rehabilitative care alliance frail senior/medically complex working group backgrounder...

Rehabilitative Care Alliance

Frail Senior/Medically Complex Working Group Backgrounder Document

October 2013

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Rehabilitative Care Alliance Frail Senior/Medically Complex Task Group

Backgrounder Document

Table of Contents

Section 1 Summary of the current state of provincial initiatives that are influencing the work of the Frail Senior/Medically Complex Working Group

Section 2 Summary of the information collected from Ontario rehabilitative care health service Page 3

providers during a ‘Request for Information’ process

Section 3 Summary of feedback collected from LHIN Lead Advisory Group members regarding Page 3 suggested key deliverables for the Frail Senior/Medically Complex Task group that would support local initiatives and efforts to optimize the care of frail senior and medically complex populations with functional goals/restorative potential.

Section 4 Summary of the findings of a literature review of relevant research related to the Page 4 objectives and deliverables of the Frail Senior/Medically Complex Working Group

Appendix A Detailed description of provincial initiatives related to and enabling the work of the Page 10 Frail Senior/Medically Complex Working Group

Appendix B Detailed description of the information provided by Ontario rehabilitative care health Page 22

service providers during the ‘Request for Information’ process Appendix C Detailed description of the feedback collected from LHIN Lead Advisory Group Page 27

members regarding suggested key deliverables for the Frail Senior/Medically Complex Task group

Appendix D Detailed description of the review of the literature related to rehabilitative care of Page 29

frail senior and medically complex populations

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CONTEXT

This ‘Backgrounder’ document has been prepared to support the work of the Frail Senior/Medically Complex Group of the Rehabilitative Care Alliance. This Group is developing a rehabilitative care approach for Frail Senior/Medically Complex populations through the operationalization of the “Essential Elements of Assess and Restore Framework”1. DEVELOPMENT OF THE BACKGROUNDER DOCUMENT

This ‘Backgrounder’ document includes the following sections:

Section 1 - Summary of provincial initiatives related to/enabling the work of the Frail Senior/Medically Complex Working Group Section 2 - Summary of the information collected from Ontario rehabilitative care health service providers during a “Request for Information” process Section 3 – Summary of feedback collected from LHIN Lead Advisory Group members regarding suggested key deliverables for the Frail Senior/Medically Complex Task group that would support local initiatives and efforts to optimize the care of frail senior and medically complex populations with functional goals/restorative potential. Section 4 - Summary of the findings of a literature review of relevant research related to the objectives and deliverables of the Frail Senior/Medically Complex Working Group

Section 1 – Provincial initiatives related to and enabling the work of the Frail Senior/Medically Complex Working Group (Note: For a detailed description of the following provincial initiatives, please see Appendix A) The following is a list of provincial initiatives that are influencing the work of the Frail Senior/Medically Complex Working Group. The Rehabilitative Care Alliance and the Frail Senior/Medically Complex Task Group will seek to align their directions with those of these groups.

1. Community Care Access Centre’s (CCAC) Integrated Client Care Model

2. Change Foundation - Transitions PATH (Partners Advancing Transitions in Healthcare)

3. Rehab/Complex Continuing Care (CCC) Coalition

4. Quality Care in the Community Reference Table (QCCRT)

5. Seniors Health Knowledge Network (SHKN)

6. Registered Nurses Association of Ontario (RNAO) Best Practice Guidelines (BPGs)

7. Local Health Integration Network (LHIN) Falls Prevention Strategies

8. Ontario’s Seniors Strategy

1 Ministry of Health and Long Term Care (2013). Assess and Restore Policy for High Risk Older Adults – Overview Deck

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9. Senior Friendly Hospital Pilot Indicators

10. Sr. Friendly Hospital Report

11. Health Links

12. Resource Matching and Referral (RM & R)

13. Physiotherapy Funding Reform

Section 2 –Information Collected from Ontario Rehabilitative Care Health Service Providers (Note: For the complete description of the information collected from Ontario rehabilitative care health service providers, please see Appendix B)

In order to develop an understanding of the current landscape in Ontario related to rehabilitative care, a “Request for Information” (RFI) process was conducted by the Rehabilitative Care Alliance Secretariat from July to September 2013. This process was used to collect information from Ontario rehabilitative care health service providers regarding a number of issues and to develop an understanding of the needs of rehabilitative care system stakeholders in Ontario. The following is a summary of the information that was collected in response to the following question:

Please describe, and provide supporting references/documents, regarding any local work or initiatives that have been completed or are underway, that might help to inform each of the four priorities of the Rehabilitative Care Alliance. NOTE: Please refer to the work plan for more detail related to each of these initiatives. Priority #2 - What work are you doing locally related to Assess and Restore, Health Links etc. that would be helpful to inform the work of the Frail Seniors and Medically Complex Task Group?

Summary of Key Local Initiatives Related to Frail Senior and Medically Complex populations as described by HSPs:

Senior Friendly Hospital Strategies and Indicator Pilots

Fall Prevention Strategies

Assess and Restore – units and philosophy of care

Utilization of standardized tools as per RGP

Health Links

Local integrated seniors projects in alignment with Ontario’s Seniors Strategy Section 3 – Summary of feedback collected from LHIN Lead Advisory Group members (Note: For a detailed description of the information collected from the literature review, please see Appendix C)

In October 2013, members of the LHIN Leads Advisory Group were polled for feedback regarding suggested key deliverables for the Frail Senior/Medically Complex Task group that would support local initiatives and efforts to optimize the care of frail senior and medically complex populations with functional goals/restorative potential. This information was collected in an effort to assist the group in prioritizing it’s initiatives in order to maximize the “value-add” of the work of the Frail Senior and Medically Complex Task group.

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Summary of themes from the feedback received from the LHIN Leads Advisory Group To inform the work and directions of the Frail Senior/Medically Complex Task Group, please suggest some key deliverables for this task group that would support your LHIN in optimizing the care of frail senior and medically complex populations with functional goals/restorative potential.

Standardized definition of Assess and Restore

A description of the patient journey across the continuum

Standardized eligibility criteria from community or acute to bedded levels of care

Standardized, simple assessment tool(s)

Common set of metrics for evaluation

Alignment with Sr. Friendly Hospital and Home First philosophies and Ontario’s Senior’s Strategy

A description of best and leading practices to link/leverage available community resources. Section 4 – Summary of the Literature Related to the Rehabilitative Care of Frail Senior and Medically Complex Populations (Note: For a detailed description of the information collected from the literature review, please see Appendix D) A literature review was conducted to address the following questions: #1 - What models of care/interventions are effective in promoting positive functional outcomes for frail seniors and medically complex individuals? #2 - What are the predictors/influencers of restorative potential for frail seniors? #3 - What patient outcomes measures should be used to evaluate rehabilitative care outcomes for frail seniors? Summary of Themes from Literature Review 1. Key Facts (See Appendix D for full a summary and references) Rehabilitation/Restorative potential was defined by Cunningham, C. et al. (2000) as “an estimate of the individual’s capability of co-operating with a rehabilitation program and making measurable functional gains” (Cunningham, C., et al., 2000). Gill et al. (2006) defined frailty as “a dynamic process, characterized by frequent transitions between frailty states (nonfrail, prefrail and frail) over time. Since frailty is a state of increased vulnerability resulting from a multisystem reduction in reserve capacity AND that reserve capacity can be boosted (not just diminished), it follows that transitions from states of greater frailty to lesser frailty are not uncommon. Thus, there is ample opportunity for the prevention and remediation of frailty.” (Gill, T.M. et al., 2006)

“Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event which increases the risk of adverse outcomes, including falls, delirium and disability. Comprehensive Geriatric Assessment is the gold standard to detect frailty. It is a process of specialist elderly care delivered by a multidisciplinary team to establish an elderly person’s medical, psychological and functional capability so that a treatment and follow-up plan can be developed. However, this assessment is limited practically by its resource intensity. An equally reliable but more efficient and responsive method of routine care

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is urgently needed. The Edmonton Frail Scale is a multidimensional assessment instrument that is quick (5 minutes), valid, reliable and feasible for routine use by non-geriatricians”. (Clegg, A.et al., 2013)

Components of Geriatric Rehabilitation: COMPREHNSIVE GERIATRIC ASSESSMENT (CGA) - There is level 1A evidence suggesting that CGA is important for frail older persons with rehabilitation needs. SCREENING - When selecting patients for geriatric rehabilitation, the dimensions used to define frailty should be assessed:

Functional impairment

Medical complexity

Psychological functioning

Social support. Patients who are too medically unstable, those who are more appropriate for palliative care and those who can remain at home and be treated as outpatients should be excluded. Low motivation to participate in rehabilitation should not necessarily be grounds for exclusion (low motivation may due to treatable depression). ASSESSMENT TOOLS - Geriatric inpatients with potential remedial geriatric syndromes (e.g. polypharmacy, confusion, falls) should be targeted for geriatric rehabilitation. There may be a threshold of severe comorbidity above which a poorer rehabilitation outcome may be expected. TEAM APPROACH TO CARE – Geriatric rehabilitation should have an interdisciplinary team approach with medical care and rehabilitation managed by a physician and team trained in the care of the elderly. (Wells, J.L. et al., 2003)

Question #1 What models of care/interventions are effective in promoting positive functional outcomes for frail seniors and medically complex individuals? (See Appendix D for a full summary and references) Physical exercise interventions for community-dwelling frail older persons show a large variation in content, duration, intensity, balance between supervised and non-supervised sessions and the level of individualization. Research indicates that multi-component, high intensity physical exercise programs may be promising, especially for moderate physically frail community dwelling older persons. Other promising features of interventions include multidisciplinary and multifactorial, individualized assessment and intervention, case management, long term follow-up and the use of adaptations/technology (Daniels, R. et al., 2010) Structured exercise training has a positive impact on the frail older adult and should be used for management of frailty. The most common exercise interventions for frail older adults included in this review were multicomponent exercise programs performed three times per week three months with each session lasting 60 minutes. Exercise seems to benefit the oldest old (>/=80 years old) frail females more than younger frail males. Exercise seems to be more beneficial in frail people living in LTC compared to the community (Olga, T. et al., 2011). Older persons who are admitted to acute care medical settings and who required supervision or assistance to ambulate at admission are the most responsive to additional exercise during hospitalization and have significantly improved LOS compared to usual care. (De Morton, N. et al., 2007)

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Cook, R. et al. (2013) describe a number of systematic reviews that suggest home-based rehabilitation produces equal or superior clinical outcomes as compared to inpatient rehabilitation for a variety of conditions (including neurologic, cardiac, stroke, mental health and musculoskeletal conditions) and can help to reduce overall health system costs. Exercise improves sit to stand, balance, agility and ambulation, reduces falls rate, slows the deterioration in the ability to perform ADLs and helps to maintain QOL. Interventions included supervised flexibility, low- or intensive-resistance, aerobic, coordination, balance and Tai-Chi exercises and repetitive performance of ADLs performed either in facilities, communities or in-home for 60-90 minutes sessions repeated daily or weekly for 3-12 months. (Chou, C. et al, 2012) Studies conducted to evaluate the effectiveness of orthopedic geriatric models of care have been heterogeneous – therefore it is difficult to draw firm conclusions. More medical conditions are recognized when a geriatrician oversees the medical care. Studies show a trend towards better outcomes in specialized geriatric models with modest effects of functional recovery, length of stay, complications and mortality. No detrimental effects were identified. (Chong, C. et al., 2009)

