A multi-state transition model among older adults receiving home care services: A population-based cohort study

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While home care services (HCS) are thought to support aging in place, little is known about the patterns of care transitions over time among this complex population. The objective is to describe transitions and quantify probabilities of transitioning, using multi-state Markov models in a population-based cohort from Quebec (Canada). Methods This is a retrospective observational cohort study, selecting recipients of HCS within a program for older adults with loss of autonomy. We estimated transition probabilities with continuous-time Markov models across the following states: A) home, B) hospital, C) at home waiting for long-term care (LTC) placement, D) LTC, and E) death. Sex, age, type of residence, and comorbidities were included in models as covariables. Results Among the 3424 HCS recipients, 65.7% were females, while males were younger on average and had more comorbidities. Several factors were significantly associated with specific transitions, such as higher rates of hospital admissions for males and higher rates of LTC transfers upon hospital discharge for males and patients with dementia. HCS were also strikingly lower in intensity, and with fewer services provided by healthcare professionals, for patients waiting at home for LTC placement, being wait-listed itself associated with dementia and residing in private senior homes. Conclusions This study highlights gaps, and hence potential areas for improvement, in HCS for older adults with loss of autonomy in Quebec and shows how multi-state models can enhance understanding of care transitions in complex populations. Care transitions Home care Loss of autonomy Multi-state Markov models Figures Figure 1 Figure 2 Figure 3 INTRODUCTION The current demographic shift invites healthcare systems to adapt to the evolving needs of individuals with complex healthcare needs, including those living with multimorbidity and dementia, while supporting autonomy [ 1 , 2 ]. Political priorities and personal preferences emphasize the importance of enabling a safe aging at home, with the support of timely and adapted home care services (HCS) [ 3 ], alongside informal care received from family and friends [ 4 ]. HCS refer to a range of healthcare and support services provided in a patient’s home, and include notably nursing care, physical therapy, and psychosocial care, as well as assistance with daily activities [ 1 ]. In Quebec, most older adults reside in the community [ 1 , 3 ], while three quarters of HCS recipients were aged 65 years or more in 2019–2020 [ 1 ] and 72% of all HCS were dedicated to support older adults’ autonomy, among services provided by public instances [ 5 ]. Thus, the complex health profiles of older adults with loss of autonomy, combined with factors such as low socioeconomic status and limited social support, place them at increased risk of experiencing care transitions [ 5 , 6 ]. Care transitions are defined as transfers involving at least one overnight stay or several consecutive days of care in different healthcare establishments, or involving changes in responsibility between professionals in different sectors, such as primary care, emergency departments (ED), and hospital [ 1 , 7 ]. The most frequent care transitions are hospital admissions and discharges, ED visits and admissions to residential and long-term care (LTC) facilities. In addition to the fragmentation of care and medication management, these processes may have negative impacts, including risks of deconditioning, undernutrition, delirium, disability, and death [ 8 ]. As a result, care transitions are increasingly seen as key areas for improving the quality of care and patient safety. And this is particularly true for transitions deemed potentially avoidable, i.e. when it occurred for chronic health conditions for which timely management, either in primary care or by HCS, could have prevented the deterioration in health status [ 9 ]. While HCS may prevent care transitions, including avoidable ones [ 10 , 11 , 12 ], several gaps remain in our understanding of care transitions for HCS recipients. Most studies focused on short-term HCS in specific contexts, such as following hospital discharge [ 10 ]. Thus, there is a need for exhaustive and longitudinal portraits of care transitions, especially in the Canadian or Quebec context where the demand for HCS continues to grow, including their various types such as waiting for LTC placement while still living in the community. Routinely collected data in electronic health records offer a great potential in informing health systems [ 13 ], and multi-state Markov models are well-suited to analyze factors associated with transition rates in a real-life context [ 14 ]. In medical research, they have mostly been applied to study disease progression [ 15 , 16 , 17 ], but rarely care transitions, although some contexts were explored [ 18 , 19 , 20 ]. Therefore, we aimed to describe care transitions experienced by HCS recipients and identify factors associated with each transition. We also provide illustrative examples of how care transition probabilities change longitudinally, according to age, sex, and chronic conditions. METHODS Design and data sources This is a retrospective cohort study using data from the Care Trajectories-Enriched Data (TorSaDE) cohort (n = 102,148 unique participants in Quebec, Canada), which links five waves of the Canadian Community Health Surveys (CCHS – 2007 to 2016) with health administrative data from the provincial health insurance board, providing universal health coverage to all residents (Régie de l'assurance maladie du Québec: RAMQ – 1996 to 2016). The TorSaDE cohort contains data of all CCHS participants who accepted to share their data with Quebec’s Statistics Institute and agreed to data linkage. A detailed description of the TorSaDE cohort is available elsewhere [ 21 ], but briefly, the CCHS provides self-reported information on health status and socio-demographic characteristics, while RAMQ data enable longitudinal follow-up of healthcare services use and diagnoses ( Supplementary Text ). Studied population We extracted data for all participants to the first three CCHS surveys (2007–2012; n = 60,791), aged 65 years and older at index date, who received HCS within the support program for the autonomy of older adults (French acronym SAPA), dedicated to promoting aging in place notably through HCS provided by local community service centers (French acronym CLSC), between July 1, 2012 and December 31, 2015. The index date is the date of the first HCS during this period. Participants were followed from the index date until death or December 31, 2016, whichever occurred first. A HCS was identified from the I-CLSC database using information on the intervention localisation (e.g., private home, private seniors’ residence). Care Transitions We considered five states, from which 12 transitions can occur ( Supplementary Fig. 1 ). State A refers to being home in the community (including private seniors’ residence and residential resources, i.e., non-institutionalized resources for persons with autonomy loss or specific needs related to mental or physical health [ 22 ]). State B refers to any hospital stay. State C refers to being at home in the community while waiting for a LTC placement. State D refers to LTC residency. Finally, State E refers to death. The state “waiting for LTC placement” (State C) was identified in the I-CLSC database as a reason for intervention, and the earliest date was considered as the entry in State C. Patient were considered waiting for a LTC placement until the transfer to LTC facilities or death, which implies that they returned to State C after a hospital discharge. Covariables We considered sex, age and location (private home, private seniors’ residence, residential resources) at the index date. Within two years prior to the index date, we