interdisciplinary approach to management of high risk elders
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Interdisciplinary Approach to Management of High Risk Elders. GRECC Clinical Demonstration Project VA Greater Los Angeles Healthcare System Host: S Castle ([email protected]) M Cirrincione, S Wilkins, A Reinhardt, J Guzman. Overview: Practical Tips. Steven Castle, MD: - PowerPoint PPT PresentationTRANSCRIPT
vers 2.17.09, VANTS operator: 304-262-7600
Interdisciplinary Approach to
Management of High Risk EldersGRECC Clinical Demonstration ProjectVA Greater Los Angeles Healthcare System
Host: S Castle ([email protected])M Cirrincione, S Wilkins, A Reinhardt, J Guzman
Overview: Practical Tips Steven Castle, MD:
Our focus: who, what and why Jenice Guzman, GNP
Med Management / Dietary Michael Cirrincione OTR/L:
OT/PT/KT tools to identify high risk Stacy Wilkins, PhD
Cognitive, Emotional factors Jenice Guzman, GNP
Structured decisional capacity Ashley Reinhardt, MSW
Active case management- who, what, how
Goal of Presentation Practical Processes of Care
Identification of High Risk Interdisciplinary Team Assessment of Self Care Requisites:
Instruments/Mitigation measures Decision Making Ability Related to High Risk Status Communication of Findings/Recommendations/Family Meeting Active Case Management
Each discipline will introduce self/ discuss content
Handouts included: Safety Risk Profile worksheet, Process Flow Chart, FIM Script for determining Decisional Capacity Neuropsychiatric tools: Mini Cog, MOCA, SLUMS, GDS, PHQ-9,
DSMIV criteria for dementia, depression
Self-Neglect?
Criteria/Defining High Risk Elder “Elderly who
Lack access or refuse needed support, Frequently live in squalor, With advanced, untreated diseases”
Dyer CB JAGS 56:s369-240, 2008 Self-Neglect Severity Scale
Overall rating of risk to Health &/or Personal Safety without intervention: none, moderate, severe
3 domains: Personal appearance, Functional status, Environment Poor correlation between domains Kelly PA JAGS 56:S253-260,2008
Challenges in Defining High Risk Elder: “Intentionality” obscures responsibility
Understands risk but has demonstrated poor outcomes Fulmer T JAGS 56:s241-243, 2008
Self Neglect: US Society: presumptively responsible for self care When does responsibility for care shift?
Connolly MT JAGS 56:s244-252, 2008
Medical Comorbidity / Disease Management: where it hinges Risk of serious outcome without intervention Falls, Medication adherence Readmission/ER visit for CHF, HTN, Diabetes, COPD
Our Approach for Defining/Active Case Management Focus: are supports for deficits in self-care/disease management in place? Recognizes but is independent of decision making ability/capacity
Based upon experience, literature review, expert panel
Reviewed later by Ashley Reinhardt: Criteria for High Risk Elderly: 2 or more Lives alone
Inadequate social support
Poor judgment with poor outcomes Decision making ability for risk is only one of many variables
Resides in unsafe living conditions
Safety Risk Profile (handout): self care deficits
Medical Complexity/Disease Management: Risk of serious outcome without intervention Falls Risk/ Disease management Objective measures
Pharmacy: MEDICATION MANAGEMENT Dietary/Nutrition
Function beyond ADLs Functional Independence Measure- reference point “Limitation Judgment” Look at interaction of resident, caregiver, environment, disease
Cognitive changes, judgment, personality Social support / risk, red flags
Assessing for medication adherence, diet/nutrition Jenice Guzman,RN, GNP-BC, PhD(c)
Medications Marian Rofail, PharmD Medication Adherence:
Ability to self medicate or availability of caregiver. Indicators of the Inability to Self-Medicate:
Cognitive impairment >5 prescriptions Inability to read prescription & auxiliary labels Difficulty opening non-child-proof containers Inability to discriminate between medication
colors/shapes
