St. Louis Chapter – 24/7 Helpline 800.272.3900 – Dementia Friendly Hospitals Care Not Crisis...

St. Louis Chapter – 24/7 Helpline 800.272.3900 – www.alzstl.org

Dementia Friendly Hospitals Care Not Crisis

BJC HealthCare

February 3, 2010

Presented by:Janis M. McGillick, MSW, LNHA, Education Director & 2009 Practice Change FellowMaggie Murphy-White, MA Hospital Initiative CoordinatorAlzheimer’s Association – St. Louis Chapter

St. Louis Chapter – 24/7 Helpline 800.272.3900 – www.alzstl.org24-Hour Helpline800-980-9080

St. Louis Chapter © 2005

Credibility Statement

Every 70 seconds someone in America develops Alzheimer’s disease

The Alzheimer’s Association Mission:• Eliminate Alzheimer’s disease- advancement of research• Provide- enhance care and support to all affected• Reduce risk through promotion of brain health

The Alzheimer’s Association-St. Louis Chapter• One of the oldest - most respected in country• Worked with acute care institutions for over 25 years• Funding to influence improved hospital care and outcomes for persons with dementia:

The Retirement Research Foundation Anheuser Busch Foundation, Practice Change Fellowship from The John A. Hartford Foundation & The Atlantic Philanthropies Foundation



The Ask

Support and endorsement to initiate practice change

through education for improved care of persons with dementia.This involves the following:

• An opportunity for program leadership (PCF/Alzheimer’s Association) to present the project to hospital decision makers (2-4 potential settings) and describe the project’s purpose and potential.

• An agreement to proceed with project: dementia specific staff training program and related research initiative

• An appropriate hospital liaison(s).• Partnership in designing and implementing a feasible, related outcomes research specific to the

hospital, based on pilot findings from previous study.• Commitment to specific timeframe for implementation of both education and research aspects of

program: Recruitment of 150 staff committed to attend 6 hours of training.• Collaborative evaluation of training program and related research findings. • Advocate appropriate follow-up activities & relationship with Alzheimer’s Association within the

hospital



Requested Resources

Resources required from hospital• Funding match to offset training expenses not expected to exceed $3000 per session. The

Association will offset other expenses through their grants.• Recruitment of trainees• Assistance in data collection for research (outcomes evidence) purposes.• A hospital designated internal team and “point person” to advance project with Alzheimer’s

Association staff. This may include some teaching faculty

Resources provided by Association• Project Coordinator • Expertise, funding provided through The Practice Change Fellowship Program• Faculty selected in coordination with hospital and Washington University’s ADRC• Tested Curriculum• Collaboration on collection & analysis of outcome data for QI• Enhanced resources for discharge planning and ongoing consultation



Financial projections

Item Alz. Assn. Hospital Total Comments

Personnel $68,000* $25,000 ** $93,000 *15% PCF & Coord & Asst.** Used average Nurses salary of $20.00/hr in computation

Research 4,000 In-kind $4,000

Training Materials(Manuals, survey materials, meals)

4,000 3,000 $7,000

Grand rounds In-kind In-kind

Webinars TBD

Dissemination 5,000 $5,000

Total $81,000 $28,000 $109,000 $96,000 for education ($330/per trainee or $55.00 per hour of training)$9,000 for Research & Dissemination•New England Journal of Medicine•Hospital falls and trauma were included as one of the eight conditions that, the CMS argues, “should not occur after admission to the hospital.” There is little argument that hospital falls fulfill the first two criteria outlined by Congress — they are high-cost and high-volume, and they result in the assignment of a case to a higher-paying DRG. Some 3 to 20% of inpatients fall at least once during their hospital stay; these falls result in injuries, increased lengths of stay, malpractice lawsuits, and more than $4,000 in excess charges per hospitalization. Thus, hospital falls represent a major patient-safety problem and may complicate a patient’s care and treatment



Problems to Address

• Alzheimer disease: most common cause of dementia

• AD/related dementias triple healthcare costs for those 65+; can lead to increased morbidity and higher mortality

• Studies suggest between 19-76% of patients with dementia are hospitalized (on average) 1.5-2 times per year. Three times more stays than the average for all Medicare beneficiaries .

• Estimated 3.2 million hospital stays involved a person with dementia (PWD) statistics in 2000, suggests that up to a quarter of hospital stays of elderly were PWD’s

• In 2000, 9% of Medicare beneficiaries had at least one claim with a diagnostic code for AD (ICD 9:

331.0) or some other form of dementia



Problems to Address

• Hospital systems-designed for cognitively intact persons, despite substantial increases in hospitalized ( PWD’s ).

