ADVANCING THE HEALTH OF OLDER ADULTS IN PRIMARY CARE The issue - - PowerPoint PPT Presentation

ADVANCING THE HEALTH OF OLDER ADULTS IN PRIMARY CARE

The issue

FRAILTY…

• State of Increased Vulnerability to Stressors
• MulGdimensional Syndrome
• Predicts Risk for Adverse Outcomes

(disability, hospital/ER visits, and death)

• Higher Prevalence in Older ages, Women,

and those with Lower SES

physical frailty cogni0ve frailty social frailty psychological frailty

• Late presentaGon of frailty to acute care services
• FragmentaGon of care
• Difficulty navigaGng
• Caregiver burnout
• Long wait Gmes for referrals
• Increased complexity and polypharmacy
• UnderuGlized Primary Care Network resources
• No standards of pracGce for frailty idenGficaGon

& management in primary care

Our soluGon

NHS Report High propor0on of professional care More complex cases 70-80% of people with long-term condi0ons Equally shared care High Risk Cases High propor0on

• f self care

“guided self care”

Integrated Model of Care

Re Re-Design Care Hospital centric à Community based ReacGve à ProacGve, preventaGve Disease oriented à Capacity focused

Integrated Care

In Insp spir ire Healt e Healthy Agin y Aging g

HolisGc approach to addressing the dynamic needs of those living with frailty & supporGng their caregivers In Integr egrated ed Ca Care e

Mental Health

Mental Wellness 101 – Intake Group SMART Recovery Addictions Support OCD Group Therapy Mindful Based Cognitive Therapy (MBCT) Anxiety and Depression Group Therapy Grief Group Therapy Effective Communication Insomnia Group Craving Change Individual Counselling Social Work Navigation Transitions – Adult Autism Program

Dietitian (Nutrition)

Healthy Eating 101 Eating Well the Mediterranean Way Cooking with Beans Cooking for One Healthy Meal Panning Label Reading Protein & Fibre: Am I Getting Enough? Craving Change Individual Counselling and Education

Disease Management & Nursing

Chronic Disease Mgmt INR & Injections Prenatal Nursing Care

Build on Prior Investment

Kinesiology (Exercise and Ac<ve Living)

Ac0ve Living 101 Move Program Edmonton Oliver Lifestyle Program (EOLP) Individual Fitness Counselling and Educa0on Prescrip0on to Get Ac0ve

Pharmacy Services

Tobacco Cessa0on Pharmacy Discharge Individual Counselling Medica0on Reconcilia0on

Referrals & Screening

Specialist Referrals Patient Health Screening Panel Management

The innovaGon

• Community-based
• Interprofessional team

approach

• Joint care planning &

assessment of care needs

• Case management
• RelaGonal & informaGonal

conGnuity

Pa0ent &

Family/Friend

Caregiver

Structured Process of Care

FRAILTY IDENTIFICATION Case-finding and risk straGficaGon

• Valid tool; Time and

resource efficient; Risk score

• Electronic Frailty Index

1

FRAILTY ASSESSMENT MulG-domain assessment to define components of frailty

• Team approach
• Primary care nurse as case

manager

2

FRAILTY MANAGEMENT Addressing components of frailty

• Falls prevenGon
• Self management strategies
• Exercise/nutriGon
• SupporGve Care Planning
• Structured MedicaGon review
• Community ConnecGons
• Referral for Comprehensive

Geriatric Assessment/COE

3

Case-finding InnovaGon - eFI

Electronic Fr Frailty Index from m Prima mary Care Data 36 Deficits (mapped to over 1000 read codes):

• Diseases, FuncGonal AbiliGes,

DisabiliGes, Labs Risk StraGfying Tool:

• Fit 0-0.12 (<5 deficits)
• Mild Frailty 0.13-0.24 (5-8 deficits)
• Moderate 0.25-0.36 (9-12 deficits)
• Severe Frailty >0.36 (13+ deficits)

NaGonal ImplementaGon in the United Kingdom 1

Bo Box 1. x 1. Li List of Defici

• f Deficits i

incl cluded ed i in t the e eFI FI

Arthri0s Ischaemic heart disease COPD Respiratory disease Atrial Fibrilla0on Dizziness Osteoporosis Falls Cerebrovascular disease Memory and cogni0ve problems Chronic kidney disease Weight loss and anorexia Diabetes Sleep disturbance Skin ulcer Urinary incon0nence Peripheral vascular disease Polypharmacy Thyroid Disease Dyspnea Foot problems Ac0vity Limita0on Fragility fracture Visual impairment Pep0c ulcer Housebound Heart failure Hearing impairment Heart valve disease Requirement for care Parkinsonism and tremor Mobility and transfer problems Hypertension Social vulnerability Hypotension/syncope Anemia and hema0nic deficiency

Example panel results using the UK eFI (manual extracGon)

• Panel = 835, n(65+) = 62

(7% of the total number)

• Age: mean = 74.2
• Female - 43 (69%)

fit (0 - 0.12) 43% mild (0.13 - 0.24) 49% moderate (0.25 - 0.36) 6% severe (>0.36) 2%

5 4 3 2 1

FIT MILD

MODERATE

SEVERE

Popula0on Density

eFI 0-0.12 (<5 deficits)- none to few chronic condi-ons that are well controlled. Independent in ADLs, IADLs. eFI 0.13-0.24 (5-8 deficits) appear to be slowing down, may need help with IADLs like finances/transporta-on/shopping eFI 0.25-0.36 (9-12 deficits) may have difficulty with outdoor ac-vi-es, mobility issues, require help with some ADLs like washing/dressing eFI >0.36 oDen dependent for personal care, have a range of long term condi-ons

àHealthy Ageing Programs àSupported Self- Management à Care & Support Planning àEoL / Pallia0ve Care

Structured Process

• f Care

STEP 1 1

FRAILTY IDENTIFICATION Case finding and risk stratification FRAILTY ASSESSMENT Multi-domain assessment to define components of frailty FRAILTY MANAGEMENT Addressing components

• f frailty

STEP 2 2 STEP 3 3

Education of Healthcare Workforce

• Curriculum on

interprofessional core competencies and principles of geriatric care;

• Toolkit & Skills session on

case finding tools, conducting multi-domain assessment, and care planning.

