The Value and Vision of the Regional Geriatric Program of Eastern Ontario RGPEO

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The Value and Vision of the Regional Geriatric
Program of Eastern Ontario (RGPEO)
Dr. William Dalziel Chief, RGPEO September 2009
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What is the longest authenticated life span for
humans?
1. 106 2. 112 3. 118 4. 122 5. 145
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What is the remaining life expectancy for an 80
year old woman?
Another 1. 2 years. 2. 4 years. 3. 6
years. 4. 8 years. 5. 12 years.
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Seniors (65) will represent what of the
population in 2025?
1. 12 2. 15 3. 20 4. 22 5. 25
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What of seniors aged 75-84 have no important
functional impairments? (They are independent).
1. 10 2. 30 3. 50 4. 70 5. 90
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Our Role

• RGPEO
• A comprehensive network of specialised geriatric
  services ranging from hospital to home. Working
  in collaboration with acute hospitals, primary
  care practitioners, community health
  professionals, seniors and family caregivers, we
  seek to optimize the health of seniors.
• A Resource for Successful Aging
• Across the Champlain Region!

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The Regional Geriatric Assessment Program(1)

• The Original Health Services Network! Now 25
  years old
• Hosted by The Ottawa Hospital
• Established in 1984 as first of 5 RGPs funded in
  Ontario Academic Health Science Centers.
• MOH Mandate for specialized care, education,
  evaluation, research and program development.
• Coordinated provincial network - RGPs Ontario
  (1998) ( Planning, Education, best practices
  and research)

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An Organized Delivery System for Seniors with
Complex Health Needs

• 6,000 seniors , 12,500 visits, 27,000 pt. days,

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Seniors Acute Care

• Seniors are high users of acute care services
• 63 of all hospital days in Ontario
• 43 healthcare in Ontario
• Their health needs are different
• Atypical presentation of illness
• Multiple co-morbidities
• Seniors are more vulnerable to adverse events and
  iatrogenic complications
• Two-fold risk of adverse events
• Hospital acquired delirium Falls, ADR
• An Acute hospitalization is often a crucial and
  pivotal event in a seniors life
• 1/3 of frail seniors lose independent function as
  a result of hospital practices
• Compounded by major provider issues related to
  training, attitudes education.

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The Role Value of Specialised Geriatric
Services Recognizing Potential

• Fundamental Assumption
• (Reversible conditions)
• Much of the disease, disability and dependency in
  old age is preventable, treatable, or manageable.
  
• Diagnostic Difficulties (co-morbidity,
  atypical presentation)
• Loss of health and independence sometimes
  associated with inaccurate diagnoses resulting in
  inappropriate treatment.
• The major healthcare challenge NOW is responding
  to the needs of the growing aging population.

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• The frail elderly are 15 of seniors and 3 of
  the overall population.
• THIS 3 USES 30 OF HEALTHCARE
• ? DO ACUTE CARE HOSPITALS CONSIDER THE ELDERLY AS
  THEIR MAJOR CLIENTS?

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Medline citations for Frail Elderly
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WHAT IS FRAILTY?

• 356 multi disciplinary attendees at CAG
• frailty was a useful concept
• represented risk or vulnerability (ADL
  dependency, adverse outcomes)
• imbalance excess demands vs reduced capacity
• represented precarious physiological balance
• being dependent
• Kaethler Y et al. Geriatrics Today J Can Ger Soc
  2003626

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• NEGATIVE
• Chronic illness
• Preexisting disabilities
• Poor social supports
• Inadequate financial resources
• Acute illness

• POSITIVE
• Robust health
• Supportive environment
• Adequate financial resources
• Rockwood K et al CMAJ 150489

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Rockwood et al. CMAJ 2005 173 489
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• CSHA Clinical frailty
• scale
• Rockwood et al CMAJ 2005173489

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What is Different About FRAIL Patients?
Multiple diseases with multiple drugs
complexity. Multiple problem areas
multidimensionality. Premorbid function
disability slippery slope. Medical/Psychiatric
interface.
- Increased importance of social network - Need
for a complex combination of medical and social
services DISCHARGE PLANNING.
VULNERABLE
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Components of an appropriate assessment of
illness in Frail Elderly

• Presenting Issues
• Past Medical History
• Medications
• Communication
• Cognition/Mood
• Function
• Environment
• Socio-economic Status
• Formal and informal supports

Usual Assessment
Comprehensive Geriatric Assessment
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Unfrailing The Top 10

• Health Promotion
• Exercise
• Early detection of acute illness (Geriatric
  Giants or atypical presentation)
• Appropriate Treatment (acute and chronic)
  optimize co-morbidities
• Review medication
• Mobilize
• Improve nutrition
• Rehabilitation
• Optimize environment minimize personal
  disabilities
• Maximize Caregiver support (family and formal)

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• Old Age Aint For Sissies
• Only recent bad habits hurt you.
• Only recent good habits help you.

