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University of Nebraska Medical Center The University of Nebraska Medical Center

Pender Geriatric

Assessment Clinic

Evaluation

PHOTO GOES HERE (Need higher resolution

Natalie Manley, MD, MPH Katherine Jones, PT, PhD

June 25, 2010Critical Issues in Geriatrics:

The Annual NEBGEC Updates Conference

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University of Nebraska Medical Center

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Funded by•Health Resources and Services Administration Grant # D31HP08840

•Kinman-Oldfield Family Foundation

I have no conflicts of interest to disclose.

University of Nebraska Medical CenterUniversity of Nebraska Medical Center

Objectives

• Describe changes in the process of care resulting from a rural geriatric assessment clinic

• Identify how the “Big 5” of teamwork skills supports effective geriatric team care

• Examine the impact of a geriatric assessment clinic on a rural community

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Presenter

Presentation Notes


Background• Define comprehensive geriatric assessment

• Why do we need to increase access to comprehensive geriatric assessment in rural areas?

• How did we evaluate the rural geriatric assessment clinic in Pender, NE?

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Comprehensive Geriatric Assessment• Interprofessional process for evaluating an older adult

in the medical, cognitive, emotional, functional & social domains to optimize quality of life– Increase function

– Decrease polypharmacy

– Increase patient/family satisfaction

– Focus on • Prevention & early detection

• Preferences and Planning

• Integration of care with local resources

• Not achievable in 15 minute office visit!

Luchi et al. Standards of care in geriatric practice. Annu. Rev.Med. 2003;54:185-1965

Presenter

Presentation Notes

Interprofessional process for evaluating an older adult …medical, cognitive, emotional, functional & social domains to optimize quality of life…achieve diagnostic precision


Why GACs in Rural Nebraska?

CDC State of Aging and Health, 2007

• Aging of population; concentration of elderly in rural areas– Poorer health status of rural elderly

– Prevalence of multiple chronic health problems in elderly

• Decreased access of rural elderly to providers trained in geriatrics

“The challenge of providing for the large numbers of elderly anticipated over the next quarter century is…a major crisis for health care and for society…” AMA White Paper on Elderly Health

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Presenter

Presentation Notes

Perfect storm of an aging population with a higher concentration of elderly in rural areas and poor access to providers who possess essential competencies in geriatrics. Fewer than 100 US medical graduates purse postdoctoral training in geriatrics each year


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Presenter

Presentation Notes

In 46 of Nebraska’s 93 counties, 20% or more of the population is 65+; 13.5% 65+ in NE (ranked 18th in US); 12.8% 65+ in US


Pender GeriatricAssessment

Clinic

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Presenter

Presentation Notes

Pender Community Hospital located in Pender, NE. NEBGEC has collaborated with HCPs in Pender, Nebraska to develop a model for interdisciplinary evaluation of complex geriatric patients in rural communities by providing standardized instruments and guidance in team processes.” In Pender the team consists of a physician, nurse, physical therapist, certified mental health practitioner, and a consulting pharmacist. They have seen three patients per month since May, 21, 2008.

http://www.lifeworksnw.org/Portals/0/images/older-adults.png�


Mixed Methods Evaluation of an Interdisciplinary Geriatric Assessment Clinic in Rural Nebraska

• NEBGEC Objective 3

• Completed by a team

– Natalie Manley, MD, MPH– Katherine Jones, PT, PhD

– Anne Skinner, RHIA

– Carrol Baier, RN

– Sally Hand

• Supported by a team– HRSA

– Kinman-Oldfield Family Foundation9

Presenter

Presentation Notes

Improve the health outcomes of older patients in rural areas by providing rural practitioners, preceptors and trainees with geriatric interdisciplinary team training emphasizing evaluation of complex patients, especially those with dementia, mental health concerns and failing functional abilities. 3.a. Develop a model of interdisciplinary team training that meets needs of rural providers by using standard geriatric assessments in a monthly clinic 3.b. Replicate model at additional site in year two Vada Kinman Oldfield & Barney Oldfield


Mixed Methods: Quantitative + Qualitative

• Interviews (Patients/Family)

– Purposive Sampling

– 5 patients

– 4 spouses

– 5 adult children

• Focus Group (providers, hospital CEO, and administrative staff)

• Direct Observation

• Chart Review

• Surveys– Area Agency on Aging

– Senior Center (members)

– Peer Providers (4 MDs & 2 PAs)

Quantitative Qualitative

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Why Qualitative?

