TRI OrientationGeriatric Rehabilitation

Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky ChauDr. Barry Goldlist | Dr. Dan Liberman | Dr. Karen Ng | Dr. Samir Sinha

Toronto Rehabilitation Institute, University Centre Site550 University Avenue

Toronto, Ontario, M5G 2A2(416) 586-4800 x 6641

Outline

• Introduction

• Geriatric consultations

• Clinics & Programs

• Rounds & Education

INTRODUCTION

Introduction

Acute medical illness & hospitalization often precipitate functional decline. Many factors

additionally contribute to further disability that often impacts rehabilitation.

Disability &

Functional Decline

Multiple medical

Comorbidities

Frailty

Acute Medical Illness &

Hospitalization

Conceptualizing Disability

WHO & ICF et al., 2002.

Impairment Activity Limitation Participation Restriction

Comprehensive Geriatric Assessment

Geriatric Rehabilitation

“ … a branch of geriatric medicine concerned with limiting the extent of disability, preventing functional

and social decline, and delaying or preventing loss of independence and institutionalization …”

AGS Education Committee. The Training of Geriatric Fellows in Rehabilitation: AGS Education Guidelines. 2002 .

A Specialized Focus

• Frail & medical complex older adults

• Holistic vs. Illness (e.g. stroke rehab) approach – All factors that impair function

• Multidisciplinary team

• Multifactorial & individualized interventions to improve function

Outcomes of Geriatric Rehabilitation

Outcomes At discharge At Follow Up

Function OR 1.75 (95% CI 1.31 to 2.35)

OR 1.36 (95% CI 1.07 to 1.71)

Nursing Home Admission

RR 0.64 (0.51 to 0.81) RR 0.84 (0.72 to 0.99)

Mortality RR 0.72 (0.55 to 0.95) 0.87 (0.77 to 0.97)

Bachmann et al., BMC 2010.

GERIATRIC CONSULTATIONS

Geriatric Consultation Team

• You!

• Geriatrician

• Florence Paat, Nurse Practitioner

Geriatric Referrals

• Automatic– Geriatric Rehabilitation Unit (6 South)– Geriatric Psychiatry Unit (5 South)– MSK Unit (7 & 8 South)

• Other– Other TRI floors

Geriatric Rehabilitation Unit (6 South)

• 25 bed inpatient unit built on a co-management model– Hospitalist (Dr. Robert Lam)– Geriatrician– Geriatric Nephrologist (Dr. Vanita Jassal)

• Geriatric patients & patients with dialysis needs are admitted into Team A, B, or C

• Consultations– Karlee Lin sends e-mail notifications of new admissions to geriatricians daily– Requests located in geriatrician mailbox on 6S nursing unit

Co-Management Focus

Geriatrics Hospitalist (MRP) Geriatric Nephrology

• Geriatric related issues (e.g. cognition, function, medications, pain, sleep, disposition)

• Management of complex medical diseases, if needed

• Management of complex medical diseases

• Urgent and/or medical emergencies

• Dialysis & Dialysis related issues*

* For dialysis patients, we complete a CGA and provide follow up as needed

Geriatric Psychiatry Unit (5 South)

• Locked unit of patients admitted with dementia related behaviours built upon a co-management model– Hospitalist (Dr. Tazkarji)– Geriatric Psychiatrist (Drs. Iaboni & Keren)

• Consultations– Requests obtained via May Seeto

MSK (7 & 8 South)

• Inpatient rehabilitation unit for patients with MSK conditions and/or those recovering after surgery built upon co-management model between hospitalist & physiatrist

• Consultation– All fractured hip patients transferred from MSH/TWH– Geriatricians receive e-mail notifications of newly

transferred patients

Limited Consultation & Follow Up

• Provides continuity of care and focused management of geriatric related issues– Cognition (e.g. delirium, depression)– Bone Health– Disposition

• Obtain MSH/TWH geriatric consultation, follow up, and sign out notes to assist with your management plan

Consult Recommendations

• GRU (6S)– Order blood work directly into EPR– Complete respective paper requisition for other investigations (e.g. ECG,

CXR, CT Head)– Write medication orders directly on order sheet

• MSK (7S & 8S)– Write suggestions in MRP’s black book

• Geriatric Psychiatry (5S)– Write suggestions in Dr. Tazkarji’s black book; or– E-mail Dr. Tazkarji (MRP) for recommendations

Consultation Notes

• All consultation notes are dictated– Include date, start/end times of consultation– Place written yellow consultation notes (if used) &

signed transcribed dictation notes in the chart

* Please ensure you obtain your UHN dictation code at the beginning of your rotation *

• Follow up notes written in multidisciplinary progress notes section

Sign-out Lists

*** ALWAYS UPDATE THE SIGN-OUT LIST ***

AMBULATORY CLINICS & PROGRAMS

Ambulatory Clinics

Geriatric Day Hospital Clinic at TRI (2nd Floor South Wing )Dr. Arielle Berger

Michelle Cordeiro (416) 597-3422 ext. 3065

Geriatric Medicine Clinic at Bickle Centre Complex Continuing Care

Specialty Clinics, Main Floor, Rm S-217Dr. Arielle Berger

Geriatric Nephrology Clinics at TGH (12NU Renal Clinics)Dr. Vanita Jassal

Samantha Ramsammy samantha.ramsammy@uhn.ca

Programs

Falls Prevention Program (2nd Floor, South Wing)Ramona Gheorghe, RN & Marlee Beallor, PT

416-597-3422 X 3777 or 3783

Geriatric Day Hospital Program (2nd Floor, South Wing)Michelle Cordeiro (416) 597-3422 ext. 3065

Inpatient Dialysis Program (Ground floor, East Entrance)Pre-arrange with Dr. Vanita Jassal

ROUNDS & EDUCATION

Weekly Rounds

Education

• Interprofessional learning with care coordinator (Karlee Lee), NP, wound care NP, OT, PT, Nutritionist, Pharmacist, SW, Recreational therapist

• Additional Quality and Risk Safety Rounds (q2nd Thursday of the month)

• Weekly article review

Resident Office

• 4th Floor, Room 131

• Obtain ID badge for access from: – Tracia Young, Medical Education Coordinator– 10th Floor, Room 119– 416-597-3422 x 3834

Thank You!

• Questions?