ADVANCING THE HEALTH OF OLDER ADULTS IN PRIMARY CARE

The issue

FRAILTY… •  State of Increased Vulnerability to Stressors

•  MulGdimensional Syndrome

•  Predicts Risk for Adverse Outcomes (disability, hospital/ER visits, and death)

•  Higher Prevalence in Older ages, Women, and those with Lower SES

physicalfrailty

cogni0vefrailty

socialfrailty

psychologicalfrailty

•  Late presentaGon of frailty to acute care services

•  FragmentaGon of care -  Difficulty navigaGng -  Caregiver burnout -  Long wait Gmes for referrals

•  Increased complexity and polypharmacy

•  UnderuGlized Primary Care Network resources

•  No standards of pracGce for frailty idenGficaGon & management in primary care

Our soluGon

NHSReport

Highpropor0onofprofessionalcare

Morecomplexcases

70-80%ofpeoplewithlong-termcondi0ons

Equallysharedcare

HighRiskCases

Highpropor0onofselfcare“guidedselfcare”

Integrated Model of Care

Re-Design Care

Hospital centric à

Community based

ReacGve à ProacGve, preventaGve

Disease oriented à Capacity focused

IntegratedCare

Inspire Healthy Aging

HolisGc approach to addressing the dynamic needs of those living with frailty & supporGng their caregivers

Integrated Care

MentalHealth

Mental Wellness 101 – Intake Group

SMART Recovery Addictions Support

OCD Group Therapy

Mindful Based Cognitive Therapy (MBCT)

Anxiety and Depression Group Therapy

Grief Group Therapy

Effective Communication

Insomnia Group

Craving Change

Individual Counselling

Social Work Navigation

Transitions – Adult Autism Program

Dietitian (Nutrition)

Healthy Eating 101

Eating Well the Mediterranean Way

Cooking with Beans

Cooking for One

Healthy Meal Panning

Label Reading

Protein & Fibre: Am I Getting Enough?

Craving Change

Individual Counselling and Education

DiseaseManagement&Nursing

Chronic Disease Mgmt

INR & Injections

Prenatal Nursing Care

Build on Prior Investment

Kinesiology(ExerciseandAc<veLiving)

Ac0veLiving101

MoveProgram

EdmontonOliverLifestyleProgram(EOLP)

IndividualFitnessCounsellingandEduca0on

Prescrip0ontoGetAc0ve

PharmacyServices

TobaccoCessa0on

PharmacyDischarge

IndividualCounselling

Medica0onReconcilia0on

Referrals&Screening

Specialist Referrals

Patient Health Screening

Panel Management

The innovaGon

• Community-based

•  Interprofessional team approach

• Joint care planning &

assessment of care needs

• Case management

• RelaGonal & informaGonal conGnuity

Pa0ent&Family/FriendCaregiver

Structured Process of Care

FRAILTY IDENTIFICATION

Case-finding and risk straGficaGon • Valid tool; Time and

resource efficient; Risk score

• Electronic Frailty Index

1FRAILTY ASSESSMENT

MulG-domain assessment to define components of frailty • Team approach

• Primary care nurse as case manager

2FRAILTY MANAGEMENT

Addressing components of frailty •  Falls prevenGon •  Self management strategies •  Exercise/nutriGon •  SupporGve Care Planning •  Structured MedicaGon review •  Community ConnecGons •  Referral for Comprehensive

Geriatric Assessment/COE

3

Case-finding InnovaGon - eFI Electronic Frailty Index from Primary Care Data

36 Deficits (mapped to over 1000 read codes):

•  Diseases, FuncGonal AbiliGes, DisabiliGes, Labs

Risk StraGfying Tool:

•  Fit 0-0.12 (<5 deficits)

•  Mild Frailty 0.13-0.24 (5-8 deficits)

•  Moderate 0.25-0.36 (9-12 deficits)

•  Severe Frailty >0.36 (13+ deficits)

NaGonal ImplementaGon in the United Kingdom 1

Box 1. List of Deficits included in the eFI Arthri0s Ischaemicheartdisease

COPD Respiratorydisease

AtrialFibrilla0on Dizziness

Osteoporosis Falls

Cerebrovasculardisease Memoryandcogni0veproblems

Chronickidneydisease Weightlossandanorexia

Diabetes Sleepdisturbance

Skinulcer Urinaryincon0nence

Peripheralvasculardisease Polypharmacy

ThyroidDisease Dyspnea

Footproblems Ac0vityLimita0on

Fragilityfracture Visualimpairment

Pep0culcer Housebound

Heartfailure Hearingimpairment

Heartvalvedisease Requirementforcare

Parkinsonismandtremor Mobilityandtransferproblems

Hypertension Socialvulnerability

Hypotension/syncope Anemiaandhema0nicdeficiency

Example panel results using the UK eFI (manual extracGon)

•  Panel = 835, n(65+) = 62 (7% of the total number)

•  Age: mean = 74.2 •  Female - 43 (69%)

fit(0-0.12)43%

mild(0.13-0.24)49%

moderate(0.25-0.36)

6%

severe(>0.36)2%

543210

FIT

MILD

MODERATE

SEVERE

Popu

la0o

nDe

nsity

eFI 0-0.12 (<5 deficits)- none to few chronic condi-ons that are well controlled. Independent in ADLs, IADLs.

eFI 0.13-0.24 (5-8 deficits) appear to be slowing down, may need help with IADLs like finances/transporta-on/shopping

eFI 0.25-0.36 (9-12 deficits) may have difficulty with outdoor ac-vi-es, mobility issues, require help with some ADLs like washing/dressing

eFI >0.36 oDen dependent for personal care, have a range of long term condi-ons

àHealthyAgeingPrograms

àSupportedSelf-Management

àCare&SupportPlanning

àEoL/Pallia0veCare

Structured Process of Care

ST

EP

1

FRAILTY IDENTIFICATION Case finding and risk stratification FRAILTY ASSESSMENT Multi-domain assessment to define components of frailty FRAILTY MANAGEMENT Addressing components of frailty

ST

EP

2

ST

EP

3

Education of Healthcare Workforce

•  Curriculum on interprofessional core competencies and principles of geriatric care;

•  Toolkit & Skills session on case finding tools, conducting multi-domain assessment, and care planning.

