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Senior Friendly Hospitals:
A win-win DeGroote Interprofessional Health Leadership Conference
October 2011
Barbara Liu, MD, FRCPC
Executive Director
1
Outline • The Challenge
• Addressing the Challenge:
RGP Senior Friendly Hospital
Framework
• The Opportunity
– TC LHIN experience
– Provincial roll out
• Bringing the framework to the
bedside - An example of an
improvement plan
2
Questions to consider
• Why do we need a senior friendly
framework?
• How or why does change happen?
• What sustains change?
• When geriatric care is such a
epidemiologic imperative, why are we so
challenged to monitor and measure
progress?
3
• LOS In Canada:
– Over 65 6 days longer
– Over 85 14 days longer
• In Ontario:
– average 53 hospital days
awaiting placement in LTC
– 16% of inpatient beds utilized for
ALC
• Senior Friendly Hospital
approach is needed to mitigate
these system challenges and
help older adults age at home
4
Seniors in Hospitals: the Challenge
Hospitalized seniors lose independence
in ADL
Covinsky KE et al. JAGS 2003;51:451
worse than baseline n=769
6
The Challenge
7
RGP Senior Friendly Hospital Framework
What we do How Who Why Where
Processes of Care
Emotional & Behavioural Environment
Ethics in Clinical Care &
Research
Organizational Support
Physical Environment
• Strategic priorities
• Organizational leadership
• Accountability
• Policies and procedures reviewed and
revised through a senior friendly lens
Organizational Support
• Assessment, diagnosis and management with
special emphasis on age-related conditions
• Emphasis on avoiding hazards of hospitalization
• Adoption of best practices and tools
• Building new models of integrated care across
sectors
Processes of Care
• Attitudes of all staff
• Organizational culture
• Health care system should be
leading change in society to
counter ageism
Emotional and Behavioural Environment
• Autonomy
• Decision-making
• Advanced directives
• Resource allocation
Ethics in Clinical Care and Research
• Enabling maximum independence in
function
• Consideration of age-related physiological
changes – sensory comfort
• Internal and external physical structure
• More than accessibility
Physical Environment
Processes of Care
Emotional & Behavioral
Environ-ment
Organizational Support
Ethics in Clinical Care &
Research
Physical Environ-ment
Emotional & Behavioural Environment
Processes of Care
Ethics in Clinical Care &
Research
Organizational Support
Physical Environment
14
“….a focus on geriatrics as the solution, not the problem.”
The goals of the SFH
• Patient / family – Minimize risk, improve safety
– Maximize functional ability, improve outcomes
– Improve care experience & satisfaction
• Staff – Enabled to deliver best practice
– Improve satisfaction
• Hospital Strategic Alignment – Improve quality
– Reduce adverse events & iatrogenic complications
– Improve capacity for independent living
– Reduce LOS and readmissions
15
TC LHIN CEO – Hospital CEO Directive
• SFH Backgrounder and
self-assessment
• Develop a plan for Senior
Friendly Strategies
• Obligation to appear in
future HSAA
The Opportunity • Healthy Communities, Healthy Seniors - 8
strategies aligned with:
– Excellent Care for All Act
– Aging at Home as it contributes to reducing
ALC
– Health equity
• Senior Friendly Hospital Strategy
– Offers a concrete quality improvement strategy that
could become part of the hospitals first Quality
Improvement Plans.
17
• Senior Friendly Hospital self-assessments in 155
organizations across the Ontario
• RGPs of Ontario worked with LHINs to generate
14 SFH summary reports and individualized
feedback letters
18
Senior Friendly Hospital Care in Ontario
• provincial summary report
describing SFH care
across Ontario with
recommended action
plans for short to
intermediate term
19
The Ontario Senior Friendly Hospital Strategy
Objective • Identify current state Plan • Hospital self- assessments • LHIN-level roll-up • Provincial roll-up
Objective • Monitor and sustain hospital and system improvements Future State • Prevent functional decline • Improve patient experience • Enable hospital staff • Improve equity
PHASE 1 PHASE 2 PHASE 3 - ONGOING
Objective • Close the gap
Plan • Implement hospital improvement plans • Develop key enablers
Patient & Care Team
20
Provincial Improvement
Priorities
LHIN priorities
Hospital Priorities
Mobilization of Vulnerable Elders
MOVE iT
In Toronto
21
• B Liu (PI) • D Brown-Farrell • S Straus • M Zorzitto • Dorothy Knights • T Izukawa • J Ritchie • S Sinha • R. Ramsden • et al.
