Unpacking the dynamics of transitional care units in Ontario, Canada

Abstract

Background and Objectives

Transitional care units (TCUs) provide short-term, low-intensity, restorative care to patients who are medically stable but unable to leave the hospital due to factors, such as lack of support. In Ontario, Canada, TCUs have been implemented over the past decade, yet little is known about their operation. This study aimed to explore the structural characteristics and the care processes of TCUs from the perspective of TCU managers.

Research Design and Methods

An exploratory descriptive qualitative design was employed. Semi-structured interviews were conducted with seven TCU managers. A five-step inductive thematic analysis was used to identify themes. Participants’ median age was 46 years (range 36–50), with four men and three women. Their experience as TCU managers at the time of the interview ranged from 2 months to 5 years.

Results

The study results suggest variation across TCUs in terms of structure and patient populations served. Four themes were identified related to the care processes across seven TCUs: (1) ensuring safe transitions; (2) managing patients’ expectations; (3) creating a team that works together; and (4) navigating a constantly changing environment.

Discussion and Implications

Taking into account the variability of models, implementation and evaluation of these programs require careful planning. The complex medical and psychosocial needs of TCU patients should be considered when designing these units to ensure effective and appropriate care delivery.

Background

Many older adults will require hospitalization. However, once intensive medical treatments are complete, some patients cannot be discharged and continue to occupy acute care beds. In Canada, these patients are designated as receiving alternative level of care (ALC), or delayed hospital discharges, to indicate that they do not require the intensity of resources or services provided in the care setting where they are located (Canadian Institute for Health Information, 2016). Reasons for ALC designation include a lack of access to community services or awaiting placement in alternative settings, such as long-term care, complex continuing care, or rehabilitation (Bender & Holyoke, 2018). Some of the risk factors associated with ALC designation include advanced age, social vulnerability, and diagnosis of dementia (Arthur et al., 2021), with dementia being the most commonly reported characteristics of individuals with ALC designation (Maisonnave et al., 2024). Individuals designated as ALC experience deconditioning, characterized as a decline in physical functioning and the loss in abilities to independently perform activities of daily living due to prolonged bedrest and lack of physical activity (Covinsky et al., 2011). ALC designation has been associated with mortality, hospital-acquired infections, depression, falls, and functional decline (Lim Fat et al., 2022; Rojas-García et al., 2018). Patient and care partner experiences upon ALC designation are suboptimal, such as mental and physical deterioration and lack of involvement in decision-making regarding their discharge and transfer to other facilities (Everall et al., 2019). In addition, ALC designation directly impacts healthcare systems by reducing patient flow contributing to hospital overcrowding (Mustafa et al., 2016), and inefficient use of healthcare services (Rojas-García et al., 2018). In 2022, 6.2% of hospital stays in Canada were designated as ALC (Canadian Institute for Health Information, 2024).

Transitional care units/programs (TCUs/Ps) were created to address the poor experiences and operational inefficiencies experienced by patients designated as ALC and their care partners. TCUs provide short-term, low-intensity, restorative care to individuals designated as ALC (McGilton, Vellani et al., 2021). TCUs are similar to skilled nursing facilities (SNF) in the US (Toles et al., 2016), and intermediate care units in the UK (Abrahamsen et al., 2016). In Ontario, Canada, TCUs began appearing around 2018 following a Ministry of Health investment to address growing number of patients designated as ALC (GTA Rehab Network, 2020). Despite wide variations in design and services offered between countries, the purpose of TCUs is to support patients as they transition between settings or levels of care. Core services identified across TCUs include assessment, care planning, treatment, discharge planning, and patient and care partner education (McGilton, Vellani et al., 2021). A recent scoping review identified at least 84 TCUs in Ontario established in community (delivered within older adults’ homes), hospital (on designated transitional units), and facility (established in rehabilitation centers or retirement homes) settings (Barber et al., 2024). Despite the considerable growth in number of TCUs in recent years and the increase in funding for these programs (Ontario, 2020), limited literature examines how TCUs are operationalized and implemented (Barber et al., 2024). The growth of TCUs in Ontario is on the rise in response to the increasing demands of the acute care sector and the need to streamline patient flow and appropriately address the healthcare needs of ALC patients (Ontario, 2020). However, there is limited literature describing how TCUs are operationalized and implemented, a recent systematic review of Canadian gray literature describing TCUs identified lack of data on funding, discharge process, and integration with other health sector (Barber et al., 2024). As TCUs are become more integral to the healthcare system, understanding how healthcare is delivered in these settings is an important area of inquiry. Exploring the day-to-day challenges experienced by TCU teams can provide insight into the gaps in healthcare delivery and identify areas for improvement to support better quality of care, and patient and staff outcomes.