considered potential factors associated with the probabilities of transitioning, using the International Classification of Diseases (ICD) codes from the hospital stay register and physician claims: presence or absence of dementia, other neurological diseases, diabetes, cancer (any tumor without metastasis, metastatic cancer), cardiovascular and cerebrovascular diseases (CVD, including myocardial infarction, congestive heart failure, cerebrovascular diseases, and vascular diseases), chronic obstructive pulmonary disease (COPD), and any mental health disorder [ 23 ]. Regarding HCS, we considered the category of worker (professional — nursing, nutrition, rehabilitation services including physiotherapy and occupational therapy, respiratory therapy services, psychosocial services; non-professional — home assistance services) and the intensity of the interventions (proportion of days spent at home where a HCS occurred, presented in days per week). Statistical analysis First, we described care transitions during follow-up. Then, using the mstate R package [ 14 ], we fitted for each transition, a transition-specific Cox proportional hazards model incorporating covariates. The resulting model estimates individual transition hazards over time, yielding dynamic transition probabilities from various states and time points, enabling personalized predictions across patient profiles and corresponding visual comparisons (e.g., age, sex, dementia) ( Supplementary Text ). RESULTS We extracted data on 3424 individuals aged 65 years and older who received HCS within the SAPA program between July 1, 2012, and December 31, 2015 (Table 1 , Supplementary Fig. 2 ). Females were older than males, while males were more likely to live in a private residence than females. The median follow-up was 2.8 years and was longer for females (almost 3 years) than for males (2.4 years). Males were sicker and had a higher mortality rate than females. Our study cohort experienced 14,792 transitions during the follow-up period (Fig. 1 ), with the vast majority (76%) of transitions being from home to hospital and vice versa. Of the 1245 deaths recorded, half occurred in hospitals, nearly one quarter in LTC facilities, and a little less in the community. Very few deaths occurred while waiting for LTC placement in the community. Half of individuals who transited to state C (waiting at home for a place in LTC) spent over three months (116 days) in that state, while the median time spent in state D (LTC) and A (home without waiting for LTC placement) was respectively around 9 months (259 days) and of 6 months (168 days; Fig. 1 ). Table 2 gives a description of each of the 12 transitions in terms of median time spent in each state. For example, almost half of people that transited from home (state A) to death (state E) during the follow-up spent less than 3 months (median 97 days) at home before dying. The highest HCS intensity was provided to individuals from state A (living at home) who transitioned to LTC (state D) (mean (SD): 1.6 days per week (2.0); median (IQR): 0.9 (2.1)) and individuals in state C (at home waiting for LTC) who transitioned to state B — hospital (mean (SD): 1.5 days per week (1.8); median (IQR): 0.9 (1.8)). The lowest HCS intensity was provided to individuals in state C who transitioned to LTC — state D (mean (SD): 0.9 days per week (1.5); median (IQR): 0.3 (1.0)). The bottom part of Table 2 presents the factors associated with the probability of transitioning resulting from the multi-state Markov model. For example, the probability of transitioning directly from home to hospital (state A to B) is increased for people with the following comorbidities, in decreasing order of effect size: COPD (aHR: 1.75, p < 0.0001), cancer (aHR: 1.38, p < 0.0001), CVD (aHR: 1.29, p < 0.0001), and mental disorder (aHR: 1.25, p < 0.0001). On the other side, people at home with dementia have a reduced probability of transitioning to the hospital (state A to B; aHR: 0.80, p < 0.0001), but an increased probability of getting on a waiting list for LTC placement (state A to C; aHR: 2.98, p < 0.0001) or directly moving to LTC facilities (state A to D; aHR: 2.27, p = 0.0185). In fact, dementia is associated with an increased probability of transitioning to states C (waiting a LTC placement) and D (LTC placement), regardless of the state of origin. In return, people with dementia are less likely to be transferred from hospital (state B) directly to home without being placed on a waiting list for LTC placement (state A) (aHR: 0.65, p < 0.0001, Table 2 ) . To illustrate the longitudinal change in probabilities of being in any of the five states estimated by our multi-state Markov model, we represented these probabilities graphically for various type of HCS recipients, by varying sociodemographic and clinical characteristics. Figures 2 and 3 show respectively a female and a male living in a private home, with varying age group (row) and comorbidities (column). Supplementary Figs. 3–4 show probabilities for HCS recipient living in private seniors’ residences without comorbidities and with dementia only, varying sex (row) and age group (column). For both sexes, dementia increases the probabilities of transiting to states C (waiting for LTC placement) and D (LTC placement) over time, compared to patients without dementia (Figs. 2 and 3 ) . DISCUSSION Our study explored the transition process across the continuum of care for older adults with autonomy loss receiving HCS. Using a statistical approach that is still rarely applied to care transitions, we have provided evidence that multi-state models allow to: describe the observed care transitions experienced by HCS recipients during their follow-up, identify factors associated with each transition, and estimate and illustrate the longitudinal care transition probabilities and states for various types of HCS recipients. Our population of HCS recipients was composed in higher proportion of females, although they had fewer chronic conditions. This finding is consistent with the sex-frailty paradox, whereby females appear to live longer than males but in a state of greater fragility [ 24 ], perhaps due to a higher predisposition for “non-life threatening” diseases and functional impairment [ 25 , 26 ]. Psychological factors and behaviors related to gender roles may also affect this sex-related imbalance in HCS users, including the higher propension of females to notice physical changes and discomfort, and their greater willingness to seek help and access healthcare [ 27 ]. We also found females to be living in private senior residences or intermediate resources in higher proportion than males at the index date, which is agreement with previous studies [ 28 , 29 ]. On the other hand, being male was associated with a greater risk of hospital admission and transfer to LTC directly from the hospital. The higher rate of hospital admission in men is concordant with results from Norway [ 30 ] and with their higher prevalence of chronic conditions, whereas their higher rate of LTC placement following hospital discharge may reflect their tendency to delay the search of a medical consultation [ 31 ]. Unplanned institutionalizations following hospital discharge are often more harmful to health, compared to those planned ahead [ 32 ], but adequate HCS may help to prevent such transitions [ 33 ]. Hospital stays themselves are often detrimental on cognitive and functional status of older adults presenting with vulnerability factors [ 34 , 35 ], leading to functional declines that may hamper their capacity to return home [ 36 ]. Dementia was also associated with a higher risk of being transferred to LTC upon hospital discharge, a finding consistent with another study from Scotland [ 37 ]. Institutionalization following a hospital stay may imply a delayed discharge (also called alternative level of care in Canada), which indeed appears to be the case for Canadian patients with dementia [ 38 ]. Patients with dementia were also more likely to be added on an