Tipping Points to Institutional Care for Persons Living with Dementia: Analyzing the Policy Trajectory in Ontario

Most people, if given a choice, would remain in their own home and community as they age. This desire does not diminish for persons living with dementia (PLWD), yet many end up prematurely or inappropriately in residential long-term care (LTC), or waiting in a hospital bed for placement. While institutional care is valuable for those in need of high intensity care, it is ill-suited for those with lower intensity care needs. Premature or inappropriate placement of PLWD is not good for individuals (PLWD and their caregivers), or for the system (inappropriate use of resources), yet occurs in part because PLWD often have multiple complex, ongoing health and social needs; however, this thesis argues that it also is a result of care systems focused on episodic, curative care, and by fragmented services that are ill-equipped to support PLWD safely and cost-effectively in the community.While much policy analysis has focused on demand side issues (e.g., an aging population, dementia projections and needs), this research addresses supply side factors - particularly local system capacity to provide needed community-based care options for PLWD to live safely and cost-effectively in the community for as long as possible. It uses Neo-institutionalism, a high-level theory drawn from political science, to explore the historical and policy legacies for community based care of PLWD and predict what one would expect to see in the future if Ontario remains on the same familiar path. It also uses a Balance of Care (BoC) simulation methodology to explore what the system will actually provide PLWD to age safely at home. The conceptual and applied approaches combined are expected to provide a greater understanding of the policy trajectory for home and community care, its impact on current resource allocation decisions at the local level in Ontario and the potential for H and concerted health and social care interventions to help offset the growing healthcare costs for high intensity users of the system like PLWD.Ph.D