This study focuses on managers’ perspectives due to their expertise and knowledge of day-to-day operations of the unit. This study aims to examine the experiences of TCU managers in operating TCUs by answering the following research question: What are the perspectives and experiences of TCU unit managers regarding the structures and processes of TCU units?

Method

Study design and setting

An exploratory qualitative design was employed (Creswell & Poth, 2016). Semi-structured interviews were conducted with the units’ managers to explore the structures and processes of TCUs. Seven transitional care units in Ontario, Canada, operated by two organizations were conveniently recruited.

Participants

Managers of units participating in a larger observational study were informed of the study and invited to participate in an interview via email. Managers were identified as individuals who (1) oversee the TCU operation, (2) supervise the staff, and (3) understand the services delivered by the TCU. Seven individuals were approached and all agreed to participate in the study.

The median age of interviewees was 43 years; four individuals identified as men and three as women. The majority were registered nurses with 12 years of experience. Years of experience as a transitional care unit manager at the time of the interview ranged from 2 months to 5 years. Four of the managers obtained master’s degrees: two obtained master’s degrees in health services management, and two in teaching or adult education. Additional demographic characteristics are described in Table 1.

Table 1.

Demographic characteristics of managers of transitional care units (n = 7).

Characteristic	Managers (n = 7)
Age (median, range)	46 (32–50)
Gender (n, %)
Men	4 (57%)
Women	3 (43%)
Professional degree (n, %)
Registered nurse	6 (86%)
Other	1 (14%)
Experience (mean, range)	12 yrs (10 months—24 yrs)
TCU experience (mean, range)	1 yr 8 months (2 months—5 yrs)
Highest education (n, %)
Master’s degree	4 (57%)
Bachelor’s degree	3 (43%)

Note: TCU, transitional care unit.

Procedures

A semi-structured interview guide was used to assist managers to reflect on the process of care of their unit (Patton, 2014). The interview guide, guided by elements of Donabedian’s Structure-Process-Outcomes framework (Donabedian, 1966), was developed by the Principal Investigator (PI) and co-investigators experienced in qualitative methods (KK, SG) and was pilot-tested with a member of the research team. The Donabedian framework is a conceptual model used to examine health services. Within the framework structures are defined as characteristics of healthcare teams, organization, or patients that influence services and outcomes, processes are the services and core components of a program, as well as actions between individuals and their surroundings, and outcomes refer to the consequences or effects of the health services on patients (Donabedian, 1966). The guide with probing questions can be found in Appendix A.

All interviews were conducted in person in each participant’s office at a time convenient for them. Interviews were audio-­recorded and conducted by the study PI (KSM) with experience in qualitative methodology. A note-taker (AK) was present at each interview to track the discussion. After each interview, the researchers debriefed, and interview notes were summarized in a running document to track discussed topics. Each participant was asked to complete the demographic questionnaire. The interviews lasted an average of one hour and were conducted between November 2022 and August 2023. All interviews were transcribed by a member of the research team. The research coordinator (AK) de-identified and reviewed the transcripts for accuracy.

Data analysis

A thematic analysis was conducted (Braun & Clarke, 2012, 2021) to examine the data: familiarization with the data; data coding; identification of themes and sub-themes; review of those themes and sub-themes; and definition and naming of the themes and sub-themes. Specifically, coding reliability thematic analysis was employed; this approach aligns with a realist epistemological perspective and emphasizes procedures for ensuring the objectivity and accuracy of coding through ­reducing coders’ personal bias by using structured codebooks, multiple coders who independently code the same data, and consensus coding (Braun & Clarke, 2021, 2023; Guest et al., 2012).

All data were imported into Dedoose, a cloud application for managing, analyzing, and presenting qualitative data (Dedoose Version 9.0.107, 2016). Each transcript was systematically and independently coded by two coders (AK and LY). A set of initial themes were identified from the running documents containing interview notes, and the coders generated additional themes throughout the coding process. To ensure reliability, the two coders met after each transcript to review their coding and reconcile discrepancies. Once the coding process was complete, the researchers (KSM, AK, LY) met to review all themes and sub-themes to ensure coherence, refining them as needed. As a final step, together the researchers generated names and definitions for the final themes and sub-themes, which can be found in Table 2.

