The Pathway of Despair -the journey for older people in our health system. Dr Chris Bollen BMP Healthcare Consulting

Transcription

1 The Pathway of Despair -the journey for older people in our health system Dr Chris Bollen BMP Healthcare Consulting

2 Lessons learnt from the CHASE Project: #3 Where do all the older people come from? Dr Dr Chris Bollen MBBS, MBA, FRACGP, FACHSM, MAICD Director, BMP Healthcare Consulting

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5 BEACH and older people Age group Consult s/year Avge length (mins) Avge GP utilisati on (mins) Consult s/year Avge length (mins) Avge GP utilisati on (mins) All ages

6 The Pathway of Despair Next Provider Older person at home Referral Pathway Ambulance Practice Nurse Emergency Department Visit GP Home Supports Discharged Home

7 Older people and EDs The attendance of an older person at an Emergency Department has been discussed as being a sentinel event, and a marker of functional decline. Nguyen et al Australian Health Review 2013 One attendance may be a marker of future attendances. Grimmer et al, Australian Health Review 2013

8 Set the scene Issues of Mrs Andrews dg4a (Acknowledge the Health Services Journal as the source of this- permission to use occurred from the HSJ editor Feb )

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10 The Pathway of Despair Next Provider Older person at home Referral Pathway Ambulance Practice Nurse Emergency Department Visit GP Home Supports Discharged Home

11 Older Person at home recognises need for help when unwell often presenting late calls family or ambulance has no escalation/crisis plan in place unaware of options

12 Ambulance Extended Care Paramedic attempts to keep person at home tries to contact GP, but may not be able to speak to him/her Minimal PHx information available CALD background and no interpreters otherwise taken to ED

13 Emergency Department Interaction here places older person at high risk of functional decline but risk not well recognised across the whole system Undiagnosed dementia, frailty, polypharmacy issues 7-15% of older people have "doctor unknown" listed as their GP system issue in ensuring this information is kept up to date Patient enrollment (Medical Home model proposed by RACGP) would assist this step in allowing information to flow accurately

14 Emergency Department Clinical interaction occurs Letter typed by ED doctor RISK! 13% letters are not actually done for the 75+ age group Results rarely sent to GP, instead the letter given to the patient requests GP to follow up urine/bloods/swab/xray RISK! 28% of letters are not received by the GP is unaware of results needing to be followed up. Risk for hospital- who is following up results for tests generated by hospital?

15 Discharged Home taxi family +/- supports and services such as Metro Referral Unit or RDNS other supports via myagedcare Delays in access due to new reforms

16 Home Supports Usually arranged if admitted >24 hours or if an ED Liaison Nurse working RISK! Not rostered for 24 hour coverage so inconsistent access Infrequent flow of information occurs to GP about services/contact details- Risk! Integration is compromised Service providers frequently do not communicate with GPs and other providers

17 GP visit usually occurs within 7 days of discharge episodic and unplanned patient physically brings ED letter to consult no faxed or ed letter for clinical handover is a risk opportunity to reflect on need for prevention and referrals to non-hospital services to optimise function and wellness if no attendance, then no information flows back to practice in current system leads to unrecognised risk of further issues opportunities for prevention activities missed

18 Practice Nurse/GP Comprehensive health assessment and care plan/team care arrangement (MBS items 705-7, 721, 723) can be arranged to improve prevention activities GAP-many people aged 75+ attending EDs currently do not have these in place) Loss of continuity occurring-often different people are performing the health assessment and the care plan.. Frailty risk can be identified using FRAIL screening tools GAP-currently this tool not understood in General Practice Optimisation plan can be developed to improve function and wellness GAP-currently this not understood in General Practice which is illness focussed Escalation plan can be discussed/documented GAP-Not shared across the health system or not done Urgent/crisis plan can be discussed/documented GAP-Not shared across the health system or not done Advance care directive GAP-Few older people have this documented and it is not shared across the health system Coordination of care opportunity GAP- No funding for non face to face interactions

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20 The numbers years- 3-7% are frail 80 years-20% are frail 90+ years -32% are frail 7% have no illness 25% have only one chronic condition

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22 Using data to find people living with Hospital admissions ED presentations frailty Data extraction tools such as PENCAT for medical software in General Practice

