dr. barbara liu senior friendly hospitals

Senior Friendly Hospitals:

A win-win DeGroote Interprofessional Health Leadership Conference

October 2011

Barbara Liu, MD, FRCPC

Executive Director

[email protected]

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

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The Challenge

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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

http://rgps.on.ca/

• Strategic priorities

• Organizational leadership

• Accountability

• Policies and procedures reviewed and

revised through a senior friendly lens


• 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


Processes of Care

Emotional & Behavioral

Environ-ment



Research

Physical Environ-ment


Processes of Care


Research



http://rgps.on.ca/

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.

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• 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

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Senior Friendly Hospital Care in Ontario

• provincial summary report

describing SFH care

across Ontario with

recommended action

plans for short to

intermediate term

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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

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Provincial Improvement

Priorities

LHIN priorities

Hospital Priorities

Mobilization of Vulnerable Elders

MOVE iT

In Toronto

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• 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

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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



Research



Processes of Care

Mobilization Algorithm

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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

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Early Mobilization Improvement Plan and RGP Senior Friendly Hospital Framework

What we do How Who Why Where

Processes of Care



Research



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)

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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

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www.seniorfriendlyhospitals.ca

www.rgp.toronto.on.ca

[email protected]

[email protected]

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

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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

http://rgps.on.ca/

dr. barbara liu senior friendly hospitals

Health & Medicine