Functional Assessment

1. Functional Assessment Janice E. Knoefel, MD, MPH Professor of Medicine & Neurology University of New Mexico Retired - Geriatrics/Extended Care New Mexico Veterans Affairs Healthcare System Albuquerque, NM

2. Disclosure Statement:Dr. Knoefel has nothing to disclose

3. Learning Objectives:1. Understand the principles of Comprehensive Geriatric Assessment 2. Develop strategies to adapt CGA for individual clinical practices

4. Functional Assessment • The model, borrowed from traditional rehabilitation by the geriatric community, has developed into the principle of comprehensive geriatric assessment (CGA) • Rehabilitation wishes to identify and treat patients who benefit from rehabilitation; the clinician wishes to identify elderly at risk for functional decline and treat appropriately.

5. Functional Assessment • Developed in the late 1940s in the United Kingdom as a way to identify seniors in need of services • Adapted in the 1970s by US as a way to screen frail seniors who appeared to require nursing home care because of physical or cognitive decline. • Many undiagnosed illnesses, 15% mortality at 6 months • Initially an inpatient model, now outpatient care

6. Traditional Rehabilitation • Disease -> impairment -> disability -> handicap • Example: Degenerative joint disease (DJD) -> pain -> gait disturbance -> unable to access 2nd-floor apartment • Interventions: Disease-specific (nonsteroidal anti-inflammatory drugs [NSAIDs], total knee replacement [TKR]) -> impairment management (pain control) -> disability compensation (cane) ->environmental modification (move to 1st-floor apartment)

7. Functional Assessment • Clinicians often back into the issue: • Patient is failing, family is complaining, something is changing. • Why is patient not the same as last year, 2 years ago? • ?Undiagnosed new illness • ?Chronic condition worsening • ?Deconditioning,?Drug effects, ?Dementia

8. Functional Assessment: Goals • Identify limitations of patient ability to function in daily life. • Develop strategies/interventions to improve function. • In other words: What cannot be done, why cannot it, what can be done to fix the limitation (patient-based intervention) or change task (environmental remediation)

9. Functional Assessment • Dimensions of assessment: • Medical, including drug use • Functional • Physical • Cognitive • Sensory • Psychologic • Social

10. Functional Assessment • Core team members: • Physician/healthcare professional • Nurse/nurse practitioner/home care nurse • Social worker • Makeup of core team members dependent on setting, specific goals of assessment team

11. Functional Assessment • Ad hoc team members: • Dietitian • Pharmacist • Rehabilitation therapist(s) • Psychologist • Dentist • Spiritual counselor • Audiologist

12. Functional Assessment • Consultative versus primary care practice • Settings: • Outpatient clinic • Inpatient unit • Home and community • Long-term care facility

13. Functional Assessment • Components of assessment: • Targeting patients likely to benefit • Performing the evaluation, making recommendations • Implementing recommendations • Monitoring outcomes

14. Functional Assessment: Targeting Frail Elders • Prevalence of disability increases with age and some have recommended using age as one criteria (ie, all individuals older than 75 years). • Investigational criteria use a number of factors: Age, comorbidity, known functional deficits, psychologic and social factors (depression, social isolation), use of health care services

15. Functional Assessment: Targeting Frail Elders • Researchers have proposed using hospitalizations or ER visits as a proxy for a high-risk population. • Post hoc analysis showed that predictive factors were: • Number of medical diagnoses • Number of drugs • Loss of 2 or more intermediate activities of daily living (IADLs)

16. Functional Assessment: Targeting Frail Elders • My criteria: • New drug compliance issues • Cancellation or no-show for appointments • Family members start calling office • Family members start to accompany patient to office • Unexplained weight loss • Change in appearance or behavior

17. Functional Assessment: Targeting New Elders • New Medicare approved “Welcome to Medicare” examination - meant as a screening and preventive examination. • This is a one-time comprehensive medical review and physical examination in the first 6 months that patient has Part B Medicare coverage. • Good way to get baseline on patients newly eligible for Medicare, however, few meet the frail elderly designation.

18. Functional Assessment: Outcomes • Decreased NH admissions • Decreased drug use • Major and minor new diagnoses • Decreased annual medical cost of care • Decreased mortality rate, no loss of quality of life (QOL) • Increased independent function • Increased patient/family satisfaction

19. Functional Assessment • Medical assessment: • Current condition • Medical and surgical history • Drugs: Prescriptions, herbal supplements, and over-the-counter (OTC) drugs • Allergies • Habits: Tobacco, alcohol, diet, exercise • Health maintenance: Immunizations; dental, eye and hearing examinations; Fecal Occult Blood; mammogram; Pap test; breast examination • Family history

20. Functional Assessment • Social assessment: • Marital status, family members • Educational and occupational history • Housing status • Financial concerns, income status • Hobbies and activities • Sexual history • Religious preferences

21. Functional Assessment • Functional status: Activities of daily living (ADL) • Bathing • Dressing • Personal grooming • Eating • Transfers • Toileting • Continence • Ambulation

22. Functional Assessment • Functional status: IADL • Shopping • Meal preparation • Taking drugs • Housekeeping • Laundry • Transportation • Telephone use/communication • Managing personal finances

23. Functional Assessment • Functional status review counts as review of systems (ROS) • Supplement for additional ROS as needed • Advance directives • Driving: • Still driving? • Any accidents? • Change of driving habits? • Gotten lost, lost the car?

24. Functional Assessment • Physical examination: • Need to include some measure of visual and auditory acuity • Cognitive examination: Mini-Mental State Examination (MMSE) • Psychiatric examination: Geriatric Depression Scale • Performance examination: Get-up-and-go test • Neurologic examination: Other measures of balance and gait

25. Functional Assessment • Coding: Use evaluation and management (E/M) codes, aim for level 5 • History: • Chief report, history of present illness • Medical and surgical history • Drug review • Family and social history • ROS need to review 10+ systems • Examination: Multisystem examination needs to look at 8 of the 12 areas

26. Functional Assessment • Decision-making needs to be high complex: • 8 or more diagnoses • Review management of all diagnoses, but do not need to change if in agreement. • Diagnoses include constipation, pain, hearing loss, skin dx, dry eyes, etc. • Counseling can upgrade 1 level: Include time in minutes and subject of discussion

27. Functional Assessment • Delegate data collection • Minimize data recording time • Keep information needed for decision-making readily available • Delegate plan execution

28. Strategies for Saving Time • Previsit questionnaire: • Medical history: • Current drugs • Drug allergies • Surgical and medical diagnosis and procedures • Social history • Health maintenance and preventive services • Home safety checklist • Advance directives

29. Strategies for Saving Time • Specific questions on: • Vision • Hearing • Dentition • Falls • Urinary incontinence • Nutrition • Depression symptoms • Functional status

30. Strategies for Saving Time • Minimize data recording time: • Dictation • Templates • Word processing programs • Computerized medical records

31. Strategies for Saving Time • Keep information needed for decision-making readily available: • Pocket guides • PDA programs • Useful books and charts • Computer retrieval system

32. Strategies for Saving Time • Delegate plan execution: • Network of health professionals • Health educators • Patient education handouts

33. Assessing Care of the Vulnerable Elderly • Assessing Care of the Vulnerable Elders (ACOVE) • http://www.geronet.ucla.edu/centers/acove/index.htm • Can find: • Office forms • Physician education • Patient education • More information and reprints