Outcomes in GEM models of geriatric care: How do we measure success? Disclosure. Objectives. Geriatric Grand Rounds

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1 Geriatric Grand Rounds Tuesday, October 7, :00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital Outcomes in GEM models of geriatric care: How do we measure success? In keeping with Glenrose Rehabilitation Hospital policy, speakers participating in this event have been asked to disclose to the audience any involvement with industry or other organizations that may potentially influence the presentation of the educational material. Disclosure will be done both verbally and using a slide or handout. Paul MB BAO BCh, CCFP Visit web sites: for handouts, poster, schedule, subscription: for on-demand archive of previous presentations: Disclosure Unfortunately, no involvement with sponsors or commercial interests. Objectives Introduction to GEM history Challenges for current Outcome measures Review of available studies on Outcome measures and GEM programs Summary of key findings Areas to address in future studies Geriatric Grand Rounds, October 7,

2 A Brief history Specialized Geriatrics began in the 1930 s in the U.K. guided by Dr.Marjory Warren the mother of geriatrics. Complete Geriatric Assessment (CGA) defined in 1987 by National Institutes as multidisciplinary evaluation in which the multiple problems of older persons are uncovered a coordinated care plan developed to focus on interventions. A Brief history Geriatric Evaluation and Management models began appearing in the 1970 s in acute hospitals Included the comprehensive assessment but emphasized multidisciplinary rehabilitation The 1990 s brought focus on GEM outpatient services to target at risk seniors Geriatric Evaluation and Management VA definition (US) a specialized program of services in an inpatient or outpatient setting where an interdisciplinary health care team performs multidimensional evaluations on a targeted group of elderly patients who will most likely benefit from these services interdisciplinary plan of care, including treatment, rehabilitation, health promotion and social service interventions. GEM outpatient program Typically: Includes a geriatric trained physician and nurse, a Social Worker +/- pharmacist, PT, OT Involved with patient follow-up Rehabilitation and Aged Services Program in Melbourne, Aus. Geriatric Grand Rounds, October 7,

3 Accountability With the 1990 s brought new emphasis on measuring outcomes in order to validate services Geriatrics had an abundance of research into outcomes due to population with co morbidities Ambulatory consult service Provision of diagnosis Community resources Implementation of follow-up and recommendations GEM-The Good Heterogeneity in: Patient targeting GEM staffing Assessments Follow-up GEM-The Bad GEM -The Ugly Variability of: Recommendation implementation and adherence Outcome measures Geriatric Grand Rounds, October 7,

4 GEM outpatient validation Variety of studies in the 1990 s with equivocal results Why?-service has little effect -Variety in GEM setup -Searching for appropriate outcome measures Research Objective A systematic review aiming to review the current literature of outcome measures used to evaluate outpatient geriatric programs. How do we measure success? Searched GEM, Geriatrics, Outpatient in PubMed, Cochrane database, Mdconsult. Limited to English language, participants >55 years old References from retrieved articles Measuring Success-Findings Many forms of Geriatric assessments, but only 10 RCT s on outpatient GEM programs since Heterogeneity of outcome measures. Results were inconsistent. Geriatric Grand Rounds, October 7,

5 Silverman 1995 GEM geriatrician + geriatric nurse + social worker (SW) 12 month follow-up. 442 subjects Selected using geriatric syndromes Excluded too healthy, terminal and LTC Improved scores in psychosocial well-being and satisfaction with physician No difference in health care utilization, functional scores Toseland/Rubenstein 1996 Geriatrician + NP + SW 8 (Toseland)and 16 mo.(rubenstein) follow-up. 160 subjects Selected those aged over 55, >10 GP visits/yr., >2 ADL impairments Excluded psych admissions in last yr., severe cognitive dementia Improved mortality, subscales of SF-36, FIM, psychosocial scales Increased cost of outpatient visits (Rubenstein), clinic visits Bernabei 1998 Geriatrician + SW + several nurses 12 month follow up 200 subjects Selection age>65, using homecare Excluded- None 23% lower costs ($1800/patient), admissions, LTC use, # of meds. Improved IADL, BADL, MMSE, GDS Increase home visits by GP Reuben/Keeler 1999 Geriatric NP + SW +/- PT. Geriatricians in case conference 363 patients, 15 month follow-up Selection: 1 geriatric syndrome, loss of function, depression on GDS Exclusion: MMSE >24, dementia, unable to complete forms Improved SF-36 subscales, restricted activity days, physical performance. Cost $97/unit SF-36. $26,500/Qaly No change in mortality, MMSE Geriatric Grand Rounds, October 7,

