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C G S / S Q G S Y M P O S I U M M A R I E - J E A N N E K E R G O A T M D , F R C P C , T O R O N T O , A P R I L 1 9 T H 2 0 1 3
PROVIDING BETTER CARE FOR OLDER CANADIANS
OBJECTIVES
• Debate with other clinicians responsible for delivering care to vulnerable older adults in Canada, on how different provincial healthcaresystems strive to meet patient’s needs.
• Share with participants the model of Adaptedapproach of care for older adults in Quebechospital centres and, their level of implementation.
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PLAN
• Overview of the Quebec healthcare system
• Referential framework of the Adapted approachof healthcare to older adults (AAPA) in Quebechospital centres
• Level of implementation of AAPA
THE QUEBEC HEALTH AND SOCIAL SERVICES SYSTEM
MINISTER
Ministry of health and social services
18 health and social servicesAgencies (ASSS)
14 advisory boards:
Régie de l’assurance-maladieOffice des personnes handicapées12 other advisory boards
95 Health and social services Centres (CSSS)
(85% include a hospital centre
Hospital centres *
Residential & long-term centres *
Rehabilitation centres *
•Institutions or organizations that are not part of a CSSS
RUISClinics & private medical officesincluding family medicine groups
Source: http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2007/07-731-01F.pdf
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HEALTH AND SOCIAL SERVICES FOR
OLDER ADULTS • Goals
• Prevent disabilities • Improve, restore the health, autonomy and well-being • Maintain autonomy and quality of life
• Standards • accessibility, continuity, quality, efficacy and effectiveness
• Referential approaches and organizational processes• Interprofessional and interorganizational collaboration• A network of integrated services (RSIPA)• Strategy for prevention and management of chronic diseases• Adapted healthcare approach for older adults in hospital centres
Politique nationale de soutien à l’autonomie December 2013Assurance autonomie April 2014
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Q U E B E C M I N I S T R Y O F H E A L T H A N D S O C I A L S E R V I C E S
ADAPTED HEALTHCARE APPROACH FOR OLDER ADULTS IN QUEBEC HOSPITAL CENTRES
CONTEXT
• Mandate from the Health and Social Services Minister (MSSS)
• Draw up the reference framework for an: Adapted Healthcare Approach for the Older adults in Hospital Centres (AAPA)
• Develop the clinical and organizational tools to support the implementation of the adapted healthcare approach
• Elaborate a training program for managers and healthcare providers in the hospital sector
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REFERENTIAL FRAMEWORK
• Adapted from the Donabedian model of assessing the quality of care and health services
• Continuous quality evaluation• Evidence based healthcare• Centered on processes of care • Interconnections between clientele, processes of
care and organizational characteristics• Identification of outcome indicators
SITUATION IN QUEBEC
• Demographics and Use of Services• 15% of the population > 65 y, 6.6% > 75 y • 45% of hospital days > 65 y, 31% > 75 y • LOS in emergency room and in units are longer
• Vulnerable population: a complex health profile with riskof adverse events
• Delirium, functional decline, immobilization, polymedication, morbidity, placement
• Non application of effective preventative interventions
• Preoccupations of patients, families, professionals,
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Functional Older Person
Acute illnessPossible Impairment
HospitalizationHostile environmentDepersonalization
BedrestStarvationMedicines
Procedures
Depressed moodNegative
Expectations
Physical Impairment
Dysfunctional Older Person
DYSFUNCTIONAL SYNDROME
Palmer, R. M., Counsell, S., & Landefeld, C. S. (1998). Clinical intervention trials : the ACE unit. Clinics in Geriatr Medi14(4), 831-849.
PREVENT FUNCTIONAL DECLINE
ACTon
DELIRIUMand the
IMMOBILIZATION SYNDROME
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RISK FACTORS, CAUSES AND CONSEQUENCES OF FUNCTIONAL DECLINE
DELIRIUM---
ImmobilizationSyndrome
MetabolicDisorders
SensoryDeprivation
MobilityDisorders
Medication
Dehydration
Malnutrition
Pain
SleepDisorders
Falls
Nosocomial Infections
Impaction,RetentionUrinaryIncontinence
SOME DISTURBING FIGURES RELATED TO
SENIORS ...
• Delirium:• 10% of seniors present at E.R. in a state of delirium.• Prevalence of delirium at admission: 10 to 31%.• Incidence during general care hospitalizations: 3 to 29%.• Post surgery: prevalence up to 74%. • Intensive Care: prevalence up to 87%.
