Feasibility of a Collaborative Intervention to Improve Care of the Elderly December 18, 2008...
-
Upload
charla-miller -
Category
Documents
-
view
216 -
download
1
Transcript of Feasibility of a Collaborative Intervention to Improve Care of the Elderly December 18, 2008...
Feasibility of a Collaborative Intervention to Improve Care of the Elderly
December 18, 2008
Stonechurch Family Health Centre, Hamilton ON
Feasibility of a Collaborative Intervention to Improve Care of the Elderly
• Introduction
• Study phases – Development– Implementation– Evaluation
• Results to date
• Next Steps
Study TeamInvestigators/Clinicians• Ainsley Moore, MD• Joy White, RN EC
Stonechurch Clinicians• Rachelle Gervais RPN• Lisa McCarthy, PharmD
Research Support• Kalpana Nair, PhD candidate• Katie Zazulak, Alison Andrews, Nida Samad
Community Partners
• Hamilton Family Health Team -Carrie McAiney
• Alzheimer’s Society-Mary Burnett, Anne Swift
• Geriatric Medicine– Dr. Chris Patterson
• CCAC – Nancy Van Esson
Introduction (1)
Primary Study Goals • Streamline care processes for
ambulatory geriatric patients• Develop expertise among providers
and residents• Foster inter-professional collaboration
Introduction (2)
Focus of Intervention• Development of office-based tools for
evaluating seniors• Establish a model for maximizing provider
input, continual feedback, communication• Strengthen relationships with external
partners (HFHT, AS, CCAC)
Development Phase (1)
Two main tools developed*:
1. Algorithm for assessment of falls– ACOVE III, Health Canada, Cochrane
2. Algorithm for assessment of cognitive impairment
– ADEPT, CMAJ (Third Canadian Consensus Conference on the
Diagnosis and Treatment of Dementia.)
*Initial development of both algorithms was based on the Seniors Health Initiative in Family Health Teams (SHIFT) that is being implemented in the Hamilton FHT
Development Phase (2)
• Model for optimizing provider and partner competencies
Collaborative Model
RDPharm SW
Fam MD
NP
Geriatrician
RN
CCACAS
Team Based Case Meetings
Seniorat risk
(assessment)
Development Phase (3)Study Protocol
• Patient recruitment– Telephone screen
• If + screen, invited to attend initial planned visit
• Planned visit 1– Part A with RPN– Part B with NP or MD for falls or cognitive
assessment
Recruitment
• Random identification of seniors living in the community > 75yrs (Team A)
Telephone Screen (1)
Process: Conducted on phone by a student
Assessment of risk of falling• “Fallen 2 or more times”?• “Fallen and hurt yourself or needed to see a
doctor because of a fall”?• “Been afraid that you would fall”?• If “yes” to any question invite to attend
scheduled office visit
Telephone Screen (2)
Assessment of risk of cognitive impairment• “I would like you to name as many animals as
you can”. • “You Have one minute”. • “Are you Ready”?• “Please begin now”• If < 11 invite to attend scheduled office visit
Telephone Screen (3)
• If screened positive for both, then would be invited for office visit for cognition first
• If screened negative information brochures (falls prevention*, memory work out**) mailed to patient
• * CCAC **MAREP
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Initial Office Visit
1. Part A Initial planned visit with RPN (Nutrition screen, GDS, Levy)
– Referral to appropriate provider
2. Part B Initial visit with NP or MD for cognitive or falls assessment
Cognitive Assessment(Initial visit, Part B)
• Patient history (identify goals)• Onset, associated symptoms and events• Risk factor assessment• Home and driving safety• Functional status • Cognitive screen (MOCA, MMSE)• Referral AS and or CCAC
Cognitive Assessment(2nd visit)
• 2nd planned visit with care giver / family • Confirm memory change• Assess early personality changes• Confirm functional status• Assess family support, social setting• Care giver status • Confirm driving / home safety
Cognitive Assessment(3rd visit)
• Physical examination
• Gait
• Investigations as appropriate
Cognitive Assessment(Team Based Meeting)
• Case discussion and collaborative care plan
• Monthly team-based case meetings with participating providers and visiting geriatrician
Cognitive assessment(4th visit)
• Patient and care giver / family visit
• Communication of assessment and plan
Cognitive Assessment(5th visit)
• Follow-up visit
• Successful adaptation to change?
Falls Assessment(Initial visit, Part B)
• Pre-appointment chronic illness review
• Circumstances of fall
• Address injuries
• Rule out syncope
• Medication review (including reminder, dispensing system)
• Alcohol consumption (CAGE)
Falls Assessment
• Initial Physical Examination
• Orthostatic hypotension
• Cardiovascular examination
• Investigations as indicated
Falls Assessment(2nd Visit)
• 2nd visit with care giver/family
• Functional status inquiry (MFES)
• Physical examination – TUG, Gait, neuromuscular exam, visual
acuity
• CCAC (identified referral)
Falls Assessment
• Case discussion and collaborative care plan
• Monthly team-based, case meeting with appropriate providers and visiting geriatrician
Falls Assessment
• Follow up visit
• Successful adaptation to change?
EvaluationHow will data be summarized
Data collectedEvaluation area
QualitativePatient / providers experience with
Screen or assessment, team meetings
Acceptability
AveragePersonnel time
Patient timeProtocol logistics
PercentageTelephone screen-Completion rate-# “at risk”
Recruitment
Results to date
Falls=1
Cognition=1
9Contacted = 20
Declined = 2
Call back later = 9
At riskCompletedTelephone Screen
Observations
Telephone screen • Eager to talk• No answer (n=XX)• Request to call back after office hours• Booking appointment (crowded provider
schedules• Forgetting appointments
Next Steps
• Continue recruitment and screening
• Goal 50 patients
Acknowledgements
• Department of Family Medicine (pilot funding)• Hamilton FHT: Carrie McAiney• Alison Andrews & Nida Samad (telephone
screening)• CCAC: Nancy Van Esson• Alzheimer’s Society: Mary Burnett, Anne Swift• Dr. Lisa Dolovich• Dr. Chris Patterson