Table 2.

Themes and sub-themes related to the care processes of transitional care units.

Themes	Sub-themes
Ensuring safe transitions	- Ensuring safe discharges - Helping patients navigate healthcare services - Advocating to hospital partners
Managing patients’ expectations	- Setting realistic expectations for care - Helping patients adjusting to a new reality - Ensuring equitable allocation of resources
Creating a team that works together	- Fostering teamwork - Interprofessional problem solving
Navigating a constantly changing environment	- Caring for a heterogenous patient population - Integration with other healthcare sectors

The following steps were taken to ensure rigor: engaging in reflexivity, researcher triangulation, establishing detailed documentation, systematic data management, and debriefing ­(Patton, 2014). Researcher triangulation was enhanced through debriefing and discussion of preliminary findings with the research team composed of individuals with varying backgrounds (nursing, health services research, rehabilitation science) and who were not involved in the coding process. Reflexivity was employed to make note of personal biases throughout the coding process which were then discussed among the coders (who have varying levels of research experience) (Olmos-Vega et al., 2022). The PI conducting the interviews is a woman, a senior scientist and a PhD prepared registered nurse with significant experience in examining and evaluating models of care for older adults. The two coders have a background in health sciences and previous experience with qualitative methodology and research in care of older adults. Their familiarity with experiences of older adults within ­healthcare systems inform their reflections. The COREQ (COnsolidated criteria for REporting Qualitative research) Checklist was followed in preparation of this manuscript (Tong et al., 2007).

Ethical considerations

Ethics approval for the study was obtained from the University Health Network Research Ethics Board (REB# 22-5216). Participation was voluntary; written informed consent was obtained from all study participants before the interviews. Data were stored electronically on the organizations’ servers. The use of study IDs ensured confidentiality, and all audio recordings were destroyed after transcription.

Results

Structural characteristics of the TCUs

The units were located in both rural (n = 2) and urban (n = 5) settings and ranged in size from 10 to 72 beds. Five of the TCUs (n = 5) were located in retirement homes, while two were in rehabilitation centers. All TCUs provided 24/7 care and were staffed by registered practical nurses (RPNs) and personal support workers (PSWs). Three of the sites also employed personal care assistants to aid PSWs with meals, laundry, and managing staffing carts. The daytime RPN- and PSW-to-patient ratios ranged from 1:8–15 and 1:5–10, respectively; at night these ratios ranged from 1:10–22 and 1:10–12, respectively. Additionally, rehabilitation health care providers (physiotherapists [PT] and occupational therapists [OT]) and medical care professionals (nurse practitioners [NPs] and physicians) staffed the units during the day. Further details on site-specific characteristics, including day and night staff: patient ratios can be found in Table 3.

Table 3.

Structural characteristics of the transitional care units (n = 7).

