Senior friendly hospital care
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Senior Friendly Hospital Care. Dr. Grant McKercher North 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.

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Senior friendly hospital care

Senior Friendly Hospital Care

  • Dr. Grant McKercher

  • North Bay Regional Health Centre

CME Rounds 9 May 2012


Disclosures

Disclosures

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


Objectives

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

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 inpatientdays and 71.6% of ALCdays in 2009/10


Senior friendly hospital care

Complications of Hospitalization

Precipitating factors / Medical Interventions

Hospitalization

Complications


Hospitalization as a pivotal event

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

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


Senior friendly hospital care

  • “... 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

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

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

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

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

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

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

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

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

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

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

Senior Friendly Initiatives at the North Bay Regional Health Centre

Organizational Support

Processes of Care


Senior friendly initiatives at the north bay regional health centre1

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

Senior Friendly Initiatives at the North Bay Regional Health Centre

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

Next Steps

Key Themes

Anticipated Outcomes


Hospital elder life program help

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

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

Delirium

Four Criteria


Delirium outcomes

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

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

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

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

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

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

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

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

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

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

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

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

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


Senior friendly hospital care

SMHIS Referrals 2010-2011

Age Distribution (n=337)

Sex Distribution (n=337)


Senior friendly hospital care

Reason for Referral


Senior friendly hospital care

Psychiatric Diagnoses

Percentage (n=337)


Senior friendly hospital care

Medical Diagnoses


Senior friendly hospital care

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

SMHIS – Future Directions


References

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.


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