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

physical frailty FRAILTY… • State of Increased Vulnerability to Stressors cogni0ve • MulGdimensional Syndrome frailty • Predicts Risk for Adverse Outcomes (disability, hospital/ER visits, and death) social frailty • Higher Prevalence in Older ages, Women, and those with Lower SES 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

Integrated Model of Care High propor0on of High Risk Cases professional care Re Re-Design Care More complex Equally shared care Hospital centric à cases Community based ReacGve à High propor0on 70-80% of people ProacGve, preventaGve of self care with long-term “guided self care” condi0ons Disease oriented à Capacity focused NHS Report

Integrated Care In Integr egrated ed Care Ca e Insp In spir ire Healt e Healthy Agin y Aging g HolisGc approach to addressing the dynamic needs of those living with frailty & supporGng their caregivers

Build on Prior Investment Mental Health Mental Wellness 101 – Intake Group SMART Recovery Addictions Support OCD Group Therapy Dietitian (Nutrition) Mindful Based Cognitive Therapy (MBCT) Healthy Eating 101 Anxiety and Depression Group Therapy Eating Well the Mediterranean Way Grief Group Therapy Cooking with Beans Effective Communication Cooking for One Insomnia Group Disease Management & Nursing Healthy Meal Panning Craving Change Label Reading Chronic Disease Mgmt Individual Counselling Protein & Fibre: Am I Getting Enough? INR & Injections Social Work Navigation Craving Change Prenatal Nursing Care Transitions – Adult Autism Program Individual Counselling and Education

Kinesiology (Exercise and Ac<ve Living) Pharmacy Services Ac0ve Living 101 Referrals & Screening Move Program Tobacco Cessa0on Edmonton Oliver Lifestyle Program (EOLP) Pharmacy Discharge Specialist Referrals Individual Fitness Counselling and Educa0on Individual Counselling Patient Health Screening Prescrip0on to Get Ac0ve Medica0on Reconcilia0on Panel Management

The innovaGon

• Community-based • Interprofessional team approach • Joint care planning & assessment of care needs Pa0ent & • Case management Family/Friend Caregiver • RelaGonal & informaGonal conGnuity

Structured Process of Care 1 2 3 FRAILTY IDENTIFICATION FRAILTY ASSESSMENT FRAILTY MANAGEMENT Case-finding and risk MulG-domain assessment Addressing components of straGficaGon to define components of frailty frailty • Valid tool; Time and • Falls prevenGon • Self management strategies resource efficient; Risk • Team approach score • Exercise/nutriGon • Primary care nurse as case • SupporGve Care Planning • Electronic Frailty Index manager • Structured MedicaGon review • Community ConnecGons • Referral for Comprehensive Geriatric Assessment/COE

Case-finding Bo Box 1. x 1. Li List of Defici of Deficits i incl cluded ed i in t the e eFI FI Arthri0s Ischaemic heart disease InnovaGon - eFI COPD Respiratory disease Atrial Fibrilla0on Dizziness Osteoporosis Falls Electronic Fr Frailty Index from m Prima mary Care Data Memory and cogni0ve Cerebrovascular disease 36 Deficits (mapped to over 1000 read codes): problems Chronic kidney disease Weight loss and anorexia • Diseases, FuncGonal AbiliGes, Diabetes Sleep disturbance DisabiliGes, Labs Skin ulcer Urinary incon0nence Risk StraGfying Tool: Peripheral vascular disease Polypharmacy Thyroid Disease Dyspnea • Fit 0-0.12 (<5 deficits) Foot problems Ac0vity Limita0on • Mild Frailty 0.13-0.24 (5-8 deficits) Fragility fracture Visual impairment Pep0c ulcer Housebound • Moderate 0.25-0.36 (9-12 deficits) Heart failure Hearing impairment • Severe Frailty >0.36 (13+ deficits) Heart valve disease Requirement for care Parkinsonism and tremor Mobility and transfer problems Hypertension Social vulnerability NaGonal ImplementaGon in the United Kingdom 1 Hypotension/syncope Anemia and hema0nic deficiency