	Unit 1	Unit 2	Unit 3	Unit 4	Unit 5	Unit 6	Unit 7
Location	Urban	Urban	Urban	Sub-urban	Rural	Urban	Urban
Setting	Retirement home	Retirement home	Retirement home	Retirement home	Retirement home	Rehabilitation Centre	Rehabilitation Centre
Number of beds	42	31	72	20	10	48	36
Room types	Private	Ward, semi-private, private	Semi-private	Semi-private	Semi-private	Ward, semi-private, private	Ward, semi-private, private
Common medical diagnoses	Cognitive impairment, stroke, heart disease	Stroke, cancer, fracture	Cognitive impairment, fracture	fracture	fracture	Cognitive impairment, cancer, stroke, heart disease, fracture	Cognitive impairment, cancer, stroke, heart disease, fracture
Common discharge disposition	LTC	Community, LTC	Community, LTC	Community	Community	Community, LTC, rehabilitation programs	Community, LTC, rehabilitation programs
Length of stay	days—mos	30d/60d/mos	30d/60d/mos	60d	60d	days—mos	days—mos
Staff mix	RPN, PSW, PCA, PT, PTA, RC	RPN, PSW, PCA, PT, PTA, RC	RPN, PSW, PCA, PT, PTA, RC	RPN, PSW, PT, PTA	RPN, PSW, PT, PTA	RPN, PSW, PT, OT, SW, NP	RPN, PSW, PT, OT, SW, NP
Day staff: patient ratio	RPN 1:10 PSW 1:7 PCA 1:22 PT 1:42 PTA RC 1: 42	RPN 1:15 PSW 1:10 PCA 1:15 PT 1:31 PTA 1:10 RC 1:31	RPN 1:10 PSW 1:9 PCA 1:24 PT 1:36 PTA 1:12 RC 1:36	RPN 1:10 PSW 1:10 PT 1:20 PTA 1:10	RPN 1:10 PSW 1:5 PT 1:10 PTA 1:10	RPN 1:8 PSW 1:8 PT 1: OT 1: SW 1:48 NP 1:48	RPN 1:8 PSW 1:8 PT 1: OT 1: SW 1:36 NP 1:36
Night staff: patient ratio	RPN 1:22 PSW 1:11 PCA 1:22	RPN 1:15 PSW 1:10 PCA 1:15	RPN 1:18 PSW 1:12 PCA 1:24	RPN 1:20 PSW 1:10	RPN 1:10 PSW 1:10	RPN 1:12 PSW 1:12	RPN 1:12 PSW 1:12
Additional staff	NP x1 a week MD on call By referral: SW, SLP, nutritionist, wound care specialist, OT, pharmacist	NP x1 a week MD on call By referral: SW, SLP, nutritionist, nurse wound specialist, OT, pharmacist	NP x1 a week MD on call By referral: SW, SLP, nutritionist, nurse wound specialist, OT, pharmacist	SLP, SW, pharmacist	SLP, SW, pharmacist	MD, pharmacist, wellness partner By referral: dietician, SLP, wound care specialist, behavioral specialist, spiritual care specialist, IPAC specialist, ACC	MD, pharmacist, wellness partner By referral: dietician, SLP, wound care specialist, behavioral specialist, spiritual care specialist, IPAC specialist, ACC

Note: LTC, long term care; RPN, registered practical nurse; PSW, personal support worker; PCA, personal care assistant; PT, physiotherapist; PTA, physiotherapy assistant; RC, recreation coordinator; OT, occupational therapist; SW, social worker; NP, nurse practitioner; SLP, speech language pathologist; IPAC, infection prevention and control; AACC, augmented and alternative communication clinic.

The funding was provided by Ontario Health, a government agency coordinating provincial health care systems, which allocated it to hospitals, which in turn distributed the funding to their TCU partners. All units accepted patients designated as ALC who were medically stable, however, eligibility criteria varied between sites. Each hospital and TCU created their own site-specific eligibility criteria; with the hospital care coordinator identifying and referring clients based on these criteria and the model of care. For example, one of the units did not accept bariatric patients due to the local by-laws restricting Hoyer lift use (Unit 5).

In general, all TCUs provided similar services to their patients; however, there were differences in how the services were allocated. Five units had three programs: 30-day, 60-day, and long-term care (LTC). The number of beds allocated to each program was determined by the hospital partners, with some units exclusively admitting patients to the LTC streams. The 30- and 60-day streams were aimed at providing daily therapy to prepare patients for discharge, primarily to the community. Patients in the LTC stream were on the LTC waiting list and mostly received group therapy. Their length of stay was indefinite, ranging from days to several months, and in some cases, over a year. Patients awaiting a LTC offer were required to pay a co-payment, which was adjusted based on their financial situation. Upon admission to the TCU, patients were asked to select five LTC homes of their preference. Two units did not have defined streams and operated on funding similar to LTC. Care plans and discharge dates were determined by the care team based on patients’ medical history and PT and OT assessments.

Processes of care of TCUs

Four themes were identified related to the processes of care of the TCUs: (1) ensuring safe transitions; (2) managing patients’ expectations; (3) creating a team that works together; and (4) navigating a constantly changing environment. The four themes are presented in Table 2 and detailed below.

Ensuring safe transitions

Ensuring safe transitions was characterized by the actions taken to respond to the needs of TCU patients while they are transitioning to their next environment. The three sub-themes related to this theme are: (1) ensuring safe discharges, (2) helping patients navigate healthcare services, and (3) advocating to hospital partners.

Many TCU patients are older adults who were previously living in the community independently but can no longer do so. Ensuring a safe discharge was described as one of the “highest priorities in meeting patients’ goals” (MG7), and the ­managers discussed the importance of ensuring that patients leaving their unit are stable and have the support they require.