LTC waiting list, either following hospital discharge or when residing at home. Cognitive and functional profiles of wait-listed individuals vary according to healthcare systems [ 39 ] and even region density (urban vs rural) [ 40 ], suggesting that waiting time for LTC placement is dependent on both local available resources and governmental guidelines dictating how priorities should be evaluated. In any case, the strong association between dementia and LTC placement, whether occurring through wait-listing or not, suggests insufficient resources to support aging in place for these individuals. In our population, HCS intensity was lower before an LTC placement for those registered on a waiting list compared to those not registered, which might indicate that more severe cases are promptly directed to LTC. Also, we cannot exclude that these patients were transferred to housing facilities offering on-site professional and/or support services (e.g., private senior residence or residential resources) while waiting for their LTC placement. Notwithstanding this, this finding raises concerns about equity in access to HCS, and future studies should seek to address factors that may explain this potential inequity. Yet, for community-dwelling individuals not on a waiting list, HCS intensity dispensed by professional healthcare providers was lower before hospitalization, raising the question of whether sufficient support was provided. Similarly, among at-home wait-listed individuals for LTC placement, only 70% received at least one professional service while in this state, a strikingly low percentage given the extent of health and psychosocial needs in this population with severe functional impairment. Nonetheless, patients waiting for LTC placement in the community remain poorly studied in Quebec. The median waiting time spent at home for a LTC placement was of 116 days, an estimation greater than previously reported [ 41 ]. Exhaustion of caregivers and rurality are both factors associated with higher risk of being added on a LTC waiting list [ 42 ]. Impairments related to instrumental activities of daily living (IADLs, e.g., meal preparation, use of transports, etc.) seem to act as key drivers for referral to LTC [ 40 ]. However, in Quebec, to be eligible for LTC services, a person must present a combination of significant physical and cognitive loss of autonomy according to the functional autonomy measurement system [ 43 ]. While HCS provide support for more basic daily activities (i.e., activities of daily living, such as feeding and bathing) [ 1 ], aid for IADLs is often granted through informal caregivers or community organizations. Residents of private senior homes were more likely to be transferred to LTC following hospital discharge, a finding in agreement with another study showing prolonged hospital stays [ 44 ]. They also had an increased probability to be added on a LTC waiting list, concordant with a report indicating longer waiting time before LTC placement for persons living in seniors residences in Toronto (Ontario), compared to hospital inpatients and private home residents [ 45 ]. This may also indicate a situation where services are being exceeded, while private senior homes offer varying levels of support [ 46 ]. Diabetes, CVD, and COPD were associated with an increased risk of hospital admission, despite being conditions considered suitable for primary care-centered treatment [ 47 ]. These results might point toward area of improvement in primary care access, management, and enhanced coordination among care providers [ 48 , 49 ]. Communication between the front line and HCS, as well as the ability of HCS to prevent potentially avoidable transitions are still open questions, given the lack of Canadian studies on the subject. In fact, despite large sums allocated to HCS (for instance, HCS for the SAPA program costed 2 billions of dollars for the fiscal year 2023–2024 in Quebec) [ 50 ], our understanding of their actual benefits, notably on care transitions, is still sparse [ 10 ]. Future studies, ideally with larger sample sizes, should try to address transitions with the highest potential for actionable interventions, such as hospital admissions and visits to the emergency department deemed avoidable because they should be treated mainly in primary care. Equity in access to HCS should also be addressed in more detail, as well as other aforementioned aspects, such as LTC wait-listed individuals. Our study has several limitations. First, due to a limited sample size, we could not analyze some transitions of interest, notably potentially avoidable visits to the emergency department and hospital admissions, as well as delayed hospital discharges. Covariables like comorbidities were only measured at baseline (2-year period before the index date), which might introduce some bias to their impact on transition probabilities if some incident cases occurred during the follow-up. Also, specialized nurse practitioners appeared relatively recently in Quebec (in the early 2000s), hence there might not be many at the time the data used here were collected. It would thus be interesting to assess how their advent in Quebec affected the care trajectories of persons with loss of autonomy, including transitions. Strengths include the use of a sophisticated statistical approach to assess transitions across various states in a comprehensive manner and with the incorporation of several covariables, as well as a cohort representative of the Quebec population. CONCLUSION Our study revealed limitations and areas for improvement in HCS provision for older adults with a loss of autonomy in Quebec, and important avenues for future research. It also demonstrated how the application of multi-state models can improve our understanding of care transition patterns for complex populations. Abbreviations aHR: Adjusted Hazard Ratio CCHS: Canadian Community Health Survey CLSC: Centres Locaux de Servives Communautaires (local community service centers) COPD: Chronic Obstructive Pulmonary Disease CVD: Cardiovascular and Cerebrovascular Diseases ED: Emergency Department HCS: Home Care Services LTC: Long-term Care ICD: International Classification of Diseases IQR: Inter-quartile Range RAMQ: Régie de l’Assurance Maladie du Québec (provincial health insurance board) SAPA: Soutien à l'Autonomie des Personnes Âgées (support program for the autonomy of older adults) SD: Standard Deviation TorSaDE: Care Trajectories-Enriched Data Cohort Declarations Clinical trial number : Not applicable. Data availability statement : The datasets analysed in this study are not publicly available due to confidentiality constraints. However, data are available upon request from the Institut de la statistique du Québec (ISQ) through the ISQ Research Data Access Desk, subject to restrictions (https://statistique.quebec.ca/en/services-recherche/rda-home). Ethics Approval and Consent to Participate : The current study was reviewed and approved by the Research Ethics Board Committee at the Université de Sherbrooke, in accordance with institutional requirements. The study was conducted using de-identified data from the TorSaDE cohort that was already available. This cohort contains data from all CCHS Québec participants who agreed to share their data with the ISQ and to data linkage for research purposes. Written informed consent from the current study population was waived under Section 67.2.1 to 67.2.3 of Act #A-2.1 (Act respecting Access to documents held by public bodies and the Protection of personal information). This study adheres to the Declaration of Helsinki. Competing Interests statement : The authors declare that they have no competing interests. Funding : This work was supported by a “Initiatives stratégiques” grant from the “ Centre de recherche sur le vieillissement ”. ID is the recipient of a Junior 1 salary grant from the Fonds de recherche du Québec—Santé . The funding bodies had no role in the study design, data collection, its analysis, and interpretation. Author Contributions : ID, DMB, MFD, NDC, HC, YMC and VL contributed to the concept and design of the study, data gathering and interpretation. JC performed the analyses. VL and JC drafted the manuscript. All authors critically reviewed the manuscript in the context of clinical practice and approved the final version. References CSBE, Commissaire à la santé et au bien-être. Bien vieillir chez soi - Tome 1: comprendre l’écosystème. . Schmidt-Mende K, Arvinge C, Cioffi G, Gustafsson LL, Modig K, Meyer AC. 