Southwestern Ontario Regional Geriatric Program Education Activities

Transcription

1 Southwestern Ontario Regional Geriatric Program Education Activities The Southwestern Ontario Regional Geriatric Program has been very active over the last 15+ years with the education of health care professionals and caregivers in acute care, long term care and in the community. Staff has presented at conferences, community consultation meetings and other related venues. On a patient level, staff provides health care teaching for patient and family. Staff has also been very active in designing, developing, presenting and evaluating education projects for various health care professional and caregivers. Numerous educational resources have been prepared and distributed. An orientation manual for staff, in house and in the community has been created. This manual includes several modules including a geriatric curriculum in self study modules, learner resources, learning plans, standardized assessment tools, skill sets required for clinical practice, report writing, the orientation process for the learner and mentor, and evaluation/feedback formats for the learning process. (A copy of the orientation manual is available upon request.). The goal is to eventually make this information available in the form of e-learning. The following section is a breakdown of the RGP educational activities throughout Southwestern Ontario Regional Geriatric Program. This does not include the education done on a case by case basis. Much time is dedicated to education of patients, family and staff at the time of visits. The time involved for this type of education is not captured in this document, but is probably one of the most effective methods of education and for knowledge transfer. Education of Colleagues in Comprehensive Geriatric Assessment. Comprehensive geriatric assessment is considered the gold standard approach to improving important health outcomes in older adults in all settings. The RGP has provided education in comprehensive geriatric assessment to various clinicians. These clinicians are typically registered nurses at a baccalaureate level of higher, occupational therapists, physical therapists and social workers. Education has also been provided for medical students, residents and geriatric fellow, in addition to family physicians. There are also many clinicians who are new to the study of geriatrics, or require updating of their knowledge and skills. As a note, it is also understood that comprehensive geriatric assessment includes a comprehensive psychogeriatric assessment, as many older adults present with psychiatric conditions, and it is important to consider all aspects of the human condition. The numbers listed below are only estimates of the number of clinicians educated in comprehensive geriatric assessment over the last fifteen years. 1. Clinicians who are in the Regional Geriatric/Psychogeriatric Programs Outreach Team, and are in their orientation experience. [~40] 2. Clinicians who are in other programs in the Specialized Geriatric Services of Southwestern Ontario (i.e., Day Hospital, Intake and Triage, Ambulatory Clinics, etc.). [~25] 3. Clinicians who have joined the County Geriatric Resource Teams in Oxford, Elgin, Huron, Perth, Grey/Bruce, Essex, Lambton and Kent within the Southwestern Ontario Geriatric Assessment Network (SWOGAN). Education not only includes theory, but also includes clinical practice. This education is

2 2 provided during the initial orientation phase, but is also offered on an on going basis. [~40] 4. Clinicians/students who are enrolled in university programs: [~25] Acute Care Nurse Practitioner. Extended Class Nurse Practitioner. Gerontology. Physical Therapy. Occupational Therapy. Social Work. Medicine. 5. Registered Nurses who are completing fellowships in geriatrics through the Registered Nurses Association of Ontario. [~10] 6. Clinicians from other Regional Geriatric Programs in Ontario, specifically Clinical Nurse Specialists and Advanced Practice Nurses have received education on specific in-depth components of comprehensive geriatric assessment. [~4] 7. We have been recently consulted to provide resources and education to Community Health Centers, and Family Health Teams across LHIN s One and Two. [~yet to be established] 8. Education on comprehensive geriatric assessment was also provided within special projects: Model s Project. This project involved intense classroom and clinical education of multidisciplinary clinicians in Oxford and Huron Counties. [~30]. CCAC Case Manager Project (Case Managers in London/Middlesex) [~2]. Multi-site Kent County Hospital Education Project (registered staff; one topic per two weeks week for about six months). Evaluation included prepost knowledge tests, and pre-post chart audits for identification and treatment of delirium, dementia and depression. [~250] St. Mary s Hospital Education Project (hospital based education for about registered staff; sessions were weekly over about two months) [~100]. Education Projects and Sessions of Geriatrics Knowledge and Skills Education sessions have been tailored to learner need, and were designed for different health care settings and differing durations, ranging from one hour in-services to all day workshops in hospitals, long term care, and in the community. This is not an entire list of sessions, but is representative of the topics. Normal aging and clinical findings. Atypical clinical presentations in the older adult. Comprehensive geriatric assessment. Comprehensive psychogeriatric assessment. Standardized testing: o Cognition/mental status. o Depression. o Delirium. o Balance. o Caregiver burden. o Functional activities. Medications and the older adult.