23 Use of PENCAT and older people Search for at risk older people Seen within last 6/12 and aged 75+ Taking 8+ medications Have a diagnosis of CKD, heart failure, COPD, depression, stroke, and /or dementia Develop a report card for older people in the practiceknow your data! % population aged 75+ % of people aged 75+ having health assessment every 12 months % of people aged 75+ taking 8+ medications % of this group having annual HMRs BMI checked within 6 months

24 Why do 75+ Health Assessments? The main purpose of health screening in this vulnerable age group is to facilitate timely and appropriate interventions to prevent further decline in function or complications associated with chronic conditions (Gray and Newbury 2004) Low take up (<20% of older people) Evidence for impact? Are the templates fit for purpose? Barriers for older people?

25 Practice Populations-demographics Practice total 75+ % practice FRAIL? A WEST % 150 B WEST % 280 C WEST % 40 D SW % 100 E EAST % 40 F SOUTH/HILLS % 30 G NE % 280 H EAST % 220 I SOUTH % 100 J NORTH % 145 K SW % 26

26 Practice Populations-prevalence Practice 8+ medications HMR CKD (30%) A WEST 60% N/a 4% B WEST N/a 15% 5% C WEST 59% 43% 19% D SW 51% 6% 16% E EAST 52% N/a 7% F SOUTH/HILLS 60% 34% 9% G NE 59% 9% 5% H EAST 48% 4% 5% I SOUTH N/a N/a N/a J NORTH N/a N/a N/a K SW N/a N/a N/a L NORTH 41% 22% 11%

27 General Practice QI Actions Training for GPs and Practice Nurses in health assessments No longer say, You are getting old, there is nothing we can do Find the at risk group with PENCAT Use day therapy referrals Recognise change is difficult for older people as patients Role of Myagedcare website?

28 Queen Elizabeth Hospital ED Community dwelling people aged /day 10 practices 53% of the ED population 20 practices 81% of the ED population 70 practices in the ED catchment

29 Royal Adelaide Hospital ED Community dwelling people aged /day 10 practices 36% of the ED population 20 practices 50% of the ED population 182 practices in the catchment

30 Lyell McEwin Hospital ED Community dwelling people aged in 3 months 19/day 10 practices 36% of the ED population 20 practices 58% of the ED population 40 practices 80% of the ED population 136 general practices in catchment

31 Referral Pathways Not well understood! community aged care provider via myagedcare website current risk is loss of referral information and delays in the referral response by the system community Geriatric Evaluation/Management team (GEM) and hospital OPD geriatric service Under resourced home medication review (MBS item 903) GAP! Not enough being requested for the right people! Many community pharmacists don t understand frailty and deprescribing Turf wars

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33 Next Provider transfer of accurate medical, functional and social information is vital poor integration of information across providers is making this very difficult

34 Practice Nurse Care Plan review Coordination of care opportunity Goal review for older person GAP! Medical goal rather than functional/wellness goals being discussed Communications from team care reviewed GAP! Is the information is being sent/received? Goal reset New referrals made.

35 Importance of wholistic approach Function/frailty Mobility Nutrition Sensory changes-eye sight, hearing, speech, taste, smell Continence- bladder and bowel Mood Pain Falls risk

36 Issues which do not support older people achieving their good health Communication issues Between providers Between provider and client Education levels of older people Cultural issues of older people Social stigma of ageing Health professionals attitudes towards ageing you are 85, what do you expect, you are getting old..not much can be done. Myagededcare website and lack of digital literacy of many people 75+ Financial concerns

37 Patient-Centred Medical/Primary care Home: What is it? What isn t it? Source: IBM Global Business Services PCMH What, why and how?

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41 Quality Improvement There is no good or bad, but there is better! What does this mean for older people?

42 Frailty recommendations (BGS) Older people should be assessed for the possible presence of frailty during all encounters with health and social care professionals. Slow gait speed, the PRISMA or FRAIL questionnaire, the timed-up-and-go test are recommended as reasonable assessments. Provide training in frailty recognition to all health and social care staff who are likely to encounter older people. Do not offer routine population screening for frailty.