Patients who received care in an inpatient rehabilitation unit specifically designed for geriatric patients were found to have increased likelihood of better function, lower nursing home admissions and lower mortality rates at discharge than those who received care in a general rehabilitation unit. These patients were also more likely to have better function, lower nursing home admissions and lower mortality rates at follow-up (3-13 months post discharge). Insufficient data are available for defining characteristics and cost effectiveness of successful programmes. (Bachman, S. et al., 2010)

After an acute admission older adults are at an increased risk of death and admission to nursing homes. Geriatric rehabilitation programmes might not only improve outcomes but might also generate long term costs savings by reducing admissions to nursing homes. Short and long term outcomes evaluated at discharge and at 3-12 months respectively include functional improvement (Katz index or Barthel Index), nursing home admission (yes/no), mortality (yes/no). Inpatient rehabilitation specifically designed for geriatric patients was shown to have the potential to improve outcomes related to function, admission to nursing homes, and mortality. Insufficient data are available for defining characteristics and cost effectiveness of successful programmes. (Bachman, S. et al., 2010)

Integrated care programs (geriatric screening, multi-dimensional assessment at ED, geriatric nursing assessment and home-based services) are shown in RCTs to reduce fragmentation and to improve the continuity and coordination of care. A “health care chain” is a coordinated activities in the health care system, linked together to achieve a final result of good quality for the patients. Care is a continuum running between different caregivers and care levels – one caregiver of high quality is not enough to create good care. Elderly people and their families must be involved in the planning, decision making and performance of care. (Wilhelmson, K. et al., 2011) A restorative approach to home care has significant advantages over the traditional approach aimed at maintenance and support only. Key interventions include provision of aids and home adaptation, basic health education, comprehensive occupational therapy interventions and participation in physical activity programs. (Ryburn et al., 2009)

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Community-based complex interventions reduced the risk of not living at home. Interventions reduced nursing home admissions but not death. Risk of hospital admissions and falls were reduced and physical function was better in the intervention groups. Benefit for any specific type or intensity of intervention was not noted. Substantial variation in the format of care, involvement of health-care professionals, and site of care provision and intensity were reported. (Beswick, A.D., 2008)

Home-based and group-based exercise interventions for frail elderly people can improve outcomes of mobility and functional ability. The most effective intensity (duration and frequency) of exercise intervention is uncertain. (Clegg et al., 2013)

Physical rehabilitation in long-term care homes include interventions that aim to maintain or improve physical function of an individual by increasing the physical exertions of an individual. These interventions can be delivered in a group format or individually, generic or tailored and delivered by rehabilitation professionals, care staff or self-directed. Studies included in the review most commonly delivered interventions as supervised 45-minute group sessions three times weekly with duration ranging between 4 weeks and a year. (Crocker, T. et al., 2013) Question #2 What are the predictors/influencers of restorative potential for frail seniors? (See Appendix D for a full summary and references)

Mobility disability in older persons is a highly dynamic process, characterized by frequent transitions between states of independence and disability. Older age, female sex, and physical frailty were generally associated with greater likelihood of transitioning to states of greater disability and lower likelihood regaining independent mobility. Episodes of intermittent disability lasted, on average, about 6 months. (Gill, T. et al., 2006)

Assessment of rehabilitation potential and the potential success of rehabilitation for older patients is challenging due to medical complexity, frailty and multiple comorbidities. Compared to the FIM the PAC (RAI-Post Acute Care) contains additional information on common characteristics that reflect clinical complexity and thus may be predictive of outcome. The PAC was more proficient than the FIM in explaining the variance in rehabilitation outcomes. Functional status on admission was the strongest predictor of rehabilitation outcomes. Cognitive status, number and type of comorbid conditions, age and gender are other commonly reported predictors. (Armstrong, J., 2010) Patients aged 85 and older with cognitive or sensory impairment were less likely to significantly improve in physical functioning after intensive rehabilitation. Severe cognitive impairment may be considered a negative predictor of functional recovery after a period of intensive rehabilitation. It would be a mistake to deny rehabilitation to all patients with any level of cognitive impairment without considering the overall clinical situation and the specific problem that needs to be rehabilitated. (Landi, F., 2002) Cognitive function, nutritional status (albumin level), pre-injury functional level, and depression were the most important prognostic factors of post-acute rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Of these, depression and nutritional status are correctable and early intervention may improve

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rehabilitation outcomes. Discharge destination was highly associated with the presence of a caregiver, followed by depression and cognitive ability. (Hershkovitz, A. et al., 2007) Cognitive performance impairment, depression, urinary incontinence, bowel incontinence and sensory impairment were associated with higher risk of poor improvement in physical functional performance. (Fusco, D. et al., 2009)

Slow gait speed, low physical activity and weight loss were independently associated with chronic disability, long term nursing home stays and death. Slow gait speed was the strongest predictor of chronic disability and long term nursing home stay and was the only significant predictor of injurious falls. Cognitive impairment was also associated with chronic disability, long term nursing home stay and death. Self-reported exhaustion and muscle weakness were not predictive of adverse outcomes. (Rothman, M.D, et al., 2008) High-risk individuals were more likely to be pre-frail than low risk individuals. Walking ability tests are clinically useful in screening older individuals at high risk of frailty. In particular, the Timed Rapid Gait test is more likely than other tests to discriminate older women at high risk of frailty. (Kim, MJ. Et al., 2010) Question #3 What patient outcomes measures should be used to evaluate rehabilitative care outcomes for frail seniors? (See Appendix D for a full summary and references)

Positive effects of rehabilitation were indicated by a change in the Barthel Index of 6 points, the FIMTM of 5 points, Rivermead Mobility Index of 0.7 points, TUG time of 5 seconds and walking speed of 0.03 m/s. Secondary outcomes showing beneficial effects include strength, flexibility, balance, and mood. (Crocker, T., et al. 2013) The Short Physical Performance Battery (SPPB) assesses lower extremity functional limitations (timed tests of standing balance, walking speed and repeated chair stands). Each element is scored 0-4. The tool takes less than 10 minutes to complete. An SPPB score of less than 10 has commonly been used to identify an “at risk” group. Older persons with scores between 10 and 12 are relatively immune to adverse outcomes over the course of 4 years. (Gill, T., 2010). The FIMTM is a valid, sensitive measure of functional status in the elderly. The Goal Attainment Scale has been shown to be valid, responsive and practical to use in a variety of settings in the care of the elderly. Tests of specific function are also commonly used e.g. the timed up and go (TUG), Berg Balance Scale (BBS), Katz ADL scale and the Lawton Brody assessment. The Cumulative Illness Rating Scale (CIRS) has been designed to assess medical comorbidities and complexity and has been validated as a measure of medical complexity for frail older adults. The CIRS, in conjunction with other indices of function (e.g. FIM or Barthel Index) can capture a patients’ level of frailty. (Wells, J.L. et al., 2003) Concluding Comments The literature reviewed for this ‘Backgrounder’ sought to answer three questions.

#1 - What models of care/interventions are effective in promoting positive functional outcomes for frail seniors and medically complex individuals?

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#2 - What are the predictors/influencers of restorative potential for frail seniors? #3 - What patient outcomes measures should be used to evaluate rehabilitative care outcomes for frail seniors? The review undertaken to address these questions found that there is great variability in the models of care/interventions that are utilized in studies evaluating functional outcomes for frail seniors and medically complex individuals making it difficult to evaluate their effectiveness and make a clear recommendation about a model of care. Next, commonly referenced predictors/influencers of restorative potential for frail seniors include age, functional status on admission/pre-admission, cognitive status, sensory impairment, gait speed, number and type of comorbid conditions. Finally, outcome measures referenced in the reviewed literature for use to evaluate rehabilitative care functional outcomes for frail seniors included the Barthel Index, the FIMTM, the Rivermead Mobility Index, the Timed-Up and Go (TUG) Test, the Short Physical Performance Battery (SPPB), the Goal Attainment Scale, Berg Balance Scale (BBS), Katz ADL scale and the Lawton Brody assessment and the Cumulative Illness Rating Scale (CIRS).

LHIN stakeholders were consulted to identify key deliverables that would support the optimization of the care of frail senior and medically complex populations with functional goals/restorative potential. To reduce the identified variability, standardization in the care of these populations was clearly pronounced including a consistent definition of ‘Assess and Restore’, assessment tools and metrics for evaluation. Stakeholders also

suggested that a description of the patient journey across the continuum and of best and leading practices to link/leverage available community resources would be helpful. Finally, stakeholders clearly identify the need to align the work of the Frail Senior/ Medically Complex Working Group with other provincial initiatives to avoid duplication and leverage existing and emerging work where possible. To this end, the Rehabilitative Care Secretariat has identified, and is seeking to remain well-informed of a plethora of enabling and influencing provincial initiatives. The literature that was reviewed for this ‘Backgrounder’ suggests that “transitions from states of greater frailty to lesser frailty are not uncommon and that there is ample opportunity for the prevention and remediation of frailty.” (Gill, T.M. et al., 2006). It is also clear that rehabilitative care has a significant role to play in addressing risk factors for and impairments related to frailty. The information contained in this document will be used by the Frail Senior/Medically Complex Working Group of the Rehabilitative Care Alliance to support its efforts to develop a rehabilitative care approach for Frail Senior/Medically Complex populations through the operationalization of the “Essential Elements of the Assess and Restore Framework”.

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Appendix A – Detailed description of provincial initiatives related to and enabling the work of the Frail Senior/Medically Complex Working Group

Initiative Target Population Scope Current Status/Focus

1. Integrated Client Care Model/CCAC

Source: The Integrated Client Care Model for Seniors with Complex Care Needs, Overview Deck, March 2011)

Frail seniors with complex medical, physical, cognitive and social conditions that require ongoing support to remain in the community. Candidates identified will: - Have a history of

frequent service use;

- Receive care from multiple providers; and

- Be at risk of hospitalization or needing long-term care.

The goals are to improve transitions and enhance quality of care, specifically: - Reduce hospitalizations,

initially focusing on high re-admission rates and avoidable admissions for ambulatory care sensitive conditions;

- Reduce ALC days, both to long term-care and to rehabilitation or complex continuing care;

- Improve client and caregiver satisfaction and experience, by enabling enhanced support in the community and improving transitions.

An intensive case management approach includes:

Central role of primary care

Active response by acute care Incorporation of best

practices and evidence

Effective July 1, 2012, ICCP became a sector wide approach to change. Continue to focus on population-focused delivery models and mixed funding models.

