Champlain Dementia Network

Transcription

1 Champlain Dementia Network Dementia: The Missing LHINk in the Integrated Health Services Plan (IHSP) Learn how the Champlain Dementia Network (CDN) can promote Aging at Home by linking patients to resources that may decrease Emergency Department visits, may decrease hospitalizations and ALC rates, and can improve stable discharges from hospital. Dr. Frank Molnar Co-chair, CDN; Geriatric Assessment Unit, The Ottawa Hospital Kelly Robinson Provincial First Link Program Manager, Alzheimer Society of Ontario Dr. Andrew Frank Cognitive and Behavioural Neurologist, Memory Disorder Clinic, Bruyère Continuing Care

2 Alternate Title DEMENTIA Health Care Planning s Elephant in the room

3 Objectives To illustrate that good community-based dementia care can assist with the management of Chronic Diseases and can help to keep people out of Emergency Departments and Acute Care Hospitals. To demonstrate how the Champlain Dementia Network (CDN) website can be a useful resource for: Families and community-based health care professionals to keep people out of emergency departments and acute care hospitals. Families and acute-care hospital health care professionals to organize stable discharges that will prevent return to emergency departments and readmissions to acute care hospitals.

4 Rising Tide: The Impact of Dementia in Canada (Alzheimer Society of Canada) Prevalence of Alzheimer's disease and related dementias in Canada: ,600 people with dementia ,125,200 people with dementia Incidence of Alzheimer's disease and related dementias in Canada: ,700 new cases per year (1 every 5 minutes)

5 Rising Tide: The Impact of Dementia in Canada Economic Burden of Dementia (in future dollars) $15 billion $37 billion $75 billion $153 billion

6 The Rising Tide Provincially (10 by 20 - Alzheimer Society of Ontario)

7 The Rising Tide - Provincially

8 The Rising Tide - Provincially

9 Dementia impacts on all of the areas that the 14 LHINs have been asked to focus on: Reduce Emergency Department waiting times Reduce ALC rates Support Ontario s Diabetes Strategy

10 Dementia impacts on all of the populations targeted in our local Champlain LHIN s Integrated Health Services Plan (IHSP) Pre-diabetes or Diabetes Mental Health Issues and Problematic Substance Abuse Complex Health Conditions

11 Mrs C a journey through the Health Care system Mrs. C. is a 76 year old woman living alone. Her medical history includes diabetes, hypertension, and osteoporosis. In the last six months she was forgetting names and occasionally needed a reminder to take her medications. MMSE 27/30. Family MD diagnoses her with Mild Cognitive Impairment (MCI). Given that the patient is having greater difficulty managing her diabetes, she was referred to a Diabetes Clinic.

12 2 Years later the warning signs MMSE 23/30 Mrs. C. is having increasing difficulty following her diabetic regimen (diet and medications). The Diabetes Clinic is responding by altering medications however Mrs. C. has even greater difficulty following the new more complex medication regimen. Mrs. C was having more trouble with cooking, was forgetting to take medications, was losing weight as she was forgetting to eat meals. Blood sugars were fluctuating from low readings (2.0) to high readings (> 12).

13 How can dementia care support the Ontario Diabetes Strategy? Reciprocal relationship between diabetes and dementia Diabetes is a risk factor for dementia Dementia is a risk factor for loss of control of diabetes (often resulting in avoidable hospitalization). Early diagnosis of dementia promotes: Simpler rather than more complex diabetes treatment regimes Possibly less tight control (to avoid low blood sugars) Closer supervision of medications, diet and glucose monitoring Rapid response should delirium, high or low blood sugars occur Referral for assessment and treatment of dementia to slow cognitive decline, maintain safety, create future and crisis plans

14 2 Years,1 Month 1st avoidable event Mrs. C has a car crash. In the Emergency Department her MMSE was 20/30. Due to leg fractures she is admitted to hospital. During the 4 month stay Mrs. C. suffers a significant delirium which slowly resolves to the point where she was felt to be safe to return home. Her Family MD makes the diagnosis of Alzheimer s dementia and she was started on anti-dementia drug therapy (cholinesterase inhibitor).

15 Balanced Health Care For acute care hospitals to function optimally, they require the support of a strong, wellfunded and well-organized community care system. Otherwise people unnecessarily deteriorate and avoidable presentations to Emergency Departments, avoidable Acute Care admissions, and avoidable Alternate Level of Care (ALC) days occur.

