Download presentation
Presentation is loading. Please wait.
1
MSH Orientation Geriatric Medicine
Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky Chau Dr. Barry Goldlist | Dr. Dan Liberman | Dr. Karen Ng | Dr. Samir Sinha Mount Sinai Hospital Suite 475, 600 University Avenue Toronto, Ontario, M5G 1X5 (416) x 7859
2
Outline Existence for Geriatric Medicine Hazards of Hospitalization
Continuum of Geriatric Models of Care Housekeeping Education & Teaching
3
Geriatric medicine & the hazards of hospitalization
4
Ageing and Hospital Utilization in Central Toronto LHIN, 2005
Number Age <65 Seniors 65 + % Seniors 75+ 2005 Population 1,142,469 87% 13% 49% Emergency Room Visits 321,044 79% 21% 62% Acute Hospitalizations 78,025 63% 37% 64% w/ Alternate Level of Care Days 4,263 17% 83% 76% w/ Circulatory Diseases 10,361 32% 68% 65% w/ Respiratory Diseases 5,928 43% 57% 73% w/ Cancer 6,743 53% 47% 54% w/ Injuries 5,809 58% 42% 71% w/ Mental Health 6,161 59% Inpatient Rehabilitation 3,368 25% 75% 66% Toronto Central LHIN, 2006 4
5
The Hazards of Hospitalization
Older people are particularly vulnerable to the risks of iatrogenic illness and functional decline The pathogenesis of functional and cognitive decline is complex and involves an interaction amongst: The ageing process Comorbid and acute illnesses The hospitalization process 5
6
Conceptualizing Functional Decline
The Hazards of Hospitalization Hostile Environment Depersonalization Bedrest / Immobilty Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Functional Older Person Acute Illness + Possible Impairment Depressed Mood Negative Expectations Physical Impairment and Deconditioning Dysfunctional Older Person Palmer et al., 1998 (Modified) 6
7
Trajectories of Functional Decline
Baseline Admission Discharge 70+ Pts N=2293 57% Stable N=1311 45% Stable N=1039 65% Discharged with Baseline Function N=1494 20% Recovery N=455 12% Hospital Decline N=272 35% Discharged with Worse than Baseline Function N=799 18% Fail to Recover Pre-Hospital Decline N=402 43% Decline N=982 5% Pre-Hospital and Hospital Decline N=125 Covinksy et al., J Am Geriatr Soc 2003 7
8
Costs of Functional Decline
The loss of independent functioning during hospitalization has been associated with: Prolonged lengths of hospital stay Increased recidivism A greater risk of institutionalization Higher mortality rates Palmer et al., 1998 8
9
Continuum of geriatric models of care
10
Mount Sinai / UHN Geriatrics Continuum
INPATIENT AMBULATORY MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital Mount Sinai / UHN Geriatrics Continuum COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership ER MSH/UHN GEM Nurses MSH ER Geri Mental Health Prog
11
ER MSH/UHN GEM Nurses MSH ER Geri Mental Health
12
ISAR (Identification of Seniors at Risk) Tool
Score > 2, at risk for functional decline, ED Visits, and hospitalization McCusker et al, 1999
13
Interprofessional team
INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit Common RFR Diagnostic/treatment challenge Functional decline, falls Delirium & dementia Transition to outpatient & home-based services Goals of care & disposition Interprofessional team Carm Marziliano, SW Natasha Behsania, PT Chris Fan-Lun, Pharm Resident Geriatric Office Rm 475, $20 key deposit
14
Automatic geriatric consultation for
INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit Automatic geriatric consultation for ALL fractured hip patients ≥65 years old Referrals Jeanette, x8419 11S, x4580 ~75% of hip, spine and forearm fractures patients are ≥65 yo Hip# admissions consume more hospital days than stroke, diabetes, or heart attack. 28% of women and 37% of men who suffer a hip# will die within the following year
15
Marcantonio et al, 2001; Siddiqi et al., 2009
A Proactive Strategy Reactive Delirium prevention (NNT = 6) & management Functional recovery Pain management Falls prevention & bone health Disposition planning Marcantonio et al, 2001; Siddiqi et al., 2009
18
Fractured Hip Patients
Geriatrics Med Consults Mental status Delirium Pre-admission cognition Mood Falls Bone Health Pain and nausea Constipation Medication rationalization Disposition planning Perioperative risk assessment Respiratory issues requiring close frequent monitoring Management of Anticoagulation Blood glucose Electrolyte abnormalities Acute kidney injury
19
Ben and Hilda Katz ACE Unit Built around Core Principles
INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit Ben and Hilda Katz ACE Unit Built around Core Principles 1) Care is patient-centered 2) Frequent medical review 3) Early rehabilitation 4) Planning for discharge is part of care 5) Hospital environment is elder friendly 28 bed located on 10N/10S, whereby beds remain GIM Beds and GIM attending's remain MRPs for ACE Unit Developed in 1990 at Case Western Reserve. Physicians came to believe that the hospital environment and processes of care — lack of coordination between disciplines, complications of immobilization, polypharmacy, poor nutrition, use of restraints, and negative attitudes — contributed to the functional decline of their frail elderly patients. Fox et al. Effectiveness of Acute Geriatric Unit Care Using Acute Care for Elders Components: A Systematic Review and Meta-analysis. JAGS ; 60: 2237 – 2245.
