Michal Boyd, 1,2,3 Joanna B Broad, 1 Xian (Tony) Zhang, 1 Ngaire Kerse, 4 and Martin J Connolly 1,3

Transcription

1 NZACA Annual Conference - Wellington 15 October 2014 Michal Boyd, 1,2,3 Joanna B Broad, 1 Xian (Tony) Zhang, 1 Ngaire Kerse, 4 and Martin J Connolly 1,3 1 Freemasons Department of Geriatric Medicine, The University of Auckland 2 School of Nursing, The University of Auckland 3 Waitemata District Health Board 4 School of Population Health, The University of Auckland

2 Hospitalisations of Older People There are many studies that evaluated the nature, predictability and avoidability of hospitalizations of frail older people living in the community and those in Aged Residential Care (ARC) facilities Most community based studies have ARC admission as an end-point and do not follow hospitalisations after that point There are few studies taking a longer view, comparing hospitalization rates before and after ARC admission Very few longitudinal cohort studies Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age and Ageing. May 2010;39(3): Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1): Ouslander JG, Lamb G, Perloe M, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs. J Am Geriatr Soc.2010;58(4):

3 NZ Hospitalisation Trends Hospital Length of Stay Readmits in 30 days

4 Older People in the ED Functional dependence at the time of emergency department admission has been found to be the most prevalent risk factor for: Functional Ability and Hospital Length of Stay BRIGHT Screen in the ED (Boyd et al. 2008, Age and Ageing) subsequent health and functional decline ED and hospital readmission institutionalisation and death

5 ARC Review Grant Thornton 2010 New Zealand Res. Aged Care Secondary Care Utilisation

6 Waitemata DHB Emergency Department Audit from 1/10/12 3/11/12: 5824 adult presentations to ED, of whom 1723 were over 65 This = 2.3% admission rate for all > are from ARC Assuming 100% res care occupancy, this = 4.2% of res care patients

7 Long Term Care Potentially Preventable Hospitalisation Ouslander & Maslow, 2012, JAGS, 60, (US perspective) Several recent interventions have focused on decreasing potentially preventable hospitalizations (PPH) for long term care residents Reasons for PPHs are complex and varied Resident and family preferences Lack of Advanced Care Planning Staffing GP, NP, PA, RN, CNA etc. Availability of facility interventions ED and hospital pressures and procedures Reimbursement policies and procedures Many interventions developed to decrease hospitalisation Danger of no hospitalisation for those that need it

8 ARC Avoidable Admissions Ouslander et al % of hospitalisations were deemed avoidable Common Diagnoses: Cardiovascular (mainly CHF and chest pain) 22% Respiratory (mainly pneumonia and bronchitis) 21% Mental status change or neurological symptom or sign 13% Urinary tract infection 11% Sepsis or fever 8% Skin (cellulitis, infected wound, or pressure ulcer) 8% Dehydration or metabolic disturbance 7% Gastrointestinal (bleeding, diarrhoea) 7% Musculoskeletal pain or fall 3% Psychiatric 1% Other (adverse drug effect, surgical consult) 2%

9 Factors Helpful to Prevent Hospitalisations (US perspective) GP/NP on-site 3 days a week NP available on a regular basis GP/NP examination in 24 hours previous to admission RN providing care vs. EN or HCA Lab tests available within 3 hours IV therapy available Pulse Oximetry Respiratory Therapy TPN PCA pumps Psychiatric consult Blood Products

10 Boyd M, et al. (2014) Journal of the American Geriatrics Society *p< 0.01 *p = 0.99

11 archus Intervention Package The intervention package was delivered for 9 months in intervention facilities and included: initial stock-take assessment of care, with benchmarking development of facility plan provision of targeted education to facility nurses & caregivers, facilitated by a GNS MDT meetings for selected residents direct access to a geriatrician and gerontology nurse specialist (GNS) clinical coaching for high-risk residents. Control facilities 2012same intervention following trial completion.

12 ARCHUS Results: Time to First Potentially Preventable Admission (Connolly MJ, Boyd M, Broad JB, et al. (2014) Journal of the American Medical Directors Association) archus

13 What Might This Mean? It is not possible to reduce avoidable hospitalisations from ARC and we have to increase acute provision to cope ($$$$$$) It is not possible to reduce avoidable hospitalisations from ARC by an outreach model and we need to increase RAC facility resource ($$$$) Need to intervene harder ($$$) Need to intervene smarter e.g. target specific diagnoses, nurse practitioner intervention -(???)

14 ARCHUS/ARCHIP Big 5

15 The Aim of Pre and Post ARC Admissions Hospitalisation Study To describe hospitalization rates in a single cohort of very high needs older people twelve months before and twelve months after admission into ARC facilities.