I think that’s a philosophy of care and approach. We really want to take some time to discharge patients more permanently. It’s not a quick fix. (MG7)

Some of the actions taken by the unit beyond routine care included liaising with building superintendents to follow up and do daily safety checks on patients discharged home; evaluating patients’ capacity capabilities and establishing power of attorney or public guardian and trustee when necessary; setting up documents, such as driver’s license and health cards; liaising with shelters on behalf of houseless patients; and ensuring that for patients returning home, their living arrangements are cleaned and debugged. In one case, the TCU team was able to locate and contact a patient’s relatives in another country to facilitate the patient’s discharge to their preferred location. Managers spoke to the importance of ensuring safe discharged for precariously housed individuals to break the cycle of recurring hospital admissions. In describing their stories, the managers highlighted the role of social workers and other rehabilitation healthcare providers in TCUs to ensure the best possible discharge outcomes for the patients. On units that did not have social workers, the managers took on these discharge responsibilities.

Managers emphasized the lack of communication patients receive in acute care and the pressure on hospitals to rapidly discharge them. Managers reported that patients admitted to the TCU often found themselves uncertain about their next discharge destination with sparse knowledge on services available to them to facilitate their return to the community, and helping these individuals navigate “the maze of home care and community services” (MG4) comprise a significant part of their workload. Several interviewees mentioned giving out their personal contact information to patients being discharged in case they have unanswered questions when they were home. In addition to liaising with home care and community, TCU staff encouraged patients to apply and use their benefits for mobility aids. One interviewee highlighted the importance of doing this for clients on the LTC waitlists, as LTC homes usually do not rent wheelchairs and residents without personal mobility aids spend more time in bed deconditioning. Managers described patients coming from acute care without their belongings and limited financial abilities, and individuals without care partners often finding themselves in a particularly vulnerable situation. In response to their needs, managers and staff donated items for patients to use during their stay.

They come over; they get pushed out of a hospital. They may not have clothes. They may not have those things available until a family member can bring them and they may live in Toronto and can’t come until the weekend. So, we always have that stuff on hand. My staff are really good. We just buy stuff and keep it here. Toiletries, pads, clothes. Anything we can because we know for some of these people, they can’t afford it. (MG4)

Finally, managers of TCUs with multiple streams of ­programs often found themselves communicating with their hospital partners and advocating on behalf of their patients who needed to transfer between streams (e.g., 60-day to LTC), as it was associated with additional costs to the hospital. This included patients in the short-stay programs who needed additional time or services before regaining their ability to return to the community, such as extra days of therapy to master walking up the stairs safely; or patients who could no longer be safely discharged home and needed to be placed on the LTC waitlist.

So sometimes, as I said, we need to flip a client from a rehab bed to an LTC [bed]. The hospital will likely push back and then I need to convey the urgency and how important it is for this client not to go home because they will get hurt. And I want to avoid that. And I know that the hospital sees things as numbers. I’m lucky enough to be on the floor enough to see these people as people. (MG3)

The TCU staff and managers were going above and beyond to pick up the missing pieces and ensure that their patients were supported.

Managing patients’ expectations

Interviewees’ described managing the expectations of patients and their care partners. This theme is defined by (1) setting realistic expectations for care, (2) helping patients adjust to a new reality, and (3) ensuring equitable allocation of resources.

Given the novel nature of TCUs, upon their admission to the unit, many individuals had little understanding of the purpose of the unit. TCUs were often confused with rehabilitation units, as this was the information patients received in the hospital. Managers spoke about the importance of having conversations with TCU patients early on to set realistic expectations for the care they will receive and plan for discharge. For patients on the LTC waitlist, conversations focused on Bill 7, provincial legislation discouraging individuals from turning down offers from LTC homes that are not of their preference (Bill 7, 2022). Managers spoke about ensuring that patients and their care partners understand their options and what will happen once they are discharged from the TCU.

Discussions related to patients’ expectations also included setting realistic care goals. Many of the TCU patients experienced a life-changing medical event that prevented them from returning to their home setting right away. All managers emphasized the role of the TCU staff in facilitating patients’ adjustment to their “new reality.” This included helping patients establish a new functional baseline through physiotherapy, occupational therapy, and recreational activities and supporting their emotional needs through spiritual care and the provision of a safe space to grieve.

