1. Keeping afloat on golden pond : Stonechurch Seniors Collaborative Care Program March 25, 2010 Stonechurch Family Health Centre, Hamilton ON

2. Overview Seniors at Stonechurch Pilot study –Objectives –Methods –Results Seniors Collaborative Care Program Lessons learned

3. Seniors at Stonechurch 1,515 patients at SC > 65 years 20 % of visits at SC with seniors (January 2009 – January 2010)

4. The Study Team Joy White - Nurse Practitioner Shelly House – Pharmacist Rachelle Gervais - Nurse Ainsley Moore – Family md Kalpana Nair - Research Assistant AJ Kadhim –Research support Chris Patterson - Geriatrician

5. Pilot Study Funding: DFM Pilot study (May 2008) Research Question: What is the feasibility of implementing interdsiciplinary program program to address seniors at risk of CI and or falling at SCFHC

6. Pilot Study Create the program: Standardize approach to cognitive impairment and risk of falls Establish a model - maximize provider input, continual feedback, communication

7. Pilot Study Recruit patients: Telephone screening Evaluate: Feasibility and acceptability

8. Pilot Study Standardize Approach Screens depression, medications, nutrition GDS. Levy, SCREEN Algorithm for assessment of cognitive assessment ADEPT, CMAJ (Third Consensus on the Diagnosis and Treatment of Dementia) Algorithm for assessment of falls ACOVE III, Health Canada, Cochrane

9. Collaborative Model Senior at risk Team Based Case meetings MD NP RPN SW RD Pharm Community Resources (AS CCAC ) Geriatrics

10. Model – Care Path Identified At Risk (telephone screen or provider) Initial Visit RPN (GDS, Levy, Nutrition Score) Evaluation by MD or NP for CI or Falls Referral to SW RD Pharm Team Based Case Review (MD NP RPN SW RD Pharm Geriatrician)) Referral Community (AS CCAC)

11. Pilot Study Recruit Patients: Random identification of seniors over 75 yrs at SCFHC Screening for risk of CI and or falls

12. Pilot Study Screening Questions: Cognitive Impairment (verbal fluency -11 four legged animals in 60 seconds) Risk of Falling (fear of falling, fall with injury, fall in the past yr)

13. Pilot Study Evaluate feasibility (objectives) 1. Telephone screening to identify seniors at risk of CI and or falling 2.Logistics (patient and provider time involved with the program) 3. Acceptability of program to patients and providers

14. Pilot Study Telephone screening Made 163 calls, established contact 114 (70%) Completed screen = 76 (66%) Screened positive = 51 (67%) CI = 30, falling = 21 Attended for app = 24 (CI = 18, falling = 6)

15. Pilot Study: Logistics ParticipantTotal hrs% casesHrs/ case (average) Patients 3.4 Nurse Practitioner 3770%2.1 Family md 1540%1.4 RPN 14.788%0.7 Pharmacist 9.130%1.1 Geriatrician 6.025%1.0

16. Summary Telephone Screening (Bad idea) Referral process much more efficient Logistics Provider time varies in concentration and total involvement

17. Acknowledgements Department of Family Medicine (pilot funding) Hamilton FHT: Carrie McAiney Seniors of SCFHC CCAC: Nancy Easson Alzheimer’s Society (Mary Burnett) Lisa Dolovich Chris Patterson

19. Acceptability of SCCP Objectives Methods Results

20. Objectives Experience of patients Level of satisfaction Program’s strengths Areas of improvement Program’s worth for seniors Experience of providers Feasibility and worthwhile of expanding program Clinician’s demographics

21. Methods Qualitative interviews Patients, MDs and RPNs In person or over telephone 15-30 minutes 5-point scale ratings & room for comments

22. Interview Guide 1.a) Please rate your overall satisfaction with the SCCP on a scale from 1 to 5, with 1 = very unsatisfied and 5 = very satisfied b) Please describe your experience with this program 2.What worked well in this program? 3.What parts of the program did not work well? What would you change?

23. Interview Guide Cont’d 4. a) How worthwhile do you feel this program is for seniors? Please rate your assessment between 1 – 5, with 1 = not very worthwhile and 5 = very worthwhile b) Please explain your response. 5. a) I believe that the Seniors’ Collaborative Care Program should be implemented in the McMaster FHT on a larger scale. Please rate on a scale of 1-5, where 1=strongly disagree, and 5= strongly agree b) Please explain your response. 6. ) Do you have any other comments that you would like to make.