Medication evaluation Evaluation of Adherence:
Medication refill history Missed doses in pill box Medication monitoring Patient response to medications (e.g., low hr if on beta
blocker) Polypharmacy: less than desirable
Unclear indication/duration, adverse effects, drug or disease interactions
Duplication, inadequate attention to pharmacokinetics vs. Polymedicine: appropriate/monitored
Effective, Appropriate Dosage, monitored for side effects
Nutrition- Jennifer Krohn, MS, RD- Nutrition Screening & Assessment
- Age & sex- Dx/ PMH- Diet Rx, diet intake /exercise history- Height & weight, weight history- UBW (usual body wt)- BMI (body mass index: kg/m2)- IBW (specific for height,frame, sex, & geriatric)- Pertinent medications, herbal supplements- Nutrition related labs- Psychosocial factors- Age related factors
Key Indicators for Nutrition Risk Disease & chronic conditions that interfere with intake Eating poorly Tooth loss/mouth pain Economic Hardship Reduced social contact Multiple medicines Involuntary weight loss/gain Needs assistance in self care Elder years (especially above 80 yrs)
Weight loss
Significant Weight Loss
10% in 6 mos
7.5% in 3 mos
5% in 1 mos
2% in 2 week
BMI: 65 years and older goal is > 23
Labs for Nutrition Evaluation
Serum albuminPre-albuminC-Reactive proteinGlucose/Hemoglobin A1CCholesterol/HDL/LDL/TriglyceridesBUN/Creatinine –
BUN: Trends higher in older adults (prone to dehydration: decreased thirst & poor concentration of urine
- Creatinine: Slightly lower value due to decreased muscle mass
Functional piece of nutrition:
- Shopping for food? - Meal preparation?- Storage of food?- Adherence to dietary restrictions or
recommendations/special diets?- Also assessed by OT
OT: Occupational TherapyEnabling people to do the activities of daily life (ADLs) “Occupation" - an activity which "occupies" our time OT-skilled treatment for independence in all facets of life
"skills for the job of living", independent and satisfying lives The World Federation of Occupational Therapists:
Promotes health & well-being through occupation 1o goal: enable people to participate in the activities of everyday life
Achieved by Enhancing an individual's ability to participate in ADLs, Modifying the environment, or Adapting the activity to better facilitate independence.
KT
Kinesiotherapy: Based on exercise principles Applied to deconditioning/ cardiac rehabilitation Adapted to enhance the strength, endurance, and mobility
Within context of functional limitations or Requiring extended physical conditioning.
PT Physical therapists (PTs)
Diagnose and treat limited ability to perform functional activities As a result of health-related conditions
Examine & develop a plan using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability.
Functional Independence Measure FIM An indicator of severity of disability, for components of ADL tasks
Quick, for large groups of people Changes during rehabilitation/ Disease progression
Major gradations: dependence to independence (7 levels) ADLs: independently vs. need for assistance
Require another person or device? Quantifies the need for help and the burden of care.
Translates time/energy another person expends To provide dependent needs of the disabled individual To achieve and maintain a certain quality of life, safety.
A measure of disability, not impairment. Measures what person with disability actually does,
Whatever the diagnosis or impairment, Not what he or she ought to be able to do, or might be able to do
if certain circumstances were different.
Description of Levels of Function & Scores Independent: other person not required for the activity (NO HELPER)
7 Complete Independence: 6 Modified Independence:
assistive device; &/or more time; &/or there are safety risks Dependent: supervision or physical assistance (REQUIRES HELPER)
5 Supervision or Set up: Standby, cueing, coaxing, no physical contact, or Help with orthoses or assistive/adaptive devices.
