3. Plan (Timely Navigation)

Transcription

1 WATERLOO WELLINGTON ASSESS AND RESTORE FRAMWORK COMPREHENSIVE GERIATRIC ASSESSMENT 1. Screen (Early Identification) 2. Assess (Standardized Assessment) 3. Plan (Timely Navigation) 4. Implement (Individualized Care) 5. Evaluate (Coordinated Transition) AUA Screening Tool **See Appendix 1 AUA Screening Tool** LOW RISK (AUA Score 1-2): Focus on increasing selfmanagement skills. Use Caredove, to refer to community support services or rehab services (ie. Exercise and falls prevention classes) or refer to CCAC for information and referral MODERATE RISK (AUA Score 3-4): Consider assessing for Geriatric Syndromes using the screening questions in **Appendix 2**. A referral to a GEM nurse or the CCAC may be appropriate. Continue to focus on selfmanagement skills and consider using Caredove or Easy Coordinated Access (ECA) referral forms to refer to community-based programs HIGH RISK (AUA Score 5-6): Refer patient to Specialized Geriatric Services and CCAC. Care planning based on the goals of care set by the client/caregivers Rule out acute medical condition as the cause of presentation or functional/ cognitive decline Does the patient have high restorative potential? **See appendix 3 for definition of restorative potential** NO Is the person safe to be at home? NO Potential care options for referral: CCAC Specialized Geriatric Services YES YES Potential care options for referral: Outpatient rehabilitation Day hospital Sub-acute complex Medical Care Convalescent Care Restorative Care Geriatric Rehabilitative Care Program Geriatric Assessment Unit Neuro-behavioural Unit **See Appendix 4 for definition of each program** Potential care options for referral: Home with CCAC support Ambulatory Care Community-based programs Memory Clinic Specialized Geriatric Services Assisted Living Retirement Home Reassess status and goals of patient compared to initial assessment Anticipatory Guidance The following should be documented and communicated with the patient/ family/caregivers and all community providers involved in the care of the patient: Identify potential red flags Identify signs and symptoms to watch for in the patient/client Identify potential considerations for followup with the patient/client in the community. Teaching and education for patient and caregiver(s). Advance directives. RISK ASSESSMENT TO OCCUR ACROSS THE CONTINUUM OF CARE (EVERY TIME A PROVIDER INTERACTS WITH A PATIENT) Phase

2 Appendix # 1 interrai Emergency Department Screener

3 QUESTION LOGIC Appendix # 1

4 Appendix # 2 Questions and Simple Tests for General Assessment of Frail Older Patients Functional Status Activities of Daily Living (ADLS) Instrumental activities of daily living (IADLs) Visual Impairment Hearing Impairment Urinary Incontinence Malnutrition Question Bathing, dressing, toileting, transferring, maintaining, continence, feeding Using the telephone, shopping, preparing meals, housekeeping, doing laundry, using public transportation or driving, taking medication, handling finances Do you have difficulty driving, watching television, reading, or doing any of your daily activities because of you eyesight, even while wearing glasses? (1) Is your age older than 70 years? Are you of male gender? Do you have 12 or fewer years of education Did you ever see a doctor about trouble hearing? Without a hearing aid, can you usually hear and understand what a person says without seeing his face if that person whisper s to you from across the room? Without a hearing aid, can you usually hear and understand what a person says without seeing his face if that person talks in a normal voice to you from across the room? Have you had urinary incontinence (lose your urine) that is bothersome enough that you would like to know how it could be treated? Have you lost any weight in the last (3) Indicator (Scoring applies to individual domains) Able to complete without assistance; able but with difficulty; unable to complete without assistance Able to without assistance; unable to complete without assistance Yes indicated positive screen Alternative Snellen eye chart 1 point Alternative is Autoscope (2) 1 point 1 point 2 points If no, 1 point If no, 2 points >3 points; positive screen Yes indicated positive screen Loss of at least 5 percent of usually body weight in last year indicates positive screen

5 Appendix # 2 Gait, balance, falls Δ (10) Depression Cognitive Problems Environmental Problems Medication Question Have you had any falls in the past year? (10) Have you fallen and hurt yourself since your last doctor s visit? For patients who have not previously fallen, screening consists of an assessment of gait and balance (10) Inquire about gait or balance problems Over the past 2 weeks, how often have been bothered by: Little interest or pleasure in doing things? Feeling down, depressed, or hopeless? 3-item recall (4) Clock drawing test(5) Home safety checklist (6) Periodic "brown bag checkups." Instruct patients to bring all pill bottles to each medical visit; bottles should be checked against the medication list (12) Transitions in care, between hospital and nursing home, or institutional setting and home, are a common source of medication errors and confusions (12) A medication review should consider whether a change in patient status (e.g. renal or liver function) might necessitate dosing adjustment, the potential for drug-drug interaction, whether patient symptoms might reflect a drug side effect, or whether the regimen could be simplified (12) Indicator (Scoring applies to individual domains) Any yes response indicates positive screen. Response score for each: 0: not at all 1: several days 2: more than half the days 3: nearly every day Total >3 positive screen <2 items recalled indicates positive screen (4) Any of the following errors indicate positive screen; wrong time, no hands, missing numbers, number substitutions, repetition, refusal (5) Alternative By performing a multifactorial fall assessment on a patient who screens positive and then treating the patient s Risk factors for falling falls can be reduced by 30% to 40%. GDS Instruments for Primary care SCT, Mini-cog,MIS, AMT, SPMSQ, FCSRT, 7MS, and IQCODE (11) The Screening Tool of Older Person's Prescriptions (STOPP) criteria were introduced in The 2003 Beers criteria have been compared to the Screening Tool of Older Person's Prescriptions (STOPP),