20
ACE Unit Model 28 internal medicine beds located on 10N/S
Most responsible physician is the GIM attending Admission Criteria Recent decline in functional abilities Recent change in cognition or behaviour Geriatric syndromes Complex social issues ISAR Score > 2 on ED assessment 28 bed located on 10N/10S, whereby beds remain GIM Beds and GIM attending's remain MRPs for ACE Unit Developed in 1990 at Case Western Reserve. Physicians came to believe that the hospital environment and processes of care — lack of coordination between disciplines, complications of immobilization, polypharmacy, poor nutrition, use of restraints, and negative attitudes — contributed to the functional decline of their frail elderly patients.
21
Weekly Conjoint Geri Med – Geri Psych Rounds
INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit Shared care for complicated: Mental health illnesses Delirium Behavioural & psychological symptoms of dementia Weekly Conjoint Geri Med – Geri Psych Rounds
22
TRI Outpatient Clinics Ground Floor (Elm Street Entrance)
AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital Please phone in to confirm the day before clinic: TRI Outpatient Clinics Ground Floor (Elm Street Entrance) Dr. Alibhai, Dr. Chau, Dr. Liberman Angela/Urooj (416) x 3047 MSH AIMGP Area 4th floor Dr. Goldlist, Dr. Ng, Dr. Sinha Jacqueline (416) x 8563
23
AMBULATORY Collaborative Multidisciplinary Clinic
MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital Collaborative Multidisciplinary Clinic OT Cognitive testing Geriatrician Medical history, Rx, non-neuro physical exam Behavioural Neurologist Neuro exam Geriatric Psychiatrist Psychiatric history One of the above Family gives collateral Multidisciplinary Team Meeting Collaborative multidisciplinary clinic where patients are assessed by geriatric medicine, geriatric psychiatry, neurology, and social work. Please report at 1pm sharp on to 5 West Wing, Toronto Western Hospital Toronto Western Hospital West Wing 5th Floor
24
Toronto General Hospital, North Wing 7th Floor
AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital Toronto General Hospital, North Wing 7th Floor
25
TRI Elm Street Entrance 1st Floor
AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital TRI Elm Street Entrance 1st Floor 12 Week Falls Prevention Program TRI 2nd Floor 12 Week Geriatric Day Hospital
26
COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership
27
Catchment Area
28
Integrated Client Care Project (ICCP)
COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership Integrated Client Care Project (ICCP) Pilot project at MSH & TWH 1 CCAC coordinator for 40 of its most complicated users Intensive case management Close collaboration with Primary Care, Psych, Geriatrics Geriatrics automatically notified when ICCP patient arrives in ER Geriatrics service to help manage care in conjunction with MRP Starting April 1st MSH launched a 1 Year Intensive Case Management Pilot for up to 40 of its most complicated elders. Through this program - 1 CCAC Care Coordinator will be assigned to manage the care of these patients throughout the continuum in close collaboration with Geriatric Medicine, Psychiatry and Primary Care Support. The goal of this initiative is to ensure these patients access and receive appropriate and integrated care, experience smooth transitions, and are supported to remain at home for as long as possible. Geriatrics Program Staff will be notified when ICCP Patients arrive at MSH – it is generally expected that the Geriatrics Service will help manage the care of these patients while they are in hospital in conjunction with the admitting team. Jennifer Thomas is the name of the CCAC Coordinator that will be working closely with the MSH Clients.
29
Housekeeping
30
Consultations Please send of new referrals to the interprofessional geriatric medicine team
31
Weekly Rounds
32
Sign-out Lists
33
Please update the sign-out list daily
“geriatrics” Please update the sign-out list daily
34
Education & Teaching
35
Education & Teaching Educational opportunities
Resident schedules and resources
36
Educational Opportunities
Informal/bedside teaching Geriatric giant seminars, journal club Specialty seminars Allied health professional teaching General medicine rounds
37
Mount Sinai education geriatrics resident resources and schedules
38
Questions
Similar presentations
![The National Audit of Falls and Bone Health in Older People [Speaker’s name and designation] On behalf of the Clinical Effectiveness and Evaluation Unit,](/14/4346764/big_thumb.jpg "The National Audit of Falls and Bone Health in Older People [Speaker’s name and designation] On behalf of the Clinical Effectiveness and Evaluation Unit,>")
