Older patients and their family caregivers wish to be involved as much as possible in decisions about their care, but often feel left out of these decisions, especially during points of transitions in care. Phrases such as "patient-centred care" and "patient engagement" are used frequently, but often without any concrete meaning for patients, their family caregivers, or their health care providers. We also know that currently, care transitions are characterized by poor communication and information sharing, and a lack of engagement of patients and families in decision making. Yet, we know that engagement does improve patient experience and health outcomes.

We looked carefully at available theories and evidence around engagement of older adults in healthcare decision-making. This work resulted in the "CHOICE" Patient Engagement Framework, however there is still a gap in how this conceptual framework can be translated to practice. We will work with patients, their caregivers and health care providers to develop an in-depth understanding of the factors that facilitate or hinder engagement in care planning and decision-making during transitions in care. We will explore what resources may be needed to support engagement, and how these resources could be implemented to change practice. By talking to all those involved and observing what happens, we will gain a good understanding of how best to develop resources and materials for patient and family engagement during care transitions.