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Santé et Services sociaux du Québec 2025 https://www.donneesquebec.ca/recherche/dataset/contour-financier-depenses-de-services-a-domicile-par-programme-et-par-region (7 May 2025, date last accessed). Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files ArticleSADMarkovSupplementary20250728.pdf Table12.docx Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2026 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 26 Sep, 2025 Reviews received at journal 18 Sep, 2025 Reviews received at journal 13 Sep, 2025 Reviews received at journal 10 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviews received at journal 04 Sep, 2025 Reviewers agreed at journal 02 Sep, 2025 Reviewers agreed at journal 01 Sep, 2025 Reviewers agreed at journal 01 Sep, 2025 Reviewers invited by journal 01 Sep, 2025 Editor assigned by journal 26 Aug, 2025 Editor invited by journal 08 Aug, 2025 Submission checks completed at journal 07 Aug, 2025 First submitted to journal 07 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7234642","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":510431960,"identity":"70a888e0-fd44-4630-a9de-fe03d1778f62","order_by":0,"name":"Isabelle Dufour","email":"data:image/png;base64,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","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":true,"prefix":"","firstName":"Isabelle","middleName":"","lastName":"Dufour","suffix":""},{"id":510431961,"identity":"ce47d46f-3f71-4843-8e0f-f7c315d29572","order_by":1,"name":"Josiane Courteau","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Josiane","middleName":"","lastName":"Courteau","suffix":""},{"id":510431965,"identity":"13b4a3d1-3009-4243-a162-30a2debafa68","order_by":2,"name":"Magalie Randlett","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Magalie","middleName":"","lastName":"Randlett","suffix":""},{"id":510431967,"identity":"85d64e18-f747-4709-be25-22e136bd5199","order_by":3,"name":"Cindy Deschênes","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Cindy","middleName":"","lastName":"Deschênes","suffix":""},{"id":510431968,"identity":"b58f9c28-c0a1-4f72-bf08-8f847d385cb7","order_by":4,"name":"Sarah Emmanuella Brou","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"Emmanuella","lastName":"Brou","suffix":""},{"id":510431969,"identity":"e689381b-8631-42a6-ade0-edcfedaf8051","order_by":5,"name":"Didier Mailhot-Bisson","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Didier","middleName":"","lastName":"Mailhot-Bisson","suffix":""},{"id":510431970,"identity":"bd04aaf5-9fb8-4e0e-9d25-0e9ad9294f1f","order_by":6,"name":"Marie-France Dubois","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Marie-France","middleName":"","lastName":"Dubois","suffix":""},{"id":510431971,"identity":"2dcd6e88-c508-4860-9b23-dd06330cc49e","order_by":7,"name":"Nathalie Delli-Colli","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Nathalie","middleName":"","lastName":"Delli-Colli","suffix":""},{"id":510431972,"identity":"c1c4d9f6-6c10-40f4-947d-c8edf8782bb5","order_by":8,"name":"Hassiba Chebbihi","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Hassiba","middleName":"","lastName":"Chebbihi","suffix":""},{"id":510431973,"identity":"5323342d-2498-46bd-a9b2-806fa6dc2310","order_by":9,"name":"Véronique Legault","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Véronique","middleName":"","lastName":"Legault","suffix":""},{"id":510431974,"identity":"dc4f3ebc-02b4-4d55-b44e-2487d7eef4b3","order_by":10,"name":"Yohann M. Chiu","email":"","orcid":"","institution":"Université de Sherbrooke","correspondingAuthor":false,"prefix":"","firstName":"Yohann","middleName":"M.","lastName":"Chiu","suffix":""}],"badges":[],"createdAt":"2025-07-28 13:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7234642/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7234642/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-026-07150-1","type":"published","date":"2026-02-11T15:58:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90883519,"identity":"b4be4147-a7a3-4f30-a1aa-f3369af65c89","added_by":"auto","created_at":"2025-09-09 09:54:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":486422,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of sojourn times and transitions between states in the cohort.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7234642/v1/882ee045edf911add74b97fb.png"},{"id":90885121,"identity":"832c3b31-c5be-4a7a-b70c-f343f2ed5ad3","added_by":"auto","created_at":"2025-09-09 10:02:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":582353,"visible":true,"origin":"","legend":"\u003cp\u003eStacked transition probabilities starting at state A (home) at index date (time=0) for a female living in private home (Stratified Cox). Red: death; orange: LTC; blue: hospital; light green: at home waiting for LTC placement; green: at home without waiting for LTC placement.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7234642/v1/d3da9de7d3cc3347e15ad649.png"},{"id":90885118,"identity":"06c11dbc-8751-4376-ad8a-6760a343d9e1","added_by":"auto","created_at":"2025-09-09 10:02:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":640602,"visible":true,"origin":"","legend":"\u003cp\u003eStacked transition probabilities starting at state A (home) at index date (time=0) for a male living in private home (Stratified Cox). Red: death; orange: LTC; blue: hospital; light green: at home waiting for LTC placement; green: at home without waiting for LTC placement.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7234642/v1/594549eae12cc755b7d0c31f.png"},{"id":102786351,"identity":"b47b5526-1dd9-495a-ba54-539ae56040f7","added_by":"auto","created_at":"2026-02-16 16:12:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2273288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7234642/v1/09eb7943-913d-467d-8f04-25f7ddadced8.pdf"},{"id":90885122,"identity":"0c0dda07-43cf-4daf-a748-3be019f12897","added_by":"auto","created_at":"2025-09-09 10:02:32","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":568211,"visible":true,"origin":"","legend":"","description":"","filename":"ArticleSADMarkovSupplementary20250728.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7234642/v1/3f36c7f472ed148726541f9f.pdf"},{"id":90886589,"identity":"538bfa14-1b99-42c8-b37c-1b9c4ce3f86d","added_by":"auto","created_at":"2025-09-09 10:10:32","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24805,"visible":true,"origin":"","legend":"","description":"","filename":"Table12.docx","url":"https://assets-eu.researchsquare.com/files/rs-7234642/v1/8441d73509601146e3fc1973.