• PWD’s-at a higher risk for delirium, falls, fractures, elopement, incidents, incontinence, dehydration, untreated pain, aggressive behaviors, physical restraint, pressure sores, functional decline, and weight loss, increasing the likelihood of re-hospitalization or nursing home placement.

• Hospitals-greater demands to improve quality and lower costs

• Few settings are engaged in model programs like NICHE (Nurses Improving Care for Hospitalized Elders), or have aggressively trained their staff in dementia specific, best practice approaches.

• Proactive person-centered approaches during in-patient care is needed and called for by consumers, professionals and advocates.

This project is one strategy to address these issues.



Project Progression



Program Participation

• 5 hospitals received 2 full day classes• 4 of those hospitals participated in the research

• Christian Hospital• St. Luke’s Hospital• Southeast Missouri Hospital• St. Anthony’s Medical Center

• 2 hospitals received Grand Rounds presentation by Dr. James Galvin, WU/ADRC

• Total of 540 unduplicated multidisciplinary hospital staff trained (180%of our goal)



Curriculum

5 Learning Modules Introduction module reviewed facts and figures associated

with AD and introduced each of the accompanying modules. Medical Overview module reviewed signs and symptoms of dementia, differential diagnosis and distinctions between dementia, delirium and depression. The module reviewed screening tools for assessing patients, such as the AD8 and Mini-Cog. Communication module reviewed language and comprehension difficulties associated with cognitive impairment and behavioral changes that accompany the different stages of dementia Dementia Friendly Care module reviewed topical issues such as safety interventions, falls, pain assessment, nutrition, use of restraints, wandering, agitation and diversion activities. Connecting the Caregiver module reviewed the importance of early initiation of interdisciplinary discharge planning and referral to services such as those provided by the Alzheimer’s Association.

Contains both didactic information & incorporates group learningGroups review case studiesGenerate model care plans and discharge plans using forms specific to each institution



Approach – the Curriculum

What sets it apart?• Family Input• Best Practices• National Advisory Panel

In partnership with: P50-AG005681 This program made possible through funding from the Retirement Research Foundation.

DEMENTIA -FRIENDLY HOSPITALS: Care Not Cr isis



Outcome Measures

Participants complete the following evaluation materials: • (1) a pre-test evaluating demographics, clinical practice

characteristics, dementia knowledge, confidence in providing care, and various practice behaviors;

• (2) a standard program quality rating form completed immediately after training;

• (3) an immediate post-test questionnaire similar to the pre-test to assess immediate gains in knowledge and confidence;

• (4) a delayed post-test at 90-120 days to test maintenance of knowledge and confidence.

• Other data is collected from Hospital reports



Pilot Data

• Mean age of the study population was 46 years.

• Most were females (90.4%).

• Participants’ reported ethnicity was 83% Caucasian, 10% African American, 3% Asian, and 2% Hispanic, while 2% did not respond.

• Participants were mainly nurses (60%); 22% completing an ADN, 10% completing an RN and 20% completing a BSN.

• Most participants worked the day shift (73.3%), and 35% reported working on a medical-surgical ward.

• Participants reported that 68% of their patients were 65 years and older and that 29% of them had some form of dementia.

• Most participants (78.6%) received three hours or less of training on dementia related issues and care within the last two years.



Training Results



Summary of current data

• Study highlights the feasibility and interest at both the hospital and staff level in increasing awareness about dementia and its impact on poorer outcomes and higher costs during hospitalization.

• The serious need for dementia training among acute care staff was identified in the pre-training survey.

• This was associated with low confidence in knowledge or ability to care for dementia patients who often present with co-morbidities.

• Training had an immediate impact on knowledge, confidence and attitudes, and confidence was maintained in 3 of 4 hospitals trained.

• Unanticipated benefits were the development of specialized care teams and activity kits.

• We were able to identify potential targets for intervention and the need for ongoing training and the administrative reinforcement necessary in order to sustain behavioral change.

• Community resources, such as local chapters of the Alzheimer’s Association, may be a key community partners in improving care outcomes for hospitalized persons with dementia.



Unexpected results

• Hospital Initiated Interventions• A-Team• Therapeutic Activity Kits & Training• Chris’ Ark

• Practice Change Fellow Award• Saint Louis University

DREAM Team Project

• Closer Partnerships ADRC Hospitals in general



•Elders•Families•Health professionals

• Fewer complaints• Higher satisfaction • Better outcomes• Better use of resources• Cost containment• Liability• Reputation

Who benefits and why



Thank You!

St. Louis Chapter – 24/7 Helpline 800.272.3900 – Dementia Friendly Hospitals Care Not Crisis...

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