3 3 Lab values and the older adult. Continence. Dementia. Depression. Delirium. Driving and the older adult. Pre and postoperative considerations in the older adult. Rehabilitation of the older adult. Emergencies and the older adult. Falls. Gait and balance. Managing behavioural and psychological symptoms of dementia. Capacity and decision making. Caregiver stress. Assessment of dizziness. Orthostatic hypotension. Nutrition and the older adult. Rest and sleep. Bowel function. Urinary tract infections. Coping with clinical challenges. Making home visits. Keeping safe on home visits. Consultation role/report writing. 2. Teaching responsibilities through formal academic affiliations with the University of Western Ontario. [On going] School of Nursing, Faculty of Health Sciences. School of Occupational Therapy, Faculty of Health Sciences. Faculty of Medicine. 3. Lunch and Learns at Kent County Hospitals (Chatham, Wallaceburg) for registered staff and physicians. [~250] 4. Fall Education Series. [ ] [ ] [ ] 5. Journal Clubs with Outreach Team. Monthly. 6. Delirium Education Projects: Oxford County. [~10] Elgin County. [~30] London. [~30] Windsor/Essex. [~85] 7. Continence Education Project in Long Term Care. In progress. 8. Best Practice Guidelines: Continence. [in progress] Wound Care. [in progress] 3D s. [in progress] 9. SWOGAN Team Exchange. [ ] [ ]

4 4 [ ] 10. Geriatric Medicine Refresher Day. Annual event (22 years) [ ] [ ] 11. Geriatric Psychiatry Symposium. [ ] 12. Meadow Park Delirium Project. [~100] Pre-post knowledge; pre-post clinical assessment; chart audits. 13. Gentle Persuasion Approach. [78 sessions = 795 participants] 14. U-First. [12 sessions = 340 participants] 15. PIECES 16 hour course [2006 x2 sessions with 60 participants] [2007 x2 sessions with 60 participants] 40 hour course [2005 x1 session with 30 participants] [2007 x1 session with 30 participants] Enabler Program. [2005 x1 session with 30 participants] [2006 x1 session with 30 participants] Acute Care/ED [2007 x5 sessions with 45 participants] 16. Falls Project in a London Long Term Care Home. In progress. 17. General corporate orientation (monthly). 18. One time education session for community groups (i.e., seniors groups) Healthy aging, retirement, sleep, depression, etc. 19. Monthly education session for medical students: Driving. Capacity and resources. Gait and mobility. 20. SGS Multidisciplinary Grand Rounds. [Jan ] [Feb ] 21. Eldercare Expo. Team members did formal presentations on topics such as Care for the Caregiver, and Recreation and Seniors. 22. Alzheimer Outreach Service of McCormick Home: Caregiver Education Series [Four times a year): o Managing Behaviours and Psychological Symptoms of Dementia. o Specialized Geriatric Services programs and resources. 23. Third Age Community Education: Various topics as outlined above. 24. Roger s Television (monthly 5 minute segments): Various topics as outlined above Dementia Networks: Elgin County knowledge cafes and workshops (3D s) [150]. Co-created video on 3D s for long term care homes in Elgin County.