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Portable integrated client record

Sectors and pilot sites coalesce around seven key

areas of focus to ensure “wrap around care”

Leverage and align with system resources

Evaluation with ICES Strong hospital and sector

leadership

System engagement and commitment to scalability

Alignment with key system initiatives

2. Change Foundation- Transitions PATH

Source: http://www.changefoundation.ca/projects/path/, August 2013

Seniors with chronic health conditions and their caregivers

As a support to Health Links, bestPATH offers a suite of tools and expertise to help identify and address gaps in the quality of care and delivery of services to individuals with complex chronic illnesses. Specifically, bestPATH is designed to facilitate the achievement of Health Links objectives by providing leadership and

The first three best PATH Improvement Packages:

Transitions of Care

Optimizing Chronic Disease Management

Supporting Health Independence Five Project Elements i) Build awareness and tools that will empower seniors and

caregiver to shape how they age, access care and community services

ii) My Health Story document: allow people to present themselves as a whole person to the healthcare system

iii) Person-Centred Care Provider model iv) Transition coaching and advocating: coaches/transition

http://www.changefoundation.ca/projects/path/



http://health.gov.on.ca/en/pro/programs/transformation/community.aspx

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support in: measurement, evidence-informed change ideas, and building sustainable capacity for change and improvement. The bestPATH initiative facilitates more coordinated, person-centered care for seniors and others with complex chronic illnesses. It is designed to be an integral support to Health Link communities as they work to smooth the gaps between sectors, improve access to care, reduce avoidable emergency room visits and hospital re-admissions, and improve the experiences of patients as they make their way through the health system. PATH Goals: - Improve healthcare

experiences and transitions - Seek solutions to the real

needs of patients and

partners will be introduced to act as “warm hands” during transitions

v) Funding model: will be explored in partnership with Central East LHIN

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caregivers - Test a totally new approach

for Ontario – healthcare co-design

- Prompt system-wide change

3. Rehab/CCC Coalition

Source: Enza Ferro, OHA, July 17, 2013

Patients with chronic comorbidities who are high health care system users (i.e. Health Links population)

Not specific to rehab/CCC

A group of researchers is working to develop a program of work and develop a draft proposal. Some synergies identified between Coalition work and Alliance priorities/deliverables

4. Quality Care in the Community Reference Table (QCCRT)

Complex Adults and Frail Older Adults

To understand the current and future community care needs to inform the development of quality based payment to community care providers

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5. Senior’s Health Knowledge Network (SHKN)

Source: http://seniorshealthknowledgenetwork.com/, August 2013

“….the aging population”

The Seniors Health Knowledge Network links people, resources and ideas together to benefit the health of the aging population. Their mission is to make a positive impact on seniors’ health by encouraging advancements in research, education, practice and policies. SHKN involves these two other networks: Alzheimer Knowledge

Exchange (AKE) Ontario Research

Coalition (ORC) of Institutes/Centres on Health and Aging

Communities of Practice: Aging and Developmental Disabilities Communicative Access & Aphasia Diabetes Falls Prevention Medication Safety Mental Health, Addictions and Behavioural Issues Nutrition Oral Health Wound Care The Network's Communities of Interest: Arts and Humanities in Health Care Information Care for Seniors Medically At Risk Older Drivers Osteoporosis Rural Seniors (North Bruce) Functional Decline RAI-MDS Hospice and Palliative Care

6. RNAO BPG Source: http://rnao.ca/bpg/guidelines, August 2013

Nurses

RNAO Mission “Our mission is to foster knowledge-based nursing practice, promote quality work environments, deliver excellence in professional development, and advance healthy public policy to improve health. We

Relevant Best Practice Guidelines /Initiatives include: Long-Term Care Best Practices Initiative - The Long-Term Care (LTC) Best Practices Coordinator role was introduced to the LTC sector as a pilot project funded by the Nursing Secretariat in 2005. Many successes in LTC Homes have been achieved through this project, including improved quality of care for residents and the facilitation of an evidence-based

http://seniorshealthknowledgenetwork.com/



http://www.shrtn.on.ca/community/aging-and-developmental-disabilities-add-community-practice

http://www.shrtn.on.ca/community/communicative-access-and-aphasia-caa

http://www.shrtn.on.ca/community/diabetes-community-practice

http://www.shrtn.on.ca/community/falls-prevention-community-practice

http://www.shrtn.on.ca/community/medication-safety-community-practice

http://www.shrtn.on.ca/community/nutrition-community-practice

http://www.shrtn.on.ca/community/oral-health-community-practice

http://www.shrtn.on.ca/community/wound-care-community-practice

http://www.shrtn.on.ca/community/arts-and-humanities-community-interest

http://www.shrtn.on.ca/community/infocare-seniors-community-interest

http://www.shrtn.on.ca/community/medically-risk-older-drivers-community-interest

http://www.shrtn.on.ca/community/osteoporosis-community-interest

http://www.shrtn.on.ca/community/rural-seniors-community-interest

http://www.shrtn.on.ca/community/functional-decline-community-interest

http://www.shrtn.on.ca/community/rai-mds-community-interest

http://rnao.ca/bpg/guidelines

http://rnao.ca/bpg/guidelines

http://rnao.ca/bpg/initiatives/longterm-care-best-practices-initiative

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promote the full participation of present and future registered nurses in improving health, and shaping and delivering health-care services.”

practice culture by front-line staff through the implementation of best practice guidelines (BPGs). Nursing Quality Indicators for Reporting and Evaluation® (NQuIRE®) - a database of quality indicators derived from recommendations within RNAO’s clinical Best Practice Guidelines (BPGs). Nursing Best Practice Research Centre (NBPRC) - The unit brings “state of the art” nursing knowledge that is based on the best available evidence, and promotes collaboration and research exchange with policy-makers and civil society groups in Canada and around the world. The centre strives to have a positive impact on practice and outcomes for the patient/client, health care providers, organization, and system, and actively promotes the generation and uptake of the best available evidence to health care professionals, policy-makers, and students in all roles and sectors. Client Centred Care The central theme of the guideline focuses on the experience of the client from his/her perspective, minimizing vulnerability, and maximizing control and respect. Prevention of Falls and Fall Injuries in the Older Adult Increase your confidence, knowledge, skills and abilities in the identification of adults within health care facilities at risk of falling and to define interventions for the prevention of

http://rnao.ca/bpg/initiatives/nquire

http://rnao.ca/bpg/initiatives/nquire

http://rnao.ca/bpg/guidelines/client-centred-care

http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult

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falling. Promoting Continence Using Prompted Voiding The purpose of this guideline is to provide information on implementing a treatment program of prompted voiding for older adults with urinary incontinence. Screening for Delirium, Dementia and Depression in the Older Adult Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients Transitions in Care The Registered Nurses’ Association of Ontario in consultation with stakeholders are developing a best practice guideline on coordination of care at transition points.

7. LHIN Falls Prevention Strategies

Source: Integrated Provincial Falls Preventions Framework and Toolkit, LHIN Collaborative, June 2011

Seniors age 65 and older

The main objective is to improve the quality of life for Ontario seniors aged 65 years and over and lessen the burden of falls on the healthcare system by reducing the number and impact of falls. Two approaches are outlined as part of the framework:

Approach #1 – Each LHIN has or is currently developing a Falls Prevention Strategy. There is varying involvement/ engagement of Public Health Units across LHINs. Approach #2 - The falls prevention framework states that “As each LHIN-wide Integrated Falls Prevention Program is being implemented, managing interLHIN/Public Health Units interaction as well as collaborating and aligning with key provincial and national organizations and initiatives can be quite challenging. To accomplish collaboration and alignment at a provincial and national level, there needs to be a

http://rnao.ca/bpg/guidelines/promoting-continence-using-prompted-voiding

http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult

http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult

http://rnao.ca/bpg/guidelines/strategies-support-selfmanagement-chronic-conditions-collaboration-clients

http://rnao.ca/bpg/guidelines/strategies-support-selfmanagement-chronic-conditions-collaboration-clients

http://rnao.ca/bpg/guidelines/transitions-care-0

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1) An effective LHIN-wide Integrated Falls Prevention Program in each LHIN and 2) A Provincial Structure Responsible for Collaboration and Alignment at a Provincial and National Level

provincial structure responsible for these essential activities. This provincial structure can be an existing or newly created structure and would operate on behalf of all the LHINs and PHUs. With coordination and alignment occurring at the provincial and national level, system-wide efficiencies can be achieved.” To date, this structure does not exist.

8. Ontario’s Seniors Care Strategy

Source: http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/docs/seniors_strategy.pdf, August 2013

Older Ontarians (i.e. those 65 years and older)

The report, released in December 2012, offers a number of strategies and recommendations for improving quality care for seniors, including strategies for promoting health and wellness, strengthening access to primary health care, enhancing home and community care services, improving the delivery of long term care, and addressing ageism and elder abuse. Five principles – Access, Equity, Choice, Value, Quality

9. Senior Friendly Hospital (SFH) Pilot Indicators

Source: http://seniorfriendlyhospitals.ca/provincial-sfh-reports, August 2013

Hospitalized clients 65 years of age and older

Identify metrics that will support the ongoing monitoring and evaluation of SFH care targeting delirium and functional decline.

Acute Care Sector i) Percentage of hospitalized patients (65 and older)

receiving assessment of ADL function with a validated tool at both admission and discharge.

ii) Percentage of patients (65 and older) with no decline in ADL function from admission to discharge as measured by a validated tool.

Acute Validated Tools = Barthel Index, Health Outcomes for Better Information in Care (HOBIC) – ADL Section, Alpha-FIM Tool®

http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/docs/seniors_strategy.pdf






http://seniorfriendlyhospitals.ca/provincial-sfh-reports



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All Hospital Care Sectors iii) Percentage of patients (65 and older) receiving delirium

screening using a validated tool upon admission to hospital

Validated tools = CAM, CAM-ICU or ICSDC iv) Incidence of delirium in patients (65 and older) acquired

over the course of hospital admission

10. Senior Friendly Hospital Report

Source: http://seniorfriendlyhospitals.ca/provincial-sfh-reports, August 2013

155 adult hospitals

In the winter of 2011, all adult hospitals across Ontario (155 in total) completed a self-assessment based on the Senior Friendly Hospital Framework

The report prioritizes that action plans that address the clinical priorities of (1) functional decline, (2) delirium, and (3) transitions in care be developed as these are linked causally to patient and system outcomes such as physical and cognitive function, safety, satisfaction, discharge options, length of stay, and readmissions.

PRIORITY #1 FUNCTIONAL DECLINE – Implement inter-professional early mobilization protocols across hospital departments to optimize physical function

PRIORITY #2 DELIRIUM – Implement inter-professional delirium screening, prevention, and management protocols across hospital departments to optimize cognitive function.

PRIORITY #3 TRANSITIONS IN CARE – Support transitions in care by implementing practices and developing partnerships that promote inter-organizational collaboration with community and post-acute services.

11. Health Links Source: http://news.ontario.ca/mohltc/en/2012/

Seniors and others with complex conditions

The goal of Health Links is to bring together health care providers to better and more quickly coordinate care for high-needs patients

Health Links will encourage greater collaboration between




http://news.ontario.ca/mohltc/en/2012/12/about-health-links.html


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12/about-health-links.html, September 18, 2013)

existing local health care providers, including family care providers, specialists, hospitals, long-term care, home care and other community supports. With improved coordination and information sharing, patients will receive faster care, will spend less time waiting for services and will be supported by a team of health care providers at all levels of the health care system.

