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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

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Envir

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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

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Psych

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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

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Envi

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InterventionsInterventionsspspéécifiquescifiques

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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)

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