24. Interview Guide Cont’d Demographics: 1. Role in McMaster FHT:______________ 2. Hours worked per week:_____________ 3. Length of time with McMaster FHT:______________ 4. Average amount of time spent with program:_____________

25. Results- Patient’s Feedback Overall satisfaction- Mean (SD): 4.4 (0.54) “felt more comfortable, help in optimizing care” Worthwhile program for seniors: 4.2 (0.44) “Seniors need more attention. This program would be quite beneficial” What worked well? …”enough time to ask questions and get clarifications” “discussing medications with a pharmacist” “Meeting with a nurse at home to avoid falls”

26. Results- MDs’ Feedback Overall satisfaction: 4.8 (0.44) “The program made me feel more comfortable” How worthwhile is program for seniors: 4.8 (0.44) “Home visits were very helpful and informative” Should SCCP be expanded: 4.8 (0.44) “…access to services in a timely manner…”

27. MDs’ Feedback Cont’d What worked well? RN visit at home was essential and allowed for a more complete picture Communication is timely and useful Multidisciplinary approach Areas of improvement/ Suggestions? Taking a more proactive role in scheduling Becoming comfortable with roles

28. Results- RPNs’ Feedback Overall satisfaction: 4.9 (0.25) “…providers were able to prevent crises from happening.” How worthwhile is program for seniors: 5.0 (0.0) “…helps in keeping patients in their homes longer.” Should SCCP be expanded: 5.0 (0.0) “It would be beneficial to expand it to the rest of Hamilton communities as there is a great need for it”

29. RPNs’ Feedback Cont’d What worked well? Case presentation; receiving different perspectives Learners (e.g. residents) were involved; good experience Collaboration between geriatric and primary care Caregiver relief Recognition of health concerns is faster Areas of improvement/ suggestions? Organizing appointments with appropriate providers requires familiarization with program

31. Clinical Program Referral based program Patients are referred from all the teams –Averaging 1-2 referrals per week Referrals are for complex elderly, and are not restricted to cognition or falls as the clinical issue

32. Clinical Team Family Doctor Dr. Ainsley Moore NP Joy White RPNRachelle Gervais PharmacistShelly House GeriatricianDr. Christopher Patterson DietitianGlenda Pauw Learnersall are welcome!

33. Clinical Team

34. Clinical Program Assessment done over 2-3 visits Case review informally with interdisciplinary team Case review with geriatrician as needed Care plan reviewed with primary care provider

35. Structure of visits Initial Appointment –Booked by RPN on Friday mornings Initial 30 minutes with RPN 60 min with MD or NP Also double-booked with resident –RPN: GDS, modified Levy, SCREEN II –MD or NP: Chart review and assessment of presenting issues Second Appointment –Meeting with family Third Appointment –Physical exam –F/u as needed

36. Case Reviews Informal –Done in the team room following the patient appointment Formal –Case reviews including Dr Patterson –Twice a month –Scheduled so physicians, allied health care providers and learners can attend

37. Case Reviews Documentation is done during the case review Follow-up time is variable following case review ( 30 to 60 min) Follow-up is shared among the team members

38. Geriatrician role Dr. Christopher Patterson –Twice a month –Willing to do case reviews, see patients in the clinic or at home, discuss topics (management of depression in older adults) –Friday mornings 9 to 12 noon 3-4 case reviews and sees 1 patient Wait to be seen by geriatrician is 2-6 weeks vs 6 months outside the clinic

39. Team Roles MD –Assess patients –provides consultation across the clinic for complex elderly NP –assess patients –case management role –case review planning –support continuity of care –knowledgeable regarding community resources

40. Team Roles Pharmacist –Medication review –Recommend changes in drug therapy –Assist in implementing changes RPN – arranges initial appointments –initial screening –knowledge of community resources –provides continuity

41. Team Roles Social Work –Provides support for complex family dynamics –knowledge of community resources Dietitian –Nutrition knowledge for promotion of seniors’ health –reducing health risk in the community

42. What are the benefits of our clinical program? Patient care Learners Health care team

43. What we have learned about patient care Patient care benefits –Improved continuity for patients –More timely specialist care –Chart reviews prior to seeing a complex senior is a good use of time –Improved use of community resources (matched to patient need) –Time taken to include family caregivers is well worth the effort –How to structure our care for improved efficiency –MOCA is a good tool for primary care

44. What we have learned about geriatrican role in primary care Role of visiting Geriatrician –Generally sees patients with atypical presentations or when multiple co-morbities are present, or when treatment plans conflict What is the most helpful? – specialist expertise in diagnosis and management of complex interacting medical issues. –Planning care at transition points. changing goals of care –Enhanced confidence skill building

45. What we have learned about health care teams Interdisciplinary team care increases the range of solutions and improves providers satisfaction –Interprofessional growth and development –Enhanced understanding and appreciation of each others roles There are disease specific guidelines but no multiple co-morbidity guidelines – this means health care teams need ongoing support when caring for these populations –reduced provider burden (antecdotal) –Incorporation of learners –work

46. Benefits for learners Incorporating learners –structured times for case reviews facilitate particiption –Residents are not always available on Friday mornings –opportunity to go on home visits –opportunity to plan care with multiple disciplines

47. What are the challenges? –How is the approach different: slower, takes time, so should we be doing it? Improved our efficiency over time –Latest literature: we can not continue usual care as it does not

48. Future directions Continued development of the team Further development of education goals and objectives for learners Care processes template for EMR Addressing continuity Group medical appointments for older adults