1. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

2. HELP Project Planning Tool In this section think about…. What will the screening process at your site look like? Fidelity to the original inclusion and exclusion criteria? What will you include in your baseline assessment ? Which units will you choose to start HELP on? The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

3. Where To Start… Every patient aged 70 years and older admitted to the HELP unit(s) is screened for enrollment into the program. The purpose of screening is threefold. 1) First, screening helps to verify that the patient has at least one risk factor for cognitive or functional decline that will allow him/her to benefit from the program. 2) Second, screening verifies that the patient does not have exclusion criteria that make interventions difficult or inappropriate. 3) Third, the risk factors that are identified during screening trigger specific intervention protocols by the HELP team. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

4. Important to note… Each patient should be screened and enrolled within 24-48 hours of admission or transfer to a HELP unit. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

5. ENROLLMENT CRITERIA FOR HOSPITAL ELDER LIFE PROGRAM PATIENTS Age 70 years and older and on HELP unit At least one risk factor for cognitive or functional decline. Risk factors include: Cognitive impairment –SMMSE <24/30 (or equivalent ratio) Any new mobility or ADL impairment Vision impairment: <20/70 best corrected vision Hearing impairment: < 3 of 6 whispers in each ear- Whisper test Dehydration: Urea x10/Cr >0.7 Able to communicate verbally or in writing. Nonverbal patients who can communicate in writing are included. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

6. Exclusion Criteria Coma Mechanical ventilation Aphasia (expressive and/or receptive) if communication ability severely impaired Terminal condition with comfort care only, death imminent Combative or dangerous behavior Severe psychotic disorder that prevents patient from understanding/participating in interventions Severe dementia (e.g., unable to communicate; SMMSE = 0). For patients with severe impairment (SMMSE <10), decision to enroll will be made on a case-by-case basis depending on their ability to participate in interventions. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

7. Exclusion Criteria cont’d Airborne precautions (e.g., tuberculosis). Neutropenic precautions Discharge firmly anticipated within 48 hours of admission Refusal by patient, family member (if patient is incompetent), or Physician The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

8. Staff Frequently Request Palliative ALC Delirious on admission Admitted for over 48 hours Under age 70 Language barrier The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

9. Case Scenario #1 84-year old lady, living in a retirement home (RH) for past 8 years following a stroke. She has Type II Diabetes and hypertension Active in her RH, using her walker, a little more forgetful and repetitive, and this has been progressive. Uses bilateral hearing aids, and bifocals. Came into ER after being found on the floor in her RH. C/O chest and abdominal pain In the ER, she is disoriented to time and place, and repeating herself often. Staff need to speak slowly and repeat instructions often. Family state that is how she is at home. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

10. Case Scenario #2 83-year old lady living alone PMHx – CHF, HTN, Glaucoma, MCI Patient fell in the night. Found by daughter 12 hours later In ER – x-ray shows fractured right femur, made NPO for surgery – no time scheduled yet – morphine, Gravol, Ativan ordered. Report from ER states that patient has been disoriented to time/person/place – pulled out IV, patient had trouble focusing and was inconsistent with following commands. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

11. Case Scenario #2 cont’d Alternates between being very restless, attempting to climb out of bed and being very lethargic Urine tested positive for e-coli, relevant labs include: elevated WBC, elevated urea and creatinine Report from family – patient was managing well at home – independent with ADLs and family assisting with IADLs Family state that patient is saying strange things (i.e. “why is it so busy in this mall?”). At times she does not make sense, and rambles in conversation. The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

12. SCREENING PROCEDURE 1. ELS reviews patient list on HELP units 2. Chart Review 3. HELP Program Description and Patient Consent 4. Baseline Assessment The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

14. Sample Assignment Sheet The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

15. Alternative to Screening HELP Referral Process Growth of the program may require a built-in referral system to allow the units to identify those at risk and increase efficiency HHS is in process of rolling out a Meditech Referral The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH

17. Where to Start Identify unit Estimate eligible pt numbers using decision support data (over 70, with risk factors, greater than 48 hours LOS ) Recruit and build volunteers to meet need Prioritize who to serve The Hospital Elder Life Program © 2000, Sharon K. Inouye, MD, MPH