5 5 Sample Case Studies Demonstrating Value Added with RGP Involvement year old married man in small community hospital recently admitted to alternate level of care unit. Placement papers completed as too heavy care for wife to manage at home. Wife distressed. He had stroke 5 months prior with resulting left sided weakness. Referred for depression and agitation. At time of assessment, pleasant, but depressed and agitated with loss of independence, and because of unsteadiness, staff using mechanical lift for transfers. Sedated from psychotropic medications. UTI s? related to urinary retention? secondary to medication. Orthostatic hypotension? related to medications. MMSE 24/30. On physical exam, able to weight bear and take a few steps with stand-by assist of two. Motivated for rehab with need to review medications, etc. Arranged for admission to GRU. Four weeks later, met patient with wife in hospital cafeteria; he was walking independently with quad-cane, and discharge home was imminent with follow-up therapy in Day Hospital Program. Couple was extremely thankful with independence restored, and quality of life improved. Depression and anxiety resolved. Several medications stopped resulting in no urinary retention, hence no UTI s. No orthostatic hypotension, hence no lightheadedness year old widowed retired professional admitted to retirement home on discharge from hospital following vertebral compression fractures secondary to osteoporosis and a fall. Referred for cognitive decline, depression with suicidal ideation and several alls. At time of assessment, pleasant, MMSE 27/30, GDS 8/15, Clock Draw minor visual spatial problems. Blood pressures in chart in normal range. On physical exam, hypertensive, parkinsonian features, focal neurological signs, constipation and urinary incontinence. Determined staff taking BP s with electronic equipment and missing systolic with auscultatory gap. Treated for hypertension. Rollator walker to decrease falls. Changed Tylenol #3s to Tylenol ES around the clock, and constipation improved. Started on antidepressant with effect. Head CT showed stroke. Started EC ASA. Mood improved, as did cognition with stopping codeine. Referral for continence assessment appropriate containment products, medication suggestions, education. 3. Same woman referred one year later. She had moved from Retirement Home to Nursing Home. Referred for cognitive decline, depression, severe back pain, constipation and functional decline. On history, the day that she moved to the Nursing Home, she got the flu, and was extremely ill with respiratory symptoms. Approximately four weeks prior to referral, she developed severe back pain. She was taken to Emerg, but no back x-ray was done, but she was given Tylenol #3 s. Since then, the pain had minimally lessened, but she had significant problems with basic function. On exam, cognitively sedated, MMSE 23/30, depressed, severe back pain with any movement, parkinsonian features more marked, and postural hypotension. Suspected vertebral compression fracture related to coughing when she had flu? cognitive decline related to codeine. Arranged for admission to GRU. X-ray confirmed compression fracture. She did well with Rehabilitation. Amount a number of medication changes, she was also started on Sinemet in a controlled environment, and mobility improved. She then moved back to the Nursing Home, and has been managing well. Cognitive