Health Links put family care providers at the centre of the health care system. Health Links will help family doctors to connect patients more quickly with specialists, home care services and other community supports, including mental health services. For patients being discharged from hospital, the Health Link will allow for faster follow-up and referral to services like home care, helping reduce the likelihood of re-admission to hospital.

All Health Links will have a coordinating partner such as a Family Health Team, Community Health Centre, Community Care Access Centre or hospital. Other members of the Health Link must be willing and able to collaborate in order to better and more quickly coordinate health care services for high-need patients such as seniors and others with complex conditions.

12. Resource Matching and Referral (RM&R)

This stream of the initiative is targeting applications for inpatient rehabilitation and CCC from acute care

According to RM&R Business Transformation Initiative Project timelines, standards are to be finalized for initial implementation in September, 2013 with initial implementation occurring between October 2013 and April 2014. Provincial implementation is scheduled to begin in April 2014.



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The RM&R initiative is looking to the Rehabilitative Care Alliance to make recommendations regarding patient and program eligibility criteria to support provincial roll-out of the RM&R standards for referral to rehab and CC.

13. PT Funding Reform

Background On April 18, 2013, the Ontario Ministry of Health and Long-Term Care announced that, as of August 1, 2013, the government would be implementing a comprehensive program for community and primary care physiotherapy. The government indicated that physiotherapy would be removed from the Health Insurance Act as an insured service and established as budget-based programs for specific programs and health sectors. The government indicated that physiotherapy services in community settings will continue to be funded and there will be improved access for Ontarians across the province. Funding for physiotherapy will be provided through five streams of care: directly to Community Care Access Centres (CCACs) so that they can treat more patients needing physiotherapy in their home; directly to Long-Term Care (LTC) homes in order that they can manage the physiotherapy needs of their residents according to their plan of care; to community based physiotherapy providers under contract across Ontario; to the LHIN to replace and expand falls prevention and exercise classes in the community and to family health care settings. There will be no effect on physiotherapy services provided by hospitals to their inpatients or through their outpatient physiotherapy departments. Below is an update on the status of the physiotherapy reforms across the five streams of care. Primary Care Stream In the past, physiotherapy services were not part of funded primary care teams. Through this initiative, there has been a call for applications to primary care practitioners across the province to add physiotherapy to primary care teams (including Community Health Centres, Family Health Teams, Aboriginal Health Teams, among others). To date, over 100 applications have been received and are currently under review. Community Rehabilitation Clinic Stream Previously, Designated Physiotherapy Clinics or DPCs, billed the Ontario Health Insurance Plan (OHIP) for physiotherapy services. The administration of these clinics, now called Community Rehabilitation Clinics, has been

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changed such that these clinics are no longer permitted to bill for services through OHIP and instead, must sign a transfer payment agreement with the Ministry of Health and Long-Term Care*. A call for applications was disseminated in July, 2013 and more than 700 applications were received. There will be announcements, beginning in October, identifying expanded clinic locations. For a listing of clinic locations by LHIN, see: http://www.health.gov.on.ca/en/public/programs/physio/pub_clinics.aspx *Note: these clinics are funded through the MOHLTC and not LHINs Long-Term Care Home Stream In the past, physiotherapy services provided in long-term care homes were billed through OHIP. Funding for physiotherapy services in long-term care homes has changed and will be implemented in the following two ways:

1. Each long-term care home will receive $750 per bed per year to provide 1:1 physiotherapy to any resident who needs this service. There is no maximum level of service. Physiotherapy services are to be provided based on the needs of the residents. This service must be provided by a regulated physiotherapist or physiotherapy assistant who is overseen by a regulated physiotherapist. Each long-term care home will receive $0.27 per resident, per day for the home to provide falls prevention and exercise classes.

2. In-Home Stream In the past, physiotherapy services provided in the home could have been provided through Community Care Access Centres (CCAC) or through providers associated with Designated Physiotherapy Clinics. CCACs are now the only designated providers that oversee the provision of in-home physiotherapy services, whether it is within a client’s private home or within a congregate care setting (i.e., seniors’ apartment or retirement home). Exercise and Falls Prevention Classes Publicly funded exercise and falls prevention classes are being expanded across the province. Classes are being expanded to more locations including retirement homes, community centres, and other community locations. Locations currently offering classes have been given an opportunity to host new classes. There are currently approximately 975 falls prevention classes operating across the province.

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Appendix B – Detailed description of the information provided by Ontario rehabilitative care health service providers during the ‘Request for Information’ process and specifically related to the following questions: (Note: Responses have been included where feedback was available/provided.)

Please describe, and provide supporting references/documents, regarding any local work or initiatives that have been completed or are underway, that might help to inform each of the four priorities of the Rehabilitative Care Alliance. NOTE: Please refer to the work plan for more detail related to each of these initiatives.

Priority #2 - What work are you doing locally related to Assess and Restore, Health Links etc. that would be helpful to inform the work of the Frail Seniors and Medically Complex Task Group?

Central

• There are Family Health Teams that are associated with all hospitals within LHIN • LHIN-wide implementation of “There’s No Place Like Home” philosophy which supports a focus on doing whatever is possible to discharge patients home from acute care and enable further longer-term living arrangements from home rather than from an acute care setting • All hospitals are participating in the Elder Health MOH initiative • Significant LHIN-wide roll out of Aging at Home including comprehensive deployment of OTN, and Outreach teams as examples • Two Early-Adopter Health Links currently being implemented in the LHIN with focus on the very complex (often senior) patients and cross-continuum care plans are being developed for these high-needs patients • 3 other Health Links are being planned in the LHIN • “Move on” program elements focusing on early mobilization implemented across LHIN • Central LHIN had a task force focusing on the ALC Rehab – including modeling of need across the LHIN, LHIN-wide development of TJR patients starting in the Orthopod office and recommendations for further action (attached)

Champlain

A lot of work is being done to guide the practice for frail seniors in the Seniors friendly hospital strategies and the Fall Prevention steering committees. This work has to be aligned with the work of the subcommittee.

Early review of data from the Health Links suggests that our high users of acute inpatient care are Seniors with chronic conditions. Most Health Links in Champlain are only at the readiness assessment stage but the groups certainly have to be linked so their work can be integrated.

The Champlain LHIN changed the focus away from assess and restore to assisted living. We have some very innovative models that address both urban and rural challenges.

Mobilization Of Vulnerable Elderly in Ontario: “MOVE ON”

The Ottawa Hospital (TOH) is one of 14 Council of Academic Hospitals of Ontario (CAHO) affiliated hospitals participating in the MOVE ON

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project in 2012-13.

The project aims to implement and evaluate the impact of an evidence-based strategy that promotes early and progressive mobilization in older hospitalized adults with the goal of preventing functional decline. The strategy shifts mobilization from being a designated task assigned to a single professional group to a shared team responsibility with all team members having complementary roles.

The goals of MOVE ON are:

1. Assess patient’s mobility status within 24 hours of admission (refer to Simplified Mobility algorithm)

2. Provide progressive, scaled mobilization at least 3 times per day

Move On at TOH commenced October 5th, 2012 with two inpatient units implemented. In this fiscal year (2012-2013), all inpatient units at TOH are implementing this program. The Program involves training to all staff on the importance of early and frequent daily mobilization. It also includes mandatory on-line training modules, lift and transfer training for all staff, focus groups with staff, focus groups with patients and families to ensure early mobilization of our patients happens daily and is part of hospital culture.

Primary care – Women’s Health Centre at the Riverside Campus – Champlain LHIN

Many of our patients with disabilities have difficulty accessing primary care. This situation was especially severe for our female patients, who often had to forego regular preventative examinations such as pap screening tests because they could not safely transfer to nor lay upon regular gynecological plinths. A joint venture in 2008 with our nurses and rehab engineering staff and the Riverside Women’s Health Centre, saw the installation of appropriate lifts and railings and other adapted equipment on the tables, to accommodate patients with spinal cord injuries and severe spasticity. There is now a time set aside each month in this clinic so that women with disabilities may receive appropriate care.

Champlain Dementia Care Strategy – a Dementia Care Strategy was submitted to the Champlain LHIN at the end of March 2013. The Strategy focused on a number of key strategies that include the following: (1) system integration; (2) Early Detection and Diagnosis (Crisis prevention and ED/Hospital Diversion); (3) System Navigation; and (4) Public Awareness. Each strategy has a number of tactics/deliverables that have been captured and prioritized within a Health Service Integration Plan (HSIP) submission to the Champlain LHIN for one time and sustainable funding. The targeted population (Persons Living with Dementia) within this strategy has been identified in a number of the Health Link readiness discussions within our region.

Champlain Falls Prevention Strategy – a Falls Prevention Strategy was submitted to the Champlain LHIN at the end of March 2013. As a result, the LHIN has identified deliverables including the development of a Falls Prevention Algorithm that integrates primary care plus the new framework for physiotherapy, exercise and falls prevention classes. The RGP has recently submitted a HSIP for both one time funding

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for a pilot of the algorithm in the second half of this fiscal year plus sustainable funding to continue rolling out the strategy.

Regional Geriatric Advisory Committee – completed a retreat that included key stakeholders across the continuum of care and had presentations from key regional strategies pertaining to complex/frail older adults that included health links, primary care network, dementia care strategy, falls prevention and behavioral support services. The executive of the RGAC is pulling together the information to be presented back to the RGAC General membership in the fall of 2013.

The Regional Geriatric and community intervention program has oversight over GEM programs and geriatric day hospital services in the Champlain LHIN. The committee strives to standardize care across the Region for both of those strategies.

Regional Geriatric Program of Eastern Ontario has identified at its retreat in 2011, two key priorities – building geriatric capacity within primary care and CCAC. The RGP has an Advanced Practice Nurse (APN) leading this initiative and has been working with early adopters within primary care to build geriatric capacity. As well, one of the APNs within the RGP has been conducting research within primary care specifically looking at perspectives and practices of primary care physicians vis-à-vis diagnosis and management of community living for older persons with dementia. A comprehensive scoping review has been completed and the next steps with the research are underway. Here is the link to a number of the reports: : http://www.rgpeo.com/en/health-care-practitioners/research.aspx

Central West

We are using standardized tools etc. as per RPG

ESC We have been studying and promoting knowledge transfer related to the Senior Friendly Hospitals initiative, around delirium and functional decline. This is in preliminary stages, but we have included this in our development of system indicators.

NE

• We currently have a number of A&R units which are located in a number of bed types, i.e. CCC and rehab. • Health Links currently established in Timmins and Temiskaming - neither has rehab beds in these communities • 9 hospitals participating in SFH indicator pilot • BSO has been rolled out but is still being developed • Chronic disease management admin lead at our LHIN is Jennifer Michaud • New Primary Care Lead for Diabetes/Chronic Disease Management for NE LHIN is NP Barbara Kiely

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NSM

• The initial two approved community Health Links (Barrie and South Georgian Bay) have begun implementation of their business plans. Three additional health links are awaiting approval of their Readiness Assessments (North Simcoe, Couchiching, and Muskoka). All five of our health links will be focusing on the target population of high users of the local health systems (seniors and people with complex conditions). They are in the midst of developing their implementation plans which will be based on person-centred design to map out the current state and future state and working in partnership with Health Quality Ontario. • The NSM LHIN adopted the “Vision for an Integrated Regional Seniors’ Health Program in North Simcoe Muskoka” in 2009. Currently the LHIN is working on bringing this vision back in alignment with Dr. Sinha’s work on Ontario’s Seniors Care Strategy. The LHIN is starting to rollout the vision document again and look how it connects with the five health links in NSM. • Under the LHIN In-Home and Community Capacity Coordinating Council, a Seniors Care Strategy Project Steering Committee is being developed to roll out the Senior’s Vision document, Dr. Sinha’s recommendations and to plan for a Regional Geriatric Program model that meets the needs of our senior population. • 15 convalescent care beds have been newly approved for LHIN (Aug/13) – 5 at Georgian Manor + 10 at IOOF Seniors Home.