• Immobilization syndrome : • Loss of mobility following hospitalization: up to 66%• Loss of certain functions, beginning the 2nd day after
hospitalization: up to 77%.• Requiring assistance to walk after hospitalization: 17%
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• 31% of hospitalizations in the elderly population are related to complications with medications• 57% of these complications are considered preventable
• While on leave from hospital:• 57% of elderly persons do not take one of their prescribed
medications• 41% of elderly persons take a non prescribed medication
• In addition, medication errors:• affect 27-54% of patients admitted for acute care• occur primarily during transitions (emergency-unit-discharge)
… AND MORE IN REGARDS TO
MEDICATION
BEST PRACTICES
• General principles:• Global approach• Special consideration to the physical environment• Objectives focused on improving the function• Moving from medical approach to team approach• The hospital stay: a phase in the continuum of care• In partnership with the elderly, develop individualized
treatment, proportionate to need and based on evidenceExamples:
• Yale Geriatric Care Program• HELP (Hospital Elder Life Program)• ACE …others
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ALGORITHM FOR CLINICAL CARE TO OLDER ADULTS IN
HOSPITAL
IDENTIFICATION OF OLDER ADULTS AT
RISK
1st step: SCREENING, TARGETING
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2nd step: EVALUATION, INTERVENTIONNAL CARE PLANS AND MONITORING
3rd step: INTERVENTIONS: IMPLEMENTATION OF CARE PLANS
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4th step: RESULTS, REVISION OF THE INTERPROFESSIONAL’S CARE PLAN
5th step: DISCHARGE PLAN,TRANSFER INFORMATION/RECOMMANDATIONS
CLINICAL INTERVENTION STRATEGIES TO PREVENT FUNCTIONAL DECLINE
InterventionsInterventionsspspéécialiscialiséées es
InterventionsInterventionsspspéécifiquescifiques
Interventions Interventions prprééventives ventives
systsystéématiquesmatiques
Envir
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men
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Envir
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PhysiquePhysique
Psych
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SYSTEMATICAND
HIERARCHICALAPPROACH
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LEVEL 1 SYSTEMATIC PREVENTIVE INTERVENTIONS
• Interview upon arrival• Assess*
• Intervene:• A measures to promote autonomy & life skills• I measures to promote skin integrity• N measures to promote nutritional health• É measures to promote elimination• E measures to promote and maintain cognitive
and emotional capacities• S measures to promote sleep
• Monitor• Notify
Adapted from: Équipe Projet OPTIMAH, Centre Hospitalier Universitaire de Montréal, 2008
Interventions
Interventions prprééventives ventives systsystéématiquesmatiques
Environnement
PhysiquePsyc
ho-socia
l
LEVEL 2: SPECIFIC INTERVENTIONS FOR PREVENTION AND TREATMENT
InterventionsInterventionsspspéécifiquescifiques
Interventions Interventions prprééventives
ventives systsystéématiquesmatiques
EnvironnementEnvironnement
PhysiquePhysique Psy
cho
Psych
o--soc
ialso
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• A autonomy / mobility
• I skin integrity
• N nutrition / hydration
• É elimination
• E cognitive status and behavior
• S sleep
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LEVEL 3: SPECIALIZED TREATMENT, INTERVENTIONS
Interventions Interventions prprééventives
ventives systsystéématiquesmatiques
Envi
ronn
emen
t
Envi
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emen
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InterventionsInterventionsspspéécifiquescifiques
PhysiquePhysique Psy
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InterventionsInterventionsspspéécialiscialiséées es
• If confinement to bed
• In cases of delirium ...
• In cases of malnutrition ...
FOR THE ORGANIZATION5 PRINCIPLES
• The organization:• Promotes a sustained transformation of care practices and
services tailored to the older adults in hospitals;
• Support the development of a culture adapted to the olderadults;
• Recognizes the importance of the care team and invests in it to support the transformation;
• Includes an interprofessional collaborative approach adaptedto older adult’s care;
• Takes into account the necessity for continuity in deliveringcare to a highly sensitive older adult population.
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STRATEGIES TO BETTER MANAGE MEDICATION
• A comparative appraisal (medication reconciliation)
• Documents medication history in a complete and precise manner
• Verifies the use of medication
• Identifies gaps
• Rectifies medication errors and acts as an interface between the different points of care.
PHYSICAL ENVIRONMENT
• Congested hallways• Incessant noise • Signals and markings• Non-existant chairs and arm-
chairs• Available water?
Take Care
Become Lost
or
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REMAINING CHALLENGES ...
• Counteract prejudices (ageism)
• Early intervention and support from the moment of first contact
• Recruit and retain manpower
• Use evidence based information
• Manage the constant changes
SUPPORT FOR SKILLS DEVELOPMENT
Two inseparable components
• Consolidation of knowledge• Clinical and organizational tools• Online interactive training
• Development of competence in action• Coaching on the units
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SUPPORT FOR THE SKILLS DEVELOPMENT
SIX MODULES OF SENSITIZATION / TRAINING
• Functional decline associated with hospitalization• Normal and pathological aging • Operationalization of the approach• Adaptation of the environment • Immobilization syndrome• Delirium
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CLINICAL TOOLS: 10 SHEETS THEORETICAL AND PRACTICAL
A Functional decline in ADLsImmobilization syndrome
I Pressure ulcers
N MalnutritionDehydration
É Urinary incontinence Constipation / fecal impaction
E DeliriumPsychomotor agitation associated with dementia
S Sleep disorders
GoogleApproche adaptée à la personne âgée
en milieu hospitalier
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ORGANIZATIONAL TOOLS
• Organizational diagnosis: identify the current situation and better understand certain dynamics
• Understand the different levels of comprehension, within the hospital, about the situation of the older adults;
• Estimate the need for the participation of each director;• Assess the interest generated by this project, in the different teams (board
of directors, senior management, managers, health units); • Find "champions" who can become leaders in the implementation process; • Obtain a consensus on the first steps to take, in order to begin this
transformation.
• Elements to consider before implementing the approach
• Guide for a communication plan
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IMPLEMENTATION OF ADAPTEDHEALTHCARE APPROACH
• MSSS Strategic PrioritiesFormal annual management contract (Agencies and hospitals)
• Identification tools in the emergency department• Follow-up mechanisms for identified elderly• Liaison professionnal dedicated to elderly (emergency department) for follow-up
and liaison interorganizations• Implementation of walking and mobility program in emergency department and
hospital units
• Regional responsability (regional project manager):Regular telephone conferences for update and follow-upRegular visits by MSSS (project manager)Support to local
• Local responsability (local project manager)Training programLocal coach for coaching activities (following training)