16 How can dementia care support the LHINs priority of Reducing Emergency Department waiting times and Hospitalizations? Injury Prevention Assess fitness-to-drive and address driving cessation for those who are no longer safe to drive BEFORE a crash occurs this will prevent ER visits as well as a lengthy and expensive hospitalizations. Many older drivers do not fully recover after a car crash and lose years of independent life. Prevent traumatic falls resulting in fractures and head injuries caused by delirium or lack of social support for a person with dementia Prevent Medication Errors (forget medications or double dose)

17 The Dementia Domino Effect Cognition is required to allow patients to safely manage their chronic medical conditions. When people develop dementia they are more prone to loss of control of chronic medical conditions (e.g. Diabetes, Heart Failure, Coronary Artery Disease, Renal Disease.) when these spiral out of control they may lead to an avoidable hospitalization often with a very slowly resolving delirium which prolongs the hospitalization.

18 3 years a 2nd avoidable event! Mrs. C. s oral intake decreased, her alcohol use increased and her diabetic control worsened. She experienced a series of falls resulting in a hip fracture. Mrs. C. was admitted to hospital for a hip replacement. Her delirium was very slow to clear (such slow and/or partial resolution of delirium is common when a person has an underlying dementia). As the delirium cleared it became increasingly obvious that Mrs. C. was suffering from a significant depression. She was started on an antidepressant and slowly responded. After 3 months in the acute care hospital she was discharged to a residence.

19 3 years, 6 months Her MMSE was 16. Mood remained an issue as she continued to demonstrate agitation, anxiety and once again presented with poor appetite. Intermittent bouts alcohol abuse were noted. Her antidepressant dose was increased. The patient s daughter experienced escalating caregiver stress. This resulted in a recurrence of her own depression. The daughter was forced to take leave from work and was started on an antidepressant.

20 How can dementia care support IHSP priority of Mental Health Issues and Problematic Substance Abuse? Good dementia care includes: Management of depression which is more prevalent and more difficult to diagnose and treat in persons with dementia Increased alcohol use may reflect a depression Alcohol has a greater cognitive impact in persons with dementia (i.e. causes delirium and traumatic falls) Management of the common symptoms of BPSD Behavioural and Psychological Symptoms of Dementia Caring for the Caregiver Caregivers of persons with dementia suffer high rates of anxiety disorders and depression

21 3 years, 8 months 3 rd avoidable event!! Mrs. C. had more falls resulting in a head injury. She was admitted to hospital with subdural hematomas. Mrs. C. was once again very delirious. This slowly improved. Unfortunately Mrs. C. did not improve to her previous cognitive baseline. After being in hospital for 4 weeks it was determined that she would need a nursing home. The nursing home application papers were completed and Mrs. C. was listed as ALC (Alternate Level of Care). She spent 3 more weeks in hospital waiting for a nursing home bed. During this time the hospital was over-capped (> 100% of beds filled) with patients waiting in the Emergency Department due to lack of in-hospital beds.

22 How does dementia contribute to ALC rates? Canadian Institute for Health Information ( ; Alternate Level of Care in Canada Dementia is a key diagnosis related to ALC. In , 57% of all hospitalizations with dementia as the main diagnosis and 25% of those with dementia as a comorbidity had at least one ALC day. Overall, dementia accounted for more than one-third of ALC days. Hospitalizations with a main dementia diagnosis had a longer median ALC length of stay (23 days) than typical ALC patients (10 days).

23 How can dementia care support the LHINs priority of reducing ALC rates Good community dementia care can prevent hospitalizations and ALC days by: Early identification and treatment of dementia, delirium and depression Teaching families to deal with issues before they reach crisis proportions Providing education and services to assist with the prevention of loss of control of other common chronic diseases (Diabetes, Heart Disease, Kidney Disease) and the prevention of trauma (falls, car crashes) Planning for relocation when such in-home support is no longer possible

24 Dementia affects all LHIN priorities Reduce Emergency Department waiting times Reduce ALC rates Support Ontario s Diabetes Strategy Mental Health Issues and Problematic Substance Abuse Complex Health Conditions

25 Are we currently providing adequate dementia care? All Local Health Integration Networks (LHINs) show dramatic increases in people with dementia, yet Only 5 of 14 LHINS have specifically included dementia in their plans for elder care Dementia is only mentioned once in the 37 page Champlain LHIN Integrated Health Services Plan

26 Are we currently providing adequate dementia care? The Aging at Home Strategy helps seniors live independently, yet The Strategy does not identify dementia as a priority Fewer Community Care Access Centres have special dementia teams than 5 years ago

27 As a system we are NOT currently providing adequate dementia care Because dementia care is not adequately integrated into Health Care planning we (persons with dementia and their families, other patients, acute care hospitals, society) are all paying the price for this oversight in terms of Increased ER visits Increased hospitalizations Increased ALC rates

28 A Community s approach to improving Dementia Care The Champlain Dementia Network (CDN)

29 The Champlain Dementia Network The Champlain Dementia Network (CDN) is a voluntary organization that was established in September 2005 Over 85 persons including health professionals and consumers. These members volunteer their time and money to keep the CDN running Links together most of the services providing dementia care in the region.