NW

Within the NW LHIN, there are multiple providers that support the Assess and Restore model. St. Joseph’s Care Group in Thunder Bay has a Geriatric Assess and Rehabilitative Care Unit, which has proven to support clients returning to an appropriate level of functioning to return to their community home. The unit also has collaborated with the local acute care partner and the Geriatric Emergency Medicine Nurse, to admit to the unit from the ER. Assess and Restore models of care are also available at hospitals in Kenora (5 beds), Dryden (4 beds), Sioux Lookout (4 beds). Clients in these beds receive the services and supports they require to assist them to return home. The NW LHIN has begun to review how local Health Links planning can align and potentially strengthen care to seniors.

SELHIN

Redesign of Seniors Ambulatory Care Services for Kingston including Day Rehab for Outpatients, for the frail elderly and at risks, falls prevention, RN Outreach visits and triage into short-term Rehab beds for both community and acute care. Implementing regional LTLD inpatient service at Providence Care. Acute care programs are; Move ON, Enhanced Activation Therapy and H.E.L.P. Currently through the Senior Friendly Hospital Initiative, many hospitals are implementing initiatives to aid in reducing functional decline. Convalescent Care beds are being established in the SELHIN Fall Prevention programs are run through Public Health Units and VON. SELHIN has seven Health Links – all are focused on frail seniors, high users of the system. Collaborations are being developed between CHC, Hospitals, SECCAC and Community Support Sector, as well as independent allied health professionals OP Referrals from community physicians are triaged for ambulatory care services to identify at risk seniors and then transition to the Geriatric Day program Complex Medical Clinics available for primary practitioners in the consultation of managing the frail elderly Considerable information management efforts are occurring to establish common assessment or sharing of assessments, tracking of frail

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elderly clients through the system, document repositories and data/information sharing between sectors.

SWLHIN

Current work is associated with developing a clear definition of restorative care and the clients it serves. The South West LHIN has undertaken a comprehensive review of CCC and Rehabilitative Care beds across the LHIN, their utilization for these populations and identified opportunity to realign beds by population demographics based on local, multi-site and specialized services. The report is available on the South West LHIN web site. Counties are reviewing and reassessing bed needs and realigning bed location for access and staff expertise.

TC

GTA Rehab Network has updated clinical care guidelines for acute care and rehab on hip fracture care (2011) The Network collects and reports acute care and rehab data quarterly on a variety of performance indicators for hip fracture Have completed a variety of ALC and Geriatric Reports see: http://www.gtarehabnetwork.ca/network-reports Need clarity on program definitions

WW

Locally, our Frail Elderly/Medically Complex Steering Committee has developed a definition of frailty: “Frailty is a state of increased vulnerability to stressors resulting from decreased physiologic reserves and/or accumulation of deficits across multiple systems that contributes to increased, but potentially modifiable risk of adverse health outcomes, including disability, dependency, falls, risk for premature institutionalization and mortality.” This was an important first step to guide the work of developing the Comprehensive Geriatric Assessment care pathway. As mentioned above, we are looking at all resources in the rehab care system as a whole (including assess and restore beds) to more appropriate plan for system capacity to support the 4 streams of care that our rehab system in WWLHIN is being built on. We recognize the important role that Health Links will play in supporting the Frail Seniors and Medically Complex population, and some discussions have begun with the 1 Health Link in our LHIN to determine how the rehab system can best support the Health Link in serving this population.

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Appendix C – Detailed description of the feedback collected from LHIN Lead Advisory Group members regarding suggested key deliverables for the Frail Senior/Medically Complex Task group. (Note: Responses have been included where feedback was available/provided.)

5. To inform the work and directions of the Frail Senior/Medically Complex Task Group, please suggest some key deliverables for this task group that would support your LHIN in optimizing the care of frail senior and medically complex populations with functional goals/restorative potential.

ESC Key deliverables for the Frail Senior/Medically Complex Task Group to support the ESC LHIN would be to create a MOHLTC-Request for Application process through respective LHIN’s similar to the Convalescent Care programming for interested parties to apply for 1x funding to advance knowledge of Assess and Restore approach that remains consistent with the Home First and Aging at Home philosophies. This application process is comprised of components to identify early identification, standardized assessment and risk, timely navigation, model of care delivery (environment, program delivery elements, outcomes, quality, costs,) and transition and reintegration back to home setting

HNHB 1. Standardized definition for Assess Restore Model. 2. Eligibility criteria that is not too restrictive to facilitate the flow of individuals from community or acute hospital programs that may require this type of programming for assessment and determination of the most appropriate care level in the community along with the restorative component. 3. Standardized simple assessment tool that is not labor intensive to be used across all sectors that provide assess restore / restorative programs. 4. Common set of qualitative and quantitative metrics for ongoing evaluation.

SW • Align with the Senior Friendly Hospital work and evolve to include the continuum of rehabilitative care • Develop venue for ongoing dialogue of best practices (SFH has interactive web ability to discuss new and best practices) • Describe the frail senior/medically complex patient journey across the continuum (Community, Hospital, Long Term Care) and how the system can be structured to meet the functional goals/restorative potential of the patient • Embed ‘Home First’ philosophy

Central Review performance outcomes of the clients currently using this service – age – gender-LOS –admitted from – discharged to -RAI outcomes. Also, need to look at the client satisfaction with the program.

NSM A small working group has been established to work through Assess and Restore.

NE Undertake to develop a current profile of this patient population

Inventory of existing best practice models of care for the frail elderly/medically complex

Identify eligibility criteria, standardized assessment tools, and common evaluation/outcome metrics including patient reported evaluations

Build upon the Sinha report and recommendations regarding Assess and Restore for this population

Align care delivery model with Health Links and Home First philosophy.

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Best practice models for consistent management of Dementia/psychogeriatric needs at a district and regional level.

NW Build on the recommendations of Ontario’s Seniors Strategy and operationalize recommendations focused on the development of an Assess & Restore framework (Recommendations 46 – 53).

SE Tools or guidelines that seek to align measurement/ evaluation approaches Appropriate common assessment tools Inventory of models of care, best practices Appropriate mix of professionals providing these services Develop a better understanding of the ALC population that falls within this category

MH Best Practice guidelines to support program development Recommended program indicators and evaluation framework Enhanced , flexible caregiver support model for families/caregivers who are supporting frail family members in the community Preventative programs to support people in place rather than development of services as result of hospital admission Best practices for linking with and leveraging services available in the community such as municipal recreation programs, services offered by public health units, geriatric assessment and preventative clinics

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Appendix D – Detailed description of the review of the literature related to rehabilitative care of frail senior and medically complex populations

General Frailty

Sternberg, S. A.,Wershof Schwartz, A., Karunananthan, S., Bergman, H. Clarfield (2011). The identification of frailty: A Systematic Review. The Journal of the American Geriatrics Society, 59(11), 2129-2138.

Type: Systematic review

Aim: Review the clinical definitions, screening tools and severity measures of frailty.

Results: Physical function, gait speed and cognition were the most commonly used identifying components of frailty and death, disability and institutionalization were common outcomes. The prevalence of frailty ranged from 5% to 58%. There is no clear definition of frailty. Targeted populations that are not “too well” but not “too sick” are most likely to benefit from CGA. Severity measures include fit, pre-frail or frail or graded using numerical scores. Frailty was also assessed to be either a static or dynamic state over time.

van Kan, G. A., Rolland, Y., Houles, M., Gillette-Guyonnet, S., Soto, M. and Vellas, B. (2010). The Assessment of Frailty in Older Adults. Clinical Geriatric Medicine, 26, 275-286.

Type: Comprehensive literature review

Aim: To explore the actual trends of research on the concept of frailty and the different models

Results: Despite a universal recognition of frailty there is still a lack of a consensus definition and a standardized assessment tool.

Frailty should be considered as a clinical syndrome resulting from multisystem impairments separated from the normal aging process.

Prevalence of frailty ranges between 33% and 88% depending on frailty tool used. No disagreement on the catastrophic impact on older individual and their families. All frailty models identify older adults at risk of poor clinical outcomes such as dementia, development of disabilities, institutionalization, hospitalization and increased mortality.

2 main phenotypes: i) Physical phenotype – 5 measureable outcomes (exhaustion, weight loss, weak grip, slow walking speed and low energy expenditure ii) multi-domain phenotype – includes cognitive, functional and social circumstances. Inclusion of other domains found to increase the predictive capacity of physical frailty for poor clinical outcomes.

Stolee, P., Lim, S.N., Wilson, L. and Glenny, C. Inpatient versus home-based rehabilitation for older adults with musculoskeletal disorders: a systematic review. Clinical Rehabilitation, 0(0), 1-16

Type: Systematic Review (12 studies included) Aim: Compare the outcomes of home-based rehabilitation to inpatient rehabilitation for older patients with musculoskeletal disorders. In 2008, seniors over the age of 65 represented 14% of the population, and accounted for 44% of health expenditures – this is expected to increase to 20% and 60% respectively in 2010 Creditor (1993) found that as many as 75% of adults 75 years or older who were functionally independent on admission to the hospital for acute illness were no longer independent at discharge. Home based exercise may help to reduce overall costs to the health system by decreasing the patient’s length of stay in hospital and replacing treatment with less expensive home visit without impeding the patient’s recovery.

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Non-financial benefits include increased patient choice, increased patient and caregiver satisfaction and improved health outcomes. Most common assessment tools used were Functional Independence Measure(FIM), Barthel Index BI), Timed Up and Go (TUG), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Oxford Hip Scores (OHS) Results: Older adults who received rehabilitation in the home had equal or higher gains than the inpatient group in function, cognition, and quality of life; they also reported higher satisfaction. Specifically, four studies found that the functional status of the home group was significantly better than the inpatient group after the rehabilitation period. Also, four studies found that quality of life was significantly better for the home-based group and one found that the rate of delirium was significantly lower for clients receiving rehabilitation at home. 4 studies measured acute LOS and found that the home group had a shorter LOS than the inpatient group. There was no difference in mortality between the groups.

Wilhelmson, K, Duner, A., Eklund, K., Gosman-Hedstrom, G., Blomberg, S., Hasson, H., Gustfason, H., Landahl, S. and Dahlin-Ivanoff, S. (2011) Design of a randomized controlled study of a multi-professional intervention targeting frail elderly people. BMC Geriatrics, 11(24).