• Used to answer descriptive and exploratory questions

• The lived experience of patients and families provides a richer understanding of outcomes than numbers alone

• Enables development of theories that can be tested with subsequent quantitative studies

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Presenter

Presentation Notes

Used to answer descriptive and exploratory questions Ulin, Robinson, & Tolley (2005) recommend using qualitative methods “when the central objectives of an inquiry are to explore and explain behavior rather than to describe it, when the subject matter is unfamiliar and insufficiently researched, or when a suitable vocabulary with which to communicate with respondents is not available” Just as with a narrative approach to eliciting a social history, qualitative researchers seek the earthy and particular…which we describe as rich, thick data, which is textual in nature…it is what we see and hear…The lived experience of patients and families provides a richer understanding of outcomes than numbers alone


Theoretical Models as a Foundation• Pronovost’s Strategy for Organizational change

– Engage, Educate, Execute, Evaluate, Expand and Endure

• Salas’ Big 5 of Teamwork and Supporting Mechanisms– Team Leadership, Mutual Performance Monitoring,

Back-up Behavior, Adaptability, Team Orientation

– Shared Mental Model, Closed Loop Communication, Mutual Trust

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Presenter

Presentation Notes

engage: how do I make the world a better place Educate: what do I need to do Execute: how do we ensure we do it Evaluate: how will I know I made a difference? Team orientation: belief in the importance of team goal’s over individual members’ goals. KSA’s we looked at were in regards to geriatrics in general, community public health resources, and teamwork.

= Supporting Mechanism

= Big 5

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Objective OneDescribe changes in the process of care resulting from a rural geriatric assessment clinic…

• Chart review results for 45 patients seen May 2008 –December 2009– Majority (62%) referred by family

– Majority (82%) NOT hospitalized in past 6 months

– Majority (51%) taking 6 or more prescription drugs

– Presenting problems addressed represent typical geriatric syndromes

– Health maintenance issues addressed

– More medications started than stopped15

Presenter

Presentation Notes

Demographics of Patients at Presentation to the GACVariable Number (%) n = 45Age 80.58 (62-91)Female Sex 30 (66.7)Ethnicity

Caucausian 39 (86.7)American Indian 3 (6.7)

Marital StatusSingle, never married 3 (6.7)Married 19 (42.2)Widowed 23 (51.1)

EducationGrade 12 22 (48.9)Post High School Education 12 (26.7)

Living EnvironmentAlone in home 12 (26.7)In home with spouse 16 (35.6)

Referral SourcePhysician 10 (22.2)Family Member 28 (62.2)Area Office of Aging 1 (2.2)

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Presenter

Presentation Notes

Forty-five charts of clients seen at the GAC between May of 2008 and December of 2009 were reviewed. The average client age was about 80 years old and 2/3 were female. Approximately 87% were Caucasian with 6.7% being American Indian indicating that Thurston County includes American Indian reservation land. About half of the clients were widowed at the first encounter and 62% of the clients lived in their own home either alone or with a spouse. Two thirds of the clients seen were referred by family members. The one person referred by the Area Agency on Aging (AAA) was referred after I informed the AAA of the GICAP in October

Health Status at Presentation Number (%) n = 45ER Visits in the previous 6 mo

Zero 41 (91.1)One 4 (8.9)

Hospital Admissions in the previous 6 moZero 37 (82.2)One 8(17.8)

Intact Activities of Daily Living (ADLs) (out of 30) 26.3 ± 5.2 (13-30)Intact Instrumental ADLs (out of 30) 21.2 ± 7.1 (8-30)Number of Prescriptions Drugs

Zero 1 (2.2)1-5 18 (40)6-10 14 (31.2)11-15 9 (19.9)

Number of Non Prescription DrugsZero 10 (22.2)1 11 (24.4)2 9 (20)3-5 9 (20)

Geriatric SyndromesDecreased Vision 42 (93.3)Depression 29 (64.4)Dementia 27 (60)Difficulty Walking 1 Block 23 (51.1)Decreased Hearing 23 (51.1) 17

