Pre workshop Survey Please complete our short survey at: - PowerPoint PPT Presentation

Pre ‐ workshop Survey Please complete our short survey at: www.gerimedrisk.com/cgs2018

Forging collaboration and improving access to geriatrics with eConsult: A WORKSHOP FOR CLINICIANS WHO ARE “ALL ALONE” 2018 CGS ASM "ADVANCES IN CARE: FROM PATIENT TO TECHNOLOGY“ APRIL 19 ‐ 21, 2018, MONTREAL, QUEBEC

Session Chair: Joanne Ho List of Speakers: • ‐ Clare Liddy Associate Professor and Clinical Investigator, C.T. Lamont Primary Health Care Research Centre, Dept. of Family Medicine, University of Ottawa ◦ cliddy@bruyere.org • Jennifer Tung, PharmD, ACPR ‐ Grand River Hospital ◦ Jennifer.Tung@grhosp.on.ca • Sophiya Benjamin MBBS, Diplomate of the American Board of Psychiatry and Neurology (Psychiatry and Geriatric psychiatry ) ‐ McMaster University/Grand River Hospital ◦ Sophiya.benjamin@grhosp.on.ca • Joanne Ho MD, FRCPC, MSc ‐ McMaster University/Schlegel Research Institute for Aging ◦ joanneho@mcmaster.ca

Session Goal To demonstrate how eConsult can enhance capacity in geriatric clinical pharmacology and psychiatry, and interdisciplinary collaboration.

Session Objectives • Discuss eConsult and its clinical and financial roles in the health care system • Recognize patient cases that may benefit from eConsult • Identify, access and utilize online tools to optimize prescribing and prevent drug interactions among seniors • Work as a team with fellow ASM attendees to optimize prescribing for complex cases of older adults with mental health and multimorbidity.

Session Outline 1. Pre ‐ workshop survey www.gerimedrisk.com/cgs2018 2. eConsult: Dr. C. Liddy 3. Application of eConsult to the complex geriatric patient: Dr. J Ho 4. Case ‐ based application of eConsult and Clinical Pearls: Dr. J Ho, Dr. J Tung, Dr. S. Benjamin 5. Clinical Tools for Medication Optimization: Dr. J. Tung

Pre ‐ workshop Survey Results Link to results: https://www.surveymonkey.com/results/SM ‐ FXH5WBS8L/

Forging Collaboration and Improving Access to Geriatrics with eConsult: A Workshop for Clinicians who are “All Alone” Dr. Clare Liddy Associate Professor and Clinical Investigator, C.T. Lamont Primary Health Care Research Centre, Dept. of Family Medicine, University of Ottawa April 20, 2018

Application of eConsult to the complex geriatric patient YOU ARE NOT ALONE!

Faculty/Presenter Disclosure Faculty: Joanne Ho, Sophiya Benjamin and Jennifer Tung Relationships with commercial interests: ◦ Grants/Research Support: none ◦ Speakers Bureau/Honoraria: none ◦ Consulting Fees: none ◦ Other: none

CFPC CoI Templates: Slide 2 Disclosure of Commercial Support This program has received no financial support. This program has received no in ‐ kind support. Potential for conflict(s) of interest: ◦ none

CFPC CoI Templates: Slide 3 Mitigating Potential Bias n/a

Disclosures (Nonprofit) McMaster University Faculty: Joanne Ho, Sophiya Benjamin Schlegel Research Institute for Aging: Joanne Ho (Clinical Scientist) Grand River Hospital (Kitchener, ON): Joanne Ho, Sophiya Benjamin, Jennifer Tung Canadian Coalition for Seniors’ Mental Health Clinical Guideline Working Groups: Joanne Ho (Benzodiazepine), Jennifer Tung (Alcohol) : Joanne Ho, Sophiya Benjamin, Jennifer Tung, Clare Liddy GeriMedRisk ‐ an interdisciplinary telemedicine geriatric clinical pharmacology and psychiatry consultation service that uses eConsult (BASE and OTN). ◦ Development, evaluation: Joanne Ho, Sophiya Benjamin, Jennifer Tung ◦ Clinician: Joanne Ho, Sophiya Benjamin, Jennifer Tung GeriMedRisk is supported by non ‐ profit health care organizations • Partners: McMaster University, Canadian Mental Health Association Waterloo Wellington, Schlegel Research Institute for Aging, St. Joseph’s Health Centre Guelph, Ontario Telemedicine Network, Ontario Poison Centre, Regional Geriatric Program Central • Grants: Canadian Centre for Aging and Brain Health Innovation, Labarge Optimal Aging Opportunities Fund, Regional Geriatric Program Central, Ontario Medical Association, Schlegel Centre for Learning Research and Innovation in LTC

Geriatrics: Teams are great! Disney

But what if you do not have your own team? Disney

Older Patients and Adverse Drug Events Increased mortality Increased morbidity ◦ Increased severity ◦ Hospital admission ◦ Decrease in function ◦ Delirium ◦ Cost ◦ >$35 million in Canada Wu et al Drugs and Aging 2009 Budnitz NEJM 2011 Morgan CMAJ Open 2016

What are risk factors for adverse drug events among older adults? Dr. Seuss “You’re Only Old Once!” 1986