6 Appendix # 2 * All except the Snellen eye chart, Audioscope, and evaluation for cognitive problems can be assessed by selfreport using questionnaire. Questions and response indicators are from the National Health and Nutrition Examination Survey (NHANES) battery. [7] Δ Questions and response indicators are from the ACOVE-2 Screener. [8] Questions and response indicators are from the Patient Health Questionnaire-2. [9] References: 1. Moore AA, Siu AL. Screening for common problems in ambulatory elderly. Am J Med 1996; 100: Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care. JAMA 2003; 289: Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman RA. Involuntary weight loss in older outpatients. J Am Geriatr Soc 1995; 43: Siu AL. Screening for dementia and investigating its causes. Ann Intern Med 1991; 115: Lessig MC, Scanlan JM, Nazemi H, Borson S. Time that tells: critical clockdrawing errors for dementia screening. Int Psychogeriatr 2008; 20: Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Injury Prevention and Control. Home safety checklists. Accessed June 9, Reuben DB, Walsh K, Moore AA, et al. Hearing loss in community-dwelling older persons. J Am Geriatr Soc 1998; 46: Wenger NS, Roth CP, Shekelle PG, et al. Practice-based intervention to improve primary care for falls, urinary incontinence and dementia. J Am Geriatr Soc 2009; 57:547. Reproduced with permission from: Rueben DB. Medical care for the final years of life: "When you're 83, it's not going to be 20 years." JAMA 2009; 302:2686. Copyright 2009 American Medical Association. All rights reserved. 9. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2. Med Care 2003; 41: David A Ganz MD, MPH, Yeran Boa, MD, Paul G Shekelle, MD PhD, Laurence Z Rubenstein MD, MPH Will My Patient Fall? JAMA 2007:297:1 11. Jennifer S Linn Al, Screening for Cognitive Impairment in Older Adults: A Systematic Review for the Us Preventative Services Task Force. Annals of Internal Medicine Nov volume 159 number Paula A Rochon, MD, MPH, FRCPC, Kennether E Schmader, MD, H Nancy Sokol, MD Drug prescribing for older adults, Up to date, Drug prescribing for older adults Questions and simple test for general assessment of frail older patients, Retrieved from UptoDate April 17, 2014

7 Appendix # 3 Rehabilitative Care Alliance Restorative Potential Definition Restorative Potential means that there is reason to believe (based on clinical expertise and evidence in the literature where available) that the patient's/client s condition is likely to undergo functional improvement and benefit from rehabilitative care. The degree of restorative potential and benefit from the rehabilitative care should take into consideration the patient s/client s: Premorbid level of functioning Medical diagnosis/prognosis and co-morbidities (i.e., is there a maximum level of functioning that can be expected owing to the medical diagnosis /prognosis?) Ability to participate in and benefit from rehabilitative care within the context of the patient s/client s specific functional goals Note: Determination of whether a patient/client has restorative potential includes consideration of all three of the above factors. Neither cognitive impairment, depression, and delirium nor discharge destination should be used in isolation to influence a determination of restorative potential.

8 Appendix # 4 WATERLOO WELLINGTON REHABILITATION/TRANSITIONAL PROGRAM FRAMEWORK Rehabilitative Care for medically stable patients who do not require 24 hour nursing or medical care will be supported in the community Medical Stability: a clear diagnosis and co-morbidities have been established medical conditions are stable and can be managed within the scope of an RN/RPN and do not require daily reassessments by a physician all abnormal lab values have been acknowledged and addressed as needed. all consults and diagnostic tests for the purposes of diagnosis or treatment of acute conditions have been completed and reported or pending test results are not anticipated to dramatically change the treatment plan. A follow-up plan is in place at the time of the referral and follow-up appointments have been made at the time of discharge from the acute hospital no acute psychiatric issues limiting the patients ability to participate in the program. REHABILITATION SECTOR COMPLEX CONTINUING CARE SECTOR LONG TERM CARE SECTOR Moderate to High Intensity Rehabilitation Restorative Care (Moderate to Low Intensity Rehabilitation) Convalescent Care (Low Intensity Rehabilitation) Intensive goal-oriented general rehab program for adults who require a minimum 60 minutes of total therapy daily. The Average LOS is goal dependent and is expected to range between 7 and 40 days as required to improve strength, endurance, or functioning to support transition to the community. Stroke patients are to be referred to Rehab regardless of the length of stay and the current level of tolerance Available at CMH, SJHCG, GRH Therapeutic Criteria: Demonstrates potential to tolerate being up in a chair 1-2 hr, 2-3 times/day OT, PT is based on a model of a minimum Moderate to Low intensity goal-oriented rehab program for adults or seniors who have functional goals and restorative potential e.g. those who are unable to return home after assessment in acute care, those who meet eligibility criteria from the community. The Average LOS is goal dependent (up to 90 days) and focuses on improving strength, endurance, and/or functioning to ensure a safe transition to the community Available at SJHCG, GRH and Groves (dependent on treatment plan and client needs) Therapeutic Criteria: Care plans are individualized and will adjust to the patient s tolerance level. Demonstrates potential to tolerate being up in a chair 1-2 hours, 2-3 times/day. Available at Sunnyside RAI-HC must be completed prior to admission WW 555 Expanded Role Working Group February 2014 EP

