Senior Friendly Hospital Care

Dr. Grant McKercherNorth Bay Regional Health Centre

CME Rounds 9 May 2012

Disclosures

• I have no affiliations, sponsorships, honoraria, monetary support or conflict of interest from any commercial source

Objectives

•review the provincial Senior Friendly Hospital initiative

•introduce the Hospital Elder Life Program at NBRHC

•review the Seniors’ Mental Health Integrated Service at NBRHC

Demographics

• Presently the population aged 65 years and older in the North East LHIN is 16%, slightly higher than the provincial average of 13.6%

• Estimated to grow faster in the coming years, increasing from 90,985 to 162,260 by 2031, a 78% increase

• with an estimated population of 552,000, nearly one in three will be older than 65 years by 2031

• Seniors are the primary users of hospital services in the Northeast, accounting for 70.7% of inpatient days and 71.6% of ALC days in 2009/10

Complications of Hospitalization

HospitalizatiHospitalizationon

HospitalizatiHospitalizationon

Precipitating factors / Precipitating factors / Medical InterventionsMedical InterventionsPrecipitating factors / Precipitating factors / Medical InterventionsMedical Interventions

ComplicationComplicationss

ComplicationComplicationss

Complications Rates

Delirium 25-60%

Functional Decline 34-50%Adverse Drug

Reactions 54%

Operative Complication 52%

Diagnostic/Therapeutic 31%

Nosocomial Infections 17%

Falls/Physical Injury 15%

Pressure Sores 10%

Hospitalization as a Pivotal Event

• Although seniors clearly benefit from acute hospital care, hospitalization presents risks for adverse events and functional loss

• Greater complexity of care complicated by multiple co-morbidities and complex interactions

• the set of complex physical, social and functional consequences is a challenge for the episodic focus of acute care in our hospitals

The Senior Friendly Hospital Framework

• developed and endorsed by the Regional Geriatric Programs of Ontario to help hospitals take a systematic, evidence-based approach to geriatric care

• five domains:

• organizational support

• processes of care

• emotional and behavioural environment

• ethics in clinical care and research

• physical environment

• “... enable seniors to maintain optimal health and function while they are hospitalized, so that they can transition successfully home or to the next appropriate level of care”

Organizational Support

• Leadership and support to make senior friendly care a priority

• Empowers development of human resources, policies and procedures, care-giving processes, and physical spaces that are sensitive to needs of frail patients

Organizational Support(Northeast LHIN)

• Strong commitment to enhance acute care of the elderly, but commitment to a systematic, organizational response is only in initial stages

• Only 26% of hospitals report using age-specific indicators (e.g. resource utilization by age cohort)

• Access to geriatric knowledge and expertise has been identified as a barrier to further development of Senior Friendly hospital care

• educational opportunities are needed to foster human resource development and collaborative planning with community partners

Processes of Care

• Care is founded on evidence and best practices based on knowledge of physiology, pathology, and social science of aging and frailty

• Care is delivered in a manner that ensures continuity within the hospital and community, so that independence of seniors is preserved

Processes of Care(Northeast LHIN)

• many hospitals have protocols in place to address clinical issues such as falls, pressure ulcers, adverse drug reactions, and restraint use

• less common are protocols for continence, hydration/nutrition, dementia related behaviours and functional decline - scenarios that lead to adverse outcomes and increased length of stay

• A number of innovative discharge programs have been successfully implemented, but concerns remain about access to home and community care in the rural north impacting safety and sustainability of discharges

Emotional and Behavioural Environment

• The hospital delivers care and service free of ageism and respects the unique needs of patients and their caregivers, thereby maximizing satisfaction and the quality of the hospital experience

• staff training in seniors sensitivity to promote a senior friendly culture throughout the hospital

Emotional and Behavioural Environment (Northeast LHIN)

• 22% of hospitals report having formal education programs to address senior friendly care on topics ranging from elder abuse to dementia

• 70% of hospitals have strategies to inform and involve seniors and their families in decisions about their care

• Limited access to geriatric expertise cited as a barrier to widely deliver training and education across the Northeast

Ethics in Clinical Care And Research

• Care provision and research are conducted in an environment that possesses the resources and capacity to address unique ethical issues as they arise

• Protects the autonomy and the interests of the most vulnerable

Ethics in Clinical Care And Research (Northeast LHIN)

• A majority of hospitals have specific policies on advance care directives

• A minority have access to an ethicist, but are sometimes able to utilize other professional staff in this capacity

Physical Environment

• The hospital's structures, spaces, equipment and facilities provide an environment that minimizes the vulnerabilities of frail patients, thereby promoting safety, independence, and functional well-being

Physical Environment(Northeast LHIN)

• Identified as a significant barrier for many Northeastern hospitals in their implementation of senior friendly initiatives

• Within limits of existing resources, they are planning design improvements, e.g.