4 Minimal Contact Assistance: touching only, Patient expends >75% effort to complete the task.
3 Moderate Assistance: more help than touching, Expends > 50%; but <75% of effort.
Complete Dependence: Max or total assistance is required 2 Maximal Assistance: Expends >25% of effort but <50% to complete task 1 Total Assistance: Subject expends <25% of effort to complete task
Capacity - Psychological and Neuropsychological Factors
Stacy S. Wilkins, Ph.D., ABPP
Capacity - Psychological and Neuropsychological Factors Cognitive
Mental limitations Emotional
Personality & coping styles Mood Psychiatric Diagnoses
Cognitive Influence Delirium
Rapid Onset, not due to other mental disorder Reduced capacity due to confusion and altered attention
Prevalence 30-40% of hospitalized patients older than 65 years 30% of patients in surgical and cardiac intensive care units 40-50% of patients recovering from surgery for hip fracture
Factors associated with a higher risk of delirium include advanced age, pre-existing brain compromise, alcohol
dependence, diabetes mellitus, cancer, sensory impairment (eg, blindness or poor hearing), malnutrition, and a history of delirium.
Inouye S, Ann Intern Med 113:941-8, 1990
Assessment for Delirium
Digit Span Normal forward is 7 +/- 2
Backwards span should be 2 less than forward
CAM (confusion assessment method) Feature 1: Acute Onset and Fluctuating Course
Feature 2: InattentionFeature 3: Disorganized thinkingFeature 4: Altered Level of consciousness
The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.
Dementia Diagnosis
Dementia Diagnosis requires: Acquired persistent decline in
Memory One other cognitive domain
language, visuospatial skills, executive function
Plus – decline in functioning, must effect their lives
Dementia
Reduced capacity often seen secondary to: Poor memory/recall Executive function/judgment problems
Also can see language or visuospatial deficits
Dementia Evaluation
Minicog 3 item recall plus clock
MMSE, SLUMS, MOCA Review (see handouts)
Independent Living Scales (ILS) Health and Safety Judgment, Finances
Psychiatric Diagnoses
Depression (GDS, PHQ-9) Low motivation and energy, poor appetite
Psychotic Disorders Paranoia, delusions
Personality Style Highly value independence
Substance Abuse
Interdisciplinary Meetings: putting it together Medical Management limitations/medications
Simplify/ train Meds, need for evaluation, reversibility Maintain nutrition, special diets
Functional deficits/recognition of limits Caregiver training response Recommended support/Care needs
Cognition and mood Screened by MDs, Psychology findings
Capacity: all disciplines assess as a part of evaluation Concerns discussed at team meetings,
Degree, reversibility of deficits/ evaluation Mitigation options (all team members)
Patient Input
Patient Declines Services….
I’ll be fine, just send me home. I’ve always managed to take care of
myself. I don’t need help from anybody! NOW What?
Assessing decisional capacity
Jenice Guzman, RN, GNP-BC, PhD(c)
Cooney et al., 2004; Resnick & Sorrentino, 2006
Decision-Making Capacity Competency – legal state, not medical;
Presumed competent unless adjudicated otherwise by court Determination of incompetence - only by a court.
Capacity – ability to make an informed consent; Any licensed clinical provider may determine capacity.
Other thoughts: A competent person chooses to run risks; an
incompetent person simply allows the risk to happen. Bad choice ≠ incompetent. Competency’s connotation is ‘all or nothing’. Capacity implies varying ability on various decisions.
Cooney et al., 2004; Grisso & Appelbaum, 1998; Kim, Karlawish, & Caine, 2002
Decision-Making Capacity Primary issue in evaluation:
What is process of making the decision, not decision itself Decision-specific Threshold for incompetence
Depends on degree of harm associated with probable choice;
Benefit vs risk. Decision-making demands fluctuate
Depends on match between functional demand and patient’s ability
Grisso & Appelbaum, 1998
Decision-Making Capacity Society values self-determination,
Must show proof of poor decisional-capacity to remove it
Expert-judgment: variability in training/ response Kim SYH, Psychosomatics 47:325-329, 2006; doi:
10.1176/appi.psy.47.4.325
Structured “capacity interview” assessing decisional abilities MacCAT-T (MacArthur Competence Assessment Tool for Treatment) Applied to decision about self care/home situation
Assumption of MacCAT-T: Criteria applied to determine capacity for any tasks/decisions are
similar at core.