43 Remember the FRAIL screen: Fatigue-are you feeling fatigued? Resistance- can you walk a flight of stairs? Ambulation- can you walk around the block? Illnesses- 5 or more chronic conditions? Loss of weight of 5% or more over past 6 months? If the older person scores 2, they are pre-frail, 3+ indicates they are frail and would benefit with immediate referral to a community based restorative care program

44 Sam s story Why is communication with and about our shared patient s important? S66Nqio

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46 Atul Gawande reflections from Being Mortal Our ultimate goal, after all, is not a good death, but a good life to very end We have been wrong about our job in medicine. We think our job is about health and survival, but it is larger than that. It is to enable wellbeing. And wellbeing is about the reasons one wishes to be alive. The importance of having the discussion about what is important to the older person It needs to be done in primary care, and not in the acute setting

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48 Pathway of despair! No anticipation in the system Low reliability in a highly complex situation Vulnerable people not supported by any system of care Exposed to risk at every encounter Volume versus value driven healthcare supports the spiral downwards Opportunities to improve but cultural barriers hinder

49 Questions? Dr Chris Bollen Contact details: LinkedIn

50 Background: The Connecting Health and Aged care Services Effectively (CHASE) project included an audit of medical records of people aged 75+ attending an emergency department plus an audit of the medical record of the general practices providing the majority of long term care. Funded through Commonwealth s Better Health Connections program.

51 What has been learnt? Some general practices have populations of more complexity than others. WHY? Will funding changes benefit/disadvantage? Need to better understand practice data and processes when the overall demographics look similar Multiple number of errors noted across the continuum in this snapshot It can be difficult to identify actual harm in the care of older people when a snapshot is taken Information sharing for complex clients poor across the system Systems to support integrated care of older complex people exist but no appetite for use when volume, not quality is rewarded GPs and Primary care nurses require education/training update programs to improve care of older people Reactive care remains the predominate care model for older people across the primary, aged and acute care sectors Opportunities for PHN/LHNs to develop reporting of interface incidents

52 Take home messages! 1. Volume driven health care systems urgently require safety nets for older vulnerable populations due to high rates of error across the continuum 2. The presentation of an older person to a hospital ED should be treated as a sentinel event as this is a marker of vulnerability for medical error, functional decline, hospital admission and death. 3. Accreditation of General Practices and hospitals is not driving the improvement in the quality of care for older people with complex care needs 4. Social history check lists can improve the focus of care but the impact still needs to be evaluated 5. Widespread integration of consumer information across acute, primary, aged and social care sectors is a long way off in Australia due to cultural and funding siloes

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55 ED data QI Actions Dr unknown to be tracked down "Dr unknown" was a significant contributor, reflecting poor processes for capturing information for integration of health care systems to support vulnerable populations. Explore reasons why some practices have higher rates than others Offer PHN support to solo GPs Work with General Practices to give different outcomes for older people

56 Flow chart for older people CHASE has helped create a picture of the current patient journey in Adelaide care is fragmented and disjointed Lots of opportunities for improvement BUT only if collaboration, communication and a cultural change occur

57 How to improve? Improvement science methodologies open and systematic identification of internal safety incidents, with the aim of developing and sharing solutions to reduce patient harm Could incident reporting post discharge be how PHNs and LHNs engage?

58 Take home messages 1. Volume driven health care systems urgently require safety nets for older vulnerable populations due to high rates of error across the continuum 2. The presentation of an older person to a hospital ED should be treated as a sentinel event as this is a marker of vulnerability for medical error, functional decline, hospital admission and death. 3. Accreditation of General Practices and hospitals is not driving the improvement in the quality of care for older people with complex care needs 4. Social history check lists can improve the focus of care but the impact still needs to be evaluated 5. Widespread integration of consumer information across acute, primary, aged and social care sectors is a long way off in Australia due to cultural and funding siloes

59 Conclusion: The small number of General Practices with a large number of older people attending EDs requires further research to understand the possible reasons for the clustering effect. This new knowledge creates opportunities for PHNs, LHNs and a small number of General Practices to work together to improve care processes and communication for a vulnerable group of the community. It also allows more understanding of the concepts of frailty and restorative care to be discussed in practices with larger numbers of older people.