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A multi-state transition model among older adults receiving home care services: A population-based cohort study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe current demographic shift invites healthcare systems to adapt to the evolving needs of individuals with complex healthcare needs, including those living with multimorbidity and dementia, while supporting autonomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Political priorities and personal preferences emphasize the importance of enabling a safe aging at home, with the support of timely and adapted home care services (HCS) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], alongside informal care received from family and friends [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. HCS refer to a range of healthcare and support services provided in a patient\u0026rsquo;s home, and include notably nursing care, physical therapy, and psychosocial care, as well as assistance with daily activities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Quebec, most older adults reside in the community [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], while three quarters of HCS recipients were aged 65 years or more in 2019\u0026ndash;2020 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and 72% of all HCS were dedicated to support older adults\u0026rsquo; autonomy, among services provided by public instances [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThus, the complex health profiles of older adults with loss of autonomy, combined with factors such as low socioeconomic status and limited social support, place them at increased risk of experiencing care transitions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Care transitions are defined as transfers involving at least one overnight stay or several consecutive days of care in different healthcare establishments, or involving changes in responsibility between professionals in different sectors, such as primary care, emergency departments (ED), and hospital [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The most frequent care transitions are hospital admissions and discharges, ED visits and admissions to residential and long-term care (LTC) facilities. In addition to the fragmentation of care and medication management, these processes may have negative impacts, including risks of deconditioning, undernutrition, delirium, disability, and death [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. As a result, care transitions are increasingly seen as key areas for improving the quality of care and patient safety. And this is particularly true for transitions deemed potentially avoidable, i.e. when it occurred for chronic health conditions for which timely management, either in primary care or by HCS, could have prevented the deterioration in health status [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile HCS may prevent care transitions, including avoidable ones [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], several gaps remain in our understanding of care transitions for HCS recipients. Most studies focused on short-term HCS in specific contexts, such as following hospital discharge [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Thus, there is a need for exhaustive and longitudinal portraits of care transitions, especially in the Canadian or Quebec context where the demand for HCS continues to grow, including their various types such as waiting for LTC placement while still living in the community. Routinely collected data in electronic health records offer a great potential in informing health systems [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and multi-state Markov models are well-suited to analyze factors associated with transition rates in a real-life context [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In medical research, they have mostly been applied to study disease progression [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], but rarely care transitions, although some contexts were explored [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, we aimed to describe care transitions experienced by HCS recipients and identify factors associated with each transition. We also provide illustrative examples of how care transition probabilities change longitudinally, according to age, sex, and chronic conditions.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign and data sources\u003c/h2\u003e\u003cp\u003eThis is a retrospective cohort study using data from the Care Trajectories-Enriched Data (TorSaDE) cohort (n\u0026thinsp;=\u0026thinsp;102,148 unique participants in Quebec, Canada), which links five waves of the Canadian Community Health Surveys (CCHS \u0026ndash; 2007 to 2016) with health administrative data from the provincial health insurance board, providing universal health coverage to all residents (R\u0026eacute;gie de l'assurance maladie du Qu\u0026eacute;bec: RAMQ \u0026ndash; 1996 to 2016). The TorSaDE cohort contains data of all CCHS participants who accepted to share their data with Quebec\u0026rsquo;s Statistics Institute and agreed to data linkage. A detailed description of the TorSaDE cohort is available elsewhere [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], but briefly, the CCHS provides self-reported information on health status and socio-demographic characteristics, while RAMQ data enable longitudinal follow-up of healthcare services use and diagnoses (\u003cb\u003eSupplementary Text\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudied population\u003c/h3\u003e\n\u003cp\u003eWe extracted data for all participants to the first three CCHS surveys (2007\u0026ndash;2012; n\u0026thinsp;=\u0026thinsp;60,791), aged 65 years and older at index date, who received HCS within the support program for the autonomy of older adults (French acronym SAPA), dedicated to promoting aging in place notably through HCS provided by local community service centers (French acronym CLSC), between July 1, 2012 and December 31, 2015. The index date is the date of the first HCS during this period. Participants were followed from the index date until death or December 31, 2016, whichever occurred first. A HCS was identified from the I-CLSC database using information on the intervention localisation (e.g., private home, private seniors\u0026rsquo; residence).\u003c/p\u003e\n\u003ch3\u003eCare Transitions\u003c/h3\u003e\n\u003cp\u003eWe considered five states, from which 12 transitions can occur (\u003cb\u003eSupplementary Fig.\u0026nbsp;1\u003c/b\u003e). State A refers to being home in the community (including private seniors\u0026rsquo; residence and residential resources, i.e., non-institutionalized resources for persons with autonomy loss or specific needs related to mental or physical health [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]). State B refers to any hospital stay. State C refers to being at home in the community while waiting for a LTC placement. State D refers to LTC residency. Finally, State E refers to death. The state \u0026ldquo;waiting for LTC placement\u0026rdquo; (State C) was identified in the I-CLSC database as a reason for intervention, and the earliest date was considered as the entry in State C. Patient were considered waiting for a LTC placement until the transfer to LTC facilities or death, which implies that they returned to State C after a hospital discharge.\u003c/p\u003e\n\u003ch3\u003eCovariables\u003c/h3\u003e\n\u003cp\u003eWe considered sex, age and location (private home, private seniors\u0026rsquo; residence, residential resources) at the index date. Within two years prior to the index date, we considered potential factors associated with the probabilities of transitioning, using the International Classification of Diseases (ICD) codes from the hospital stay register and physician claims: presence or absence of dementia, other neurological diseases, diabetes, cancer (any tumor without metastasis, metastatic cancer), cardiovascular and cerebrovascular diseases (CVD, including myocardial infarction, congestive heart failure, cerebrovascular diseases, and vascular diseases), chronic obstructive pulmonary disease (COPD), and any mental health disorder [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Regarding HCS, we considered the category of worker (professional \u0026mdash; nursing, nutrition, rehabilitation services including physiotherapy and occupational therapy, respiratory therapy services, psychosocial services; non-professional \u0026mdash; home assistance services) and the intensity of the interventions (proportion of days spent at home where a HCS occurred, presented in days per week).