Grisso & Appelbaum, 1998
MacCAT Tool Functional decision-making steps:
Ability to understand relevant information r/t memory, previous knowledge
Ability to appreciate the significance of the information for one’s own situation e.g, probable consequences
Ability to reason & engage in a logical process of weighing treatment options/recommendations
Ability to express a choice See sample script MacCAT tool available at:
http://www.prpress.com/books/mactfr.html
Patient found to lack capacity: Confusion or Delusional thinking Illogical beliefs
Watch for cultural context… Affective states related to mental disorder Inability to manipulate information rationally
or to verbalize consequences Inability to communicate
IF Patient found to lack capacity:Then Suggested Alternative approaches:
Improve functional abilities E.g., use of reminder system (white boards); Recommending use of hired caregiver
Decrease polypharmacy Decrease decision-making demands of the
situation (e.g., meals on wheels) Safety Net:
HBPC, Home health, APS, active telephone follow up
Social Work: Assessment Guide for High Risk Elders Assessment Guide: Financial Resources:
Medicare, Medicaid (Medi-cal), Social Security, Service Connected Compensation or VA Pension
Social Network: Primary Caregiver, Assess Other Social SupportsIdentify Durable Power of Attorney in Health Care (Review
Advance Directive)Values & Context based upon culture and family
Access to available services: Transportation and Meals
Based upon experience, literature review, expert panel
Criteria for High Risk ElderlyFollow up ‘Active’ Case Management If 2 or more of the following: Lives alone
Inadequate social support caregiver/family members live far, and/or cannot provide care regularly
Demonstrates poor judgment or insight that leads to poor outcomes e.g. frequent ER visits and hospitalizations Decision making ability is one of many variables assessed
Resides in unsafe living conditions
Social Work Assessment of High Risk Elders What are the veteran’s goals?
Patient-centered care
What are the needs of the veteran based on the findings of the interdisciplinary team?
What resources are available to match the veteran’s goals, his needs, and his access to appropriate care?
Process Steps: Social Work
Active Case Management
Flow Map of Follow-up Care Note: followed if high risk regardless of capacity
Addresses challenge of when “Intentionality” obscures responsibility Fulmer T JAGS 56:s241-243, 2008
Criteria for high risk of self- neglect? (footnote 1)
Yes:IDT
Safety Risk Profile of safety & self-care and rec’s
for identified deficits
NO:Proceed with regular GEM
discharge
Discuss:o recommendations with veteran & family.o Negotiate- what rec’s/ changes willing to make.
Provide interventions & resources(footnote 2)
If increase help in place, then
regular GEM D.C.; 1 f/u call
New GEM admission/ social work
assessment
Comprehensive D/C Plan:- Facilitate consults and appointments-Provide resources-GRECC clinic FU- social work & Attending or Fellow on GEM ward
Contact veteran &/or family members 2-5 days after discharge and review status of discharge plan
Evaluate:-Need for
active follow up -Troubleshoot
gaps in service
Yes:-Add to High Risk Elderly (HealthE Vet)-Continue monthly phone calls/chart review - GRECCclinic F/U
NO: 1 more follow up phone call & chart review
Criteria:(see footnote 3)
Social Work High-Risk Follow up Care for Veterans Flow Map: From GEM Admission to Discharge Home or Other Level of Care
Footnotes:1. Criteria for High Risk (>2 of following):o Lives aloneo Inadequate social support (caregiver/family can’t provide care daily or regularly; distance, time) o Poor judgment or insight that leads to frequent ER visits and hospitalizations, etc. o Resides in unsafe living conditions/environment
Footnotes (continued):3. Discharge Criteria from High Risk FU:o Veteran linked into a system of careo Veteran declines care, but demonstrates independence at
follow upO Veteran deteriorates and then agrees to a higher level of care
Footnotes (continued):2. Interventions post D/C to home:o VA/non-VA affiliated resourceso Refer to Senior CenteroRefer to VA Service Connection (if needed)o Discuss Appropriate consults placed: HBPC, Telehealth, Home Care nurse, PT/OT, Home Safety Eval, Social Work Home Health follow upo Facilitate FU appts– 1 GRECC f/u appt if no PCPo Assess need to File APS report
Veteran referred to higher level of care
Criteria for high risk of self- neglect? (footnote 1)
Yes:IDT
Safety Risk Profile of safety & self-care and rec’s
for identified deficits
NO:Proceed with regular GEM
discharge
Discuss:o recommendations with veteran & family.o Negotiate- what rec’s/ changes willing to make.