I think they also kind of come to terms… ‘This is now the new lifestyle that I have to work with,’ and that kind of gives them that buffer period and then they feel more safe, there’s more acceptance, they know what to expect. It buys them time to arrange some stuff at home, whether that be with an OT to kind of put some safety devices at home, so I think it’s a benefit all around. (MG2)

However, given the limited health human resources of the TCU, care discussions also often involved difficult conversations regarding allocation of resources, such as differences in allocation of physiotherapy hours between patients with discharge plans for the community versus LTC. Managers also spoke of taking the time to help families accept the changes in patients’ functioning and one in case, the manager discussed staff’s inability to assist patients with getting up out of bed every day.

Creating a team that works together

The third theme indicated the importance of creating and maintaining a well-functioning team to meet the needs of the patients admitted to the TCU, marked by (1) fostering teamwork and (2) interprofessional problem-solving.

The involvement of the unit managers in day-to-day activities stood out, as they recognized their role is building and fostering good team dynamics and “coordinating to connect the dots” (MG6). As one of the strategies, all managers engaged in daily huddles on their units to cultivate good communication between staff. The huddles were used as a “safe zone” to address safety concerns, bring forward changes in patients’ well-being, or as teaching opportunities. All staff, including personal care assistants and students, were encouraged to speak up.

For me, number one is to be beside your team. Delivering good communication, treating them with respect, and leaving the door open for them. Because if you have a strong team, everything goes so naturally, so smooth. (MG1)

Managers emphasized maintaining an “open-door” policy, were hands-on, and maintained a strong presence on the unit. They spoke about stepping in for PSWs or RPNs when the unit was experiencing staffing shortages, engaging in bedside teaching, and dedicating time to getting acquainted with new patients and their care partners.

Being present I would say works well. When your staff know that you are willing to jump in when they need to—when the staff knows you have their back and you will support them if they need it. (MG2)

Given the complexity of patients’ care needs, an interprofessional team approach to care was emphasized by all the managers. They recognized the importance of all team members participating in care discussions to create a tailored, individualized approach to each patient. Regular interprofessional rounds enabled staff to “problem-solve.” In addition, good communication pathways between all team members enabled medical personnel to respond to patient needs promptly, as interviewees highlighted the key role PSWs play in communicating psychosocial changes experienced by patients to the rest of the team.

The staff—the RPNs, the PSWs, the whole interprofessional team, everybody is willing to learn and for me that’s the biggest blessing you can have because that means individuals are not putting up obstacles. But they’re part of the solution—and that’s what I really appreciate about this unit here. (MG6)

Despite the managers’ dedication to the team, they emphasized several systemic challenges. This included staffing shortages, the need to resort to agency staff (temporary staff contracted by a third-party for a fee), and staff workload and experience of burnout.

Navigating a constantly changing environment

The fourth theme was characterized by managers’ descriptions of operating a unit in the changing context of healthcare, such as (1) changes in the patient population and (2) changes in resources within other healthcare sectors.

Managers stated that although the majority of the TCU patients were older adults with cognitive impairment designated as ALC, the TCUs’ patient eligibility criteria were described as constantly “shifting.” This included patients with a variety of medical, mental, and social conditions. The changes in patient population were attributed to challenges experienced in acute care and society: “In a 3-month period every patient we would get was homeless going to emergency. I think we’re driven by a lot by what’s happening in our society, health care, pandemic” (MG7). Interviewees reflected on the heterogeneous patient population of their units, as one manager with less than a year of experience at the TCU put it, “Our patient population has changed even from the time that I’ve started here” (MG6). Given this fluidity, managers spoke to the difficulty of operating a unit that was not specialized. They emphasized the constant pressure on care staff (PSWs and RPNs in particular) to learn and flex their care approaches.

It’s like a GIM [general internal medicine] floor but we are not trained to manage all the diversity of—you get cardiac patients, kidney transplant patients, you get heart patients, then you get oncology patients. You’re flexing your approach, your care directions, really individualizing it but at the same time managing expectations and the workload. I think that’s the workload and managing patient expectations in meeting the needs of the shifting population day-to-day. (MG7)

In addition to the changes in the patient population, managers spoke about navigating the changes occurring in the community. Relationships between the TCU and community partners permitted the TCU team to ensure that patients will have the support they need after their discharge. However, changes and reductions in the availability of home care services and the scarcity of home care, especially in rural areas, impacted these relationships and impeded timely patient discharges, as patient safety could not be guaranteed.

