Identifying High-Risk Patients for Personalized Care Plans John P. - PowerPoint PPT Presentation

Identifying High-Risk Patients for Personalized Care Plans John P. Hirdes, PhD FCAHS 1 George Heckman, MD 1,2 Paul Hebert, MD 3 Allan Garland, MD 4 1-School of Public Health and Health Systems, University of Waterloo 2-Schlegel-UW Research Institute for Aging 3-CHUM 4-University of Manitoba Twitter: @interrai_Hirdes www.interrai.org

Agenda • Targeting high risk populations in long term care • Frailty • Health instability • Personalized care plans based on interRAI assessments • CFN Strategic Impact Grant: • Predicting transitions in health and service use – effect of advance directives • CFN Transformative Grant: • Intervention study on advance care planning in LTC Twitter: @interrai_Hirdes www.interrai.org

3 Use of interRAI Instruments in Canada RAI 2.0/ interRAI Long Term Care Facilities RAI-Home Care RAI-Mental Health interRAI Community Mental Health interRAI Emergency Screener for Psychiatry interRAI Brief Mental Health Screener interRAI Child/Youth Mental Health interRAI Intellectual Disability interRAI Palliative Care interRAI Acute Care/Emergency Department interRAI Contact Assessment interRAI Community Health Assessment interRAI Subjective Quality of Life Solid symbols refer to implentations that have been mandated by government Hollow symbols refer to research, pilot studies, or implementation planning underway Twitter: @interrai_Hirdes www.interrai.org

Deriving Frailty Index from interRAI Systems Twitter: @interrai_Hirdes www.interrai.org

FI Scores in Ontario Complex Continuing Care Hospitals (n=662,946) & Long Term Care Homes (n=3,223,459) over Time 60 Restructuring Commission 50 Health Services % of Assessments 40 30 20 10 0 1996_3 1997_1 1997_3 1998_1 1998_3 1999_1 1999_3 2000_1 2000_3 2001_1 2001_3 2002_1 2002_3 2003_1 2003_3 2004_1 2004_3 2005_1 2005_3 2006_1 2006_3 2007_1 2007_3 2008_1 2008_3 2009_1 2009_3 2010_1 2010_3 2011_1 2011_3 2012_1 2012_3 2013_1 2013_3 2014_1 2014_3 2015_1 2015_3 2016_1 2016_3 2017_1 2017_3 2018_1 CCC (<.25) CCC (.25-.39) CCC (.40+) LTC (<.25) LTC (.25-.39) LTC (.40+) Twitter: @interrai_Hirdes www.interrai.org

Distribution of FI Scores in LTC & CCC by Province/Territory, 1996-2018 (n=5,044,480 assessments) 80% 60% 40% 20% 0% YT BC AB SK MB* ONLTC ONCCC NB* NS* NL <.25 .25-.39 .40+ Twitter: @interrai_Hirdes www.interrai.org

7 Applications of interRAI’s Assessment Instruments: One assessment … multiple applications Case-mix Single Point Entry Care Plan Resource Allocation Evaluation Best Practices Assessment Balance incentives Risk Management Outcome Measures Quality Indicators Patient Safety Quality Improvement Public Accountability Accreditation Twitter: @interrai_Hirdes www.interrai.org

8 interRAI Clinical Assessment Protocols (CAPs) Clinical tools to identify • Need • Risk of adverse change/event • Potential for improvement Twitter: @interrai_Hirdes www.interrai.org

9 interRAI CAPs for Nursing Homes, Home & Community Care • Functional Performance • Clinical Issues • Social Life Physical activities promotion Falls Activities • • • Instrumental activities of daily Pain Informal support • • • living Pressure Ulcer Social relationships • • Home environment • Cardiorespiratory conditions • Institutional risk • Undernutrition • Physical restraints • Dehydration • Feeding tube • • Cognition/Mental Health Prevention • Cognitive loss • Appropriate medications • Delirium • Tobacco & alcohol use • Communication • Urinary incontinence • Mood • Bowel conditions • Behaviour • Abusive relationships • Twitter: @interrai_Hirdes www.interrai.org

10 Triggering rates for two multi-level interRAI Clinical Assessment Protocols (CAPs), by province/territory & setting 100 Falls CAP Mood CAP % Clients triggered CCC LTC CCAC SH LTC CCC CCAC SH 80 (2.0) (2.0) (HC) (CHA) (2.0) (2.0) (HC) (CHA) 60 40 20 0 Moderate Risk High Risk Twitter: @interrai_Hirdes www.interrai.org Twitter: @interRAI_Hirdes

interRAI Clinical Assessment Protocol (CAP) Triggering Rates by FI Score among LTC Residents, 9 Provinces/Territories (n=2,266,402 admission/annual assessments) 100 80 Percentage Triggered 60 0.24 40 .25-.39 .40+ 20 0 Twitter: @interrai_Hirdes www.interrai.org

