EXTRA Team Photo

Centre intégré universitaire de santé et de services sociaux de Capitale Nationale / Centre hospitalier universitaire de Québec Université Laval (Québec)

  • Nancy Drouin,  Directrice adjointe programme soutien à l'autonomie des personnes âgées, CIUSSS Capitale Nationale et CHU de Québec Université Laval, Québec, Québec
  • Lucille Juneau, Directrice adjointe programme soutien à l'autonomie, CIUSSS Capitale Nationale et CHU de Québec Université Laval, Québec, Québec
  • Brigitte Martel, Directrice soins infirmiers, CHU de Québec Université Laval, Québec, Québec

Transitioning Seniors from their Home Environment to a Hospital Setting 

Seniors often have multiple comorbidities due to the coexistence of a multitude of chronic illnesses, cognitive decline and/or physical disability. They often have to consult many clinicians in different settings, which can lead to the fragmentation of care and inefficiencies in healthcare services. Seniors are significantly affected by a breakdown in the continuum of care, namely transition points.  A number of problems which have been observed stem from the absence of continuity of care, i.e. duplication of assessments and investigations, inappropriate treatments, unnecessary delays in the healthcare process and even a breakdown in care which can undermine the elderly person’s integrity at a time when they are already in such a weakened state. These transitions require adaptation on the part of the elderly, a need to relearn self-care and a need to reorganize daily life in order to acquire and preserve their autonomy. Interventions on the part of different healthcare professionals can support the elderly in their recovery. Working with seniors and their loved ones, this project aims to set up frontline interventions and measures in a hospital setting with a view to promoting smooth transitions. Experimentation with outcome measures will be carried out with elderly persons living in the National Capital Region (NCR) and within Laval’s Teaching Hospital in Quebec City. A continuous improvement plan will enable the transfer of evidence-based interventions to other areas of the NCR.