Type: Randomized controlled trial

Aim: Present the implementation process and “Continuum of Care for Frail Elderly People” intervention.

Population: Elderly people (80 years of age or older OR 65-79 with at least one chronic disease and dependent in at least one ADL) who sought care in a ED and then discharged to their own homes

Intervention = early CGA, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly person and their family in the planning process.

Results: Integrated care programs (geriatric screening, multi-dimensional assessment at ED, geriatric nursing assessment and home-based services) used internationally and shown in RCTs to reduce fragmentation and to improve the continuity and coordination of care

“Health care chain” – coordinated activities in the health care system, linked together to achieve a final result of good quality for the patients. Care is a continuum running between different caregivers and care levels – one caregiver of high quality is not enough to create good care. Elderly people and their families must be involved in the planning, decision making and performance of care.

Physical Frailty Indicators Possible Measures

Weakness Reduced grip strength

Fatigue “Have you suffered any general fatigue/tiredness over the past three months?”

Weight loss “Have you suffered any weight loss over the past three months?”

Physical Activity Taking outdoor walks 1-2 walks per week or less

Balance Value of 47 or less on the BBS

Gait Speed Walking 4 meters with a gait speed of 0.6m/sec or slower

Visual impairment Visual acuity of 0.5 or less using the KM chart

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Cognition Scoring below 25 on MMSE

Crocker, T., Forster, A., Young, J., Brown, L., Ozer, S., Smith, J., Green, J., Hardy, J., Burns, E., Glidwell, E., Greenwood, D.C. (2013). Physical rehabilitation for older people in long term care (Review). The Cochrane Collaboration, Wiley & Sons.

Type: Update of a Cochrane review first published in 2009

Aim: Evaluate the benefits and harms of rehabilitation interventions directed at maintaining, or improving, physical functional for older people in long-term care through the review of randomized and cluster randomized controlled trials.

Rehabilitation = interventions based on exercising the body

Physical rehabilitation = interventions that aim to maintain or improve physical function of an individual by increasing the physical exertions of an individual. Can be delivered in a group format or individually, generic or tailored and delivered by rehabilitation professionals, care staff or self-directed.

Interventions most often delivered as supervised 45-minute group sessions three times weekly. Duration = 4 weeks and a year.

Results: 67 trials involving 6300 participants. 51 reported the primary outcomes of ADLs with effects of rehabilitation being a change in the Barthel Index of 6 points, the FIM of 5 points, Rivermead Mobility Index of 0.7 points, TUG time of 5 seconds and walking speed of 0.03 m/s. Secondary outcomes showing beneficial effects include strength, flexibility, balance, and mood. Rehabilitation does not increase risk of mortality. Some evidence that studies with shorter interventions had larger effects than those with longer interventions. Some evidence that participants with greater mobility benefitted more from rehabilitation than those with less mobility at baseline.

The study provides preliminary evidence that physical rehabilitation interventions may be associated with significant improvements across various measures of physical and mental functioning, without increasing mortality risk in elderly home-care residents. The size and duration of the effects of physical rehabilitation interventions are unclear. The specific types of interventions and how these relate to resident characteristics is unclear.

Olga, T., Stathokostas, L., Roland, K. K., Jakobi, J. M., Patterson, C., Vandervoort. A.A., Jones, G.R. (2011) The effectiveness of exercise interventions for the management of frailty: A systematic review. Journal of Aging Research, 1-19.

Type: A systematic review

Aim: To consider the use of the term “frailty” in relation to exercise interventions and to examine the effectiveness of current exercise interventions for the management of frailty

Frailty is a state of vulnerability, caused by multi-system reduction, ranging in severity from mild to severe, which places an individual at increased risk of adverse health outcomes. Frailty is composed of a mix of physiological, psychological, social, and environmental factors. Frailty should be treated to avoid the human and economic burden associated with this syndrome. Evidence suggests that exercise interventions can be used to restore and/or maintain functional independence in older adults and may potentially prevent, delay, or reverse the frailty process.

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There is not yet a standardized and valid method of clinical screening for frailty

The most commonly use definitions of frailty are:

The Frailty Phenotype(Fried et al.) – five indicators of physical frailty: muscle weakness, subjective fatigue, reduced physical activity, slow gait speed and weight loss.

The Classification of Frailty and Vigorousness (Speechley and Tinetti) - Older adults are classified as vigorous, transitional, or frail based on ten characteristics: age, gait/balance, walking activity for exercise, other physical activity for exercise, depression ,use of sedatives, near vision status, upper and lower extremity strength and lower extremity disability

The Frailty Index (Rockwood and Mitnitski) – mathematical of accumulation of deficits where a deficit can be any symptom, sign, disease, disability, and laboratory abnormality

The Edmonton Frail Scale – ten frailty indicators: cognition, self-rated health status, hospitalizations functional independence, social support, medication use, nutrition, mood, continence, and mobility.

The American College of Sports Medicine position on exercise for older adults (1998) recommends that exercise prescription for frail people is more beneficial than any other intervention and that the contraindications to exercise for this population are the same as those used with healthier/younger people. Resistance and/or balance training should precede the aerobic training for this population.

Results: The term frailty was used extensively in relation to published exercise interventions. Structured exercise training has a positive impact on the frail older adult and should be used for management of frailty.

The most common exercise interventions for frail older adults included in this review were multicomponent exercise programs performed three times per week over three months with each session lasting 60 minutes. Exercise seems to benefit the oldest old (>/=80 years old) frail females more than younger frail males. Exercise seems to be more beneficial in frail people living in LTC compared to the community.

Cook, R., Berg, K., Lee, K., Poss, J., Hirdes, J., Stolee, P. (2013). Rehabilitation in Home Care is Associated with Functional Improvement and Preferred Discharge. 94:1038-47

Type: Observational Study

Results: Cook et al. identify a number of systematic reviews that suggest home-based rehabilitation produces equal or superior clinical outcomes as compared to inpatient rehabilitation for a variety of conditions (including neurologic, cardiac, stroke, mental health and musculoskeletal conditions) and can help to reduce overall health system costs.

Chong, C., Savige, J., Lim, W.K. (2009). Orthopedic-geriatric models of care and their effectiveness. Australasian Journal on Aging. 28(4):171-176.

Type: Review Article

Aim: Evaluate the effectiveness of orthopedic geriatric models of care

Results: Studies conducted to evaluate the effectiveness of orthopedic geriatric models of care have been heterogeneous – therefore it is difficult to draw firm conclusions. More medical conditions are recognized when a geriatrician oversees the medical care. Studies show a trend towards better outcomes in specialized geriatric models with modest effects of functional recovery, length of stay, complications and mortality. No detrimental

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effects were identified.

De Morton, N., Jones, C. T., Keating, J.L., Berlowitz, D.J., MacGregor, L., Lim, W. K., Jackson, B., Brand, C. A. (2007). The effect of exercise on outcomes for hospitalized older acute medical patients: an individual patient meta-analysis. Age and Ageing. 36:219-228.


Aim: Investigate the effects of additional exercise for acutely hospitalized older adults.

Results: Older persons who are admitted to acute care medical settings and who required supervision or assistance to ambulate at admission are the most responsive to additional exercise during hospitalization and have significantly improved LOS compared to usual care.

Wells, J.L., Seabrook, J.A., Stolee, P., Borrie, M.J., Knoefel, F.D. (2003). State of the Art in Geriatric Rehabilitation. Part 1: Review of Frailty and Comprehensive Geriatric Assessment. Archives of Physical Medicine Rehabilitation. 84: 890-896.

Type: Review Article

Aim: To increase recognition of geriatric rehabilitation and to provide recommendations for practice and future research.

Geriatric rehabilitation is defined as “evaluation, diagnostic and therapeutic interventions whose purpose is to restore functional ability or enhance residual functional capability in elderly people with disabling impairments”. Its distinguishing feature from the rehabilitation of younger adults is the higher burden of comorbid disease requiring input from several subspecialties and professional disciplines to investigate and manage the medical issues and rehabilitation needs.

COMPREHNSIVE GERIATRIC ASSESSMENT - A comprehensive geriatric assessment involves a multidimensional team approach that determines an older person’s biomedical, psychological and environmental needs so that an appropriate treatment and follow-up plan can be initiated. There is level 1A evidence suggesting that CGA is important for frail older persons with rehabilitation needs.

SCREENING - When selecting patients for geriatric rehabilitation, the dimensions used to define frailty should be assessed: Functional impairment, medical complexity, psychological functioning and social support. Patients who are too medically unstable, those who are more appropriate for palliative care and those who can remain at home and be treated as outpatients should be excluded. Low motivation to participate in rehabilitation should not necessarily be grounds for exclusion (low motivation may be due to treatable depression).

ASSESSMENT TOOLS - The FIMTM is a valid, sensitive measure of functional status in the elderly. The Goal Attainment Scale has been shown to be valid, responsive and practical to use in a variety of settings in the care of the elderly.

Geriatric inpatients with potential remedial geriatric syndromes (e.g. polypharmacy, confusion, falls) should be targeted for geriatric rehabilitation. There may be a threshold of severe comorbidity above which a poorer rehabilitation outcome may be expected.

Tests of specific function are also commonly used (e.g. the timed up and go (TUG), Berg Balance Scale (BBS0), Katz ADL scale and the Lawton Brody assessment).

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The Cumulative Illness Rating Scale (CIRS) has been designed to assess medical comorbidities and complexity and has been validated as a measure of medical complexity for frail older adults. The CIRS, in conjunction with other indices of function (e.g. FIMTM or Barthel Index) can capture a patients’ level of frailty.

TEAM APPRAOCH TO CARE – Geriatric rehabilitation should have an interdisciplinary team approach with medical care and rehabilitation managed by a physician and team trained in the care of the elderly.

Results: Frail elderly patients should be screened for rehabilitation potential. Standardized tools are recommended to aid diagnosis, assessment and outcome measurement. The team approach to geriatric rehabilitation should be interdisciplinary and use a comprehensive geriatric assessment. Medication reviews and self-medication programs may be beneficial.

Gill, T.M., Gahbauer, E.A., Han, L., Allore, H. G. (2006). Transitions between frailty states among community-living older persons. Archives of Internal Medicine. 166: 418-423.

Type: Prospective study

Aim: To determine the transition rates between frailty states and to evaluate the preceding frailty state o subsequent frailty states.

Results: Of the 754 participants, 57.6% had at least 1 transition between and 2 of the 3 frailty states during the 54 month study period. The likelihood of transitioning between frailty states was highly dependent on one’s preceding frailty states.

Frailty is a dynamic process, characterized by frequent transitions between frailty states (nonfrail, prefrail and frail) over time. Since frailty is a state of increased vulnerability resulting from a multisystem reduction in reserve capacity AND reserve capacity can be boosted (not just diminished), it follows that transitions from states of greater frailty to lesser frailty are not uncommon. Thus, there is ample opportunity for the prevention and remediation of frailty.

Gill, T.M., Gahbauer, E.A., Han, L., Allore, H. G. (2011). The relationship between intervening hospitalization and transitions between frailty states. Journal of Gerontology. 66A(11):1238-1243.

Type: Prospective longitudinal study

Aim: To evaluate the relationship between intervening hospitalizations and the transitions between frailty states over time.