\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eFirst, we described care transitions during follow-up. Then, using the \u003cem\u003emstate\u003c/em\u003e R package [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], we fitted for each transition, a transition-specific Cox proportional hazards model incorporating covariates. The resulting model estimates individual transition hazards over time, yielding dynamic transition probabilities from various states and time points, enabling personalized predictions across patient profiles and corresponding visual comparisons (e.g., age, sex, dementia) (\u003cb\u003eSupplementary Text\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe extracted data on 3424 individuals aged 65 years and older who received HCS within the SAPA program between July 1, 2012, and December 31, 2015 (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cstrong\u003eSupplementary Fig.\u0026nbsp;2\u003c/strong\u003e). Females were older than males, while males were more likely to live in a private residence than females. The median follow-up was 2.8 years and was longer for females (almost 3 years) than for males (2.4 years). Males were sicker and had a higher mortality rate than females.\u003c/p\u003e\n\u003cp\u003eOur study cohort experienced 14,792 transitions during the follow-up period (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), with the vast majority (76%) of transitions being from home to hospital and vice versa. Of the 1245 deaths recorded, half occurred in hospitals, nearly one quarter in LTC facilities, and a little less in the community. Very few deaths occurred while waiting for LTC placement in the community. Half of individuals who transited to state C (waiting at home for a place in LTC) spent over three months (116 days) in that state, while the median time spent in state D (LTC) and A (home without waiting for LTC placement) was respectively around 9 months (259 days) and of 6 months (168 days; Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e gives a description of each of the 12 transitions in terms of median time spent in each state. For example, almost half of people that transited from home (state A) to death (state E) during the follow-up spent less than 3 months (median 97 days) at home before dying. The highest HCS intensity was provided to individuals from state A (living at home) who transitioned to LTC (state D) (mean (SD): 1.6 days per week (2.0); median (IQR): 0.9 (2.1)) and individuals in state C (at home waiting for LTC) who transitioned to state B \u0026mdash; hospital (mean (SD): 1.5 days per week (1.8); median (IQR): 0.9 (1.8)). The lowest HCS intensity was provided to individuals in state C who transitioned to LTC \u0026mdash; state D (mean (SD): 0.9 days per week (1.5); median (IQR): 0.3 (1.0)).\u003c/p\u003e\n\u003cp\u003eThe bottom part of Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the factors associated with the probability of transitioning resulting from the multi-state Markov model. For example, the probability of transitioning directly from home to hospital (state A to B) is increased for people with the following comorbidities, in decreasing order of effect size: COPD (aHR: 1.75, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), cancer (aHR: 1.38, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), CVD (aHR: 1.29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and mental disorder (aHR: 1.25, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). On the other side, people at home with dementia have a reduced probability of transitioning to the hospital (state A to B; aHR: 0.80, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), but an increased probability of getting on a waiting list for LTC placement (state A to C; aHR: 2.98, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) or directly moving to LTC facilities (state A to D; aHR: 2.27, p\u0026thinsp;=\u0026thinsp;0.0185). In fact, dementia is associated with an increased probability of transitioning to states C (waiting a LTC placement) and D (LTC placement), regardless of the state of origin. In return, people with dementia are less likely to be transferred from hospital (state B) directly to home without being placed on a waiting list for LTC placement (state A) (aHR: 0.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eTo illustrate the longitudinal change in probabilities of being in any of the five states estimated by our multi-state Markov model, we represented these probabilities graphically for various type of HCS recipients, by varying sociodemographic and clinical characteristics. Figures \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e show respectively a female and a male living in a private home, with varying age group (row) and comorbidities (column). \u003cstrong\u003eSupplementary Figs.\u0026nbsp;3\u0026ndash;4\u003c/strong\u003e show probabilities for HCS recipient living in private seniors\u0026rsquo; residences without comorbidities and with dementia only, varying sex (row) and age group (column). For both sexes, dementia increases the probabilities of transiting to states C (waiting for LTC placement) and D (LTC placement) over time, compared to patients without dementia (Figs. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study explored the transition process across the continuum of care for older adults with autonomy loss receiving HCS. Using a statistical approach that is still rarely applied to care transitions, we have provided evidence that multi-state models allow to: describe the observed care transitions experienced by HCS recipients during their follow-up, identify factors associated with each transition, and estimate and illustrate the longitudinal care transition probabilities and states for various types of HCS recipients.\u003c/p\u003e\u003cp\u003eOur population of HCS recipients was composed in higher proportion of females, although they had fewer chronic conditions. This finding is consistent with the sex-frailty paradox, whereby females appear to live longer than males but in a state of greater fragility [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], perhaps due to a higher predisposition for \u0026ldquo;non-life threatening\u0026rdquo; diseases and functional impairment [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Psychological factors and behaviors related to gender roles may also affect this sex-related imbalance in HCS users, including the higher propension of females to notice physical changes and discomfort, and their greater willingness to seek help and access healthcare [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. We also found females to be living in private senior residences or intermediate resources in higher proportion than males at the index date, which is agreement with previous studies [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn the other hand, being male was associated with a greater risk of hospital admission and transfer to LTC directly from the hospital. The higher rate of hospital admission in men is concordant with results from Norway [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and with their higher prevalence of chronic conditions, whereas their higher rate of LTC placement following hospital discharge may reflect their tendency to delay the search of a medical consultation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Unplanned institutionalizations following hospital discharge are often more harmful to health, compared to those planned ahead [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], but adequate HCS may help to prevent such transitions [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Hospital stays themselves are often detrimental on cognitive and functional status of older adults presenting with vulnerability factors [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], leading to functional declines that may hamper their capacity to return home [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDementia was also associated with a higher risk of being transferred to LTC upon hospital discharge, a finding consistent with another study from Scotland [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Institutionalization following a hospital stay may imply a delayed discharge (also called alternative level of care in Canada), which indeed appears to be the case for Canadian patients with dementia [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Patients with dementia were also more likely to be added on an LTC waiting list, either following hospital discharge or when residing at home. Cognitive and functional profiles of wait-listed individuals vary according to healthcare systems [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and even region density (urban vs rural) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], suggesting that waiting time for LTC placement is dependent on both local available resources and governmental guidelines dictating how priorities should be evaluated. In any case, the strong association between dementia and LTC placement, whether occurring through wait-listing or not, suggests insufficient resources to support aging in place for these individuals.