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1o Prevention

• Tobacco Cessation
• Nutritional Advice
• Calcium 1200-1500 mg elemental Calcium daily
• Exercise
• Aerobic
• Strength

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1o Prevention

• Safe Driving Counselling /Screening
• Vaccinations
• Influenza (annual)
• Pneumococcal high risk, ? 65, (once or twice?)
• Tetanus single booster at age 65
• Advice re sun exposure.
• Vitamin D 1000 IU

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Recognition of Frailty is anOpportunity
to UNFRAIL
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The Benefits of Quadriceps Strength Training in
Nonagenarian Women in a Nursing Home
10 leg lifts, 6 times per day increased quad
strength in 8 weeks by what ??

• 12
• 31
• 55
• 100
• 175

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HOME ASSESSMENT
Geriatric Assessment Outeach Team
Physical Functional
Locomotor Environmental Psychosocial
Mental health
ONE ASSESSOR ONE CLIENT
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Optimizing Seniors Health Integrating
Geriatric Principles into our Health System

• Regional Geriatric Advisory Committee
• Strategic Directions ( 2007-2011)
• Maximize the Health Potential of Seniors
• Enhanced community support services
• Successful Aging framework
• Increase System Capacity Responsiveness
• Senior Friendly Hospital Strategy
• Geriatric Emergency Management (GEM)
• LTC Physician Education Network
• Rural Geriatric Networks
• Coordinated Service Delivery
• Supportive Housing
• ALC Reduction Strategies

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Education

• Undergraduate
• Postgraduate
• Continuing Education
• Geriatric Assessor Training

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RGAP Research Program
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Regional Provincial Leadership

• Gerontological Nursing
• Convalescent Care Bed Project
• Geriatric Emergency Management
• Senior Friendly Hospital Strategy
• Resource Integration for Seniors in the Community
  (RISC)
• Successful Aging Ottawa unfrailing Ottawa
  seniors!
• Driving safety
• Rural Geriatric Networks
• Aging in Place Supportive Housing Program
• Designated Community of Practice for the Local
  Health Integration Network
• Aging _at_ Home Task Force
• Interdisciplinary Centre of Excellence in
  Geriatric Care

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Changing the trajectory to ALC designation The
key to start early, target and treat
HEALTHY ELDERLY
FRAIL ELDERLY
FRAIL NOW SICK ELDERLY IN ED
SENT HOME
FRAIL NOW SICK ELDERLY IN ED
BEING ADMITTED
ALC Patient
ALC UNIT LTC PLACEMENT
6 Safety Nets
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Champlain Integrated Regional Geriatric
Community Intervention Program

• Geriatric Emergency Management
• Targets High-risk seniors discharged home from ER
• The Opportunity
• Seniors account for 48 of admissions from ERs in
  Ottawa.
• Readmissions 75 account for 9 of all acute days
• The majority of seniors ER visits are repeat
  visits ( 55 2-5/yr.)
• Program Objectives
• Improve quality sustainability of ER discharges
• Reduce repeat ER visits subsequent admissions

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GEM Service Bundles
CCAC Quick Response
GEM RNs
CSS Day Program
Geriatric Outreach Assessors
Integrated Geriatric Teams
Geriatric Psychiatry Outreach
CSS Safe _at_ Home
Training Support
Geriatric Day Hospital
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TOH GEM Program 2007/08

• 65 decrease in rate of subsequent admission
• Median ER LOS 8.25 hrs
• 96 Overall satisfaction
• Source TOH Decision Support

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TOH GEM Program Post GEM Repeat ER Visits(343
GEM Pts Sept-Dec 2007)

• 35 in repeat ER visits
• Source TOH Decision Support

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The Geriatric Paradigm/Model of Care
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Bullshit BINGO 2008