Project 465985

Long-Term Care (LTC) residents are in the final stage of their life's journey, a stage characterised by many healthcare transitions. One quarter of residents transition to hospital every 6-months and half transition to end-of-life care every 18 months. Each transition can be guided by residents' values and wishes but often are not. Goals of care discussions between residents, their family members, and the medical team can prepare family members for in-the-moment decision making about transferring to hospital or transitioning to end-of-life care when acute illness arises. The goal of this team grant is to improve transitions in the long-term care journey by ensuring they are guided by an understanding of illness trajectory and the resident's personal preferences. Our team will create interactive web-based decision support tools for LTC residents and their family members to navigate decisions about transfer to hospital and transitions to end-of-life care. These decision support tools will guide users in reflecting on and documenting what is most important to them, considering the harms and benefits of transitions, and tell them what is likely to happen to their health-related quality of life in the future using predictive models. We will use big data to create predictive algorithms that tell LTC residents and their family members how long they may live, how their physical function will change in the future and how their ability to think and interact will change. We will work with LTC residents and their family members throughout this project so that the tools will meet their needs. We will test the tools in 3 LTC homes in Ontario to determine if they help residents and family members express and document their most important goals. We will also measure hospital transfers regret and satisfaction with care. We have partnered with a national network of LTC homes to share and spread the tools we are developing across Canada.