Frailty is recognized as a geriatric syndrome, distinct from disability and comorbidity, which results from a multisystem reduction in reserve capacity, confers high risk for an array of adverse outcomes and is potentially amenable to prevention and remediation.

Results: Illnesses and injuries leading to hospitalization reduced the likelihood of transitioning from states of greater frailty to lesser frailty (i.e. impeded recovery), but had more modest and less consistent effects on transitions from states of lesser frailty to greater frailty. Intervening hospitalizations were strongly associated with the transition to death from each of the three frailty states. The likelihood of transiting from nonfrail to frail was relatively low in the absence of a hospitalization

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What models of care/interventions are effective in promoting positive functional outcomes for frail seniors and medically complex individuals? (See Appendix D for full summary and references)

Ryburn, B, Well, Y. and Foreman, P. (2009) Enabling independence: restorative approaches to home care provision for frail older seniors. Health and Social Care in the Community, 17(3), 225-234.

Type: Comprehensive literature review

Aim: Provide an overview of the evidence on whether restorative programs in home care result in improved functional and social well-being.

Results: Current home care ’dependency models’ are based on service provision rather than a new focus on activity, rehabilitative potential, independence and successful aging. There is strong evidence that an emphasis on the promotion of healthy lifestyles and daily routines, social support, exercise and autonomy and control is linked to the maintenance of health and independence in older adults

Current funding models limit focus on restorative care as services are funded for short, task-focused home care making it very difficult to provide a flexible goal-oriented approach.

Focus of home care for the management of intellectually disabled groups has focused on concepts of “normalization” and “social role valorization”. Older adults are entitled to the same “empowerment-oriented” and independence-focused approached.

UK has adopted restorative home care services.

“Re-enablement”- intensive and time limited multidisciplinary home care service interventions developed for people with poor physical and/or mental health to help them learn or re-learn the skills necessary to manage their illness and to maximally participate in everyday activities.

A restorative approach to home care has significant advantages over the traditional approach aimed at maintenance and support only (e.g. a reduction in the on-going use of home care and community care services in comparison to what would have been expected with the provision of “usual” services).

Key interventions = provision of aids and home adaptation, basic health education, comprehensive occupational therapy interventions and participation in physical activity programs.

Chou, C., Hwang, C. and Ying-Tai, W. (2012). Effect of Exercise on Physical Unction, Daily Living Activities and Quality of Life in the Frail Older Adults: A Meta-Analysis. Archives of Physical Medicine and Rehabilitation 93, 237-244.

Type: Meta-Analysis

Aim: To determine the effect of exercise on physical function, daily activities and quality of life in the frail older adults.

Results: Exercise is beneficial to increase gait speed, improve balance and improve performance in ADLs in the frail older adults.

Exercise slows down the physiologic changes associated with aging, promotes cognitive health and complements the management of chronic disease in the older adults. Exercise improves sit to stand, balance, agility and ambulation, reduces falls rate, slows the deterioration in the ability to perform ADLs and helps to maintain QOL.

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Interventions included supervised flexibility, low- or intensive-resistance, aerobic, coordination, balance and Tai-Chi exercises and repetitive performance of ADLs performed either in facilities, communities or in-home for 60-90 minutes sessions repeated daily or weekly for 3-12 months.

Orr, R., Raymond, J. and Fiatarone Singh, M. (2008) Efficacy of Progressive Resistance Training on Balance Performance on Older Adults. Sports Medicine, 38 (4), 317-343.

Type: Systematic literature review

Aim: Examine the effect of progressive resistance training (PRT) on balance

Results: Limited evidence in published data has not consistently shown that the use of PRT in isolation improves balance in the study population (aged, elderly, geriatric, older adults, senior)

Daniels, R., van Rossum, E., de Witte, L., Kempen, G and van den Heauvel W. (2008) Interventions to prevent disability in frail community-dwelling elderly: a systematic review. BMC Heath Services Research, 8, 278.


Aim: Assess the content, the methodological quality and the effectiveness of intervention studies for the prevention of disability (IADL/ADL) in community-dwelling physically frail elderly.

Population: Community dwelling frail older persons

Current literature supports frailty as a pathway to disability that is not a direct result of chronic disease but is instead associated with age related loss of physical condition and reserve.

Physical frailty is a construct that can be identified by frailty components.

Interventions for physical frailty stem from the idea that the causal pathway towards frailty is a negative spiral in which inflammation, neuroendocrine deregulation and sarcopenia play a role implying that interventions can be targeted at physical frailty independent of specific diseases.

Results: Some indication that long-lasting high-intensity exercise programs for moderately frail older persons can have an effect in disability outcomes.

Physical Frailty Indicators Possible Measures

Mobility Gait speed

Strength Grip strength, chair rise, knee extensor strength

Endurance Lack of energy, tiredness, oxygen-uptake

Nutrition Decreased food intake, weight loss, BMI, obesity

Physical inactivity Frequency and direction of walking and bicycling in the previous week and the average amount of time spent each month on hobbies, gardening, odd jobs, sports

Balance Items from Berg Balance Scale

Motor Processing Coordination, movement planning and movement speed

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Bachman, S., Finger C., Huss, A. et al. (2010) Inpatient rehabilitation specifically designed for geriatric patients: a systematic review and meta-analysis of randomized controlled trials. British Medical Journal, (340), c1718

Type: Systematic review and meta-analysis of randomised controlled trials

Aim: To assess the effects of inpatient rehabilitation specifically designed for geriatric patients compared with usual care in functional status, admission to nursing homes and mortality

After an acute admission older adults are at an increased risk of death and admission to nursing home. Geriatric rehabilitation programmes might not only improve outcomes but might also generate long term costs savings by reducing admissions to nursing homes.

Short (at discharge) and long term (at 3-12 months) outcomes evaluated = functional improvement (Katz index or Barthel Index), nursing home admission (yes/no), mortality (yes/no)

Results: Inpatient rehabilitation specifically designed for geriatric patients has the potential to improve outcomes related to function, admission to nursing homes, and mortality. Insufficient data are available for defining characteristics and cost effectiveness of successful programmes.

Van Craen, K., Braes, T., Wellens, N., Denhaerynck, K., Flamaing, J., Moons, P., Boonen, S., Gossett, C., Petermans, J., Milisen, K. (2010). The effectiveness of inpatient geriatric evaluation and management units: A systematic review and meta-analysis. Journal of American Geriatrics Society, 58, 83-92.

Type: Systematic review and meta-analysis

Aim: To examine how geriatric evaluation and management units (GEMUs) are organized and to examine the effectiveness of admission on a GEMU.

Results: GEMUs are organized in heterogeneous ways and the included studies gave no thorough description of comprehensive geriatric assessment (CGA). Involvement of a multidisciplinary team was a key element in all GEMUs. Admission to a GEMU has one or more favorable effects on outcomes of interest with two significant effects: less functional decline at discharge from the GEMU and a lower rate of institutionalization 1 year after discharge.

Rodriquez, C., Kergoat, MJ., Latour, J., Lebel, P., Contandriopoulos, AP (2003). Admission criteria in short-term Geriatric Assessment Units.

Type: Delphi survey of panel of experts in Quebec

Aim: Determine criteria that target the greatest number of individuals most likely to benefit from hospitalization in a Geriatric Assessment Unit

Results: A typical clinical profile of a patient who should be admitted to a GAU: an elderly person with multiple pathologies, acute or sub-acute functional reduction with risk of deterioration of health status or risk of nursing home admission, related psychosocial problems, history of frequent re-hospitalizations AND who presents with potentially reversible complications resulting from recent onset of immobility who comes from the community or another hospital unit. Exclusion Criteria include: a single pathology or chronic problems that can be managed in other services or specialized units, requires admission for LTC, can be managed by ambulatory care, shows a

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lack of motivation and cooperation.

Beswick, A.D., Rees, K., Dieppe, P., Ayis, S., Gooberman-Hill, R., Harwood, J., Ebrahim, S. (2008) Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. The Lancet, 371; 725-735.

Type: Systematic review and meta-analysis

Aim: Review the effectiveness of community-based complex interventions in preservation of physical function and independence in elderly people.

Results: 89 trials including 97,984 participants. Interventions reduced the risk of not living at home. Interventions reduced nursing home admissions but not death. Risk of hospital admissions and falls were reduced and physical function was better in the intervention groups. Benefit for any specific type or intensity of intervention was not noted. Substantial variation in the format of care, involvement of health-care professionals, and site of care provision and intensity was reported.

Daniels, R., Metzelthin, S., van Rossum, E., de Witte, L., van den Heuvel, W. (2010). Interventions to prevent disability in frail community-dwelling older persons: an overview. European Journal of Ageing. 7: 37-55.

Type: Narrative review

Aim: Provide an overview of the variety of interventions aimed at disability prevention in community-dwelling frail older persons.

Disability (defined as experienced difficulty in performing activities in any domain of life) is generally considered as one of the major adverse outcomes of frailty. Prevention of disability in frail older persons can lead to the maintenance of quality of life and reduced health care costs.

Results: 48 studies were included in the review. Physical exercise interventions for community-dwelling frail older persons show a large variation in content, duration, intensity, balance between supervised and non-supervised sessions and the level of individualization. Indication that multi-component, high intensity physical exercise programs may be promising, especially for moderate physically frail community dwelling older persons. Other promising features of interventions include multidisciplinary and multifactorial, individualized assessment and intervention, case management, long term follow-up and the use of adaptations/technology.

What are the predictors/influencers of restorative potential for frail seniors?

Landi, F., Onder, G., Cesari, M., Barillaro, C., Lattanzio., Carbonin, P.and Bernabei, R.(on behalf of the SILVERNET_HC Study Group) (2004). Comorbidity and social factors predicted hospitalization in frail elderly patients. Journal of Clinical Epidemiology 57, 832-836.

Type: Observation cohort study

Aim: Examine the rate of hospitalization and to identify the most important clinical and patient-centered factors associated with the hospital admission amongst frail elderly people.

Results: Of the 1291 patients studied, 26% were hospitalized during the 12-month study. Persons living alone were more likely to be admitted to hospital than those living with a caregiver as were those with economic hardship, comorbidities and previous hospital admission.

Conclusion: A mix of social and health problems are independent predictors of hospitalization

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Davies, D.H.J., Rockwood, M.R.H., Mitnitski, A.B. and Rockwood, K. (2011) Impairments in mobility and balance in relation to frailty. Archives of Gerontology and Geriatrics, (53), 79-83.

Type: Prospective population-based cohort study.

Aim: Describe the relationship between impaired balance, mobility and frailty, and relate these to risk of death.

Results: Impaired mobility and balance contribute to frailty, but neither is sufficient to define a participant as frail. Mobility impairment is common in frailty and near universal when frailty is severe. Setting changes in balance and mobility against other potential state variables such as attention-concentration, social engagement etc. may lead to a more complete understanding of frailty.

Gill, T., Allore, H. G., Hardy, S. E., Guo, Z. (2006). The Dynamic Nature of Mobility Disability in Older Persons. Journal of American Geriatric Society, 54, 248-254.

