In Ontario, the population of older adults is increasing. While the provincial government is taking action to address increasing demand on health systems, older adults are still suffering the consequences of a health system that is not able to meet their complex care needs. Older adults face barriers to continuity of care including difficulties with memory, reliance on informal caregivers, frailty, and difficulties scheduling appointments. These barriers also exist within the long-term care setting. Long-term care facilities are making efforts to provide more effective care, including designing care approaches aimed to meet the complex care needs of older adults. Aspects of a goal-oriented approach suggest that it has the potential to reduce fragmentation and positively impacting continuity of care. However, the impact of goal-oriented care on continuity of care in a long-term care setting has yet to be explored. This thesis uses an exploratory case study methodology to describe how a goal-oriented care approach influenced continuity of care in a long-term care setting, as perceived by residents, staff, and administrators. The case study setting is the Perley & Rideau Veterans Health Centre in Ottawa, Ontario, where the SeeMe program, a frailty-informed approach with a goal-oriented component, was recently introduced. Factors associated with the SeeMe program and other organizational factors perceived to facilitate and inhibit informational, relational and management continuity were identified. Aspects of the SeeMe program that facilitated informational continuity were: goals-of-care meetings with residents, their care team and family; care conferences that helped residents understand their care options; and, procedures that ensured consistency in where resident’s goal information is stored. Aspects that facilitated relational continuity were: understanding residents’ values and preferences; staff increasing awareness of the program for families; and, integration of the family perspective into a resident’s care. Program aspects that facilitated management continuity were: discussions that led to informed decision-making; use of assessments as a reference tool in the case of an acute health event; discussions that empowered residents to talk to external care providers; and, creation of a structure that facilitated consistencies in care. These factors can be targeted when designing care approaches aimed to improve continuity in long-term care settings.

Introduction: Primary care in Flanders is undergoing reform. Researchers are looking at ways to understand the context in order to be able to implement person-centred and goal-oriented care approaches such as reablement. Aim: The aim was to illuminate the lived experiences of older people with chronic conditions and what it means to receive paid care at home. Method: Using an interpretative phenomenological analysis approach, this study aimed to understand the lived experience of someone living at home receiving paid care. Results: Six in depth interviews were analysed generating nine themes and related subthemes. Conclusions: The study illuminated the experiences of six people who received care at home and generated themes around autonomy, adaptability, respect, identity, flexibility, self determination, power, acceptance, and control that reflected the literature and concepts around person-centred and goal-oriented care as well as the importance of the role of occupational therapy. Significance: In the Flemish context, this was the first study looking at the experiences of people living at home with paid care and the chances and barriers to reablement and occupational therapy in the community setting.