Evaluation of the STEP Intervention for Long-Term Care Residents Facing Hospital Transfer Decisions

Inclusion Criteria Residents-care partner dyads: * Must be residents of either Perley Health or Bruyère Health Saint-Louis LTC home. * Residents must be 55 years of age or older. * Must be able to communicate in French or English. Both members of the dyad will be included where applicable. For dyads in which residents do not have the capacity to participate, inclusion will occur through the involvement of their substitute decision-maker (e.g., power of attorney for personal care). LTC staff: * Must be a nurse, nurse practitioner, social service worker or physician actively involved in care planning, annual conferences, or managing acute health events at Perley Health or Bruyère Health. * Must have been employed at the LTC home for at least 6 months to ensure familiarity with the care environment and residents. * Must play a role in facilitating discussions, providing clinical input (where applicable), or guiding decision-making processes related to hospital transitions or acute care management. * Must be able to communicate in French or English.