Twitter: @interrai_Hirdes www.interrai.org

Multistate Transition Model for Nursing Home Residents Effect of: X Controlling for: • Age • Sex • Marital status • Day of stay at ax Hospital Facility size • Died • Province • ADL Hierarchy • Cognitive Performance • Physician visits COPD • CHESS CHESS CHESS • Pneumonia 1,2 0 3+ • Diabetes • Arthritis • Renal failure Urinary tract infection • • Alz & Related Dementia Other • Heart Failure • Cancer Home • Depression Advanced directives DNR • • Advanced directives DNH Twitter: @interrai_Hirdes www.interrai.org

Multistate Transition Model for Nursing Home Residents Effect of: X Controlling for: • Age • Sex • Marital status • Day of stay at ax Hospital Facility size • Died • Province • ADL Hierarchy • Cognitive Performance • Physician visits COPD • CHESS CHESS CHESS • Pneumonia 1,2 0 3+ • Diabetes • Arthritis • Renal failure Urinary tract infection • • Alz & Related Dementia Other • Heart Failure • Cancer Home • Depression Advanced directives DNR • • Advanced directives DNH Twitter: @interrai_Hirdes www.interrai.org

Multistate Transition Model for Nursing Home Residents Effect of: X Controlling for: • Age • Sex • Marital status • Day of stay at ax Hospital Facility size • Died • Province • ADL Hierarchy • Cognitive Performance • Physician visits COPD • CHESS CHESS CHESS • Pneumonia 1,2 0 3+ • Diabetes • Arthritis • Renal failure Urinary tract infection • • Alz & Related Dementia Other • Heart Failure • Cancer Home • Depression Advanced directives DNR • • Advanced directives DNH Twitter: @interrai_Hirdes www.interrai.org

Multistate transition model for nursing home residents: Adjusted odds ratios for advanced directives (ref=not present), Nursing homes in Ontario, BC & Alberta Transitions at follow-up (T 2 ) Remained in Nursing Home Admitted to Discharged Discharged CHESS Score Died Hospital Other Setting Home 0 1-2 3+ Do Not Hospitalize (ref=Not Present) CHESS Score 0 -- 1.04 1.10 0.67 1.48 ns ns at baseline (1.02-1.07) (1.03-1.19) (0.65-0.69) (1.38-1.58) 1-2 0.92 -- 1.07 0.63 1.46 ns ns (T 1 ) (0.90-0.95) (1.03-1.12) (0.61-0.65) (1.40-1.52) 3+ 0.76 0.81 -- 0.47 1.48 ns ns (0.68-0.85) (0.76-0.87) (0.43-0.52) (1.37-1.60) Do Not Resuscitate (ref=Not Present) CHESS Score 0 -- 1.08 1.32 0.90 1.36 0.82 0.58 at baseline (1.05-1.11) (1.21-1.45) (0.87-0.92) (1.25-1.49) (0.72-0.94) (0.51-0.65) 1-2 0.91 -- 1.19 0.82 1.38 0.85 0.55 (T 1 ) (0.88-0.94) (1.12-1.26) (0.80-0.85) (1.30-1.47) (0.74-0.98) (0.48-0.63) 3+ 0.75 0.85 -- 0.63 ns ns 0.53 (0.64-0.86) (0.77-0.95) (0.57-0.71) (0.32-0.87) Twitter: @interrai_Hirdes www.interrai.org

Multistate transition model for nursing home residents: Adjusted odds ratios for advanced directives (ref=not present), Nursing homes in Ontario, BC & Alberta Transitions at follow-up (T 2 ) Remained in Nursing Home Admitted to Discharged Discharged CHESS Score Died Hospital Other Setting Home 0 1-2 3+ Do Not Hospitalize (ref=Not Present) CHESS Score 0 -- 1.04 1.10 0.67 1.48 ns ns at baseline (1.02-1.07) (1.03-1.19) (0.65-0.69) (1.38-1.58) 1-2 0.92 -- 1.07 0.63 1.46 ns ns (T 1 ) (0.90-0.95) (1.03-1.12) (0.61-0.65) (1.40-1.52) 3+ 0.76 0.81 -- 0.47 1.48 ns ns (0.68-0.85) (0.76-0.87) (0.43-0.52) (1.37-1.60) Do Not Resuscitate (ref=Not Present) CHESS Score 0 -- 1.08 1.32 0.90 1.36 0.82 0.58 at baseline (1.05-1.11) (1.21-1.45) (0.87-0.92) (1.25-1.49) (0.72-0.94) (0.51-0.65) 1-2 0.91 -- 1.19 0.82 1.38 0.85 0.55 (T 1 ) (0.88-0.94) (1.12-1.26) (0.80-0.85) (1.30-1.47) (0.74-0.98) (0.48-0.63) 3+ 0.75 0.85 -- 0.63 ns ns 0.53 (0.64-0.86) (0.77-0.95) (0.57-0.71) (0.32-0.87) Twitter: @interrai_Hirdes www.interrai.org