Presenter

Presentation Notes

~Vast majority of patients evaluated had not been seen in the ER or admitted to the hospital in the 6 months prior to their evaluation. This finding indicates that appropriate patients were evaluated; those for whom significant functional decline could be prevented or slowed. ~the Average # of intact Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) the clients had were 26 and 21 respectively; which is consistent with functional loss in dementia and depression. ~ 50% were on 6-15 prescription drugs at the first encounter (0-17) ~40% were on 2-5 non-prescription drugs. ~Most encountered geriatric syndromes: decreased vision and hearing, depression, Dementia difficulty walking one block. ~72% were referred because of cognitive decline


Problems Addressed• Durable Power Of Attorney

for Health Care…….100%

• Code Status …………..96%

• Other common problems addressed– Vision and Hearing

– Dementia

– Depression

– Walking

– Medication management

– Caregiver burden

• Process reflects domains of geriatric assessment and geriatric syndromes– Medical

– Cognitive

– Emotional

– Functional

– Social

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Presenter

Presentation Notes

The other most common issues addressed in the GAC recommendations were vision, dementia, medication management, walking, hearing, depression and caregiver burden, which closely matches the geriatric syndromes most commonly encountered shown in the previous table. Main geriatric syndromes… all impact whether or not a person will be able to stay in their own home.

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2

4

6

8

10

0 1 2 3 4 5 6 7 8 9

Num

ber o

f Pat

ient

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Number of Medications Started

Average # meds started per patient = 3.9

0

5

10

15

20

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0 1 2 3 4 5 6

Num

ber o

f Pat

ient

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Number of Medications Stopped

Average # meds stopped per patient = 1.04

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Presenter

Presentation Notes

About half of patients had at least one medication stopped. Will need to further investigate which medications were started and stopped. The average number of medications newly implemented was 3.9 per client and the average number of medications stopped was 1.04 per client. The average number of medications increased in dosage was 0.58 per client and the average number decreased in dose was 0.18 per client.

Health Maintenance Variable N (% within gender) N = 45

Male FemaleColonoscopy reminderColonoscopy stop

10 (66.7)4 (33.3)

17 (56.7)13 (43.3)

Dexa ReminderDexa StopDexa not addressed

5 (33.3)2 (13.3)8 (53.3)

23 (76.7)7 (23.3)0 (0)

Calcium and Vitamin D reminderCalcium and D stopCalcium and D not addressed

7 (46.7)1 (6.7)7 (46.7)

26 (86.7)0 (0)4 (13.3)

Bisphosphonate ReminderBisphosphonate stopBisphosphonate not addressed

0 (0)0 (0)15 (100)

7 (23.3)2 (6.7)20 (66.7)

Breast Cancer Screening reminderBreast Cancer Screening stop

20 (66.7)10 (33.3)

Prostate screening reminderProstate Screening stopProstate Screening not addressed

11 (73.3)3 (20)1 (6.7)

Influenza Vaccine reminderInfluenza Vaccine not addressed

15 (100)0

28 (93.3)1 (3.3)

Pneumovax reminder 15 (100) 29 (96.7)Zostavax ReminderZostavax Not Addressed

015 (100)

1 (3.3)28 (93.3)

Tetanus Reminder 15 (100) 28 (93.3)20

Presenter

Presentation Notes

Note that part of geriatrics is educating people as to when certain screening tests are no longer needed. For example, the USPSTF recommends that…..until age 75 if there are no signs, symptoms. 17 people were educated that colonoscopies were no longer necessary for them. The team did a good job about calcium and vitamin D reminders, but not as well with bisphosphonates. 66% of women were reminded to get a mammogram and 33% were told it was no longer necessary. They do a great job reminding about vaccinations except for the shingles vaccine.


