PROVIDING BETTER CARE FOR OLDER CANADIANS OBJECTIVES

Transcription

1 PROVIDING BETTER CARE FOR OLDER CANADIANS CGS/ SQG SYMPOSIUM MARIE-JEANNE KERGOAT MD, FRCPC,TORONTO, APRIL 19TH 2013 OBJECTIVES Debate with other clinicians responsible for delivering care to vulnerable older adults in Canada, on how different provincial healthcare systems strive to meet patient s needs. Share with participants the model of Adapted approach of care for older adults in Quebec hospital centres and, their level of implementation. 1

2 PLAN Overview of the Quebec healthcare system Referential framework of the Adapted approach of healthcare to older adults (AAPA) in Quebec hospital centres Level of implementation of AAPA THE QUEBEC HEALTH AND SOCIAL SERVICES SYSTEM 14 advisory boards: Régie de l assurance-maladie Office des personnes handicapées 12 other advisory boards Clinics & private medical offices including family medicine groups RUIS MINISTER Ministry of health and social services 18 health and social services Agencies (ASSS) Hospital centres * Residential & long-term centres * Rehabilitation centres * 95 Health and social services Centres (CSSS) (85% include a hospital centre Institutions or organizations that are not part of a CSSS Source: 2

3 HEALTH AND SOCIAL SERVICES FOR OLDER ADULTS Goals Prevent disabilities Improve, restore the health, autonomy and well-being Maintain autonomy and quality of life Standards accessibility, continuity, quality, efficacy and effectiveness Referential approaches and organizational processes Interprofessional and interorganizational collaboration A network of integrated services (RSIPA) Strategy for prevention and management of chronic diseases Adapted healthcare approach for older adults in hospital centres Politique nationale de soutien à l autonomie December 2013 Assurance autonomie April

4 ADAPTED HEALTHCARE APPROACH FOR OLDER ADULTS IN QUEBEC HOSPITAL CENTRES QUEBEC MINISTRY OF HEALTH AND SOCIAL SERVICES CONTEXT Mandate from the Health and Social Services Minister (MSSS) Draw up the reference framework for an: Adapted Healthcare Approach for the Older adults in Hospital Centres (AAPA) Develop the clinical and organizational tools to support the implementation of the adapted healthcare approach Elaborate a training program for managers and healthcare providers in the hospital sector 4

5 REFERENTIAL FRAMEWORK Adapted from the Donabedian model of assessing the quality of care and health services Continuous quality evaluation Evidence based healthcare Centered on processes of care Interconnections between clientele, processes of care and organizational characteristics Identification of outcome indicators SITUATION IN QUEBEC Demographics and Use of Services 15% of the population > 65 y, 6.6% > 75 y 45% of hospital days > 65 y, 31% > 75 y LOS in emergency room and in units are longer Vulnerable population: a complex health profile with risk of adverse events Delirium, functional decline, immobilization, polymedication, morbidity, placement Non application of effective preventative interventions Preoccupations of patients, families, professionals, 5

6 DYSFUNCTIONAL SYNDROME Functional Older Person Acute illness Possible Impairment Hospitalization Hostile environment Depersonalization Bedrest Starvation Medicines Procedures Depressed mood Negative Expectations Physical Impairment Dysfunctional Older Person Palmer, R. M., Counsell, S., & Landefeld, C. S. (1998). Clinical intervention trials : the ACE unit. Clinics in Geriatr Medi14(4), PREVENT FUNCTIONAL DECLINE ACT on DELIRIUM and the IMMOBILIZATION SYNDROME 6

7 RISK FACTORS, CAUSES AND CONSEQUENCES OF FUNCTIONAL DECLINE Metabolic Disorders Sensory Deprivation Mobility Disorders Impaction, Retention Urinary Incontinence Nosocomial Infections DELIRIUM --- Immobilization Syndrome Medication Dehydration Malnutrition Falls Sleep Disorders Pain SOME DISTURBING FIGURES RELATED TO SENIORS... Delirium: 10% of seniors present at E.R. in a state of delirium. Prevalence of delirium at admission: 10 to 31%. Incidence during general care hospitalizations: 3 to 29%. Post surgery: prevalence up to 74%. Intensive Care: prevalence up to 87%. Immobilization syndrome : Loss of mobility following hospitalization: up to 66% Loss of certain functions, beginning the 2nd day after hospitalization: up to 77%. Requiring assistance to walk after hospitalization: 17% 7

8 AND MORE IN REGARDS TO MEDICATION 31% of hospitalizations in the elderly population are related to complications with medications 57% of these complications are considered preventable While on leave from hospital: 57% of elderly persons do not take one of their prescribed medications 41% of elderly persons take a non prescribed medication In addition, medication errors: affect 27-54% of patients admitted for acute care occur primarily during transitions (emergency-unit-discharge) BEST PRACTICES General principles: Global approach Special consideration to the physical environment Objectives focused on improving the function Moving from medical approach to team approach The hospital stay: a phase in the continuum of care In partnership with the elderly, develop individualized treatment, proportionate to need and based on evidence Examples: Yale Geriatric Care Program HELP (Hospital Elder Life Program) ACE others 8

