Optimizing Outcomes For Frail High Risk Seniors Through Specialist-Specialist and Primary Care- Specialist Collaborative Models RGPs of Ontario
Perioperative Surgical Home For The Frail Elderly Dr. Daniel McIsaac The Ottawa Hospital RGPs of Ontario
Intraoperative Postoperative Preoperative PERIOPERATIVE SURGICAL HOME FOR THE FRAIL ELDERLY Daniel I McIsaac MD, MPH, FRCPC 3 Affiliated with • Affilié à
PERIOPERATIVE SURGICAL HOME (PSH) “…multidisciplinary, team-based approach to patient-centered care that aims to reduce variability, provide continuity …ensure best-practice across the perioperative continuum of care ” 4 Affiliated with • Affilié à
No conflicts of interest ▶ Program funding: ▶ • Canadian Frailty Network • University of Ottawa Department of Anesthesiology • TOHAMO • Canadian Anesthesiologists’ Society • International Anesthesia Research Society Collaborators ▶ • • Luke Lavalee Paul Beaule • • Colin McCartney Gregory Bryson • • Hussein Moloo Alan Forster • • Julie Nantel Sylvain Gagne • • Allen Huang Janet Squires • • Monica Taljaard John Joanisse • • Carl van Claire Kendall • Walraven Manoj Lalu 5
THE PERIOPERATIVE HEALTHCARE SYSTEM Intraoperative Postoperative Preoperative 6
A COMPLEX SYSTEM Intraoperative Postoperative Preoperative • • • Diagnosis Pain management Anesthesia • • • Evaluation Recovery/rehabilitation Surgery • • • Decision making Sub-acute monitoring Pain management • • • Care planning Transition to community Acute monitoring • • Optimization Return of normal function 7
A COMPLEX SYSTEM Intraoperative Postoperative Preoperative Continuum of Care • • • Diagnosis Pain management Anesthesia • • • Evaluation Recovery/rehabilitation Surgery • • • Decision making Sub-acute monitoring Pain management • • • Care planning Transition to community Acute monitoring • • Optimization Return of normal function 8
PERIOPERATIVE FRAILTY Preoperative frailty predicts ▶ • Mortality • Morbidity • ICU admission • Length of stay • Institutional discharge • Self reported new disability 9 Affiliated with • Affilié à
SO, YOU’RE NOT SURPRISED 10 Affiliated with • Affilié à
PERIOPERATIVE CARE JAMA Surgery, 2016 The Association of Frailty with Outcomes and Resource Use After Emergency General Surgery: a Population-Based Cohort Study Daniel I. McIsaac, Husein Moloo, Gregory L. Bryson, Carl van Walraven Anesthesia & Analgesia , accepted 11 11 Affiliated with • Affilié à
2 KEY OUTCOME MESSAGES 1. Early mortality risk ▶ • Day 1 20-30 times higher • Day 3 15-20 times higher • Markedly elevated for ~3 months after surgery 2. Loss of independence ▶ • 30-50% discharged to an institution - All community dwelling before surgery • 2-6 times increased relative risk 12 Affiliated with • Affilié à
Intraoperative Postoperative Preoperative • IDENTIFY • RISK STRATIFY • DECISION SUPPORT • OPTIMIZATION • ENHANCED CARE PATHWAYS 13 Affiliated with • Affilié à
Intraoperative Postoperative Preoperative • • IDENTIFY DECREASE • RISK STRATIFY VARIATION • • DECISION SUPPORT BEST SUPPORT PRACTICE • • OPTIMIZATION RISK RE- • ENHANCED STRATIFICATION CARE PATHWAYS 14 Affiliated with • Affilié à
Intraoperative Postoperative Preoperative • • • IDENTIFY DECREASE MONITOR (pre- • RISK STRATIFY VARIATION and post-discharge) • • • DECISION SUPPORT BEST ENHANCED SUPPORT PRACTICE RECOVERY • • • OPTIMIZATION RISK RE- IMPROVE • ENHANCED STRATIFICATION CONTINUITY AND CARE PATHWAYS TRANSITIONS 15 Affiliated with • Affilié à
S TRENGTHS W EAKNESSES O PPORTUNITIES & T HREATS 16 Affiliated with • Affilié à
S STRENGTHS WEAKNESSES W • Multidisciplinary • Insufficient patient • MDs engagement • RNs • KT/Imp Sci • Scientists Who Is Involved OPPORTUNITIES THREATS • People care about frailty • Competing priorities • System and Pt outcomes • Who’s patient is this? O T
S STRENGTHS WEAKNESSES W • Growing • No institutional external/internal program funding research funding Funding Sustainability OPPORTUNITIES THREATS • MOHLTC Innovation • QBPs (procedure, not funding patient-centered) • The iron is hot O T
