CARES: Com m unity Action & Resources Em pow ering Seniors A - PowerPoint PPT Presentation

CARES: Com m unity Action & Resources Em pow ering Seniors A Model for Early Frailty Assessment and Management in Primary Care Annette Garm, Fraser Health 1 1

Problem Statem ent  Early-frail seniors are becoming more frail unnece cess ssarily Imagine a frailty management plan that: - Supports GPs with enhanced assessment and planning - Increases seniors’ self management - Supports research 2 2

Evidenced Based Aim To proactively delay frailty in early frail seniors:  Periodic comprehensive geriatric assessments (CGA) are associated with better health outcomes for the pre-frail senior (Beswick et al., 2008).  Augment health assessments to enhance seniors natural protective factors with wellness planning and coaching (Wang et al., 2014).  Primary care providers are ideally situated to incorporate proactive and best practices in their daily clinical work (Lacas et al., 2012). 3 3

The CARES 4 -Step Model for Frailty Prevention in Prim ary Care Wellness Comprehensive Active Case Intervention: Benefits & Geriatric Summary/ Finding for At Health Outcomes of Assessment & Community Frailty Indexing Risk Seniors Coaching CARES Referral (eFI-CGA) Primary care team Senior receives over- identify “at risk” 1.Seniors age well; risk the-phone health senior in for frailty decreased. A Comprehensive A summary of the CGA coaching for up to 6 community Geriatric Assessment is shared with the months to address 2.Reduce acute & ED (eFI-CGA) is completed patient and a referral frailty: nutrition, utilization. by Physician & Nurse to a community health exercise and social Selection criteria: 3.Enhance provider in the EMR. coach is made as part engagement. Rockwood CFS 3-6 experience. of the senior’s and chronic Frailty Index supports Wellness Plan 4.Delay admission to disease individualized care eFI-CGA repeated at 6 residential care. management planning. months to review issues. impact of coaching. Early Assessment and Frailty Management Process 4 4

Frailty Prevention and CARES Program : Benefits for the Physicians, Patients and the Com m unity What are the benefits to physicians/ nurse practitioners? • Enhanced access to frailty education. What are the benefits to patients? • Evidence-based frailty • Reassurance of a comprehensive frailty assessment. Physicians assessment tool in EMR. Patients • Ability to participate in wellness planning. /GPs • Improved sensitivity in • Opportunity to develop self management capacity. measurement of frailty with • Support and navigation of community resources access to CGA and Frailty • Evidenced based health aging approach that decreases Index. their chance for frailty in the future • Ability to track and monitor frailty over time with Frailty • Improved seniors’ health and quality of life in Community Index (FI). later years • In-office support to complete eFI- CGA and assist with care planning. How will Fraser Health support this work? • Provide education on frailty and use of eFI-CGA. What are the benefits to the community? • Implementation support for eFI-CGA tools into clinic EMR. • More seniors with wellness plans that are engaging with community partners to stay healthy and active. • Provide in-office support for completion of eFI-CGA • Reduced number of seniors with frailty. • Provide seniors with take-home Wellness Plans and • Reduced admissions to hospital/residential care. information on healthy ageing and frailty prevention • Provide a model for early frailty assessment and • Follow up with seniors for evaluation frailty prevention for at risk seniors. • Support with the primary care patient medical home model • Build capacity between primary care settings, through joint practice patients and Self-Management BC to prevent frailty 5 5

The Pathway to Deploying CARES in Primary Care Oct 2017 Identify DoFP agrees Project willing to proceed team Establish clinics meets legal physician agreement Project Frailty team education Installs Physician for RN begins eFI-CGA recruits 10 physicians eFI-CGA patients assessment Physician finishes eFI-CGA & Patient 12 month Patient reviews care follow up Coaching with planning Share assessment patient data Outcomes: Improved frailty assessment & Evaluation monitoring tool for physicians Improved patient health & self management capacity 6 6

Frailty Assessment Tools Nurse Administered Tools:  Montreal Cognitive Assessment (MoCA) - Nasreddine, Z. (2003) or  Mini-Cog – Borson (2016)  Five Times Sit to Stand Test - Guralnik (2000)  Delegated eCGA sections Physician Administered Tools:  Community Comprehensive Geriatric Assessment (CCGA) -Geriatric Medicine Research, Dalhousie University (2016) Medical Office Assistant  Faxes coaching referral form to Self- Management BC 7 7

CARES and CI HR Research  CIHR funding to test reliability and validity of electronic CGA  Funding for physician participation and patient participation  Research Protocol supported by education with Dr. Ken Rockwood from Dalhousie  Research protocol outline provided 8 8

 What is the Self-Management Health Coach program?  It is a three month telephone program that supports participantss to identify health goals and develop a plan to manage their health conditions.  A coach works with participants one-to-one through weekly telephone support.  Who developed the program?  The program was developed by the University of Victoria, Institute on Aging & Lifelong Health.  It is considered a best practice program in self-management.  What does it cost to participate?  It is FREE to participants.  The program is funded by the Ministry of Health and delivered through Self-Management BC; a Patients as Partners Initiative administered by the University of Victoria.  Why we choose to partner with Self-Management BC?  Provides evidence based programs that demonstrate improvements in health.  Links health assessments with community based programs that enhance participants “protective factors”. 9 9

Results: Success of CARES Work to Date 10 10