ACEing Age Old Issues in the Care of Older Canadians

Transcription

1 ACEing Age Old Issues in the Care of Older Canadians Dr. Samir K. Sinha MD, DPhil, FRCPC Peter and Shelagh Godsoe Chair in Geriatrics and Director of Geriatrics Sinai Health System and the University Health Network Associate Professor of Medicine, University of Toronto and Assistant Professor of Medicine, Johns Hopkins School of Medicine Long-Term Care Association of Manitoba 9 May, 2017

2 Triumph or Tsunami? Triumph or Tsunami? According to the 2014 Global AgeWatch Index Canada ranks 4/96 behind Norway, Sweden and Switzerland as the best country to age in. The Primary Concerns for Older Canadians surrounds their Health and Finances

3 16.9% = 65+

4 CANADIAN HOSPITALIZATIONS 42%

5 OVERALL DAYS IN HOSPITAL 59%

6 OLDER USERS OF HEALTHCARE 10% = 60% $$$

7 CANADIANS STUCK EACH DAY IN HOSPITAL HOSPITAL 7,500

8 ANNUAL COST OF WAITING TO GO ELSEWHERE HOSPITAL $2.4 Billion

9 Why Hospitals often Fail Older Adults

10 Ageing and Hospital Utilization in the 70+ Inconsistently High Users Consistently High Users 6.8% 4.8% 24.6% 42.6% Consistently Low Users No Hospital Episodes Only a small proportion of older adults are consistently extensive users of hospital services (Wolinsky, 1995)

11 What Defines our Highest Users? Polymorbidity Functional Impairments Social Frailty

12 THE HAZARDS OF HOSPITALIZATION HOSPITAL Functional Older Person Acute Illness + Possible Impairment Hostile Environment Depersonalization Bedrest / Immobility Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Depressed Mood, Delirium, and Negative Expectations Physical Impairment and Deconditioning Dysfunctional Older Person Palmer et al., 1998 (Modified)

13

14 < $Billions Our Future Will Cost Us More 8.0 (Ontario Health Care Spending Predictions, MOHLTC) $24 billion

15 Our Dilemma The way in which our cities, communities, and our health care systems are currently designed, resourced, organised and delivered, often disadvantages older adults with chronic health issues. As Canadians and Manitobans, our Care Needs, Preferences and Values are evolving as a society, with increasing numbers of us wanting to age in place.

16 Developing an Elder Friendly Approach

17 Acute Care for Elders (ACE) Strategy Redesigns or establishes new sustainable interprofessional team-based approaches that seek to enhance and improve upon current service models. Requires a shift in traditional thinking that currently underpins the administration and culture of most traditional care organizations. Is not adverse to identifying risk factors and needs and in intervening early to maintain independence. Requires a relentless focus on monitoring and evaluating its outcomes to support continuous quality improvement

18 The Elder Friendly Hospital Model These dimensions work together to minimize functional decline, promote safety, and mitigate adverse social and medical outcomes. Social Behavioural Culture Physical Design Policies and Procedures Care Systems, Processes and Services (Parke et al, 2001).

19 THE ACE CONTINUUM OF CARE OUTPATIENT MODELS Outpatient Geriatric Medicine, Geriatric Psychiatry & Palliative Medicine Clinics Telemedicine Clinics INPATIENT MODELS Geriatric Medicine, Geriatric Psychiatry & Palliative Medicine Consultation Services Orthogeriatrics Program Intensive Care Unit Geriatrics Program Safe Patients/Safe Staff ACE Unit ACE Unit Home Care Coordinator MAUVE Volunteer Program ACE Tracker Hospital at Home Program ACUTE CARE for ELDERS (ACE) STRATEGY COMMUNITY MODELS Home-Based Geriatric Primary/Specialty Care Program: House Calls Temmy Latner Home-Based Palliative Care Program Integrated Client Care Management Program Nurse Led Outreach Teams to LTC Reitman Centre for Alzheimer s Support and Caregiver Training Community and Staff Education Programs Community Outreach Team Community Paramedicine Program ED MODELS ISAR Screening Geriatric Emergency Management (GEM) Nurses Geri-EM.com Staff Training Program New Programs Launched Since Fiscal Year

20 Evidence in Action

21 HOSPITAL AVOIDANCE STRATEGIES HOSPITAL AT HOME (Leff, 2009; Shepperd et al., 2009) Patients with acute illnesses requiring hospital-level care are identified in the ED and offered their care at home. Under this model costs were lower, patients experienced fewer clinical complications, mortality at six months was lower, and patients were more satisfied. COMMUNITY PARAMEDICINE (Sinha, 2012) Paramedics often see frail older adults in their own homes in preemergent situations and have opportunities to intervene proactively by connecting them to more appropriate care. Paramedics are also being utilized to provide enhanced primary care.

22 INTENSIVE CASE MANAGEMENT THE INTEGRATED CLIENT CARE PROGRAM Starting April 1, 2011 MSH launched a Intensive Case Management Project for up to 60 of its most complicated elders. 2 Home Care Coordinator are assigned to manage the care of these patients throughout the continuum in close collaboration with Geriatric Medicine, Psychiatry and Primary Care Providers. Goal is to ensure these patients access and receive appropriate and integrated care, experience smooth transitions, and are supported to remain at home for as long as possible.

23

24 ED / ALTERNATIVE CARE PROGRAMS MOBILE LTC EMERGENCY NURSING PROGRAM (Sinha, 2011) ED Based Mobile RNs provide urgent care assessment and management services with 35 partnering LTC Homes. Model Involves - Prevention, Avoidance, Rapid ED Engagement and Follow-up Components. Up to a 30% decrease in Non-Urgent, Less Urgent, and Urgent unscheduled Ambulance Transfers. The cost/visit with the Mobile Team is 21% less than an ED visit. Enhancements in resident quality of life, nursing knowledge, and overall ED and LTC provider satisfaction noted.