\u003c/p\u003e\u003cp\u003eIn our population, HCS intensity was lower before an LTC placement for those registered on a waiting list compared to those not registered, which might indicate that more severe cases are promptly directed to LTC. Also, we cannot exclude that these patients were transferred to housing facilities offering on-site professional and/or support services (e.g., private senior residence or residential resources) while waiting for their LTC placement. Notwithstanding this, this finding raises concerns about equity in access to HCS, and future studies should seek to address factors that may explain this potential inequity.\u003c/p\u003e\u003cp\u003eYet, for community-dwelling individuals not on a waiting list, HCS intensity dispensed by professional healthcare providers was lower before hospitalization, raising the question of whether sufficient support was provided. Similarly, among at-home wait-listed individuals for LTC placement, only 70% received at least one professional service while in this state, a strikingly low percentage given the extent of health and psychosocial needs in this population with severe functional impairment. Nonetheless, patients waiting for LTC placement in the community remain poorly studied in Quebec.\u003c/p\u003e\u003cp\u003eThe median waiting time spent at home for a LTC placement was of 116 days, an estimation greater than previously reported [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Exhaustion of caregivers and rurality are both factors associated with higher risk of being added on a LTC waiting list [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Impairments related to instrumental activities of daily living (IADLs, e.g., meal preparation, use of transports, etc.) seem to act as key drivers for referral to LTC [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, in Quebec, to be eligible for LTC services, a person must present a combination of significant physical and cognitive loss of autonomy according to the functional autonomy measurement system [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. While HCS provide support for more basic daily activities (i.e., activities of daily living, such as feeding and bathing) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], aid for IADLs is often granted through informal caregivers or community organizations.\u003c/p\u003e\u003cp\u003eResidents of private senior homes were more likely to be transferred to LTC following hospital discharge, a finding in agreement with another study showing prolonged hospital stays [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. They also had an increased probability to be added on a LTC waiting list, concordant with a report indicating longer waiting time before LTC placement for persons living in seniors residences in Toronto (Ontario), compared to hospital inpatients and private home residents [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This may also indicate a situation where services are being exceeded, while private senior homes offer varying levels of support [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDiabetes, CVD, and COPD were associated with an increased risk of hospital admission, despite being conditions considered suitable for primary care-centered treatment [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. These results might point toward area of improvement in primary care access, management, and enhanced coordination among care providers [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Communication between the front line and HCS, as well as the ability of HCS to prevent potentially avoidable transitions are still open questions, given the lack of Canadian studies on the subject. In fact, despite large sums allocated to HCS (for instance, HCS for the SAPA program costed 2 billions of dollars for the fiscal year 2023\u0026ndash;2024 in Quebec) [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], our understanding of their actual benefits, notably on care transitions, is still sparse [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Future studies, ideally with larger sample sizes, should try to address transitions with the highest potential for actionable interventions, such as hospital admissions and visits to the emergency department deemed avoidable because they should be treated mainly in primary care. Equity in access to HCS should also be addressed in more detail, as well as other aforementioned aspects, such as LTC wait-listed individuals.\u003c/p\u003e\u003cp\u003eOur study has several limitations. First, due to a limited sample size, we could not analyze some transitions of interest, notably potentially avoidable visits to the emergency department and hospital admissions, as well as delayed hospital discharges. Covariables like comorbidities were only measured at baseline (2-year period before the index date), which might introduce some bias to their impact on transition probabilities if some incident cases occurred during the follow-up. Also, specialized nurse practitioners appeared relatively recently in Quebec (in the early 2000s), hence there might not be many at the time the data used here were collected. It would thus be interesting to assess how their advent in Quebec affected the care trajectories of persons with loss of autonomy, including transitions. Strengths include the use of a sophisticated statistical approach to assess transitions across various states in a comprehensive manner and with the incorporation of several covariables, as well as a cohort representative of the Quebec population.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study revealed limitations and areas for improvement in HCS provision for older adults with a loss of autonomy in Quebec, and important avenues for future research. It also demonstrated how the application of multi-state models can improve our understanding of care transition patterns for complex populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eaHR: Adjusted Hazard Ratio\u003c/p\u003e\n\u003cp\u003eCCHS: Canadian Community Health Survey\u003c/p\u003e\n\u003cp\u003eCLSC: Centres Locaux de Servives Communautaires (local community service centers)\u003c/p\u003e\n\u003cp\u003eCOPD: Chronic Obstructive Pulmonary Disease\u003c/p\u003e\n\u003cp\u003eCVD: Cardiovascular and Cerebrovascular Diseases\u003c/p\u003e\n\u003cp\u003eED: Emergency Department\u003c/p\u003e\n\u003cp\u003eHCS: Home Care Services\u003c/p\u003e\n\u003cp\u003eLTC: Long-term Care\u003c/p\u003e\n\u003cp\u003eICD: International Classification of Diseases\u003c/p\u003e\n\u003cp\u003eIQR: Inter-quartile Range\u003c/p\u003e\n\u003cp\u003eRAMQ: R\u0026eacute;gie de l\u0026rsquo;Assurance Maladie du Qu\u0026eacute;bec (provincial health insurance board)\u003c/p\u003e\n\u003cp\u003eSAPA: Soutien \u0026agrave; l\u0026apos;Autonomie des Personnes \u0026Acirc;g\u0026eacute;es (support program for the autonomy of older adults)\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e\n\u003cp\u003eTorSaDE: Care Trajectories-Enriched Data Cohort\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e: The datasets analysed\u0026nbsp;in this\u0026nbsp;study are not publicly available\u0026nbsp;due to confidentiality constraints.