30 The Champlain Dementia Network (CDN) Our Mandate to further develop a more coordinated, integrated and efficient system for clinical care and service delivery, education, research and policy development related to dementia.

31 How can the Champlain Dementia Network help the community at large? it can help negotiate the system of dementia care services it can help find services that will address legal, safety and residential issues it can help direct families to education and counselling services it advocates for better funding for dementia care

32 Supporting Community Caregivers In order to keep persons with dementia as healthy and safe as possible while keeping them out of acute care hospitals, the CDN and partner services support 2 groups: Family Physicians and other Community / Acute Care Health Care Professionals Family Caregivers

33 How can the Champlain Dementia Network help Health Care Professionals locate RESOURCES?

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40 CDN Physician Education Dr. Andrew Frank Neurology training at the Ottawa Hospital, and completed fellowship training in Alzheimer's disease and dementia at the Mayo Clinic. Cognitive Neurologist and Medical Director of the Memory Disorder Clinic at Bruyère Continuing Care

41 CDN Physician Education Physician Dementia Newsletter Produced three times per year Contains articles relevant to family physicians on the topic of diagnosis and management of dementia and Alzheimer s disease Contains information on obtaining services of Alzheimer Society First Link program Contains invitation to make use of Physician Teaching Sessions provided by the CDN Plan to take the newsletter province-wide through the Ontario Dementia Network

42 CDN Physician Education Physician Dementia Newsletter Recent Topics FP Office Cognitive Testing/Interpretation Medical treatment of Dementia and Alzheimer s Mild Cognitive Impairment Driving Safety Assessment/Reporting Capacity Assessment Managing Agitation in Dementia

43 CDN Physician Education Physician Teaching Sessions Dementia specialist physician travels to family physician office to provide direct teaching on diagnosis and management of dementia and Alzheimer s disease One-on-one approach promotes incorporation of information into clinical practice

44 Memory Disorder Clinic Located at Elisabeth Bruyere Hospital Only clinic in Champlain Region dedicated to assessment of mild memory complaints, determining which cases represent mild dementia due to Alzheimer s disease Early diagnosis leads to early treatment, and early connection to community services (e.g. Alzheimer Society First Link, CCAC) Improved outcome (i.e. increased safety surrounding driving issue, living arrangements) Diminished usage of acute care hospitalization Recently funded for expansion by Champlain LHIN

45 How Can I Locate specific SERVICE PROVIDERS?

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49 How Can I LINK FAMILIES to Educational Resources?

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51 The FIRST LINK Program Kelly Robinson Provincial First Link Program Manager, Alzheimer Society of Ontario responsible for managing the roll out of the First Link program across Ontario with a goal of ensuring consistency and establishing best practice in dementia care in the community.

52 Taking a Pro-Active Approach The Benefits of Linking Early

53 We know that Relatively few individuals and family members access services, such as those provided by the Alzheimer Society, early in the course of the disease and many wait to seek help until they face a crisis or until the burden of caregiving has become too great. (Pratt et al., 2006)

54 We also know Caregivers of individuals with dementia use fewer community services than caregivers of individuals without dementia (Canadian Study of Health and Aging Working Group, 1994b).

55 In general Family caregivers tend to access services late in the disease process. (Gaugler, Kane, Kane, & Newcomer, 2005) At this point, caregivers are overwhelmed, distressed, and limited in their capacity to cope.

56 A Brief History Originally implemented in 2002 by the Alzheimer Society of Ottawa, in collaboration with the Dementia Network of Ottawa (now Champlain Dementia Network) Most Recently two year pilot project, ending March 2009, in Ottawa, Kingston (Belleville/PE Cty), Sudbury (Timmins) and Grey Bruce (Huron/Perth) 22 Chapters in Ontario receive Aging at Home funding to implement the First Link Program

57 A Referral to First Link Contributes to: A safe discharge home Improved patient and care partner capacity: Increases understanding of dementia and what to expect Provides information for planning for the future Enhances coping skills and strategies Eases navigation of the dementia care system Overall, reduced crises and improved quality of life through empowerment

58 What is First Link? Quickly connects newly diagnosed individuals and their families to healthcare services and support in their community In partnership with the Champlain Dementia Network, offers referrals, practical information, ongoing support, as well as a Progressive Learning Series Support and information is provided early and throughout the continuum of the disease

59 Mrs. C. Presenting Issues: Living alone, Confusion, Depression, Loss of License First Link Offers Referral: Triage for Follow up and Supportive Counselling To Learning Series To Support Group(s) Community Support Services In-Home Help, Day Program, Transportation CCAC

60 It is good to know others in the same boat. When we do have to call on the Society for help and information, it's good to already have an acquaintance with it and its people.