The services are very, very sparse, especially trying to get people up to rural areas. People just won’t go, in terms of PSWs or nurses. Now at some point, people are just not qualifying for services. Or if they have to do wound [care] they’re sending them to clinics versus them coming to the house. And for many of our people—Like for our [patient], he doesn’t drive, his wife doesn’t drive, so he has no clue how he’s going to get to the clinic to get his care. (MG4)

Discussion

This is the first study to examine the structural characteristics and process of care of TCUs from the perspective of unit managers from Ontario, Canada. Despite the limited sample of seven TCUs, variations in structural characteristics across these models were recognized. Four themes were identified related to the processes of care of the TCUs: (1) ensuring safe transitions; (2) managing patients’ expectations; (3) creating a team that works together; (4) navigating a constantly changing environment. Findings illustrate the work conducted by TCU teams to ensure successful discharges while functioning with limited resources. TCU patients have complex medical and psychosocial needs which require an interprofessional team approach. TCUs are a relatively new model of care in Canada, implemented to alleviate the stress of patients designated as ALC in acute care. Considering the substantial growth of TCUs in the last few years and variability of models, implementation and evaluation of these programs require careful consideration in the future.

The current healthcare system is struggling to meet the needs of the older adult population. In response to this need and to alleviate the burden on acute care and prevent deconditioning of patients, transitional care interventions, such as TCUs and SNF are implemented. Evidence suggests that transitional care units internationally and in Canada contribute to positive patient outcomes, such as reduced hospital readmissions (Barber et al., 2024; Cadth, 2024; Toles et al., 2016). Similarly, our findings illustrate TCU staff’s work to address patients’ individual medical and psychosocial needs to ensure permanent discharges. However, findings demonstrate that the ability of TCU teams to ensure safe and timely discharges is limited by external systemic challenges, such as a lack of housing, home care, social, and rehabilitation services in the community and the availability of LTC beds. Homecare is an integral aspect contributing to older adults’ safe and independent living in the place of their choice, including persons living with dementia (Marani, Shaw et al., 2023). COVID-19 changed the landscape of home care availability and individuals’ needs, further exacerbating the crisis (Marani, Allin et al., 2023). Access to home care and allocation of hours of care is inequitable, particularly in rural areas (Yakerson, 2019), which contributes to delayed discharges, LTC admissions and waiting lists (Scott et al., 2024). Older adults with complex health problems transitioning between care settings are at higher risk of experiencing adverse events (Allen et al., 2014; Naylor et al., 2011). Given demographic aging and the projected growth of the older adult population worldwide (World Health Organization, 2024) and persons living with dementia (Alzheimer’s Disease International, 2024), more attention is required to establish a well-functioning system and ensure the care needs of patients are being met.

TCU patients experience a life-changing event and deconditioning in acute care, which requires time to adjust and improve. Previous research examining the experiences of ALC-designated patients reveals feelings of uncertainty about the future, disbelief about their functioning, and a lack of engagement in decision-making (Everall et al., 2019). The results of this study further corroborate these findings through participants’ accounts of patients’ experiences. The purpose of the TCU is not always understood by the patients and their care partners, similar to findings reported by Liapi et al. (2023). Lack of communication from healthcare providers in acute care leaves patients distressed and with expectations that cannot be met. Transitional care is not defined by a strict beginning (Allen et al., 2014) and can be initiated in acute care before patients’ arrival at TCUs. Starting this process during patients’ hospitalization, such as initiating discharge planning and creating behavioral safety plans, can improve continuity of care and expedite access to necessary resources, in addition to improving patients’ transition experiences. Furthermore, increased collaboration at the administrative and clinical levels between acute care and TCU, such as hospital staff visiting the TCU, may improve understanding of TCU services and inter-organizational linkage, contributing to positive patient outcomes (­Rahman et al., 2018).

