated Transitional Care Model To Address Alternate Level Of Care And Promote Aging In Place An Experienced Based Co-Design


Jake Tran ,

The Salvation Army Toronto Grace Health Centre, Canada, CA
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Kevin Woo

Queen's University, CA
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Introduction: An alternative level of care (ALC) designation is given to patients who occupy a bed in hospitals but do not require the intensity of resources available in that care setting. Clinically, an ALC designation is given when 1) the patient is stable and/or the patient's status has plateaued; 2) the patient has low risk for rapid decline; or 3) the care team is no longer searching for additional diagnoses. Hospital care for ALC patients has been deemed to be suboptimal. The lack of appropriate care commonly results in ALC patients in acute care hospitals experiencing a continuing decline in their physical condition, decreased ability to perform daily self-care activities, and excess disability. Designing a collaborative model of care to reduce avoidable displacement from home to hospital has emerged as a key health services goal. An Integrated Transitional Care Model (ITCM) to promote successful aging in place is needed to facilitate the discharge of ALC patients to the community.

Objectives: We aim to create efficient, innovative, and practical discharge pathways to the community for older adults who are frail that are co-designed using the experiences of Canadian users and healthcare experts. The specific objectives of the study are:

1.To understand the experience of transition for older adults who are frail from hospital to home by conducting interviews that capture the perspectives of patients and family caregivers.

2.To explore the barriers to and facilitators of transition for older adults who are frail to help clients discharge to the home using the perspectives of patients, family caregivers, health care professionals, hospital leadership team, community providers, and funders.

3.To co-design care pathways to address the different challenges and barriers faced during the discharge process.

Research Question: Can we improve the experience of older patients who are frail when transitioning from hospital to home using an experienced-based co-design (EBCD) to reduce ALC in hospital?

Research Methodology:We propose a qualitative study that uses modified experience-based co-design (EBCD) to allow patients, informal caregivers, staff from various clinical background, and administrators to participate in co-designing appropriate care pathways for older ALC patients to be discharged from hospital to their homes.  Using EBCD, we seek to identify opportunities for the improvement and the usability of transition care service to inform design change.  The workshops will be conducted using an in-depth, semi-structured format. This is a reflective process for all attendees, and should elicit thoughts about the discharge experience from the varied participants. Data will be analysed using framework analysis.

Significance: With the continued expansion of the ITCM, the types of patients discharged into the program can be expanded, which will free up more hospital beds and reduce the number of patients requiring acute or long-term care admission. Its benefit is the potential delivery of innovative and improved care pathways, in which discharge protocols can be tailored to suit the needs of individual institutions and health care systems and evaluated. This co-design process offers the possibility of creating theoretically informed care pathways.


How to Cite: Tran J, Woo K. Co-Designing An Integrated Transitional Care Model To Address Alternate Level Of Care And Promote Aging In Place An Experienced Based Co-Design. International Journal of Integrated Care. 2022;22(S3):96. DOI:
Published on 04 Nov 2022.


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