The objectives of this synthesis are to highlight some of the evidence presented by the other articles in this issue and to discuss how this evidence can be used to design policies and deliver health care services which foster seniors' independence within a health reform context. This paper, therefore, first examines health reform and proceeds from there to discuss the key findings of the studies reported in this journal issue. The discussion then focusses on the importance of the evidence presented for policy making, planning and practice within the current context. Each section concludes by identifying the specific gaps in knowledge that require either additional literature reviews or further research.

The results of examining all hospitalizations of the elderly consequent to injury in one Canadian province indicate that 66.3% were for accidental falls and 21.3% were for “other accidents” and for adverse effects of therapeutic regimens. Nursing home residents were significantly more likely to be hospitalized for falls than community dwellers but very elderly institutionalized females, who comprise 40% of the nursing home population, used significantly fewer days than their community peers.

This research uses data from the Manitoba Longitudinal Study on Aging and multiple logistic regression analysis to assess the impact of twenty-eight sociodemographic and health status variables on nursing home admission. The results indicate that 1) all the short-term predictors continue to be significantly associated with facility bed use in the long run, suggesting that the high risk elderly can be identified relatively early; 2) the key sociodemographic characteristics are better predictors of admission than health and physical functioning characteristics; and 3) time itself appears to change the relationship of the study variables to admission.

Edelman's (1967,1977) analysis of political processes is used as the theoretical framework within which to examine the role of international conferences such as the recent World Assembly on Aging. The function of such international assemblies and the role of participating policymakers and experts are interpreted as part of a symbolic process which legitimates problem definitions and national policies, and validates the roles of policy makers, bureaucrats and experts. The paper questions whether these meetings have real potential for influencing national policies and discusses the factors which limit their relevance and usefulness for developing countries.

This paper describes the nursing home component of the population-based health information system developed in Manitoba, and four years (1989/90 to 1992/93) of data produced by this information system. The study presents regional comparisons of nursing home bed ratios, admissions per 1,000 elderly, days of care per capita, mean expected length of stay for new admissions and median length of waiting time prior to admission. Selected hospital indicators for long-stay patients are also presented. The study indicates that a population-based information system is a useful tool for managing the nursing home sector by highlighting the degree to which a province achieves distributional equity and equality of access to nursing home beds.

Data from the Manitoba Study of Health and Aging were used to compare the utilization and direct costs of formal community care services among the elderly diagnosed as persons with no cognitive impairment, with cognitive impairment/no dementia and with dementia. The results of the analyses indicate that, in addition to living arrangement and limitation on basic and instrumental activities of daily living, mental function diagnosis is an independent predictor of community care use. A diagnosis of dementia increases the likelihood of community care use over those with unimpaired mental functioning, whereas cognitive impairment without dementia does not. The three diagnostic groups differ in the type of services used. Standardization by age, sex and the other variables which significantly affect the need for community care can help a program improve its ability to project realistic cost estimates.

Data from the Manitoba Longitudinal Study on Aging were used to focus on the elderly who used 31 or more hospital days in one year and to see if their high use was an isolated event or a persistent pattern by examining their hospital use over a 6-year period. The relationship of several service-provider characteristics to high use was also examined. The majority (58%) of high users were decedents or those about to enter a nursing home and another 22% used 31 or more days in only one of the six years. Indications are that bed/population ratios and physician practice styles are positively related to the hospitalization utilization patterns of high users. These and other findings raise issues requiring further research.

Routinely-collected administrative data and Cox's proportional hazards models are used to compare outcomes of care while controlling for age, sex and dependency level. The results indicate that the overall quality of nursing home care in Manitoba is good but that residents in certain regions and in certain types of nursing homes have specific outcomes that are poorer than others. These outcome indicators must not be treated as definitive signs of poorer care but as “triggers” suggesting a need for a closer look because the methodology and outcomes used in this study are still in the experimental stage. The results also indicate that secondary data provide a relatively inexpensive starting point for evaluating outcomes of nursing home care.

Administrative home care data from the Manitoba Support Services Payroll (MSSP) system for fiscal years 1995/1996 to 1998/1999 were utilized to study home care client characteristics and changes in home care use over time. Patterns in home care access and use after hospitalization, before admission to a nursing home, and before death were examined. The study found that the majority of home care clients were female, aged 65 and over, and not married. The proportion of Manitobans using home care increased slowly, but significantly, over the 4 years. The greatest increases were found among the older age groups. The average number of days that clients received home care before death or before admission to a nursing home was stable over time, while a significant increase over time in home care use after hospitalization was experienced. These findings can be useful to regional health authorities for planning and budgeting.

Previous studies report geographic variation in the use of home care services. In the province of Manitoba, home care is a core service that Manitoba' twelve regional health authorities (RHAs) are obligated to deliver. Manitoba' RHAs range from remote northern and rural southern regions to a major city, resulting in different challenges for delivering home care. Given this potential for inconsistent delivery and the previous findings of regional variation in other settings, the objective of this study was to measure and assess variation in the use of home care across Manitoba' RHAs. We used data from the Provincial Home Care Program' client registry, other health care administrative databases, and Vital Statistics. Home care use was measured using multiple indicators, including rates of population use, use after hospitalization, before entry to a long-term care facility, and before death. While some important differences emerged, overall we found comparable use of home care across Manitoba.