Provide interventions & resources(footnote 2)
If increase help in place, then regular GEM D.C.; 1 f/u
call
New GEM admission/ social work
assessment
Social Work High-Risk Follow up Care for Veterans Flow Map: From GEM Admission to Discharge Home or Other Level of Care
Veteran referred to a higher level of care
Post Discharge Options (footnote 2)Active Case Management/Facilitation Community Resources (VA / non-VA)
Meals, Transportation, Emergency Alert Caregiver training/support, Adult Day Care, Senior Centers Eligibility: Assess need for In Home Supportive Services, Aid
and Attendance and Homemaker Health Aid Program Discuss Need for Appropriate Consults
HBPC vs. Home Health Agency: Medication Management, PT, OT, Social Worker
Telehealth (rural/isolated with cognition/motivation) Follow up appointments
Post Discharge, one follow up in Geriatrics/GRECC Primary Care Provider
Comprehensive D/C Plan:- Facilitate consults and appointments-Provide resources-GRECC Clinic FU- social work & Attending or Fellow on GEM ward
Contact veteran &/or family members 2-5 days after discharge and review status of discharge plan
Evaluate:-Need for
active follow up -Troubleshoot
gaps in service
Yes:-Add to High Risk Elderly (HealthE Vet)-Continue monthly phone calls/ chart review -GRECC Clinic F/U-Assess need to report to APS-Review Home health input/status-Consider home telehealth, cognition Ok, lives in remote area
NO: 1 more follow up phone call & chart reviewD/C Criteria:
(see footnote 3)
Social Work High-Risk Follow up Care for Veterans Flow Map: Follow Up at time of GEM Discharge
Footnotes (continued):3. Discharge Criteria from High Risk FU:o Veteran linked into a system of careo Veteran declines care, but demonstrates independence at follow
upo Veteran deteriorates and then agrees to a higher level of care
Summary: “Intentionality” obscures responsibility: focus on Risk/severity
Decision making ability is one piece of puzzle
Identify Specific deficits of Self-Care Requisites (Safety Risk Profile) Medical (falls)/ Pharmacy/ Dietary- risk of harm Functional: Limitations, Judgment, Support, Environment Cognitive: impairments, severity
With dementia, decision making ability declines
Communicate findings/concerns Family Meeting Process, Documentation
Family meeting tips-Team consensus prior to family meeting-Identify legal decision maker-Ask “What is understanding of medical status, risks”-Define consensus plan, differences, concerns
Conducting a Family Conference, Ambuel, B.; Weissman, D.; www.eperc.mcw.edu
Summary: Active follow up regardless of Capacity
See that Plan is carried out, Important to have documented what was plan… Detect early decline, need for intervention
Have confidence in strong IDT/ communication/ documentation Westfall Act (28 U.S.C. Sec 2679(b)(1)
Federal Employees immunity from tort claims, In course of official duty if within scope of employment
Federal Tort Claims Act, Section 2679(d)(1),(2) Upon such certification, United States is substituted as defendant Employee has status of a witness
If patients refuse or lack ability to comply with safety recommendations; Government liability is unlikely when there is thorough documentation of all
efforts made and patient’s response Rita Mendosa, VA Legal Counsel
Nurse practitioner:[email protected]
Occupational [email protected]
Social [email protected]
Geriatrician:[email protected]