9 Appendix # 4 REHABILITATION SECTOR COMPLEX CONTINUING CARE SECTOR LONG TERM CARE SECTOR Moderate to High Intensity Rehabilitation minutes, 5-7 times per week with a therapist or therapy assistant Restorative Care (Moderate to Low Intensity Rehabilitation) Goals for therapy must be SMART goals Convalescent Care (Low Intensity Rehabilitation) Demonstrates achievement of functionally significant and consistent progress towards the identified goals. Must be able to follow therapy instructions and participate in therapy. Patient has demonstrated the potential to attain functional goals, have the ability to participate, and readily integrate new learning into daily life, based on clinical expertise and evidence in the literature. Staffing Ratios Realistic Discharge Plan Initiated: Discharge dependant on goal attainment and/or functional plateau. Initiated discharge plan to the community (e.g. previous living arrangement such as: home, RH, supervised living, independent living) from sending site. Palliative clients with a longer life expectancy should be considered within the admission criteria as long their medical treatment plan does not limit participation in the therapy program. LTC patients who resided in LTC prior to admission should return to LTC to receive rehabilitative care OT, PT is limited (based on the model of minutes of therapy up to 5 days per week) within an interdisciplinary therapeutic setting that includes nursing rehabilitation, a community dining room, and opportunities for socialization. SJHCG PT: 0.5:15 OT: 0.5:15 TA: 0.9:15 SLP: 0.3:15 SW: 0.6:64 Nursing: 3.78 hrs/day (RN/RPN/PSW) 2.06 hrs/day ( RN/RPN) GRH PT: 1:32 patients Mon-Fri OT: 1:32 patients Mon-Fri TA: 1:21 patients Mon-Fri SLP: 0.2:32 patients CDA: 0.2:32 patients Recreation: 0.2:32 patients Elder Life Specialist 1:32 patients Nursing: 3.5 hrs/pt/day (RN/RPN) Realistic Discharge Plan Initiated: Discharge is dependent on goal attainment and/or functional plateau. Sunnyside PT: 0.7:25 patients Mon-Fri OT: by consultation TA: 1:25 patients Mon-Fri SLP: by consultation CDA: n/a SW: 0.6:25 Recreation: 0.3:25 Nursing: 1.8 hrs/pt/day (RN/RPN) 1.9 hrs/pt/day (PSW) A realistic and viable discharge plan the community (e.g. previous living arrangement such as: home, RH, supervised living, independent living) has been initiated and has been discussed with the individual. Applicable Legislation Public Hospital Act Discharge planning will follow the Home First Philosophy. Applicable Legislation Public Hospital Act Applicable Legislation Long Term Care act 2007 WW 555 Expanded Role Working Group February 2014 EP

10 Appendix # 4 The guideline below has been developed to assist in determining which program would be most suitable for patients to be referred; keeping in mind that emphasis is to be placed on the individual s unique needs. Geriatric Assessment Unit Complex Continuing Care Program Mild cognitive decline with multiple co-morbidities Physical/Functional decline (i.e. polypharmacy, falls) No serious/persistent mental health illness complicated by aging, mild cognitive issues, comorbidities No definitive cognitive related diagnosis requires an initial/full assessment of cognitive impairment Not a risk to self or others Exclusion Criteria: Those exhibiting physically responsive behaviours In need of high flow oxygen (>4L/min) Exacerbation of a chronic psychiatric diagnosis Formed patients Neurobehavioral Unit Complex Continuing Care Program Diagnosis of mild-moderate cognitive impairment associated with dementia or neurodegenerative disorder Medical and neuropsychiatry comorbidities related to dementia including agitation, resistance and BPSD Persistent delirium evaluation and treatment of Exclusion Criteria: Those exhibiting physically responsive behaviours In need of high flow oxygen (>4L/min) Exacerbation of a chronic psychiatric diagnosis Formed patients Seniors Specialized Mental Health Schedule 1 Psychiatric Unit Established diagnosis of moderate to severe cognitive impairment, typically related to dementia significantly affecting functional ability Medical issues stable and well defined Acute psychiatric issues relatively managed and stable Behaviours may pose risk to self or others Has not responded to recent, less intensive interventions and supports. Exclusion Criteria: Axi 1 diagnosis; not dementia; not medically stable