\u0026nbsp;However, data are available upon request from the Institut de la statistique du Qu\u0026eacute;bec (ISQ) through the ISQ Research Data Access Desk, subject to restrictions\u0026nbsp;(https://statistique.quebec.ca/en/services-recherche/rda-home).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e: The current study was reviewed and approved by the Research Ethics Board Committee at the Universit\u0026eacute; de Sherbrooke, in accordance with institutional requirements. The study was conducted using de-identified data from the TorSaDE cohort that was already available. This cohort contains data from all CCHS Qu\u0026eacute;bec participants who agreed to share their data with the ISQ and to data linkage for research purposes. Written informed consent from the current study population was waived under Section 67.2.1 to 67.2.3 of Act #A-2.1 (Act respecting Access to documents held by public bodies and the Protection of personal information). This study adheres to the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests statement\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This work was supported by a \u0026ldquo;Initiatives strat\u0026eacute;giques\u0026rdquo; grant from the \u0026ldquo;\u003cem\u003eCentre de recherche sur le vieillissement\u003c/em\u003e\u0026rdquo;. ID is the recipient of a Junior 1 salary grant from the \u003cem\u003eFonds de recherche du Qu\u0026eacute;bec\u0026mdash;Sant\u0026eacute;\u003c/em\u003e. The funding bodies had no role in the study design, data collection, its analysis, and interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e: ID, DMB, MFD, NDC, HC, YMC and VL contributed to the concept and design of the study, data gathering and interpretation. JC performed the analyses. VL and JC drafted the manuscript. All authors critically reviewed the manuscript in the context of clinical practice and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCSBE, Commissaire \u0026agrave; la sant\u0026eacute; et au bien-\u0026ecirc;tre. 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Biopsychosocial factors related to the length of hospital stay in older people. Rev Lat Am Enfermagem 2011; 19: 1377\u0026ndash;1384.\u003c/li\u003e\n\u003cli\u003eUm S, Iveniuk J. Waiting for Long-Term Care in the GTA: Trends and Persistent Disparities. Wellesley Institute.\u003c/li\u003e\n\u003cli\u003eLestage C, Dubuc N, Bravo G. [Development and validation of a Quebec classification of private residences with services welcoming of older persons]. Can J Aging 2014; 33: 72\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003ePurdy S, Griffin T, Salisbury C, Sharp D. Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians. Public Health 2009; 123: 169\u0026ndash;173.\u003c/li\u003e\n\u003cli\u003eDuminy L, Ress V, Wild E-M. Complex community health and social care interventions \u0026ndash; Which features lead to reductions in hospitalizations for ambulatory care sensitive conditions? A systematic literature review. Health Policy 2022; 126: 1206\u0026ndash;1225.\u003c/li\u003e\n\u003cli\u003eMansfield E, Noble N, Sanson-Fisher R, Mazza D, Bryant J. Primary Care Physicians\u0026rsquo; Perceived Barriers to Optimal Dementia Care: A Systematic Review. The Gerontologist 2019; 59: e697\u0026ndash;e708.\u003c/li\u003e\n\u003cli\u003eGouvernement du Qu\u0026eacute;bec. Contour financier - D\u0026eacute;penses de services \u0026agrave; domicile par programme et par r\u0026eacute;gion - 2023-2024. Sant\u0026eacute; et Services sociaux du Qu\u0026eacute;bec 2025 https://www.donneesquebec.ca/recherche/dataset/contour-financier-depenses-de-services-a-domicile-par-programme-et-par-region (7 May 2025, date last accessed).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Care transitions, Home care, Loss of autonomy, Multi-state Markov models","lastPublishedDoi":"10.21203/rs.3.rs-7234642/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7234642/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOlder adults with loss of autonomy experience multiple care transitions, some of which can be burdensome. While home care services (HCS) are thought to support aging in place, little is known about the patterns of care transitions over time among this complex population. The objective is to describe transitions and quantify probabilities of transitioning, using multi-state Markov models in a population-based cohort from Quebec (Canada).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis is a retrospective observational cohort study, selecting recipients of HCS within a program for older adults with loss of autonomy. We estimated transition probabilities with continuous-time Markov models across the following states: A) home, B) hospital, C) at home waiting for long-term care (LTC) placement, D) LTC, and E) death. Sex, age, type of residence, and comorbidities were included in models as covariables.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong the 3424 HCS recipients, 65.7% were females, while males were younger on average and had more comorbidities. Several factors were significantly associated with specific transitions, such as higher rates of hospital admissions for males and higher rates of LTC transfers upon hospital discharge for males and patients with dementia. HCS were also strikingly lower in intensity, and with fewer services provided by healthcare professionals, for patients waiting at home for LTC placement, being wait-listed itself associated with dementia and residing in private senior homes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study highlights gaps, and hence potential areas for improvement, in HCS for older adults with loss of autonomy in Quebec and shows how multi-state models can enhance understanding of care transitions in complex populations.\u003c/p\u003e","manuscriptTitle":"A multi-state transition model among older adults receiving home care services: A population-based cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 09:54:27","doi":"10.21203/rs.3.rs-7234642/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-26T14:02:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T13:11:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-13T18:08:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-10T21:20:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81890371207331068153936594289215117022","date":"2025-09-09T11:38:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-04T20:11:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56147060382875891885159520317068134729","date":"2025-09-02T19:17:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115275577833886262511245775002626221570","date":"2025-09-01T11:37:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173022636937565794788838746477159834122","date":"2025-09-01T10:14:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-01T05:47:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-26T04:12:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-08T09:03:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-07T14:28:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-08-07T14:25:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bfc50394-3d70-48ef-8d06-11f8cf18db99","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:10:23+00:00","versionOfRecord":{"articleIdentity":"rs-7234642","link":"https://doi.org/10.1186/s12877-026-07150-1","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2026-02-11 15:58:06","publishedOnDateReadable":"February 11th, 2026"},"versionCreatedAt":"2025-09-09 09:54:27","video":"","vorDoi":"10.1186/s12877-026-07150-1","vorDoiUrl":"https://doi.org/10.1186/s12877-026-07150-1","workflowStages":[]},"version":"v1","identity":"rs-7234642","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7234642","identity":"rs-7234642","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}