Type: Prospective Cohort Study

Aim: To determine the rates of clinically meaningful transitions in mobility disability; evaluate how these transitions differ according to age, sex, and physical frailty; and depict the duration of the resulting episodes of mobility disability.

Mobility Disability = inability to walk one quarter of a mile and to climb a flight of stairs, respectively without personal assistance

Older persons who lose independent mobility are less likely to remain in the community, have higher rates of morbidity and mortality and experience poorer quality of life with greater likelihood of depression and social isolation.

Results: Mobility disability in older persons is a highly dynamic process, characterized by frequent transitions between states of independence and disability. Older age, female sex, and physical frailty were generally associated with greater likelihood of transitioning to states of greater disability and lower likelihood regaining independent mobility. Episodes of intermittent disability lasted, on average, about 6 months. Programs designed to enhance independent mobility should not only focus on the prevention of mobility disability but also on the restoration and maintenance of independent mobility in older persons who become disabled

Armstrong, J., Glenny, C., Stolee, P., Berg, K. (2010). A comparison of two assessment systems in predicting functional outcomes of older rehabilitation patients. Age and Ageing. 39 (3): 394-399

Type: Review Aim: To collect data with both the FIMTM and the PAC (RAI-Post Acute Care) to assess their relative ability to predict discharge outcomes for older patients receiving inpatient rehabilitation. Inpatient rehabilitation can improve physical functioning and quality of life of older persons with MSK disorders. Small gains in ADLs may result in large improvements in functional status and independence. It is therefore useful to identify factors that predict successful rehabilitation in order to target limited resources to patients who are most likely to benefit. This information would also be helpful to provide realistic expectations to patients and caregivers and to guide care and discharge planning. Assessment of rehabilitation potential and the potential success of rehabilitation for older patients is challenging due to medical complexity, frailty and multiple comorbidities.

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Compared to the FIMTM the PAC contain additional information on common characteristics that reflect clinical complexity and thus may be predictive of outcome

Results: The PAC was more proficient than the FIMTM in explaining the variance in rehabilitation outcomes. Functional status on admission was the strongest predictor of rehabilitation outcomes. Cognitive status, number and type of comorbid conditions, age and gender are other commonly reported predictors.

Landi, F., Bernabei, R., Russo, A., Zuccala, G., Onder, G., Carosella, L., Cesari, M., Cocchi, A. (2002) Predictors of Rehabilitation Outcomes in Frail Patients Treated in a Geriatric Hospital. Journal of American Geriatric Society, 50:679-684.

Type: Observational Study

Aim: To evaluate the effect of medical indicators of health status on functional gain during rehabilitation of frail older persons.

Rehabilitation was provided for 3 hours per day, 6 days per week and included all purposeful activities to achieve maximal functional independence in mobility, to prevent or correct disability and to maintain health (e.g. strengthening, ROM exercise, musculoskeletal control, trunk and UE positioning, transfer training, postural and gait training, functional and self-care retraining and adaptive equipment training).

The goal of rehabilitation is to restore functional independence when possible and to facilitate psychosocial adjustment to residual disability. Advanced age, inability to follow commands, severe memory problems, urinary incontinence, pressure ulcers and visuospatial deficits have been considered indicators of poor prognosis.

Results: Patients aged 85 and older with cognitive or sensory impairment were less likely to significantly improve physical functioning after intensive rehabilitation. Severe cognitive impairment may be considered a negative predictor of functional recovery after a period of intensive rehabilitation. It would be a mistake to deny rehabilitation to all patients with any level of cognitive impairment without considering the overall clinical situation and the specific problem that needs to be rehabilitated.

Hershkovitz, A., Kalandariov, Z., Hermush, V., Weiss, R., Brill, S. (2007). Factors Affecting Short-Term Rehabilitation Outcomes of Disabled Elderly Patients with Proximal Hip Fracture. Archives of Physical Medicine Rehabilitation, 88: 916-21

Type: Research study

Aim: To identify factors associated with post-acute rehabilitation outcomes of disabled elderly patients with proximal hip fracture.

One third of patients with a hip fracture will regain their former levels of function. Successful inpatient rehabilitation accounts for most functional recovery in improving patients’ mobility and ADLs. This extended process continues with patients’ discharge and further treatment in the community.

Results: Cognitive function, nutritional status (albumin level), pre-injury functional level, and depression were the most important prognostic factors associated with proximal hip fracture. Of these, depression and nutritional status are correctable and early intervention may improve rehabilitation outcomes. Discharge destination was highly associated with the presence of a caregiver, followed by depression and cognitive ability.

Fusco, D., Bochicchio, G., Onder, G., Barillaro, C., Bernabei, R., Landi, F. (2009) Predictors of Rehabilitation Outcome Among Frail Elderly Patients Living in the Community. Journal of American Medical Directors

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Association, 10:335-341.

Type: Research Study

Aim: To evaluate the association of functional and medical indicators of health status on functional recovery during rehabilitation of frail elderly living in the community using the MDS-HC.

Results: The mean LOS of the program was 6 months. Thirty-three percent had improvements in their ADL score. Cognitive performance impairment, depression, urinary incontinence, bowel incontinence and sensory impairment were associated with higher risk of poor improvement in physical functional performance.

Rothman, M.D., Leo-Summers, L., Gill, T.M. (2008). Prognostic Significance of Potential Frailty Criteria. Journal of the American Geriatric Society. 56:2211-2216.

Type: Prospective cohort study

Aim: To determine the independent prognostic effect of seven potential frailty criteria on several adverse outcomes

Results: Slow gait speed, low physical activity and weight loss were independently associated with chronic disability, long term nursing home stays and death. Slow gait speed was the strongest predictor of chronic disability, long term nursing home stay and was the only significant predictor of injurious falls. Cognitive impairment was also associated with chronic disability, long term nursing home stay and death. Self-reported exhaustion and muscle weakness were not predictive of adverse outcomes.

Slow gait speed, low physical activity, weight loss and cognitive impairment are key indicators of frailty.

Kim, MJ., Yabushita, N., Kim, MK., Nemoto, M., Seino, S., Tanaka, K. (2010). Mobility performance tests for discriminating high risk of frailty in community-dwelling older woman. Archives of Gerontology and Geriatrics. 51:192-198.

Type: Research study

Aim: To compare and identify high and low risks of frailty in community-dwelling women by using five mobility performance tests. Mobility performance tests included 5-chair sit-to-stand (STS), alternate step, timed up-and-go (TUG), Timed Rapid Gait (TRG) and usual gait speed (UGS).

Results: High-risk individuals were more likely to be prefrail than low risk individuals. Walking ability tests are clinically useful in screening older individuals at high risk of frailty. In particular, the Timed Rapid Gait test is more likely than other tests to discriminate older women at high risk of frailty.

What patient outcomes measures should be used to evaluate rehabilitative care outcomes for frail seniors? (See Appendix D for full summary and references) What are the predictors/influencers of successful and sustained functional gains for frail seniors? (See Appendix D for full summary and references)

Clegg, A., Young, J., Iliffe, S., Olde Rikkert, M. and Rockwood, K. (2013). Frailty in elderly people. The Lancet, 381, 752-62.

Type: Review

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Aim: Review methods to detect frailty and measure its severity

Frailty = a state of increased vulnerability to poor resolution of homeostasis after a stressor event which increases the risk of adverse outcomes, including falls, delirium and disability.

Frailty models: i) Phenotype models – unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed, and weak grip strength, ii) Cumulative deficit model – the cumulative effect of multiple deficits

Prevalence – 4-59.1%, more prevalent in women, increased steadily with age

Transition to a level of worse frailty is more common than is improvement in frailty and the development of frailty often leads to a spiral of decline in increasing frailty and higher risk of worsening disability, falls, admission to hospital and death.

Frailty and comorbidity – two or more of nine specific diseases – present in 46.3% of population

Fragility and disability - the presence of restriction in at least one activity of daily living – present in 5.7% of population

All three – present in 21.5%, frailty alone was present in 26.6%

Frail elderly functional questionnaire (19 questions) was identified as a potential outcome measure for frailty interventions

Timed Up and Go and grip strength, pulmonary function tests investigated as single assessments to detect frailty; however, diagnostic accuracy of these test not confirmed.

Edmonton Frail Scale – multidimensional assessment instrument – quick (5 minutes) , valid, reliable and feasible for routine use by non-geriatricians

Comprehensive Geriatric Assessment is the gold standard to detect frailty. It is a process of specialist elderly care delivered by a multidisciplinary team to establish an elderly person’s medical, psychological and functional capability so that a treatment and follow-up plan can be developed. However, this assessment is limited practically by its resource intensity. An equally reliable but more efficient and responsive method of routine care is urgently needed; limitation = time and expertise.

Future approaches need to be underpinned by the cumulative deficit frail model in order to support the shift in the care of the frail elderly towards a more appropriate goal-directed approach.

Frail elderly people receiving inpatient CGA on specialist elderly care wards are more likely to return home, are less likely to have cognitive or functional decline and have lower in-hospital mortality rates than those who are admitted to a general medical ward setting.

Complex interventions based on CGA delivered to elderly people in the community can increase the likelihood of continuing to live at home mainly through reduced need for care-home admission and fewer falls. The most frail patients benefit the least.

Exercise has physiological effects on the brain, endocrine system, immune system and skeletal muscle. Three systematic reviews of home-based and group-based exercise interventions for frail elderly people showed that exercise can improve outcomes of mobility and functional ability. The most effective intensity (duration and frequency) of exercise intervention is uncertain.

Failure to detect frailty potentially exposes patients to intervention from which they might not benefit and

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indeed could be harmed

Gill, Thomas (2010). Assessment of Function and Disability in Longitudinal Studies. Journal of the American Geriatrics Society, 58: S308-S312.

Type: Monograph

Aim: Focused on the assessment of functional limitations

Summary: Functional limitations are useful to assess because they are often strong predictors of clinically meaningful distal outcomes, such as disability, nursing home admission and death. In contrast to measures of disability, measures of functional limitations are usually free of environmental influences; often focus on a specific task, such as gait speed, leading to greater specificity; and offer the potential for greater responsiveness to clinically meaningful changes. Traditional measures of disability include indicators of difficulty and dependence.

The Short Physical Performance Battery (SPPB) assesses lower extremity functional limitations (timed tests of standing balance, walking speed and repeated chair stands). Each element is scored 0-4. The tool takes less than 10 minutes to complete. An SPPB score of less than 10 has commonly been used to identify an “at risk” group. Older person with scores between 10 and 12 are relatively immune to adverse outcomes over the course of 4 years.

Eklund, K., Wilhelmson, K. (2009). Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review of randomized controlled trials. Health and Social Care in the Community. 17(5): 447-458.


Aim: Evaluate integrated and coordinated interventions (i.e. those with case management or equivalent organization) targeting frail elderly people living in the community

Results: Nine articles were included. Seven studies reported at least one outcome measurement significantly in favour of the intervention, one reported no difference and one was in favour of the control. Two studies reported caregiver outcomes and both were in favour of the intervention for caregiver satisfaction but with no effect on caregiver burden. Outcomes focusing on healthcare utilization were significantly in favour of the intervention.

rehabilitative care alliance frail senior/medically complex working group backgrounder...

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