This multiple case study explored how Long-Term Care (LTC) teams in Ontario, Canada, manage informational continuity when older adults transition from community-based care to LTC. Five LTC homes, varying in size and rurality, participated, with 20 professionals interviewed across various roles, including nursing, medicine, rehabilitation, and administration. LTC providers emphasized the importance of comprehensive, accurate, and up-to-date biopsychosocial information to support effective care. However, information transferred from community and hospital sources was often incomplete or outdated. To address gaps, LTC staff sought additional details from electronic health records, families, care coordinators, and hospitalists. Their ability to obtain missing information was influenced by organizational capacity, physician's practice location, power dynamics between providers, availability of family caregiver support, and access to electronic health records. A stronger primary/hospital-LTC collaboration, incentives for informational continuity, and a specific staff managing transition information and activities could optimize the LTC transition information exchange process.
Okoh et al. (Sun,) studied this question.