6 Burns 2000 Geriatrician + NP + SW +/- psychologist 24 month follow-up of 128 subjects Selection 65, admitted to acute care, 1 ADL deficit, 2 medical conditions, 2 Acute hospitalizations/12 months, 6 meds Exclusion: MMSE <18, mod-severe dementia, terminal illness, GEM inpatient, LTC resident Improved clinic visits, MMSE, psychosocial scores No change in Mortality, hospitalization, ADL s Boult 2001 SW home visit + 2 GEM clinic visits (NP and geriatrician) 568 patients. Followed at 6, 12, 18 months Selection: Medicare patients deemed at risk for hospitalization (18-item Pra) Exclusion: LTC resident, frequent GP visits, communication barrier, restrictive insurance, travel >3 months of the year Improved restricted and bed days, GDS, psychosocial scales & decreased HC use No benefit to health care use, mortality, cost Cohen 2002 Geriatrician + SW + nurse. Veteran Affairs 6 & 12 month follow-ups subjects Selection: in-hospital, frail, 1 BADL loss, CVA in last 3 months, geriatric syndrome, unplanned admissions in last 3 months, on bed rest Exclusion: LTC resident, GEM inpatient, severe disablement/dementia Improved SF-36 subscales, general health perception No change in health care use, mortality, cost, ADL s, PPT Caplan 2004 CGA mainly by RN post ED visit and rounded with team including geriatrician, geriatric nurse, PT & OT 739 subjects. 18 month follow-up Selection: Emergency visit Exclusion: LTC resident Improved total admissions,ed admissions (NNT=10), Barthel & cognitive 6,12 mo. No change in mortality, LTC admissions, Barthel and 18 mo. Geriatric Grand Rounds, October 7,

7 Counsell 2007 GRACE model: NP + SW +geriatrician. For low-income seniors. 1 in-home visit, 1 visit with GP. In-home and monthly phone followup 951 patients. 6,12,18 & 24 month follow up Selection: 65, 200% of poverty line, Exclusion: LTC resident, dialysis, severe hearing loss, and poor cognition with no caregiver consent Counsell 2007 cont. Improved SF-36 subscales, ACOVE subscales. BUT! High risk group=less ED visits & admissions No change in mortality, health care use admissions, ADL s, satisfaction Results 12 RCT s, 2 of which were repeat analyses of the same studies 7 were prior to 2000, 5 post-2000 Table 1 Outcome Type Pre-2000 System Function Psychosocial Silverman * * Toseland/Rubenstein * * Bernabei * * Reuben/Keeler * Epstein * Post-2000 Burns * * * Boult * * Cohen * Caplan * * Counsell * Totals 6/10 8/10 3/4 -outcome measured *-outcome significant -outcome nonsignificant Geriatric Grand Rounds, October 7,

8 Table 3 Functional Outcomes Table 2 Health Care System Utilization Outcomes Epstein * * increased increased Reuben/Keeler Caplan * * Boult *decreased with GEM Counsell Other Meds Home- Mortality Cost Admissions Inpatient Clinic ED visits Care use days visits Toseland/Rubenstein * * Increased * increased * Bernabei * * *home * visits up Silverman *- ACOVE * for high risk Burns * Cohen Totals 1/1 1/1 2/3 1/3 decreased 1/10 2/4 1 decreased 1/8 2/8 if include high risk in Counsell *for high risk 0/4 4/7 3 increased 3/6 4/6 if include high risk in Counsell SF-36 Barthel FIM Other Bed Days Restricted Days BADL IADL MSE Bernabei * * * Reuben * *- PPT * Epstein Toseland/ Rubenstein Silverman Burns * * Boult * SIP:PFD Cohen * subscales - PPT * * Caplan benefit not sustained to 18 mo. Counsell * * MSQ not 18 mo. Total 3/3 0/2 0/1 2 /3 1/2 2/2 1/6 2/6 2/5- by end of trial GDS Quality of Well Being Table 4 Psychosocial Outcomes QALY Satisfaction with care Self- Perception Bernabei * Reuben/Keeler Silverman * * Toseland * Epstein Boult * Burns * * * Counsell Total 2/3 3/6 1/4 2/3 Well being/global burden scale Health system utilization Few benefits to Mortality and admission (1/10, 1/8) But majority showed decreased ED visits (4/6) Clinic visits increased (3/7) But! Cost of GEM only increased in one study. Decreased in another Early increases offset over time Geriatric Grand Rounds, October 7,

