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Update on Research in Geriatrics Presentation March 6-7 2009
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Cutting Edge:Cutting Edge: Update on Research Advances in Geriatrics
Janet E. McElhaney, MD, FRCPC, FACP
Professor of Medicine
Allan M. McGavin Chair, Geriatrics Research
UBC, PHC and VGH Division Head, Geriatric Medicine
Objectives
What’s hot, what’s not – but should be; transforming seniors’ care
Assessment of the older patient – Right view, Right care, Right discharge and follow-up
Interprofessional collaborative practice to integrate clinical strategies, optimize best practice, and improve quality of care – in BC, it’s the law!
Seniors’ Health: Seniors’ Health: Adding Life To YearsAdding Life To YearsSeniors’ Health: Seniors’ Health: Adding Life To YearsAdding Life To Years
60 70 80 9060 70 80 9060 70 80 9060 70 80 90AgeAgeAgeAge
2000’s2000’s2000’s2000’s
1990’s1990’s1990’s1990’s
1980’s1980’s1980’s1980’s
Successful Successful AgingAging
Usual AgingUsual Aging
Frail Frail SeniorsSeniors
Seniors in Seniors in LTCLTC
Chronic diseases increase risk for catastrophic disability
Risks Associated with Hospitalization
65+ population are hospitalized 3X more often than younger adults; 36% of hospitalizations and 50% of hospital expenditures
At discharge, 33% are more disabled
5% die in hospital, 20-30% die in the year after hospitalization
Elixhauser A et al; AHRQ Pub. No. 00-0031, HCUP Fact Book No. 1, 2000Covinksy KE et al; J Am Geriatr Soc; 51:451, 2003
Transforming Seniors Care – what’s not hot but should be
Strategy: Implement Best Practice Informed Geriatric Care
• Consistent, evidence-informed guidelines– Catheter use (bladder and bowel care) – Medication use in elderly – Nutrition and hydration – Delirium (including PPO) – Functional mobility – “Every day is an activation day”
• Rapid development and implementation• Build on existing structures and processes• Complement Evidence Based work
Seniors Care: Estimated “recoverable” acute days
• Local evidence shows 5 times the savings:– Geriatric Medicine Unit at PHC
reduced ALOS:ELOS ratio by 0.5 (1.35 to 0.83)– Acute Care for Elders (ACE) unit at VGH
ALOS reduction of 4.8 days
• Conservative demand savings account for:– Different implementation approach, Broader scope (entire HA)
• Resources:– Reallocation of existing network/continuum staff to support
coordination and evaluation at each entity– Identify existing guidelines and support local implementation
Demand savings from Seniors Transformation
ALC
ELOS
LOS
Acute days that exceed ELOS
Prevent 20% of cases from becoming ALC
Remove 50% of acute days that exceed ELOS
Acute
Reduction of acute days by 16,556 per yearReduction of acute days by 16,556 per year
Total Savings Possible for “Target Group”
Includes:
CMGs grouped by guideline
Seniors aged 70+
VCH residents only
Excludes:
COPD (CMG 139) & Stroke
Seniors Transformation Opportunity in Vancouver by Guideline - (Days; Percentage of Total)
Catheter; 1399; 17%
Delirium; 2479; 30%Functional
mobility; 1644; 20%
Medication; 1293; 16%
Nutrition / Hydration / Friction /
Seating; 1388; 17%
Assessment of the Older Patient
Right view – predisposing factors Confidence in mobility Competence in decision-making ability Connection to community
Right care – precipitating factors Appropriate medical management – acute on chronic Understands risks of proposed interventions
Manages complexity and risk for increased frailty - TSC Right follow-up – perpetuating factors
Managing transitions across the points of care Patients (and their families) as partners to establish goals of
care
One presentation of dynamic frailty
Picture an 82 year old woman who presents in the ED with a cough andincreasing SOB while walking with her 3 K-a-day Club on the Sea Wall.
Dynamic frailty can be a mask that limits our view of possible outcomesDynamic frailty can be a mask that limits our view of possible outcomes
Picture an 82 year old woman who presents in the ED with confusion and a cough. She was walking with her 3 K-a-day Club on the Sea Wall 2 days ago.
Learn to look behind the mask …Learn to look behind the mask …
Catastrophic DisabilityCatastrophic Disability
Ferrucci et al. JAMA 277:728, 1997Ferrucci et al. JAMA 277:728, 1997
Acute Illness: Prevent or Minimize DisabilityAcute Illness: Prevent or Minimize Disability
80 80 80 80 80Age
Cardiovascular DiseaseCardiovascular DiseaseDiabetesDiabetesOsteoporosisOsteoporosisChronic Lung DiseaseChronic Lung DiseaseCognitive ImpairmentCognitive Impairment
Dynamic Dynamic FrailtyFrailty
Usual Usual AgingAging
IADL IADL FrailtyFrailty
ADL ADL FrailtyFrailty
We’re all in the same boat!We’re all in the same boat!
Interprofessional Collaborative Practice
ICP integrates clinical strategies, optimizes best practice, and improves quality of care
Reasons for ICP Patient safety – evidence is unequivocal Staff recruitment and retention Quality of care Sustainability
Health Professions Act (April 2008) – it’s the law
Regulations pursuant to the Act were amended to state that all colleges of health disciplines will require its members to work in a way that supports “interprofessional collaborative practice”
Collaborative Practice:
Care that integrates best available research evidence with professional judgment and patient values
First, think of collaboration as a continuum …
Then, see the continuum from the patient’s perspective
Accommodate: Multidisciplinary professionals intervene on an autonomous, parallel basis.
Cooperate then Coordinate: Interdisciplinary team members cooperate then coordinate assessments and care plans.
Collaborate: Professionals have a narrower margin of autonomy but the team as a whole is more autonomous and its members better integrated
Transforming seniors’ care Focus on best practice for common geriatric conditions Appropriate management that understands risk Predisposing, precipitating and perpetuating factors managed
across the transitions in points of care Potential for recovery:
Confidence in mobility Competence in decision-making Connection to “community”
Knowledge translation through ICP To optimize prevention strategies and maintain independence Sustainable health care