Example panel results using the UK eFI (manual extracGon) moderate severe (>0.36) (0.25 - 0.36) 2% 6% • Panel = 835, n(65+) = 62 (7% of the total number) fit (0 - 0.12) • Age: mean = 74.2 43% • Female - 43 (69%) mild (0.13 - 0.24) 49%

eFI 0-0.12 (<5 deficits)- none to few chronic à Healthy Ageing condi-ons that are well controlled. Independent in Programs 5 FIT ADLs, IADLs. eFI 0.13-0.24 (5-8 deficits) appear to be à Supported Self- 4 slowing down, may need help with IADLs Management MILD like finances/transporta-on/shopping 3 eFI 0.25-0.36 (9-12 deficits) may have à Care & Support difficulty with outdoor ac-vi-es, Planning mobility issues, require help with some 2 MODERATE ADLs like washing/dressing Popula0on Density 1 SEVERE eFI >0.36 oDen dependent for à EoL / personal care, have a range of Pallia0ve Care long term condi-ons 0

Structured Process Education of Patient & Caregiver Partnership in Care Metrics of Care Healthcare Workforce Empowerment FRAILTY • Curriculum on • Patients and families • Integrating care with • Building consistency of IDENTIFICATION interprofessional core engaged as partners in social and community care processes and 1 STEP 1 Case finding and risk competencies and design, delivery, and support services; measurement to stratification principles of geriatric care; evaluation of care; improve capacity to • Health Technology as a collect, analyze and • Toolkit & Skills session on • Patient & Family Advisory partner (e.g. clinical use data. case finding tools, Board; support triggers in EMR, conducting multi-domain automate frailty index); • Patient-oriented, FRAILTY ASSESSMENT 2 STEP 2 • Clinic environment to assessment, and care provider and health Multi-domain assessment enhance patient • Clinical, Academic & planning. system measures to define components of experience. Intersectoral bridges frailty (Strategic clinical networks; Researchers, Smart City Challenge). FRAILTY MANAGEMENT 3 STEP 3 Addressing components of frailty

Outcomes

Outcomes Patient-Oriented Provider System • Functional status using SMAF • Perceptions on collaborative • Number of ER visits • Level of frailty (change in index) practice • Hospital admission days • Appropriateness of meds (START/ • Satisfaction with care provided • Long-term care admission STOPP) • Death • Quality of life using EQ-5D/VAS • Carer burden (Caregiver risk screening tool) • Satisfaction of services provided

Results

88 PATIENTS AGE EDUCATION CHRONIC CONDITIONS MAIN REASON Avg/Mean 81 Primary (K-9) 16 Average Number 5 PATIENT ASSESSED: Secondary (Gr. 10-12) 39 Cognition 29 TOP CONDITIONS Post-Secondary 31 Falls & mobility 27 Females 53 Arthritis 70 Unknown 1 Chronic pain 16 Hypertension 59 Depression 15 Hyperlipidemia 51 Caregiver Burden 10 Atrial fibrillation 32 Medication Review 10 COPD 25 Medically complex 9 Males 28 MARITAL STATUS AVG NO. of MEDS LIVING ACCOMODATION Mean eFI Score 0.30 Married 46 9 Medications Living Alone 30 Mean FI-CGA 0.35 Divorced 5 Independent home living 74 Single 8 Private Supportive Living 11 Widowed 28 Designated Supportive Unknown 1 Living 2 Other 1

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 oriented outcomes:

Impact

“If it wasn’t for that appointment with the Hub, my dad “Rather than trying to make the patient would be in long-term care … doing nothing with his life.” population fit into their program, they are continuously flexing their initial plan, as they learn more about their patients and “I am very their needs … ” – citizen advisor happy, and I “HUB makes me feel listened feel more confident to.” about how I can “ … aware of the value that everyone in every position is deliver elderly care.” providing now … from reception to the nursing, to how the EMR is working, to “We have helped pa0ents and their the doctors, everything.. caregivers in a variety of ways from work end-to-end a little bit providing emo0onal support, assis0ng better in this model.” “The Seniors’ Community Hub has physicians with obtaining diagnoses, really helped me with my linking to community programs such diabetes … I am really happy with as home care, reducing medica0ons my care, it is helpful for planning and finding suitable housing.” and has given me better knowledge.”

Challenges & RecommendaGons

Adding More to Primary Care “My Bucket is Full”

Practice Change Management ADKAR Model Reinforcement Abilities Knowledge Desire Awareness

Acceptance of “frailty” Frailty Intrinsic Capacity