9 Discussion-Functional outcomes Wide variety! Most common functional outcomes measured BADL s and IADL s had rarely shown improvement (1/6,2/6) SF-36, Bed Days, Restricted Activity Days, consistently better than UC Psycho-Social outcomes Few studies post Changing emphasis? Improved GDS (2/3), Satisfaction with care (3/6), Global burden scale (2/3) BUT: only 1/4 studies showed improved selfperception of health So why are the results inconsistent? Are appropriate outcomes being used? Variation in GEM programs Inconsistent Patient targeting Unreliable implementation and adherence to recommendations Are we measuring the right thing? How can satisfaction improve without ADL, self-perception Elizabeth Bradley sets of patients from geriatric assessment center, primary family caregivers, physicians & case managers Describe goals of geriatric assessment expressed by those involved Geriatric Grand Rounds, October 7,

10 E. Bradley cont. Most common goals: Caregivers, physicians & case managers. Referrals for services 57% (including adult day care, home care). Enhancing social/family relations 53%. Caregivers. Burden only indicated by 10%. Future health service use <2%. Patients. 31% maintaining general health and well being. 30% maintain functioning and independence. Are we Measuring the right thing? Patient improvement may have no relation to functional scores Alan Jette, et al. Disablement outcomes in Geriatric Rehabilitation 1996 WHO classification of Impairment vs.. Nagi formulation Disability= limitation in socially defined roles and tasks within a specific sociocultural environment Attribute vs. Relational outcomes Attribute: Characteristic properties of a patient e.g. muscle strength Relational: Abilities in relation to social role/expectation e.g. ADL s, IADL s, occupational role, social activities e.g. two Parkinson s patients with the same impairment (rigidity, bradykinesia). One isolated socially, poor ADL s. Other Socially active, independent Geriatric Grand Rounds, October 7,

11 Patient Targeting Often cited as the first step in a Geriatric Program Need to identify patients too unwell or too healthy Patient Targeting Targeting in these studies varied 3 studies had little inclusion criteria: Counsell, Caplan and Epstein Of these, Counsell showed benefits (4 subscales on SF-36) Caplan Increase overall visits to clinic and ED for GEM patients Table 5 Patient Targeting Exclusion criteria Inclusion criteria Pre-2000 Silverman Toseland/Rubenstein Bernabei receiving Home care Reuben/Keeler MMSE < 24, dementia Epstein Post-2000 Burns mmse 18 Boult communication difficulties -Repeated admission instrument Cohen Caplan LTC Counsell LTC -poverty Patient Targeting Counsell study Resources utilized, follow-up, recommendation adherence, but no targeting Showed benefit to subscales of SF-36 (general health, vitality, social functioning, mental health) after 2 yrs BUT: Subgroup analysis of high risk patients (PRA > 0.4) showed improved SF- 36, reduced admissions and ED visits at 2 yrs Geriatric Grand Rounds, October 7,

12 Patient Targeting Toseland/Rubenstein selected patients with >10 GP visits/year-? Selection bias. Boult 2001, Burns 2000 and Reuben 1999 used stronger inclusion criteria All showed significant benefits in functional outcomes Implementation and Adherence of Recommendations Physician implementation and patient adherence Factors: GEM follow-up, communication with allied health professionals, health care provider-patient relationship No GEM trials comparing follow-up methods Great variation between GEM programs No set criteria defining GEM from a CGA Implementation of Recommendations Reuben patients received CGA. Overall implementation was 71%. 83% of most important recommendation Adherence 82% if physician initiated, 37% if self-care. Maly patients receiving CGA. Physician-patient concordance powerful predictor of implementation & adherence. Key Points Benefits in ambulatory setting inconsistent There are benefits in health utilization, function and psycho-social well being Cost appears neutral with usual care Trend of fewer ED visits & admissions Geriatric Grand Rounds, October 7,

13 Key Points ADL s rarely show a benefit Relational outcomes i.e. bed days, restricted days, satisfaction with care tend to show improvement Psychosocial scores show improvements but no longer popular Patient targeting inconsistent, but important factor Future Direction Patient targeting standards Methods of implementation needed Studies comparing different GEM programs required Outcomes based on quality of life vs. quantity Outcomes with individualized targets? Acknowledgements Dr. Sheny Khera Dr. Marjan Abbasi Thank you Questions? Geriatric Grand Rounds, October 7,