Patient & Caregiver Empowerment

•  Patients and families engaged as partners in design, delivery, and evaluation of care;

•  Patient & Family Advisory Board;

•  Clinic environment to enhance patient experience.

Partnership in Care

•  Integrating care with social and community support services;

•  Health Technology as a partner (e.g. clinical support triggers in EMR, automate frailty index);

•  Clinical, Academic & Intersectoral bridges (Strategic clinical networks; Researchers, Smart City Challenge).

Metrics

•  Building consistency of care processes and measurement to improve capacity to collect, analyze and use data.

•  Patient-oriented, provider and health system measures

Outcomes

Outcomes

Patient-Oriented Provider System

•  Functional status using SMAF •  Level of frailty (change in index) •  Appropriateness of meds (START/

STOPP) • Quality of life using EQ-5D/VAS •  Carer burden (Caregiver risk

screening tool) •  Satisfaction of services provided

•  Perceptions on collaborative practice

•  Satisfaction with care provided

•  Number of ER visits •  Hospital admission days •  Long-term care admission •  Death

Results

LIVING ACCOMODATION Living Alone 30

Independent home living 74 Private Supportive Living 11

Designated Supportive Living 2 Other 1

88PATIENTS

Females 53

Males 28

AGE Avg/Mean 81

MARITAL STATUS Married 46 Divorced 5

Single 8 Widowed 28 Unknown 1

EDUCATION Primary (K-9) 16

Secondary (Gr. 10-12) 39 Post-Secondary 31

Unknown 1

CHRONIC CONDITIONS Average Number 5

TOP CONDITIONS Arthritis 70

Hypertension 59 Hyperlipidemia 51 Atrial fibrillation 32

COPD 25

AVG NO. of MEDS 9 Medications

Mean eFI Score 0.30 Mean FI-CGA 0.35

MAIN REASON PATIENT ASSESSED:

Cognition 29 Falls & mobility 27 Chronic pain 16 Depression 15

Caregiver Burden 10 Medication Review 10 Medically complex 9

The InternaGonal ConsorGum for Health Outcomes Measurement (ICHOM) Availablefrom:hap://www.ichom.org/medical-condi0ons/older-person/

Successes of the program thus far

Improvementsinthesepa0entorientedoutcomes:

Impact

“I am very happy, and I feel listened

to.”

“HUB makes me feel more confident

about how I can deliver elderly care.”

“… aware of the value that everyone in every position is

providing now… from reception to the nursing, to how the EMR is working, to

the doctors, everything.. work end-to-end a little bit

better in this model.”

“Wehavehelpedpa0entsandtheircaregiversinavarietyofwaysfromprovidingemo0onalsupport,assis0ngphysicianswithobtainingdiagnoses,linkingtocommunityprogramssuchashomecare,reducingmedica0onsandfindingsuitablehousing.”

“If it wasn’t for that appointment with the Hub, my dad would be in long-term care … doing nothing with his life.”

“The Seniors’ Community Hub has really helped me with my diabetes… I am really happy with my care, it is helpful for planning and has given me better knowledge.”

“Rather than trying to make the patient population fit into their program, they are continuously flexing their initial plan, as they learn more about their patients and their needs…” – citizen advisor

Challenges & RecommendaGons

Adding More to Primary Care “My Bucket is Full”

Practice Change Management ADKAR Model

Awareness

Desire

Knowledge

Abilities

Reinforcement

Frailty

IntrinsicCapacity

Acceptance of “frailty”

SENSORY

PSYCHOLOGICAL

LOCOMOTION

COGNITION

VITALITY

Timeorienta0on

Threewordsrecall

Abdominalobesity BMI Grip

Strength

Snellentest

Audiometryorwhispertest

Lowenergy/fa0gue

Coresymptomsofdepression

ASSESSMENT OF INTRINSIC CAPACITY Balance ChairTest Gaitspeed

INTRINSIC CAPACITY

�

ComprehensiveCarePlan:incorpora0ngICandself-management

Managementofcomplexlongtermchroniccondi0ons

SocialCareandsupport

ComprehensiveHealthAssessmentplusICmonitoring:•  Physicalmobility•  Vitality•  Psychosocial•  Sensory•  Cogni0ve

Geriatricassessment:•  Nutri0onalassessment•  Medica0onreview•  Mul0morbidity/chronic

diseaseevalua0on•  Environmentassessment•  Careandsupportneeds

Tradi<onalclinicalevalua<on:•  Singlediseaseandriskfactor

iden0fica0onandtreatmentOlderPerson

ICmul<dimensionalprograms:•  Mul0modalexerciseprogramincluding

strengthprogressiveresistancetraining•  Increaseinproteinintake,dietaryadvice,

oralnutri0onalsupplements•  Cogni0ves0mula0oninpsychological

interven0ons•  Visualandhealingscreeningfollowedby

0melyprovisionofearandeyecare

Opera0onalisingtheconceptofintrinsiccapacityinclinicalsefng.WHOClinicalconsor0umonhealthyageingNovember21-22,2017.

MarjanAbbasiMarjan.Abbasi@albertahealthservices.caShenyKhera skhera@ualberta.ca