Objective TwoIdentify how the “Big 5” of teamwork skills supports effective geriatric team care (are essential tools )

• Interviews (Patients/Family)

– Purposive Sampling

– 5 patients

– 4 spouses

– 5 adult children

• Focus Group with (providers, hospital CEO, and administrative staff)

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Presenter

Presentation Notes

Identify how the “Big 5” of teamwork skills are an essential tool to support effective geriatric team care Comprehensive Geriatric Assessment Clinics (GACs) Why GACs in rural Role of teamwork in Geriatric Assessment


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Teamwork in GACsComplementary skillsInterdependent tasksClear role expectations

Common purposePerformance goals Mutual accountability

Presenter

Presentation Notes

Teams have the potential to offer greater adaptability, productivity, and creativity than any one individual can offer (e.g., Gladstein, 1984; Hackman, 1987) and provide more complex, innovative, and comprehensive solutions to organizational problems Complementary skills Interdependent tasks Clear role expectations Common purpose Performance goals Mutual accountability


Role of Teamwork in GACs• Only a team can…

– Evaluate and plan across medical, psychological, functional & social domains to optimize quality of life

– Have extensive knowledge of aging process

– Provide proactive, longitudinal care

– Coordinate care and link to community resources

– Use communication skills to elicit and integrate patient’s values, goals, preferences into care plan

– Ensure safe, continuous care across settingsCassel CK. Policy for an aging society. JAMA. 2009;302:2701-2702.AGS Interdisciplinary Advisory Group. Interdisciplinary care for older adults with complex needs: AGS Position Statement. JAGS. 2006;54: 849-852. 23


Provider Themes Coded > 10%...reveal impact of teamwork skills

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0%

5%

10%

15%

20%

25%

30%

Presenter

Presentation Notes

For the providers the most common themes were: Communication, team members, challenges, clarity, team orientation.


Themes: Communication, Team Members, Challenges, Clarity, Team Orientation

Provider1: “I think they [get an understanding of all of the issues facing them]…especially when we are talking about change in living status…We want to try to keep them in their homes as long as we can, as safely as we can. Family input does help to get those things out in the forefront and then they start to realize that they do need to make some changes and that mom or dad really need this or that.”

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Themes: Shared Mental Model, Communication, Team Members, Clarity, Team Orientation,

Provider2: “We all pretty much have the same goals … a lot of times we all kind of catch the same drifts at the same time…I know it sounds impossible, but really it does happen.”

Provider1: “I do not think anyone is too proud—that they need control. If they hear one of the other [team] members say, ‘well maybe this would be a good idea,’ if that is different than what I came up with, no one is going to say, ‘well no, it's my way or the highway’.”

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Themes: Closed Loop Communication, Shared Mental Model, Communication

Provider1: “I probably need to do a better job [following up with referring physicians and] actually call them before they get the assessment and let them know that we saw the patient and that they will be getting it. We usually always fax or mail [the assessment results] right away as soon as I sign off on it so they have all the information. But, Sometimes it is nice to just pick up the phone and call to let them know what your initial thinking is on that patient.”

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Patient/Caregiver Themes Coded > 10%

0%

5%

10%

15%

20%

25%

30%

35%

40%

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Presenter

Presentation Notes

So you can see here the main themes discussed by the client/caregiver


Themes: Caregiver, Communication, Process, Clarity

Caregiver: “I knew they had tested him for Alzheimer’s and dementia… [I thought, ]‘Am I going to have to go home and really pull myself together…or is this something we can work out?’ Then when I got into [the family meeting]…they had not completely confirmed the Parkinson’s, but they said it was a pretty sure thing. I thought, ‘ok, this [is something] we can live with.’ So, then I was more calm.”

29http://home-care-lafayette-in.carebuzz.com/moving-elderly-parent-in/

Patient/Caregiver Themes

http://home-care-lafayette-in.carebuzz.com/moving-elderly-parent-in/�














Themes: Geriatric Knowledge, Evaluate;

Caregiver, Evaluate, Communicate, Process

Caregiver: “I have never heard a doctor tell her to take more Vitamin D and Calcium, they never talk about that. Provider1 ... told her to take more; that this was going to help her.”

Caregiver: “We could get the whole picture…What should we do with our family member? Do we want to keep them at home? Should we take them to live with someone? How it is all going to work? At least families are able to ask those questions.”