25 Enabling Function through Design ENABLING FUNCTION THROUGH DESIGN

26

27 HIGH RISK SCREENING AND IDENTIFICATION TOOLS IDENTIFICATION OF SENIORS AT RISK - ISAR (McCusker et al., 1999) 2 = Predicts Functional Decline, Recidivism, Institutionalization

28

29 ED-BASED CASE MANAGEMENT GERIATRIC EMERGENCY MANAGEMENT (GEM) ED Nurses focused on improving the care of older patients. Frail older patients receive specialized geriatric assessments and interventions to enhance their care. Effective at reducing hospital admissions, recidivism, and increasing adherence and satisfaction of patients and staff Sinha et al, Annals of Emergency Medicine, 2011

30 KEEPING CONNECTED TO BETTER MANAGE CARE AND TRANSITIONS

31 SAFER PROTOCOLIZED CARE Improving Practice Standards for ACE and Other Patients

32 Example: A 90 year old patient who has been admitted for 6 days and is currently delirious with a background history of cognitive impairment. They have a history of falls and have a high risk of falling according to their Morse Score of 75 and has urinary catheter in place. Patient has a low pain score of 1 and has not been prescribed or administered any BEERS medications but is still on 12 in total. PT, OT and SW are involved. Unclear if full delirium work-up has been completed with a proper medication review and if there is an opportunity to get rid of the catheter which will also pose a significant fall risk for them? USING DATA TO DRIVE REAL TIME CARE IMPROVEMENTS

33 HOME-BASED CARE Provides ongoing comprehensive interprofesional homebased primary/specialty care to frail, marginalized, cognitively impaired, and house-bound elders who would not otherwise have access to primary care. The first hybrid primary/specialty geriatrics model in Canada that maintains a daily caseload of 300 homebound patients. 5 GPs, Nurse Practitioner, OTs, PT, Social Work, Community Paramedic and Pharmacist w/ Specialist Support. Initiation of primary care can occur within 48hrs. A Continuum of Care that spans Hospital and Home.

34

35 THE POWER OF EFFECTIVE HBPC 37% of patients are referred after a hospital episode Average (Age Adjusted) CCI/Mortality = 3.7(7.9) = 1 Year 52%(85%) Mortality Average Patient Age at Enrollment is 87 OUTCOMES FOR PATIENTS ENROLLED AFTER INDEX ADMISSION 30 DAY READMISSION REDUCTION 50% ANNUALIZED REDUCTION IN HOSPITAL ADMISSIONS 50% ANNUALIZED REDUCTION IN HOSPITAL DAYS 65% OVERALL PROGRAM DIE AT HOME RATE 70% (Stall et al. 2014)

36 THE OVERALL IMPACT OF ACE +53% -26% -14% -93% +99% $6.7 Million

37 IMPLEMENTING ACE ACROSS NORTH AMERICA & BEYOND Acute Care for Elders (ACE)

38 THE ACE COLLABORATIVE 4

39 Enabling A National Approach

40 Why Develop a Provincial Strategy? In 2011, the province announced a new vision to make Ontario, Canada the best place to grow up and grow old in North America. Given our current and future challenges, the development of Ontario s Seniors Strategy began in 2012 to establish sustainable best practices and policies at a provincial level. With a focus on ensuring equity, quality, access, value and choice, recommendations were developed that could support older Ontarians to stay healthy and independent for as long as possible.

41 Living Longer, Living Well Supporting the Development of Elder Friendly Communities Promoting Health and Wellness Strengthening Primary Care for Older Ontarians Enhancing the Provision of Home and Community Care Services Improving Acute Care for Elders Enhancing Ontario s Long-Term Care Environments Addressing the Specialized Care Needs of Older Ontarians Medications and Older Ontarians Caring for Caregivers Addressing Ageism and Elder Abuse Addressing the Unique Needs of Older Aboriginal Peoples Necessary Enablers to Support a Seniors Strategy for Ontario

42 Our Future Requires Choices Hospitals 34.5% Doctors 23.0% Drugs 7.6% Other 14.6% Long-Term Care Homes 8.0% Capital 2.5% Community Care 6.2% (Ontario Health Care Spending, MOHLTC).

43 Spending on Home and Long-Term Care Across OECD Nations.

44 We Have Choices and Options One Day in Hospital Costs ~ $1000 One Day in Long-Term Care Costs ~ $160 One Day of Supportive Housing or Home and Community Care Costs ~ $55 Denmark avoided building any new LTC beds over two decades, and actually saw the closure of thousands of hospital beds, by strategically investing more in its home and community care services. The Ontario government while freezing its hospital and physician budgets has committed to at least an annual 5% increase in the Home and Community Care Budget from 2011 through to 2018.

45 Enabling Living Longer, Living Well With More Home and Community Care Available, the Supply (-2.7%) of, Demand (-6.9%) for, and Placement Rates (-26%) into LTC Beds have all decreased in Ontarians aged 75 and better. Work is underway to ensure our future health and social care workforce has the knowledge and skills needed to care for Older Ontarians. Traditional Scopes of Practice are being Expanded to Improve and Bring Care Options Closer to Home (eg. Nurse Prescribing, Pharmacists Giving Vaccinations, Community Paramedicine).

46

47 This is Our Time to Lead

48 Thank You Samir K. Sinha MD, DPhil, FRCPC Director of Geriatrics Mount Sinai and the University Health Network Hospitals Architect of Ontario s Seniors Strategy ssinha@mtsinai.on.ca