16 The OPAL Study (2008) Database: A census-type survey of ARC facilities and residents in Auckland (89% response rate) 152 LTC facilities and over 6800 residents of greater Auckland (90% of ARC population) Facility staff collected individual resident information using one 36-item assessment covering demographics, functional and disability levels and care needs The initial survey and follow-up of individual residents received approval from the Auckland regional ethics committee(ntx/11/exp/193) Broad JB, Boyd M, Kerse N, et al. Residential aged care in Auckland, New Zealand : do real trends over time match predictions? Age Ageing. Jul 2011;40(4): Boyd M, Broad JB, Kerse N, et al. Twenty-year trends in dependency in residential aged care in Auckland, New Zealand: a descriptive study. Journal of the American Medical Directors Association. Sep 2011;12(7):

17 Methods NHI was obtained for each resident and matched with a national healthcare database OPAL residents hospital admissions were evaluated twelve months before and after ARC admission

18 Sample OPAL ,810 residents with linkage 4,564 residents entered RAC more than 12 months before OPAL survey 2,244 residents entered RAC within 12 months before OPAL survey 2,244 residents 3,402 hospitalisations during 24-month period 39 hospitalisations that were transfers between hospital wards/units 2,244 residents 3,363 hospitalisations during 24-month period

19 All Sample Hospitalisation Months 1-6 Months 7-12 Months Months Total hospitalisations 755 1, Mean hospitalisations per week Person-years of follow-up 1, , , Hospitalisations per year per 100 residents (95% CI) (62.5, 72.1) (141.6, 155.9) (44.9, 53.3) (37.1, 45.1) Rate ratio vs Months 1-6 (referent (95% CI) group) (2.03, 2.41) (0.65, 0.82) (0.54, 0.69)

20 Alive at 12 Months Dead at 12 Months

21 Hospitalisation Rest Home and Pvt Hospital* ARC Admit N Baseline hospitalisation Months 7-12 Months Months people rate # 95%CI RR 95%CI p-value RR 95%CI p-value RR 95%CI p-value Bed type at survey* Hospital (67.5, 82.8) 2.11 (1.86, 2.38) < (0.52, 0.73) < (0.38, 0.57) < Resthome 1, (55.0, 67.2) 2.31 (2.05, 2.61) < (0.72, 0.97) (0.64, 0.87) *per year/100 residents

22 Entry from hospital or from community ARC Admit

23 Comparison to Other Studies Australian study: ED admission of ARC residents twice that of community-dwellers ARC sample older with more co-morbidity A European longitudinal cohort study of hospitalizations compared 3 months before ARC admission and 3 months after admission rate 6.0/person year before ARC admission and 1.1/person year after ARC admission Ingarfield SL, Finn JC, Jacobs IG, et al. Use of emergency departments by older people from residential care: a population based study. Age Ageing. 2009;38(3): Ramroth H, Specht-Leible N, Brenner H. Hospitalisations before and after nursing home admission: a retrospective cohort study from Germany. Age Ageing. May 2005;34(3):

24 2005 Canadian study compared hospitalization rates over a two-year period for: ARC facility residents community care recipients healthy older adult sample The mean hospitalization rate over two years: 0.29/person in ARC 1.46/person for those receiving home care services in the community Wilson D, Truman C. Comparing the health services utilization of long-term-care residents, home-care recipients, and the well elderly. The Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmieres. Dec 2005;37(4):

25 US Studies A study of home and community-based ARC substitution programs Hospitalisation for those receiving community care was more than twice the rate of LTC residents after one year Another recent study found a 58% increased risk of hospitalisation for those that were transitioned back into the community after an extended ARC stay Sands LP, Xu H, Weiner M, Rosenman MB, Craig BA, Thomas J, 3rd. Comparison of resource utilization for Medicaid dementia patients using nursing homes versus home and community based waivers for long-term care. Medical care. Apr 2008;46(4): Wysocki A, Kane RL, Dowd B, Golberstein E, Lum T, Shippee T. Hospitalization of Elderly Medicaid Long-Term Care Users Who Transition from Nursing Homes. J Am Geriatr Soc. Jan

26 Delaying ARC Admission Decades of trials attempting to decrease hospitalizations and delay or prevent ARC entry for high needs older people However, the cost/benefit is still not clear because: People truly at risk of institutionalisation are difficult to identify prospectively Hospital readmission risk identification is difficult e.g. Pra (predicting risk of readmission) AUC 0.70 Woodwork effect Woodhams V, de Lusignan S, Mughal S, et al. Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network. BMC health services research. 2012;12:153. Kane RL, Lum TY, Kane RA, Homyak P, Parashuram S, Wysocki A. Does home-and community-based care affect nursing home use? Journal of aging & social policy. 2013;25(2): Weissert WG, Frederick L. The woodwork effect: estimating it and controlling the damage. Journal of aging & social policy. 2013;25(2):

27 Development of a predictive model to identify inpatients at risk of readmission within 30 days of discharge (PARR-30) Billings, et al., BMJ Open 2012;2:e doi: /bmjopen Patient age Index of multiple deprivation (IMD) for the patient's place of residence emergency admission emergency hospital discharge in the past 30 days. The number of emergency hospital discharges in the last year History in the prior 2 years (from any HES primary or secondary diagnostic field) of 11 major health conditions from the Charlson co-morbidity index. The hospital of the current admission C statistic

28 Ageing in Place ageing in place is the desired goal for those with high levels of disability and frailty It is difficult to know when risk of harm from increased hospitalisations (e.g. failing health) outweighs the benefits of living at home Community programs may never be able to effectively and efficiently provide the intensity of supervision and care needed to decrease hospitalisations immediately prior to ARC admission

29 Avoidable for whom? Hospital use at the end of life Gott, M (2014). Palliative Medicine Internationally there are policies about avoidance of hospitalisation at the end of life win/win Hospitalisation is detrimental to older people s health However: Patients and/or their families request hospitalisation at the end of life because impending death causes fear Hospitals represent a reprieve from death from many families Ageism plays a role in determining inappropriate Hospitals seen as not the right place for older people Cost Shifting also plays a role Could it be the hospital that needs to change the response to older people in general rather than labelling their admissions as inappropriate?

30 Thank You.