61 Mrs. C. Presenting Issues: Living alone, Confusion, Depression, Loss of License. First Link Offers Education: First Steps Learning Series How to navigate through dementia care system Strategies around discussing and preparing for tough decisions Tips and strategies to cope with memory loss Peer Support

62 First Steps Learning Series One of the wonderful things we cherish from the First Steps program was the friends we made, who are facing the same challenges as we are, and with whom we continue to socialize after the learning series was complete.

63 First Link helped my husband to be less anxious about the disease through this learning and meeting others who also have dementia

64 Mrs. C. Presenting Issues: Apathy, Anxiety, Agitation Daughter Stress, Overwhelmed, Grief First Link Offers Support: 1:1 Follow up with daughter providing Supportive Counselling and Education Discussion and planning around tough decisions Access to Daughters Support Group

65 Why is First Link Important? Research tells us: Early and continuous education and counselling increases coping skills to tackle challenges throughout the progression of dementia Caregiver support programs can delay long-term care placement by 18 months Mittelman, Nov 2006, Neurology

66 Time to Referral Average # of Months between Diagnosis and Referral * Average # of Months First Link Type of Referral Self McAiney, Hillier & Stolee, 2010 * p < 0.001

67 If I would not have attended most of the meetings in 2010, I would have known very little about Alzheimer s disease. Our counsellors are very knowledgeable of the disease and are very helpful to us. Without them I would not know what I know of the disease.

68 My understanding of this disease has been heightened to a point where I feel better equipped to help my dad as well as the rest of my family (and myself)! As my husband s disease progresses, I am able to not only apply what we had learned but also access services that were discussed. It has made my role as caregiver easier to cope

69 Alzheimer Societies serving Champlain Region Alzheimer Society of Ottawa and Renfrew County or call Alzheimer Society of Cornwall & District Phone: Alzheimer Society of Ontario or call toll free:

70 The FUTURE?

71 Ontario Dementia Network (ODN) Newly established in 2009 Co-chairs Dr. Bill Dalziel and Kathy Wright from Champlain Dementia Network (CDN) Members are 13 Regional Dementia Networks (by LHIN region) plus representatives from LHIN Collaboration, College of Family Physicians of Ontario, the Alzheimer Society of Ontario, the Alzheimer Knowledge Exchange, The Regional Geriatric Programs of Ontario and the Regional Geriatric Psychiatry Programs of Ontario. Mandate to provide leadership in dissemination of knowledge and in the promotion of best practices between and among networks

72 Ontario Dementia Network (ODN) Accomplishments to date: Accepted as a Community of Practice with the Ontario Alzheimer s Knowledge Exchange (AKE) Consolidated Regional Dementia Networks resources/products on AKE website Considering a provincial physicians' newsletter

73 Bill 52 for Alzheimer Advisory Council May 20, 2010, Toronto, ON Ontario MPPs sent a private member s Bill to establish an Alzheimer Advisory Council to the Justice Committee. The Alzheimer Advisory Council would report annually to the Minister of Health and Long-Term Care on issues related to Alzheimer s disease and other forms of dementia and recommend solutions in areas of research, early diagnosis, prevention and community care.

74 Federal Liberal National Brain Strategy The Globe and Mail, Jan 29, 2010 [On January 29th, 2010, at a roundtable hosted by Dr. Kirsty Duncan, Liberal Critic for Public Health, and Mr. Ignatieff, Leader of the Official Opposition, focusing on Alzheimer s and Dementia held at Parliament Hill] Mr. Ignatieff announced that the Liberals plan to develop, in time for the next election campaign, a national strategy to fight brain diseases such as Parkinson's disease and Alzheimer's.

75 ?????????????????????????????????????? Will these initiatives (National Brian Strategy, Provincial Alzheimer Advisory Council ) move forward to become a reality????????????

76 Conclusions Symbiotic Relationship between Community and Acute Care: good communitybased dementia care will benefit Acute Care Hospitals. Until we acknowledge that good community care is the foundation upon which acute care hospitals rest we will not be able to correct the problems of acute care hospital this will result in future bed gridlock.

77 Conclusions Inadequate dementia care is the Weak Link in Health Care planning Dementia Care Networks, such as the Champlain Dementia Network, can help Acute Care Hospitals, LHINs and possibly Provincial and National Dementia Strategies achieve their goals of optimal patient care.

78 Final Conclusions 1. Dementia needs to be better integrated into the 14 LHIN Strategic Plans as it is a crosscutting foundational theme affecting many elements of acute and community care. 2. The Dementia Network model should be considered by provincial and national dementia strategies. 3. Dementia Networks cannot continue to rely solely on unstable and unpredictable voluntary donations. A source of stable predictable funding is needed