2. HELP Project Planning Tool In this section think about…. What will the screening process at your site look like? How strict to the original inclusion and exclusion criteria will you be? What will you include in your baseline assessment ? Which units will you choose to start HELP on?

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.

4. Important to note… Each patient should be screened and enrolled within 24-48 hours of admission or transfer to a HELP unit.

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 – MMSE <24/30 (or equivalent ratio) Any mobility or ADL impairment Vision impairment: <20/70 best corrected vision Hearing impairment: < 3 of 6 whispers in each ear on Whisper test Dehydration: Urea x10/Cr >0.7 Able to communicate verbally or in writing. Nonverbal patients who can communicate in writing are included.

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; MMSE = 0). For patients with severe impairment (MMSE <10), decision to enroll will be made on a case-by-case basis depending on their ability to participate in interventions.

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

8. Exceptions to the Rules Palliative ALC Delirious on admission Admitted for over 48 hours Under age 70 Language barrier

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 getting slowly worse over the past year or so. She wears bilateral hearing aids, and bifocals. Came into ER after being found on the floor in her RH. Unable to get up and complaining of 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. She is consistently alert and coherent. Family state that this is how she is at home.

10. Case Scenario #2 83-year old lady living alone PMHx – CHF, Htn, Glaucoma, MCI Patient was getting up in the middle of the night, forgot to use her walker, and fell. On the floor for over 12 hours – daughter found her the next morning incontinent of foul-smelling urine. Taken to ER – xray shows fractured right femur, bladder catheter inserted, 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 3x, patient had trouble focusing and was inconsistent with following commands.

11. Case Scenario #2 cont’d Very restless, attempting to climb out of bed. 30 minutes later, patient is sleeping but does arouse with verbal stimulus 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 BADLs 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.

12. SCREENING PROCEDURE 1. ELS Reviews patient list on HELP units 2. Chart Review 3. HELP Program Description and Patient Consent 4. Baseline Assessment

14. Sample Assignment Sheet

15. Allocation of Patients Started on medical ward at McMaster Receptivity to improving geriatric care Supportive manager Champion for HELP familiar with the unit HELP research was done in medical population Expansion to Juravinski hospital to orthopedic surgery ward High rate of delirium Expansion to orthopedics at McMaster Transitioned McMaster resources to two medical units at Hamilton General