Developing an Integrated System of Care for Frail Seniors in the WWLHIN

Transcription

1 Developing an Integrated System of Care for Frail Seniors in the WWLHIN George Heckman MD MSc FRCPC HTCP-1 RIA-UW Schlegel Research Chair in Geriatric Medicine Associate Professor, School of Public Health and Health Systems University of Waterloo Lead Geriatrician WWLHIN December 5, 2011

2 What is Frailty? Bergman et al. J Gerontol 2007;62A:7;731-7 Vulnerability resulting from the age-related accumulation of deficits across multiple physiologic systems Leads to Functional impairment / disability Caregiver burden and ill-health Falls Homecare use, institutionalization ED / hospitalization / ALC / death Stressors Any medical illness or complication Medications Source: Non senior friendly system 2

3 An Example 85 year-old woman prescribed new eye-drops at bed-time for glaucoma Bitter taste: drinks 2 glasses of water Nocturia++ leads to frequent night-time washroom visits One night, mistakes basement door for washroom Falls: fractured wrists, ICH, fractured odontoid Despite rehab, ends up in long-term care 3

4 Key Features Previously fairly independent person but at risk Stressor: seemingly banal bitter medicine Multi-system impairment / chronic diseases Bladder, eye-sight, strength, balance, living environment (layout of stairs, no caregiver) Underlying osteoporosis Outcome: negative life-changing 4

5 Frailty x Stressor = Bad outcome 5

6 The System as a Stressor Bergman 1997; Hebert 2003 Canadian health care challenges include multiple entry points service delivery influenced less by patient need and more by available contracted services piecemeal care planning duplicated assessments, limited use of standardized di d tools, inadequate information sharing long wait times 6

7 Need to Frailty can be Managed identify treat compensate for the accumulated deficits Need to manage stressors, including health care system design 7

8 The Role of Care Integration in Managing Frailty 8

9 What are the Elements of Integration? Vedel et al IGIC 2011; Hollander & Prince HQ 2008 Involvement of clients and families: emphasis on enhancing self-care Commitment to the psychosocial model of care (in addition to medical services) Consistent case manager over time and across system 9

10 Integration (continued) Single/coordinated-entry system provides focal point for community resources; limits the set of care providers needed for standardized assessment Standardized system-level assessment facilitates t appropriate determination ti of need Single system-level client classification system Commitment to analysis and evidence-based decisionmaking Integrated electronic information systems 10

11 Care Integration: What is the Evidence? Systematic reviews by Johri et al 2003 and Eklund 2009 Reduced acute care use Better patient outcomes Reduced costs The problem Takes time and is challenging to achieve 11

12 Goal: Develop an Integrated System of Care for the WWLHIN How are we doing currently? The World Tour 12

13 Goals: WWLHIN Focus Group Interviews Identify unmet needs and challenges faced by seniors in the WWLHIN; Identify changes that are needed to existing health services for seniors; and Identify key geriatric services that are needed to meet the health needs of seniors in this area and to identify priorities iti for an integrated t clinical services plan for seniors. 13

14 Methods Focus group interviews Interviews recorded and transcribed and / or detailed notes taken Feedback incorporated into the data analysis Data saturation achieved Clearance provided by Office of Research Ethics at the University of Waterloo 14

15 Results 20 focus groups 186 participants 4 to 19 / group; average = 9 Interviews ranged from 1 to 1.5 hours 29 consumers and / or informal caregivers 15

16 Participating Groups Intensive Geriatric Support Workers Upper Grand FHT WW Seniors Services Lang's Farm CHC Grand River Hospital Geriatric GEM Nurses Service Cambridge Memorial Geriatric Services Waterloo Region Public Health Freeport Hospital Geriatric Services Mount Forest Family Health Team WW Dementia Network St. Mary's General Geriatric service WW CCAC Part 1 WW CCAC Part 2 WW Adult Day Programs Osteoporosis Society LTC Physicians Woolwich CHC Guelph Alzheimer's Society KW Alzheimer's Society Caregivers

17 System Strengths Primary care services Family Health Teams, Community Health Centres Specialized geriatric services Community supports 17

18 Limited Challenges primary care capacity to assess and manage frailty eligibility for home care support respite for caregivers of persons with dementia person-centered care limited access to specialists in the community 18

19 Cross-sectoral sectoral challenges Limited capacity for care for frail seniors Limited expertise in care of the elderly E.g. delirium i prevention/management t in hospitals Limited training on interprofessional care Limited communication across system Limited exchange of information Limited communication with caregivers and seniors System navigation 19

20 What is System Navigation? Implicit in chronic disease and prevention management (CDPM) Informed, empowered patient; self-care support Coordinating care delivery from person perspective p Seniors understanding who, how and when to contact to access appropriate care Care providers facilitate safe and effective transitions within and across care settings 20

21 Direct clinical System Navigator Responsibilities Skilled home visits and/or phone support Medication management Assessment and management of health status Care or treatment planning Care coordination Collaboration with health care providers Service/care provider access and coordination Patient advocacy Self-care support Patient and family self-care education 21

22 Systematic review: Outcomes Hospital readmissions Cost- hospital, community services Time until next admission Patient and caregiver satisfaction Psychological well-being Mental quality of life Adherence to self-care regimes ADL and IADL improvements Quality of care 22

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24 Service Gaps Services and activation for frail seniors Adult Day Programs and respite Leisure, recreation, activation for frail seniors Assistance with IADLs (including finances) Palliative care for non-malignant disorders Multidisciplinary care for frail seniors Better management of depression, pain, wounds Medication management and adherence physiotherapy and occupational therapy Prevention/management of delirium in hospitals 24

25 System Gaps Ability to provide culturally sensitive care Crisis orientation rather than proactive care Lack integration ti between specialists / primary care Accessing local (close to home) LTC beds Limited capacity to diagnose and manage dementia 25

26 Proposed System Improvements Empowered seniors: enhancing self-care skills Clinical best practices Adequate human resources to facilitate greater interprofessional approaches to care Capacity building to improve competence in geriatric care among all providers More proactive and preventative access to specialist consultation and follow-up 26

27 Proposed System Improvements Coordination best practices Improved communication, continuity of care and coordination between providers, health care sectors and clients Improved access to services and care, particular during care transitions Improved system navigation for seniors (clients and caregivers) and health care providers 27

28 Highlighted Recommendations 1. Support for system navigation should build upon existing services in the WWLHIN, such as IGSWs and Easy Coordinated Access, adding APN-led Transitional Care services for more complex seniors. 2. Need for standardized comprehensive assessment across all sectors can be met by interrai instruments. Full clinical functionality of these tools must be realized and dall clinicians ca sand dcaepo care providers desbeta trained in how to use it. 28

29 Recommendations 4. Develop multidisciplinary capacity for geriatric care in primary and specialty care sectors, including specific programs such as HELP. 5. Promote greater integration of specialty care within primary care in order to more proactively manage frailty and prevent poor outcomes 6. Manage mild frailty through closer collaboration of primary care, Public Health, pharmacists, and community physical activity programs 29

30 Recommendations 8. Encourage WWLHIN communities to formally endorse principles of healthy cities as outlined by the WHO 9. Foster and encourage closer collaboration between existing and future health service providers and local academic institutions 30

31 Progress Several recommendations / elements being implemented Home first Coordinated access to community support services HELP programs Consider oversight / development role for WW Geriatric Services Network 31

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