Samir Sinha: Canadian innovation in caring for older adults
Canadian Innovations inCaring for Older AdultsAcross the Continuum of CareSamir K. Sinha MD, DPhil, FRCPCDirector of GeriatricsMount Sinai and the University Health Network HospitalsAssistant Professor of MedicineUniversity of Toronto and the Johns Hopkins University School of MedicineResearch AffiliateOxford Institute of AgeingNuffield Trust Health Policy Summit1 March 2012
Presentation Objectives Provide the Canadian context that demands innovations in caring for older adults. Demonstrate how current care delivery paradigms are problematic and require an elder friendly approach. Introduce the Acute Care for Elders (ACE) Strategy as an integrated care model that can deliver better patient and system outcomes.
Canadian Healthcare 101 We have a universal health care system that is independently administered by 13 provincial and territorial governments. Hospitals are independently governed authorities with a public mandate Ontario is the largest HMO in North America with a budget of 47.1 B and population of 13.3 M
Ageing and Hospital Utilizationin Central Toronto Number Age <65 Seniors 65 + % Seniors 75+Total Population 1,142,469 87% 14% 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 87% 13% 59%Inpatient Rehabilitation 3,368 25% 75% 66%Toronto Central LHIN
Ontario Inpatient HospitalizationsAge Discharges Total LOS Days ALOSPopulation Total 945,089 6,075,270 6.4Population 65+ 370,039 (39%) 3,516,006 (58%) 9.865-69 6.9% 7.9% 7.370-74 7.7% 9.8% 8.275-79 8.5% 12.5% 9.480-84 7.9% 13% 10.585-89 5.3% 9.4% 11.490+ 2.8% 5.3% 12.2Canadian Institutes for Health Information (CIHI)
Ageing and Hospital Utilization in the 70+ Inconsistently High Users Consistently High Users 4.8% 6.8% 42.6% 24.6% Consistently Low Users No Hospital Episodes Only a small proportion of older adults are consistently extensive users of hospital services (Wolinsky, 1995)
What Defines our Highest Users? Polymorbidity Functional Impairments Social Frailty
Conceptualizing Functional Decline The Hazards of Hospitalization Hostile Environment DepersonalizationFunctional Acute Illness Bedrest / Immobilty Older + Possible Malnutrition / Dehydration Person Impairment Cognitive Dysfunction Medicines / Polypharmacy Procedures Depressed Mood, Delirium, Physical Impairment and Negative Expectations and Deconditioning Dysfunctional OlderPalmer et al., 1998 (Modified) Person
Trajectories of Functional Decline Baseline Admission Discharge 70+ Pts 57% Stable 45% Stable 65% Discharged N=2293 N=1311 N=1039 with Baseline Function 20% Recovery N=1494 N=455 12% Hospital Decline N=272 35% Discharged 43% Decline 18% Fail to Recover with Worse than N=982 Pre-Hospital Decline Baseline Function N=402 N=799 5% Pre-Hospital and Hospital DeclineCovinksy et al., J Am Geriatr Soc 2003 N=125
The Hazards of HospitalizationTHE COST OF FUNCTIONAL DECLINE (Palmer, 1995)The loss of independent functioning during hospitalizationhas been associated with: Prolonged lengths of hospital stay Increased recidivism A greater risk of institutionalization Higher mortality rates
The DilemmaThe way in which acute hospital services are currentlyresourced, organised and delivered, often disadvantagesolder adults with chronic health problems. (Thorne, 1993)
Acute Care for Elders (ACE) Strategy Redesigns or establishes new sustainable approaches that seek to enhance and improve upon current service models. Requires a shift in traditional thinking that currently underpins the administration and culture of most traditional care organizations. Is not adverse to identifying risk factors and needs and in intervening early to maintain independence.
Geriatrics at Mount Sinai In 2010, Mount Sinai became the first acute care academic health sciences centre in Canada to make Geriatrics a core strategic priority. Our ACE Strategy is being operationalized through the implementation of a comprehensive and integrated strategic delivery model that utilizes an interprofessional team-based approach to patient care. Our Strength relies on the partnership of our Geriatric Medicine, Geriatric Psychiatry, Primary Care, Palliative Medicine, and Emergency Medicine programs.
The Elder Friendly Hospital™ ModelThese dimensions work together to minimize functionaldecline, promote safety, and mitigate adverse social andmedical outcomes. Social Behavioural Culture Physical Design Policies and Procedures Care Systems, Processes and Services
The Mount Sinai Geriatrics Continuum Home-Based Geriatric Primary/Specialty CareOutpatient Geriatric Program: House CallsMedicine, GeriatricPsychiatry and Palliative Temmy Latner Home-BasedMedicine Clinics Palliative Care ProgramCCAC – Clinic Coordinator CCAC – Integrated Client Care Project (ICCP) Site Reitman Centre for Alzheirmer’s Support and Caregiver Training Community and Staff Education ProgramsGeriatric Medicine,Geriatric Psychiatryand Palliative MedicineConsultation ServicesOrthogeriatrics Program ISAR ScreeningICU Geriatrics Program Geriatric EmergencyMAUVE Volunteer Program Management (GEM) NursesACE Unit ED Geriatric Mental Health ProgramCCAC – ACE Coordinator RED = New Programs Launched in FY 10/11
Evaluating ACE at Mount SinaiLENGTH OF STAY (Age 65+) FY 09/10 = 8.0 → 6.5 (Provincial Average = 9.8)% RETURN HOME (Age 65+) FY 09/10 = 71.7% → 78.4% (Regional Average = 70.9%)CATHETER UTILIZATION RATIO (Age 65+) FY 09/10 = 56% → 19%READMISSION w/n 30 DAYS (Age 65+) FY 09/10 = 14.4 → 12.5%PATIENT SATISFACTION (Age 65+) FY 09/10 = 95.9 → 96.8% (Regional Average = 93.5%)STAFF EXPERIENCE w/ GERIATRICS FY 09/10 = 63 → 66.9 (Canadian Average = 56.2)
MSH/House Calls Partnership Provides ongoing comprehensive interprofesional home- based primary/specialty care to frail, marginalized, cognitively impaired, and house-bound elders who would not otherwise have access to primary care. The first hybrid primary/specialty geriatrics model in Canada that provides excellent training opportunities. GPs, Nurse Practitioner, Occupational Therapist, Social Worker and Team Coordinator w/ Specialist Support. Initiation of primary care can occur within 48hrs. A Continuum of Care that spans Hospital and Home.
Evaluating the House Calls Program Average Patient Age at Enrollment is 87 Average Daily Census is ~ 180 Annual House Calls Program Budget = 480K/Year Average Nursing Home Cost/Client = 50K/Year 37% of patients are referred after a hospital episode… Average (Age Adjusted) CCI/Mortality = 3.7(7.9) = 1 Year 52%(85%) Mortality Unscheduled Readmissions at 30/90 Days vs (Usual Care) = 12% (14%) and 22% (31%) for 65+ 67% of House Calls patients die at home.
Concluding Thoughts Whereas hospitalization offers older patients potential benefits it also exposes them serious risks. Pursuing an ACE Strategy requires a shift in traditional thinking. Programs only succeed through collaborations and partnerships internally and externally. Implementing an ACE Strategy will allow providers to remain leaders in the delivery of complex medical care.