• Way finding, flooring, doorways to enhance safe

mobilization of older patients

Senior Friendly Initiatives at the

North Bay Regional Health Centre

• Multidisciplinary Elder Care Committee, promoting program development, staff education

• PIECES, GPA training for staff

• With the new management structure we are developing integrated seniors’ services across the organization (e.g. Complex Care and Seniors’ Mental Health)

• Protocols for monitoring and prevention of falls, medication errors, pressure ulcers, restraint use; stroke care

• Assess and Restore program

• Hospital Elder Life Program

• Multidisciplinary discharge planning and community partnerships, e.g. CCAC/Home First

Processes of CareOrganizational Support

Senior Friendly Initiatives at the

North Bay Regional Health Centre

• Support for cultural diversity, e.g. moving towards more comprehensive bilingual service delivery; native services coordinator; traditional healing program

• Chaplaincy and Spiritual Care

• Patient education/involvement, e.g. admission package, educational booklets

• Staff education in Gentle Persuasive Approaches and PIECES

• Advance Care Directive policies

• Access to ethicist for consultation regarding challenging ethical issues

Emotional & Behavioural Environment

Ethics in Clinical Care

Environmental

• patient rooms, windows/natural light• Courtyards/gardens• Way-finding• Ceiling lifts

Next Steps

• Optimize senior friendly programs and services

• Promote an integrated continuum of care

• Senior friendly education and culture

• Designated clinical protocols

• Improved physical environment

• Improved safety and quality of care

• Improved patient flow and reduced ALC days

• Improved ER wait times and utilization

• Implementation of senior friendly strategies

Key Themes Anticipated Outcomes

Hospital Elder Life Program(HELP)

•Helping to maintain cognitive, physical, and emotional well-being in hospitalized older adults

http://hospitalelderlifeprogram.org

What is the Hospital Elder Life Program?

• a comprehensive program of care for hospitalized older adults, designed to prevent delirium and functional decline

• based on randomized controlled trial demonstrating clinical effectiveness (Inouye et al., 1999)

• targets patients >70 years of age with LOS >2 days

• individualized patient care plans targeting specific risk factors for delirium and functional decline

• demonstrated cost-effectiveness through lower resource use during hospitalization

Delirium

• 1) Disturbance of consciousness with reduced ability to focus, sustain and shift attention

• 2) Change in cognition (e.g. memory, orientation or language) OR perceptual disturbance

• 3) The disturbance develops over a short period of time and tends to fluctuate

• 4) There is evidence from the history, physical or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition

Four Criteria

Delirium Outcomes

• Mortality rates 25 – 33%

• 2x length of stay in acute care

• Increased institutionalization rate

• Decreased functional ability

Delirium may serve as a marker for future cognitive decline, annual incidence 20%

HELP Program Goals

• maintain physical and cognitive functioning throughout hospitalization (through daily interventions

• maximize independence at discharge

• assist with appropriate transition from hospital to home

• improve geriatric skills of staff

Innovative Staffing Model

• utilizes a small team, comprised of a new role, the Elder Life Specialist (ELS) and an advanced practice geriatric nurse, the Elder Life Nurse Specialist (ELNS), with support from a geriatrician

• uses structured program with detailed orientation and oversight to engage a Volunteer force of 20+ individuals to provide 3 shift, 7 day/week coverage

What the Patient Experiences

• a lot of attention: encouragement and support to participate in getting better

• predictable cycle each day with access to ‘someone who can listen’

• volunteers can help identify patient needs and communicate with staff; volunteers do not discuss clinical issues with patients

• consistent support for orientation, mobility, and therapeutic activities

What the Nursing Staff Experiences

• non-clinical needs of patient are effectively met by volunteers and ELS, reducing interruptions and demands on floor staff

• in-services on geriatric topics and regular interdisciplinary rounds

• oversight by ELNS assists floor staff in identifying geriatric needs and coordinating care plans and discharge plans

