Transitions of older adults between emergency departments and community care in Quebec: a case study

This study aimed to examine the care coordination processes and challenges between emergency department and primary care interdisciplinary teams, with a focus on the role of nurses in ensuring safe transitions for older adults. A case study was conducted within an Integrated Health and Social Services Centre in Quebec. Two types of data were used: documents and semi-structured interviews with 15 professionals involved in the transition. The Transitional Care Model guided the study. Several challenges were identified, namely establishing trust and continuity with older adults, balancing their wish to return home with ensuring their safety, the limited training of nurses to fulfill this role, the lack of communication across care levels, and the shortage of resources within primary care level. Given the aging population and its complex needs, it is urgent to move away from hospital-centrism and to strengthen primary care to enable older adults to age healthily in their community.