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

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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