• reduced rate of delirium and fewer iatrogenic complications in their patients

Expected Results

• Clinical trial demonstrated a reduction in rate of delirium from 15% to 9.9% in study population

• improved quality of care

• reduction in length of stay

• reduction in hospital costs related to patient care

• Increased scores on cognitive function tests

• Smoother discharges and fewer re-admissions

• Increased patient satisfaction

Opportunities

• Consistent with quality initiatives to reduce adverse drug reactions, falls, pressure ulcers, and functional decline

• Responsive to patient and family needs for more consistent patient support (often for non-clinical tasks)

• Best management of care of our elderly patients may reduce length of stay and reduce overall hospital costs

HELP Summary

• An organized, focused intervention with proven results

• reduces the incidence of delirium in hospitalized older adults

• optimizes independence at discharge

• improves the geriatric skills of hospital staff

• significant financial savings for the hospital through cost-avoidance

HELP at NBRHC

• Initiated in January of 2012

• funding approved by senior administration

• Elder Life Specialist hired

• Recruitment and training of volunteers is on-going

• Currently 11 volunteers providing 4 day/week service on general medicine wards

The Hospitalized Older Adult

•Psychiatric problems are common among hospitalized older adults

• Delirium - 30-75%

• Dementia with behavioural disturbance - 20%+

• Mood disturbances - 15-30%

• Substance abuse - 20%

Consequences of Psychiatric Co-morbidity

• Delirium

• Poor prognosis

• Mortality up to 75%

• 6-12 month mortality is >25%

• Depression

• Persists in the medically ill - often unrecognized

• Adverse effect medical outcomes

• Increase in mortality

• All diagnoses: Increase morbidity and mortality, increase length of stay, reduce likelihood of returning to home

The Seniors’ Mental Health Integrated Service(SMHIS)

• Team-based model of Geriatric Consultation-Liaison Psychiatry

• Registered Nurse Clinicians (1.6 FTE)

• Geriatric Psychiatrist

• Family Physician (Care of the Elderly)

Seniors’ Mental Health Integrated Service(SMHIS)

• Principles and Practice

• By referral from Most Responsible Physician

• Provide comprehensive mental health assessments of hospitalized seniors manifesting a psychiatric/behavioural disturbance

• Encourage evidence-based practice, support front-line hospital staff, and assist in transition/discharge planning process

• Liaise with community partners to support appropriate disposition and continuity of care

4.0%

20.0%

46.0%

29.0%

0% 20% 40% 60%

<65

65-74

75-84

>85

Ag

e

Sex Distribution (n=337)

46.0%

54.0%

0% 20% 40% 60%

Male

Female

Se

x

Age Distribution (n=337)

Sex Distribution (n=337)

SMHIS Referrals 2010-2011

50.0%

23.0%

10.0%

9.0%

8.0%

0% 10% 20% 30% 40% 50% 60%

Cognition

Behaviour

Delirium

Mood

Other

Reason for Referral

Title

47.0%

7.0%

6.0%

2.0%

4.0%

15.0%

21.0%

0% 10% 20% 30% 40% 50%

Dementia

Delirium

Mood Disorder

Substance Abuse

MCI

BPSD

Other

Psychiatric Diagnoses

Percentage (n=337)

21.5%

53.9%

26.3%

10.5%

30.0%

32.0%

0% 10% 20% 30% 40% 50% 60%

CVD

HTN

Diabetes

Renal Failure

ASHD

Other

Medical Diagnoses

48.0%

22.0%

9.0%

9.0%

5.0%

7.0%

0% 10% 20% 30% 40% 50% 60%

Home

LTCH

Retirement Home

Died

Still Inpatient

Other

Disposition

SMHIS – Future Directions

• on-going efforts to recruit another geriatric psychiatrist for the team

• outcome measures re:

• evidence-based geriatric care

• Impact on quality of care

• Impact on length of stay and disposition

• Patient/caregiver satisfaction

• Increase educational role

References

• Senior Friendly Hospital Care Across Ontario. K Wong, D Ryan, B Liu Regional Geriatric Program of Toronto, November 2011.

• A Summary of Senior Friendly Care in North East LHIN Hospitals. C Martel, M Auchinleck, K Rossi. Martell Consulting, June 2011.

• A multicomponent intervention to prevent delirium in hospitalized older patients. Inouye SK, Bogartus ST, Charpentier PA, et al. New England Journal of Medicine 340:9;669-76, 1999.