S STRENGTHS WEAKNESSES W • Evidence-based • No standard framework and focus hospital or • Best practice guidelines ministry policy (ACS/AGS/BGS) Policy Support OPPORTUNITIES THREATS • Novel area of research • Frailty isn’t woven into • Emerging team based and healthcare policy-yet comprehensive care O T models
S STRENGTHS WEAKNESSES W • Buy in from clinical leads • Silos • Motivated program lead • Acute hospital- transition gap Setting OPPORTUNITIES THREATS • Evaluation hotbed • Competing interests • Built into hospital data systems O T
S STRENGTHS WEAKNESSES W • Pt-oriented focus • No Shared Decision Making integrated to date Decision-Making OPPORTUNITIES THREATS • Ottawa-Decision making • High prevalence of frailty leadership O T
S STRENGTHS WEAKNESSES W • High prevalence of frailty • High-prevalence of • Poor patient-centered frailty (40-50%) outcomes Patient Selection OPPORTUNITIES THREATS • Data to establish criteria • Resources needed to support some interventions for high risk O T frail elders
S STRENGTHS WEAKNESSES W • Patient centered outcomes • Co-ordination a work in and processes progress • Infrastructure for • How to ‘force’ care plan information flows and goal review AGS Person-Centred Care OPPORTUNITIES THREATS • Inter-professional team • Who’s patient is this? • Outcome overload engaged • KT/Imp Sci experts from O T day 1
FACILITATORS-A SUMMARY • Everyone seems to ‘get’ frailty – Surgeons, other MDs, patients, … • People are eager to get on board • Research funders are engaged • Momentum – For our local project – For improved care of frail and older patients generally – Comprehensive care models 24 Affiliated with • Affilié à
CHALLENGES-A SUMMARY • How do YOU define frailty? – How frail do you need to be for focused intervention • $ – Continued research funding – Institutional funds for long-term implementation • Competing interests of collaborators • Patient engagement • Massive variations in care • Designing a process for a continuum of care currently built in silos 25 Affiliated with • Affilié à
THANK YOU 26 Affiliated with • Affilié à
WHO IS INVOLVED STRENGTHS Multidisciplinary Anesthesiologists Geriatricians Surgeons Family Physicians Scientists Methodologists Nurse Specialists KT/Implementation Science 27 Affiliated with • Affilié à
WHO IS INVOLVED STRENGTHS WEAKNESSES Multidisciplinary Pt engagement Anesthesiologists Just starting Geriatricians Complexities Surgeons Competing interests Family Physicians Scientists Methodologists Nurse Specialists KT/Implementation Science 28 Affiliated with • Affilié à
WHO IS INVOLVED STRENGTHS WEAKNESSES OPPORTUNITIES Multidisciplinary Pt engagement PEOPLE CARE Anesthesiologists Just starting Frailty makes sense Geriatricians Complexities Pt engagement Surgeons Competing interests The iron is hot Family Physicians Outcomes speak Scientists PROMs Methodologists KT approach Nurse Specialists Theory guided KT/Implementation Science 29 Affiliated with • Affilié à
WHO IS INVOLVED STRENGTHS THREATS WEAKNESSES OPPORTUNITIES Multidisciplinary Engagement Pt engagement PEOPLE CARE Anesthesiologists Competing priorities Just starting Frailty makes sense Who’s Pt is it? Geriatricians Complexities Pt engagement Surgeons The silos again Competing interests The iron is hot Family Physicians Outcomes speak Scientists PROMs Methodologists KT approach Nurse Specialists Theory guided KT/Implementation Science 30 Affiliated with • Affilié à
SUSTAINABLE FUNDING STRENGTHS External Consistent & growing x 3 years Internal Research funding 31 Affiliated with • Affilié à
SUSTAINABLE FUNDING STRENGTHS WEAKNESSES External Research funding Consistent & No program or growing x 3 years institutional funds Internal Research funding 32 Affiliated with • Affilié à
SUSTAINABLE FUNDING SUSTAINABLE FUNDING STRENGTHS WEAKNESSES OPPORTUNITIES External Research funding Innovation funding Consistent & Translation to clinical No program or care growing x 3 years institutional funds Pt engagement Internal We’re working on it Research funding Population dynamics Ageing population 33 33 Affiliated with • Affilié à
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