9 ALGORITHM FOR CLINICAL CARE TO OLDER ADULTS IN HOSPITAL IDENTIFICATION OF OLDER ADULTS AT RISK 1 st step: SCREENING, TARGETING 9

10 2 nd step: EVALUATION, INTERVENTIONNAL CARE PLANS AND MONITORING 3 rd step: INTERVENTIONS: IMPLEMENTATION OF CARE PLANS 10

11 4 th step: RESULTS, REVISION OF THE INTERPROFESSIONAL S CARE PLAN 5th step: DISCHARGE PLAN,TRANSFER INFORMATION/RECOMMANDATIONS CLINICAL INTERVENTION STRATEGIES TO PREVENT FUNCTIONAL DECLINE SYSTEMATIC AND HIERARCHICAL APPROACH Environnement Environnement Interventions spécialis cialisées Interventions spécifiques Interventions préventives systématiques Physique Psycho-socialsocial 11

12 LEVEL 1 SYSTEMATIC PREVENTIVE INTERVENTIONS Interview upon arrival Assess* Intervene: A measures to promote autonomy & life skills I measures to promote skin integrity N measures to promote nutritional health É measures to promote elimination E measures to promote and maintain cognitive and emotional capacities S measures to promote sleep Monitor Notify Environnement Interventions préventives systématiques Physique Psycho-social Adapted from: Équipe Projet OPTIMAH, Centre Hospitalier Universitaire de Montréal, 2008 LEVEL 2: SPECIFIC INTERVENTIONS FOR PREVENTION AND TREATMENT A autonomy / mobility I skin integrity Environnement N É nutrition / hydration elimination Interventions spécifiques Physique Psycho-social social E cognitive status and behavior Interventions préventives systématiques S sleep 12

13 LEVEL 3: SPECIALIZED TREATMENT, INTERVENTIONS If confinement to bed In cases of delirium... Environnement Environnement Interventions spécialis cialisées Physique Psycho Psycho-social social In cases of malnutrition... Interventions spécifiques Interventions préventives systématiques FOR THE ORGANIZATION 5 PRINCIPLES The organization: Promotes a sustained transformation of care practices and services tailored to the older adults in hospitals; Support the development of a culture adapted to the older adults; Recognizes the importance of the care team and invests in it to support the transformation; Includes an interprofessional collaborative approach adapted to older adult s care; Takes into account the necessity for continuity in delivering care to a highly sensitive older adult population. 13

14 STRATEGIES TO BETTER MANAGE MEDICATION A comparative appraisal (medication reconciliation) Documents medication history in a complete and precise manner Verifies the use of medication Identifies gaps Rectifies medication errors and acts as an interface between the different points of care. PHYSICAL ENVIRONMENT Take Care or Become Lost Congested hallways Incessant noise Signals and markings Non-existant chairs and armchairs Available water? 14

15 REMAINING CHALLENGES... Counteract prejudices (ageism) Early intervention and support from the moment of first contact Recruit and retain manpower Use evidence based information Manage the constant changes SUPPORT FOR SKILLS DEVELOPMENT Two inseparable components Consolidation of knowledge Clinical and organizational tools Online interactive training Development of competence in action Coaching on the units 15

16 SUPPORT FOR THE SKILLS DEVELOPMENT SIX MODULES OF SENSITIZATION / TRAINING Functional decline associated with hospitalization Normal and pathological aging Operationalization of the approach Adaptation of the environment Immobilization syndrome Delirium 16

17 CLINICAL TOOLS: 10 SHEETS THEORETICAL AND PRACTICAL A Functional decline in ADLs Immobilization syndrome I Pressure ulcers N Malnutrition Dehydration É Urinary incontinence Constipation / fecal impaction E Delirium Psychomotor agitation associated with dementia S Sleep disorders Google Approche adaptée à la personne âgée en milieu hospitalier 17

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19 ORGANIZATIONAL TOOLS Organizational diagnosis: identify the current situation and better understand certain dynamics Understand the different levels of comprehension, within the hospital, about the situation of the older adults; Estimate the need for the participation of each director; Assess the interest generated by this project, in the different teams (board of directors, senior management, managers, health units); Find "champions" who can become leaders in the implementation process; Obtain a consensus on the first steps to take, in order to begin this transformation. Elements to consider before implementing the approach Guide for a communication plan 19

20 IMPLEMENTATION OF ADAPTED HEALTHCARE APPROACH MSSS Strategic Priorities Formal annual management contract (Agencies and hospitals) Identification tools in the emergency department Follow-up mechanisms for identified elderly Liaison professionnal dedicated to elderly (emergency department) for follow-up and liaison interorganizations Implementation of walking and mobility program in emergency department and hospital units Regional responsability (regional project manager): Regular telephone conferences for update and follow-up Regular visits by MSSS (project manager) Support to local Local responsability (local project manager) Training program Local coach for coaching activities (following training) 20

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