Patient & Caregiver Empowerment

• Patients and families

engaged as partners in design, delivery, and evaluation of care;

• Patient & Family Advisory

Board;

• Clinic environment to

enhance patient experience.

Partnership in Care

• Integrating care with

social and community support services;

• Health Technology as a

partner (e.g. clinical support triggers in EMR, automate frailty index);

• Clinical, Academic &

Intersectoral bridges (Strategic clinical networks; Researchers, Smart City Challenge).

Metrics

• Building consistency of

care processes and measurement to improve capacity to collect, analyze and use data.

• Patient-oriented,

provider and health system measures

Outcomes

Outcomes

Patient-Oriented Provider System

• Functional status using SMAF
• Level of frailty (change in index)
• Appropriateness of meds (START/

STOPP)

• Quality of life using EQ-5D/VAS
• Carer burden (Caregiver risk

screening tool)

• Satisfaction of services provided
• Perceptions on collaborative

practice

• Satisfaction with care provided
• Number of ER visits
• Hospital admission days
• Long-term care admission
• Death

Results

LIVING ACCOMODATION Living Alone 30 Independent home living 74 Private Supportive Living 11 Designated Supportive Living 2 Other 1

88

PATIENTS

Females 53 Males 28

AGE Avg/Mean 81 MARITAL STATUS Married 46 Divorced 5 Single 8 Widowed 28 Unknown 1 EDUCATION Primary (K-9) 16 Secondary (Gr. 10-12) 39 Post-Secondary 31 Unknown 1 CHRONIC CONDITIONS Average Number 5 TOP CONDITIONS Arthritis 70 Hypertension 59 Hyperlipidemia 51 Atrial fibrillation 32 COPD 25 AVG NO. of MEDS 9 Medications Mean eFI Score 0.30 Mean FI-CGA 0.35 MAIN REASON PATIENT ASSESSED: Cognition 29 Falls & mobility 27 Chronic pain 16 Depression 15 Caregiver Burden 10 Medication Review 10 Medically complex 9

The InternaGonal ConsorGum for Health Outcomes Measurement (ICHOM)

Available from: hap:// www.ichom.org/medical- condi0ons/older-person/

Successes of the program thus far

Improvements in these pa0ent

• riented outcomes:

Impact

“I am very happy, and I feel listened to.” “HUB makes me feel more confident about how I can deliver elderly care.”

“… aware of the value that everyone in every position is providing now… from reception to the nursing, to how the EMR is working, to the doctors, everything.. work end-to-end a little bit better in this model.”

“We have helped pa0ents and their caregivers in a variety of ways from providing emo0onal support, assis0ng physicians with obtaining diagnoses, linking to community programs such as home care, reducing medica0ons and finding suitable housing.” “If it wasn’t for that appointment with the Hub, my dad would be in long-term care … doing nothing with his life.” “The Seniors’ Community Hub has really helped me with my diabetes… I am really happy with my care, it is helpful for planning and has given me better knowledge.” “Rather than trying to make the patient population fit into their program, they are continuously flexing their initial plan, as they learn more about their patients and their needs…” – citizen advisor

Challenges & RecommendaGons

Adding More to Primary Care “My Bucket is Full”

Practice Change Management ADKAR Model

Awareness Desire Knowledge Abilities Reinforcement

Frailty Intrinsic Capacity

Acceptance of “frailty”

SENSORY PSYCHOLOGICAL LOCOMOTION COGNITION VITALITY

Time

• rienta0on

Three words recall Abdominal

• besity

BMI Grip Strength Snellen test Audiometry or whisper test Low energy/ fa0gue Core symptoms

• f depression

ASSESSMENT OF INTRINSIC CAPACITY

Balance Chair Test Gait speed

INTRINS INTRINSIC IC CAP CAPACITY CITY

• Comprehensive Care Plan: incorpora0ng IC and self-management

Management of complex long term chronic condi0ons Social Care and support Comprehensive Health Assessment plus

IC monitoring:

• Physical mobility
• Vitality
• Psychosocial
• Sensory
• Cogni0ve

Geriatric assessment:

• Nutri0onal assessment
• Medica0on review
• Mul0morbidity/chronic

disease evalua0on

• Environment assessment
• Care and support needs

Tradi<onal clinical evalua<on:

• Single disease and risk factor

iden0fica0on and treatment

Older Person IC mul<dimensional programs:

• Mul0modal exercise program including

strength progressive resistance training

• Increase in protein intake, dietary advice,
• ral nutri0onal supplements
• Cogni0ve s0mula0on in psychological

interven0ons

• Visual and healing screening followed by

0mely provision of ear and eye care

Opera0onalising the concept of intrinsic capacity in clinical sefng. WHO Clinical consor0um on healthy ageing November 21-22, 2017.

Marjan Abbasi Marjan.Abbasi@albertahealthservices.ca Sheny Khera skhera@ualberta.ca