• MOVE iT plus • Kelly Milne • Stephanie Amos • Sharon Marr • Barry Lumb
MOVE ON
Ontario
Adverse effects of bedrest
• Atelectasis, aspiration
• Orthostasis
• Thrombosis
• Decubitus ulcers
• Muscle deconditioning, joint contracture
• Bone demineralization
• Sensory deprivation
22
Brown, C et al JAGS 2009;57:1660
Lying
Sitting
Walking
83% of measured hospital stay spent in bed
Median time spent standing or walking
= 43 minutes or 3% of day
23
24
Patient-related
Illness severity, comorbidity,
pain, delirium
Treatment-related
Activity order, devices,
medications
Institution-related
Staffing, time constraints, equipment
Attitudinal factors
Patient or staff, expectations, concern
falling
Barriers to Mobilization
25 Brown, C et al J Hosp Med 2007;2:305
Processes of Care
Emotional & Behavioural Environment
Ethics in Clinical Care &
Research
Organizational Support
Physical Environment
Processes of Care
Mobilization Algorithm
26
Mobilization algorithm • Can they respond to verbal stimuli?
• Can they roll side to side?
• Can they sit at edge of bed?
• Can they straighten one or both legs?
• Can they stand?
• Can they transfer to a chair?
• Can they walk a short distance?
27
C
B
A
Mobility Level
Co
rpo
rate
Sta
nd
ard
of
Pra
ctic
e
28
Early Mobilization Improvement Plan and RGP Senior Friendly Hospital Framework
What we do How Who Why Where
Processes of Care
Emotional & Behavioural Environment
Ethics in Clinical Care &
Research
Organizational Support
Physical Environment
Mobilization assessment
algorithm and care pathway
Culture training Ageism
Awareness
Priority setting in rounds
Corporate standard of
care; Strategic theme
Clutter initiative
Selected RCT evidence for early mobilization
Surgical
Dx
Many RCTs
Pneumonia LOS 5.8 vs 6.9 days (Mundy Chest 2003;124:883-889)
Stroke Barthel Index at 3 months Earlier return to walking 3.5 vs 7 days P=0.03 (Cumming TB Stroke 2011; 42 :153)
Cochrane Review (2009)
Discharge to home, NNT=16 LOS by 1.08 days (-1.93 to -0.22)
29
Is it feasible to mobilize frail older patients on medical units?
30
First step is to dangle To Chair
32
Respiratory ICU Intermountain Medical Center Salt Lake City, Utah
Key messages
• Senior friendly framework guides improvement
plan
• Scalable interventions
• High yield
• Invest in development of knowledge, skills, attitude
• Geriatric issues require an interprofessional
approach
33
Acknowledgements
TC LHIN
• C Orridge
• V Sakelaris
• R Cook
• T Martins
• G Whitehead
• S Smit
TC LHIN SFH Taskforce
• J Bennett (Co-Chair)
• B Liu (Co-Chair)
• M Codjoe
• C Cotton
• S VanDeVelde-Coke
• P Cripps-McMartin
• L Dess
• C Levy
• MK McCarthy
• J Merkley
• C Millar
• J O’Neill
• J Walsh
• C Ross
• K Velji
RGPs of ON
• K Wong
• D Jewell
• K Milne
• E Plain
• E McCarthy
• K Rossi
• M Awad
• D Ryan
SFH LHIN Leads Working
Group of ON
35
A Anderson
J Girard
G Whitson Shea,
S Isaak
S Stewart
N Jaffer
H Willis
T Martins
• The Senior Friendly Hospital Strategy is an initiative of
Ontario’s Local Health Integration Networks
A Marcuzzi
B Laundry
C Russell
C LeClerc
P Istvan
S Colwell
M Auchinleck
B Villella
K Tasala