Specialised Geriatric Services

Heather Gilley

Sharon Straus

Learning Objectives

To review the evidence around specialised geriatric assessment in the community

To outline the SMH Geriatric Outreach Program

What is a specialised geriatric service? Spectrum of services available including

community-based, ambulatory, acute care, long-term care, rehabilitation

Different models of care Chronic care management focused on frail

elderly

Who does this?

Geriatricians<150 in Canada0.5 geriatricians/10000 Canadians aged 65

and greater10000 in US – but it’s largely a primary care

specialty

What’s the evidence?

RCT of primary prevention of disability (impairment in IADLs or ADLs) or LTC Home admission in community dwelling persons age 75 and older

Carried out mainly by NPs with support of geriatricians Intervention effective in reducing disability and LTC home

admissions

Not targeted to high risk group No effect on acute hospital admissions Intervention group had more MD visits overall

NEJM 1995;324:1184-90.

What’s the evidence?

Systematic review and meta-analysis of randomised trials of community based, multifactorial interventions in elderly people living at home with at least 6 months of follow up

89 trials with 98000 people Decreased risk of:

not living at home RR 0.95 (0.93 to 0.97) LTC admission RR 0.87 (0.83 to 0.90) Hospital admission RR 0.94 (0.91 to 0.97)

No impact on death RR 1.0 (0.97 to 1.02) Lancet 2008;371:725-35

But

Very different Interventions IntensitySite of care

Largest effect sizes seen in studies done prior to 1993!

What’s the evidence?

In a more focused systematic review of randomised trials of older patients in preventive home visit programs

21 studies included Trend for decreased mortality OR 0.92 (0.80 to

1.02) Trend for decreased NH admissions OR 0.86

( 0.68 to 1.1) J Gerontol A Biol Sci Med Sci 2008;63A:298-307.

But

Heterogeneity present in Interventions PopulationsCare setting

Summary

Consider targeting patients at high riskLess impact in primary prevention

CGA is a complex interventionWhat are the active ingredients?What’s the dose/formulation?

Follow up on the recommendations made Consider the resources necessary

St. Michael’s Team: August 2009

Interprofessional: Full Time Advanced Practice Nurse (Gerontology) Part Time Physiotherapy, Occupational Therapy, Social

Work, Administrative Assistant, Clinical Manager 2 Physicians – 1 Psychiatrist, 1 Geriatric Medicine 1 “Intensive Case Manager” from COTA Health 1 CCAC Care Coordinator

Data from August 2009-March 2010

251 referrals, 174 new patients seen over 683 visits Reasons not seen: out of catchment, dead, admitted to hospital, patient

refused, needs another type of service Referrals from ED (43), Acute Care (58), Primary care (64) Team involved on average 3.5 weeks Patient profile:

53% have mental health issues – dementia, behaviour problems, delusions/hallucinations, depression, ….

51% moderately or severely frail (5-7/7)using Clinical Frailty Scale 16% do not have a family MD, much higher percentage have a family

MD whom they cannot see 2/3 female

Team MD sees patient about 25% of time Client satisfaction high based on brief 5-item survey

Clinical Frailty Scale

1 – very robust 2 – well – no active disease but less fit than 1 3 – well with treated comorbid disease 4 – apparently vulnerable 5 – mildly frail; limited dependence on others for IADLS 6 – moderately frail; help needed for IADLs and ADLs 7 – severely frail; completely dependent on others,

terminally ill CMAJ 2005;173(5)

Centre for Aging Research and Education

CARE will: Create generalisable knowledge: Develop a research

program to create and evaluate innovative models of generalist and specialty care along the continuum of care and across the transition points

Create capacity: Develop an applied educational research program to create and evaluate innovative models of education for the provision of high quality care

Implement knowledge: Build on existing LKSKI strengths and collaborations to translate the generalisable knowledge to optimise care and transform health systems

CARE “PRODUCTS”:• New knowledge about high quality care for older persons• Commercial tools and products • Educational interventions for informal care givers• Innovative training models• Evidence-based educational strategies

Transformative Research Program

An interprofessional network conducting clinical research that will create and evaluate new interventions

Applied Education Research Program

An internationally recognized program integrating evidence-based education with clinical practice and decision making

OUTCOMES:• Enhanced interprofessional capacity in caring for older persons • Better delivery of high quality of care for older persons• Engaged and informed older persons and informal caregivers • Cost effective strategies that can be applied to healthcare systems

worldwideKn

ow

led

ge

Tra

nsl

atio

n a

cro

ss t

he

Co

nti

nu

um

Older persons age with dignity, independence and vitality

Kn

ow

led

ge

Tra

nsl

atio

n a

cro

ss t

he

Co

nti

nu

um

Centre for Advanced Research and Education (CARE)