Many of the TCU patients are living with cognitive impairment, and the complexity of their needs requires the right skill mix and education. Individuals with dementia are at higher risk of experiencing adverse outcomes, such as infections and poor hydration, in hospital settings when compared to individuals with no impairment (Royal College of Psychiatrists, 2019). In this study, all units were RPN-led with support from PSWs. TCU staff need to be well-versed in person-centered approaches to care defined by putting individuals at the center of their care through respect and recognition of personhood (McCormack & McCance, 2006). Experience in understanding the biological and psychosocial responses of persons with dementia may aid TCU staff meeting the needs of their patients (Handley et al., 2017). In addition to improving patient outcomes (Handley et al., 2017), positive attitudes of staff focusing on person-­centered care for individuals with dementia may contribute to higher job satisfaction (Moyle et al., 2011). In this study, all units had an NP as part of the care team. In other settings, such as LTC homes, in addition to their clinical role, NPs often assume leadership responsibilities in mentoring, educating and supporting staff (McGilton et al., 2021; Sangster-Gormley et al., 2013). Given the complexity of TCU patients, future research needs to focus on how to best support staff and support the role of NPs in building TCU staff’s capacity.

Interviewees discuss the challenges in allocating limited resources, such as physiotherapy, particularly for patients waiting for an LTC home offer. Physiotherapy is recommended for older adults to maintain function regardless of their setting, including LTC homes (de Souto Barreto et al., 2016), and evidence suggests that persons with cognitive impairment can have improvements in functional status during their TCU stay (Cumal et al., 2022). Rehabilitation programs with person-centered approaches may be beneficial to older adults with cognitive impairment. Future research needs to focus on examining physiotherapy guidelines for all TCU patients, including individuals on the LTC wait lists. Appropriate rehabilitation healthcare providers staffing ratios necessary to provide equitable access to resources for this population need to be established.

The number of precariously housed older adults is on the rise, projected to triple between 2017 and 2030 (Ureste et al., 2022). Precariously housed older adults are at increased risk of experiencing poor age-related outcomes (Brown et al., 2017) and may benefit from TCU services. Teams need to understand the needs of their patients who are frail with multiple comorbidities, unhoused, and have limited support systems. Organizations operating TCUs must employ rehabilitation healthcare providers, social workers, NPs and physicians, spiritual care workers, and behavioral specialists to ensure the necessary skills and knowledge to provide care for this complex population. In this study, managers emphasized the work done by the TCU team in providing a safe space for patients to grieve and adjust to their new baseline. Interviewees discussed the role of TCU staff in guiding patients through the system to establish the support that is necessary for them. However, the continuously changing landscape provides additional workload. Health system organization was identified as a barrier by TCU stakeholders previously (Weeks et al., 2021). Policymakers need to create an infrastructure facilitating referrals to community and government resources (Serchen et al., 2024) and must support healthcare professionals through efficient communication on the resources and community services available to patients.

The study has several limitations. The study is exploratory and based in Ontario, and the findings may not be transferrable to other health systems or other Canadian provinces. Participants were conveniently recruited, due to which the sample size is limited. Although one of the participants had only 2 months of experiences as a TCU manager, they were able to compare their limited experience to previous roles. Furthermore, the TCUs of individuals who were interviewed for the study were facility-based and belonged to two large organizations, and therefore, the findings may not represent experiences of TCU managers in other settings. Finally, how the variations in structural characteristics affect the processes of individual TCUs was not examined. Nonetheless, this is the first study to explore the structures and processes of facility-based TCU through perspectives of unit managers in Canada.

In summary, TCUs have potential to be an essential component in the healthcare system, as TCU teams help patients transition from acute care to other settings by addressing the individual medical and psychosocial needs of their patients. Future research needs to focus on understanding the experiences and needs, as well as outcomes, of patients, their care partners and TCU staff to better understand how TCUs can be optimized. Wide variations in what constitutes TCUs need to be recognized when evaluating effectiveness of these models of care. Results may be used by healthcare organizations and policy decision-makers to inform the processes of care of TCUs in the future.

Supplementary material

Supplementary material is available online at The Gerontologist.

Data availability

Raw data are not publicly available to preserve the privacy of research participants, as study participants did not provide consent for the data to be shared publicly. However, coding inquiries are available from the corresponding author, KSM, upon reasonable request. The study was not pre-registered.

Funding

This work was supported by the Canadian Institutes of Health Research (CIHR; grant number 180618); The Walter and Maria Schroeder Institute for Brain Innovation & Recovery (K.M, J.B); a Tier 2 Canada Research Chair in the care for frail older adults (M.P); the University of Toronto Centre for the Study of Pain (D.G); the Trillium Health Partners Foundation (K.K).

Conflicts of interest: We have no conflict of interest to declare.