Em Emer ergency ncy Hospit spitaliz alizatio ions ns fo for Adv Adver erse se Drug Drug Ev Events in in Ol Older der Americ Americans ans National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance (NEISS–CADES) project Budnitz et al NEJM 2011 ◦ Hospital visits (ER and hospital admissions) ◦ Unintentional ◦ 58 nonpediatric hospitals ◦ 2007 ‐ 2009 ◦ Medications ◦ HEDIS, Beers

Em Emer ergency ncy Hospit spitaliz alizatio ions ns fo for Adv Adver erse se Drug Drug Ev Events in in Ol Older der Americ Americans ans ◦ 12,666 cases ‐ >estimated 265,802 emergency department visits/year 2007 ‐ 2009 among adults >=65 years. ◦ 37% required hospitalization ◦ Factors: ◦ Advanced age ◦ 3.5X more likely to be admitted compared to those 65 ‐ 69 years old ◦ Polypharmacy (>=5 meds)

Top Offenders 1. Warfarin 2. Insulin 3. Oral antiplatelet 4. Oral hypoglycemic 5. Opioid analgesics 6. Antibiotics 7. Digoxin 8. Antineoplastic agents 9. Antiadrenergic agents 10. Renin angiotensin inhibitors 11. Sedative or hypnotic agents Wu et al Drugs and Aging 2009 Budnitz NEJM 2011 Morgan CMAJ Open 2016

Inci Incidence dence and and Econom onomic Bur Burden en of of Adv Adverse Dr Drug ug Re Reactions among among Elderly Elderly Patien tients ts in in Onta ntario Emer Emergency ncy Depar Departmen ments  Ontario ED visits for adverse drug reactions among seniors in 2007  7222 ED visits  95% had their own family physicians  Risk factors  Age  3% increased risk of severe ADR/year increase in age  LTC  Multiple prescribers  Multiple pharmacies  Multiple medications  Multiple comorbidities  New medications Wu et al 2012

The Senior with Multimorbidity Pharmacy Primary Psychiatrist Care Patient Cardiologist Gastroenterologist Nephrologist

Who’s talking to Whom About Medications? Pharmacy Psychiatrist Primary Care Patient Cardiologist Gastroenterologist Nephrologist

Geriatric Pharmacology Needs Assessment What is the need for geriatric pharmacology expertise among clinicians caring for older adults in the Waterloo Wellington Region? ◦ Clinicians: Survey ◦ Multidisciplinary and clinical settings ◦ Geriatric focus ◦ Public Engagement ◦ Schlegel Research Institute for Aging July 22, 2017 ◦ Waterloo Wellington LHIN Geriatric Services Network

What do you feel are the most important or pressing issues facing seniors related to medications?

Geriatric Pharmacotherapy Needs Assessment • multiple prescribers • multiple pharmacies System • lack of reviews and reassessments • lack of evidence ‐ based guidelines • lack of support for patient education and homecare • multiple medications • multiple prescribers Clinician • lack of knowledge in geriatric pharmacotherapy • prescribing inertia • lack of communication between professions. Patient • Adherence to medications • Cognitive impairment

GeriMedRisk is an interdisciplinary telemedicine geriatric clinical pharmacology consultation service for clinicians • Serving Doctors, Nurse Practitioners and Pharmacists • eConsult , telephone, eVisit • Geriatric pharmacy, Geriatric medicine, Geriatric psychiatry, Clinical pharmacology, Pharmacogenomics (as needed)

Pilot Consult Origin Outpatient Specialist Care 4% Acute care 15% Primary care 34% Long Term Care 47%

Impact  Feedback  Patient  Clinicians  Outcomes  Clinical  Cost

Feedback “Without the [GeriMedRisk] recommendation I would still be on too many medications … It’s a great service and I would recommend it highly to anybody”. Senior Feedback, Waterloo, ON It totally is an excellent example of collaborative care. GeriMedRisk is extremely valuable in my eyes ‐ totally helpful! Family were happy with the care and outcome. Thanks so much for your help! Family Physician, Waterloo, ON

Preliminary Results Waterloo Wellington pilot ‐ 8 months, 3 LTC, 10% primary care (n=144) # Prevented Cost Savings to System Hospitalizations 6 $110,028.00 (acute and mental health) In ‐ person consultations 3 specialities 20 $12,816.00 geri pharm/psych/med/clin pharm 2 specialities 78 $28,009.00 geri pharm + psych or med or clin pharm 3 additional consults generated as a result of GMR consults CIHI acute medical 2004 ‐ 2005 MOHLTC mental health 2015 ‐ 2016

Educational Activities 2500 Events 2000 • In person • telemedicine/videoconference Cumulative # of Clinicians 1500 1000 500 0 Jan ‐ 17 Feb ‐ 17 Mar ‐ 17 Apr ‐ 17 May ‐ 17 Jun ‐ 17 Jul ‐ 17 Aug ‐ 17 Sep ‐ 17 Oct ‐ 17 Nov ‐ 17 Dec ‐ 17

Summary • eConsult and telephone • Make your own team!

Small group session COMPLEX CASES ‐ MAKE YOUR TEAM

Case 1