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Patient/Caregiver Themes

http://www.lifeworksnw.org/Portals/0/images/older-adults.png

http://www.lifeworksnw.org/Portals/0/images/older-adults.png�


Patient/Family vs. Provider Focus Group

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0%

5%

10%

15%

20%

25%

30%

35%

40%

family/caregiver

focus group* *

* * **

Presenter

Presentation Notes

What is interesting to see is that clarity of problem identification and treatment planning, the major theme of our results, was coded with at the same proportion for the focus group and the interview participants. This finding indicates that clarity in problem identification and planning is the shared team objective – the share value-- of the providers, patients, and families. Similarly social implications of the GICAP and support systems for the client/family were approximately equally coded for each group, which demonstrates the shared value for importance of the GICAP in terms of the non-medical aspects of health. But acceptance of change came up much more often for the client/family. Lastly, the client/family were more often coded for their evaluation of outcomes than were the focus group participants. This result is another indicator of a lack of evaluation of client/family outcomes by the GICAP team.


Effective teamwork enables clarity in problem identification and planning

“One of our patients really summed it up for me, that this was just a defining moment…She sat while [we were] doing the recommendations and her family was there and we brought up a lot of issues that were problems for her that she could not talk about to them… She could not say, ‘I need help with this or I am having these kind of problems.’ She said, ‘I am so glad we are able to talk about this and bring it out in the open’.”

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Effective teamwork enables clarity in problem identification and planning

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Interviewer: “What did you like about [the team approach]?”

Male Patient: “They (GAC team) are all sitting there, and they can talk amongst themselves [about] what should be done. Otherwise, if you go see one and then wait an hour and go see another one, then you don’t know what is getting communicated and what is not.”


Objective ThreeExamine the impact of a geriatric assessment clinic on a rural community

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Clarity in problem identification and planning achieve goal of geriatric assessment… improved quality of life

Presenter

Presentation Notes



Objective ThreeExamine the impact of a geriatric assessment clinic on a rural community Family Member: “It sure helped us.

….what should we do with our family member? Do we want to keep them at home? Should we take them to live with someone? How it is all going to work? At least families are able to ask those questions. Find out resources—I think Provider1 has been one of the only ones that has shown an interest to do that.

•.”35http://home-care-lafayette-in.carebuzz.com/moving-elderly-parent-in/

Presenter

Presentation Notes




“It’s amazing how someone comes in and they’re a mess in the morning and in the afternoon or by the follow-up they have this figured out in their head. Where do I live, their meds and all that stuff. It is all straightened out.”

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Examine the impact of a geriatric assessment clinic on a rural community

Objective Three


Objective ThreeExamine the impact of a geriatric assessment clinic on a rural community Caregiver: “She (LMHP)

enlightened us about things that we could [do]…nursing home, getting their money and financial situations in order because you never know….We handled a lot of family financial things—a Power-of-Attorney medically and financially; put money in a trust. You know, that kind of stuff.”

37http://www.homehelpersnyc.com/

Presenter

Presentation Notes


http://www.homehelpersnyc.com/�


SummaryWhat are the essential structures and processes needed to evaluate complex geriatric patients in a rural community?

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Team Members

Evidence-based processes of comprehensive geriatric assessment

Value the “Big Five” of teamwork as a means to achieve comprehensive geriatric assessment

Support from administration and peers

Presenter

Presentation Notes

These were the methods with which I answered the question


Team structure is essentialProvider1: “You do need to have somebody that …is willing to look for the key players to implement the ideas as you cannot do it on your own.”

Provider4: “There are no major egos here. We're all just there to help.”

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Presenter

Presentation Notes



Support from administration and peers is essential

CEO: “Honestly, financially it is not going to be a huge money maker—but I do not think that is what is important. There are a lot of services that we provide because they provide tremendous benefits [to the patients and families].”

Peer Physician: “…following very thorough evaluation [at the GAC and] many changes in care implemented—[the patient] has been more active, more up-beat, and repeat visits have been decreased.”

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Presenter

Presentation Notes



Previous ToolsWhat are the essential structures and processes needed to evaluate complex geriatric patients in a rural community?