6 6 function improved, and depressive features settled. She remains functionally independent with minimal assistance year old widowed woman admitted to a community hospital from her apartment with decline in function, inability to manage independently at home, and query dementia. Placement papers in progress. Osteoarthritis. Presenting history included cognitive and functional decline since death of husband eight months ago. Additional history of childhood abuse disclosed during interview. MMSE 26/30. GDS 15/15. History and physical exam revealed weakness, fatigue, cold intolerance, constipation, weight gain, loosing hair, and dry itchy skin suggestive of hypothyroidism. Blood work revealed elevated TSH (45). Started on thyroid replacement. Mood somewhat improved, as did function and symptoms. Started on antidepressant. In two months time, daughters had to rerent their mother s apartment and refurnish it, as patient was discharged home year old widowed woman with multiple sclerosis, osteoporosis and history of compression fractures living in a nursing home. Social worker in collaboration with the physician referred for weakness and low mood with goal to sit up in a chair. Six years prior, she was involved in a motor vehicle collision in which the Para transit van that she was a passenger was struck, and she sustained a fractured hip. She had not been out of a bed since that time. Staff found her care challenging, as she was definite about the manner in which she was cared. The assessment was accomplished over a number of visits, first to establish a trusting and working relationship. History revealed that she had had some bad experiences with previous transfers. MMSE 30/30, GDS 8/15. Motivated to goal, but anxious. Physical exam findings consistent with MS, but very limited flexion at hips and very limited at knees. Blood pressure hypotensive. Blood work revealed anemia and low ferritin. Poor medication adherence with calcium, vitamin D, and iron. Through education, patient eventually agreed to start medications in addition to starting antidepressant to help with mood and pain. Physical therapist from Outreach Team was asked to see patient regarding goal potential. Outreach PT saw patient, and then consulted with the LTC PT, and devised a step-by-step plan as to how to achieve the goal. This began with staff working with patient in changing positions, increasing flexion and increasing tolerance. Once this was accomplished, PT s facilitated a transfer to a chair. She was then sent to Complex Care for a three week period for seating assessments and a motorized customized chair. Her quality of life has dramatically changed, as has her independence, as has her relationship with staff. Her spirits lifted, and her pain lessened year old married gentleman four days ago moved into long term care. Sent several times to the Emergency Department for violent behaviour (i.e., tried to threw 26 television through patio door, and threatened to cut throat of staff with knife), but was repeatedly sent back to Nursing Home with diagnosis of dementia and recommendations for antipsychotics, having been given an antipsychotic while in Emergency Department. Referred for management of violent behaviour. In obtaining the history, noted that he had previously been admitted to hospital for sepsis, and that this was eventually related to an undiagnosed urinary tract infection (staff and family unaware). On history and physical, had been febrile on admission to Nursing Home, history of BPH, some pain in knees, visual

7 year old woman recently discharged from hospital post hip replacement, and now staying with her daughter until returning to her apartment in seniors building. Visiting nurses had been in to teach daughter about dressing changes, as she had post-op complication of infection, for which she had been given antibiotics, and the wound was healing. Referred for agitation. On assessment, features of delirium evident with inattention, disorganized thoughts, disorientation and altered levels of consciousness. The onset of confusion had been abrupt, and the course, fluctuating. Two evenings previous, she had become confused, disoriented and agitated, up and restless in the night. On physical exam, she had significant pain in affected leg. Blood pressures and heart rate were elevated. She was short of breath on exertion, and had a couple of falls. Colour was quite pale. Dressing was removed, and the wound was draining thick green fluid. The physician was contacted, case discussed, and she was sent to Emerg for medical review. In Emerg, hip x-ray was done to rule out fracture from fall. Antibiotic was started for wound infection. She was then sent to a Respite Bed in a Nursing Home, and attending physician planned to see her later in the day. Note send to attending physician and staff prior to physician seeing her history provided, and concerns outlined re: features suggestive of delirium and possible contributing factors including wound infection, pain mediations (narcotics), two antipsychotic medications and benzodiazepines, anemia related to blood loss during surgery (was not transfused post-op), dehydration, etc.. Attending physician followed up with blood work, wound culture, urine culture and changing antibiotic, reducing/stopping psychotropic medications, and transferred to hospital for rehydration and two units packed cells. Patient improved overall. Follow-up two months later, as daughter called upset that mother again confused, agitated, and being restrained in chair. During the two months, significant change over in staff and different attending physician. On assessment, features again were consistent with delirium. So weak, she was unable to hold head up without support. Patient moved to another Nursing Home the day of visit. Chart reviewed; no recent blood work, several medications

8 8 added for agitation including psychotropic medications, had been unable to sleep because of noisy roommate; therefore given hs sedation. No recent physical therapy. Had a couple of falls, and was then no allowed to walk with walker independently. Made visit to new Nursing Home, and discussed case with staff and physician. Patient in private quiet room. Physical therapy started, and staff walked to bathroom rather than in diapers. Medications were again changed to decrease psychotropic medications and stopped benzodiazepine. Follow-up visit with geriatrician. Blood work and x-ray of neck to rule out fracture suggested (neg). With no restraints, increased mobility, encouraging patient to do her own care, decreasing/stopping psychotropic mediations, nice room, etc. patient markedly improved. Again, cognitively much improved, relatively independent and functionally mobile with walker. Enjoying life and daughter relieved happy with having mother back in her life.