1. Feasibility of a Collaborative Intervention to Improve Care of the Elderly December 18, 2008 Stonechurch Family Health Centre, Hamilton ON

2. Feasibility of a Collaborative Intervention to Improve Care of the Elderly Introduction Study phases –Development –Implementation –Evaluation Results to date Next Steps

3. Study Team Investigators/Clinicians Ainsley Moore, MD Joy White, RN EC Stonechurch Clinicians Rachelle Gervais RPN Lisa McCarthy, PharmD Research Support Kalpana Nair, PhD candidate Katie Zazulak, Alison Andrews, Nida Samad

4. Community Partners Hamilton Family Health Team -Carrie McAiney Alzheimer’s Society - Mary Burnett, Anne Swift Geriatric Medicine –Dr. Chris Patterson CCAC –Nancy Van Esson

5. Introduction (1)‏ Primary Study Goals Streamline care processes for ambulatory geriatric patients Develop expertise among providers and residents Foster inter-professional collaboration

6. Introduction (2)‏ Focus of Intervention Development of office-based tools for evaluating seniors Establish a model for maximizing provider input, continual feedback, communication Strengthen relationships with external partners (HFHT, AS, CCAC)

7. Development Phase (1)‏ Two main tools developed*: 1.Algorithm for assessment of falls –ACOVE III, Health Canada, Cochrane 2.Algorithm for assessment of cognitive impairment –ADEPT, CMAJ (Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.)‏ *Initial development of both algorithms was based on the Seniors Health Initiative in Family Health Teams (SHIFT) that is being implemented in the Hamilton FHT

8. Development Phase (2)‏ Model for optimizing provider and partner competencies

9. Collaborative Model RD PharmSW Fam MD NP Geriatrician RN CCAC AS Team Based Case Meetings Senior at risk (assessment)‏

10. Development Phase (3) Study Protocol Patient recruitment –Telephone screen If + screen, invited to attend initial planned visit Planned visit 1 –Part A with RPN –Part B with NP or MD for falls or cognitive assessment

11. Recruitment Random identification of seniors living in the community > 75yrs (Team A)‏

12. Telephone Screen (1)‏ Process: Conducted on phone by a student Assessment of risk of falling “Fallen 2 or more times”? “Fallen and hurt yourself or needed to see a doctor because of a fall”? “Been afraid that you would fall”? If “yes” to any question invite to attend scheduled office visit

13. Telephone Screen (2)‏ Assessment of risk of cognitive impairment “I would like you to name as many animals as you can”. “You Have one minute”. “Are you Ready”? “Please begin now” If < 11 invite to attend scheduled office visit

14. Telephone Screen (3)‏ If screened positive for both, then would be invited for office visit for cognition first If screened negative information brochures (falls prevention*, memory work out**) mailed to patient * CCAC **MAREP

16. Initial Office Visit 1.Part A Initial planned visit with RPN (Nutrition screen, GDS, Levy)‏ –Referral to appropriate provider 2.Part B Initial visit with NP or MD for cognitive or falls assessment

17. Cognitive Assessment (Initial visit, Part B)‏ Patient history (identify goals)‏ Onset, associated symptoms and events Risk factor assessment Home and driving safety Functional status Cognitive screen (MOCA, MMSE)‏ Referral AS and or CCAC

18. Cognitive Assessment (2nd visit)‏ 2nd planned visit with care giver / family Confirm memory change Assess early personality changes Confirm functional status Assess family support, social setting Care giver status Confirm driving / home safety

19. Cognitive Assessment (3rd visit)‏ Physical examination Gait Investigations as appropriate

20. Cognitive Assessment (Team Based Meeting)‏ Case discussion and collaborative care plan Monthly team-based case meetings with participating providers and visiting geriatrician

21. Cognitive assessment (4th visit)‏ Patient and care giver / family visit Communication of assessment and plan

22. Cognitive Assessment (5th visit)‏ Follow-up visit Successful adaptation to change?

23. Falls Assessment (Initial visit, Part B)‏ Pre-appointment chronic illness review Circumstances of fall Address injuries Rule out syncope Medication review (including reminder, dispensing system)‏ Alcohol consumption (CAGE)‏

24. Falls Assessment Initial Physical Examination Orthostatic hypotension Cardiovascular examination Investigations as indicated

25. Falls Assessment (2nd Visit)‏ 2nd visit with care giver/family Functional status inquiry (MFES)‏ Physical examination –TUG, Gait, neuromuscular exam, visual acuity CCAC (identified referral)‏

26. Falls Assessment Case discussion and collaborative care plan Monthly team-based, case meeting with appropriate providers and visiting geriatrician

27. Falls Assessment Follow up visit Successful adaptation to change?

29. Evaluation How will data be summarized Data collectedEvaluation area Qualitative Patient / providers experience with Screen or assessment, team meetings Acceptability Average Personnel time Patient time Protocol logistics Percentage Telephone screen -Completion rate -# “at risk” Recruitment

30. Results to date Falls=1 Cognition=1 9Contacted = 20 Declined = 2 Call back later = 9 At riskCompletedTelephone Screen

31. Observations Telephone screen Eager to talk No answer (n=XX)‏ Request to call back after office hours Booking appointment (crowded provider schedules Forgetting appointments

32. Next Steps Continue recruitment and screening Goal 50 patients

33. Acknowledgements Department of Family Medicine (pilot funding)‏ Hamilton FHT: Carrie McAiney Alison Andrews & Nida Samad (telephone screening)‏ CCAC: Nancy Van Esson Alzheimer’s Society: Mary Burnett, Anne Swift Dr. Lisa Dolovich Dr. Chris Patterson