Evidence-based processes of care…tools summarized by Dr. Timm last year; tool kit available at http://www.unmc.edu/intmed/geriatrics/nebgec/index.cfm?conref=46

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GAC Pre-Visit Questionnaire

Berg Balance Scale

Geriatric Depression Scale

Mini Mental State Exam

Montreal Cognitive Assessment

Physician Orders

Physician Physical Assessment

Presenter

Presentation Notes


http://www.unmc.edu/intmed/geriatrics/nebgec/index.cfm?conref=46�


New Tools• General Screening Recommendations for

Chronic Disease and Risk Factors in Older Adults – From The Hartford Institute for Geriatric Nursing

– American Geriatrics Society: health screening decisions for older adults should be individualized and based on the patient’s life expectancy, preferences, plan for what the patient may or may not want to do further if screening had positive findings as well as degree of burden to the patient.

http://consultgerirn.org/uploads/File/trythis/try_this_27.pdf42

http://consultgerirn.org/uploads/File/trythis/try_this_27.pdf�


New Tools• Multidisciplinary Competencies in the Care of

Older Adults at the Completion of the Entry-level Health Professional Degree – From The Partnership for Health in Aging; convened

by AGS in 2008

– 23 geriatrics core competencies that all healthcare providers should have to better care for elderly patients

http://www.americangeriatrics.org/files/documents/health_care_pros/PHA_Multidisc_Competencies.pdf

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http://www.americangeriatrics.org/files/documents/health_care_pros/PHA_Multidisc_Competencies.pdf�

http://www.americangeriatrics.org/files/documents/health_care_pros/PHA_Multidisc_Competencies.pdf�


New Tools• Teamwork Attitudes Questionnaire

– T-TAQ assesses attitudes toward the core components of teamwork

• Developed as part of Agency for Healthcare Research and Quality’s National Implementation of TeamSTEPPS

• Complete instructions available at http://teamstepps.ahrq.gov/abouttoolsmaterials.htm

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http://teamstepps.ahrq.gov/abouttoolsmaterials.htm�


Other Findings… • Extended Family and referring physician need

to be included as integral members of the team

• Need to follow-up with patients/families 6 mo -1 yr after assessment to evaluate outcomes

• Community resources for older adults not well known

• Stigma associated with clinic name

45

Presenter

Presentation Notes

Family members not involved regularly or involved too late Family unsure of process/outcomes of the GAC. Team assumes one family member will inform all others (and only provide one pamphlet)


Policy Issues• CMS does not reimburse for

– Family counseling in absence of the patient

– Record Review

– Outpatient nutrition assessment in Critical Access Hospital setting

• Need for more providers with minimal competencies in geriatrics

• Healthcare reform addresses geriatric issueshttp://www.americangeriatrics.org/advocacy_public_policy/health_care_reform/ 46

Presenter

Presentation Notes

Geriatric education and training; career awards; comprehensive geriatric education (Sec. 5305) Authorizes funding to geriatric education centers to support training in geriatrics, chronic care management, and long‐term care for faculty in health professions schools and family caregivers; develop curricula and best practices in geriatrics; expand the geriatric career awards to advanced practice nurses, clinical social workers, pharmacists, and psychologists; and establish traineeships for individuals who are preparing for advanced education nursing degrees in geriatric nursing. Expanding Access to Primary Care Services and General Surgery Services (Sec. 5501) Would establish a new 10% bonus on select E&M codes under the Medicare fee schedule for five years, beginning Jan. 1, 2011 for primary care practitioners, including those in FM, IM, geriatric or pediatric medicine (also includes advanced practice nurse or physician assistant). Practitioners must furnish 60% of their services in the select codes. Half of the cost of the bonuses would be offset through an across‐the‐board reduction to all other codes. Distribution of Additional Residency Positions (Sec. 5503) Beginning July 1, 2011, directs the Secretary to redistribute residency positions that have been unfilled for the prior three cost reports and directs those slots for training of primary care physicians. In distributing the residency slots under this section, special preference will be given to programs located in States with a low physician resident to general population ratio and to programs located in States with the highest ratio of population living in a health professional shortage area (HPSA) relative to the general population.

http://www.americangeriatrics.org/advocacy_public_policy/health_care_reform/�

http://www.americangeriatrics.org/advocacy_public_policy/health_care_reform/�


Future Research• Role of adult children in GAC… If adult

children are not involved in the GAC process, then recommendations are less likely to be carried out.

• Role of onsite pharmacist…If an onsite pharmacist specialized in geriatrics is not available, then fewer medications will be stopped.

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Questions?

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Presenter

Presentation Notes

Talk about what I got out of this….

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