Senior Friendly Hospitals:A win-winDeGroote Interprofessional Health Leadership ConferenceOctober 2011Barbara Liu, MD, FRC...
Outline   • The Challenge          • Addressing the Challenge:            RGP Senior Friendly Hospital            Framewor...
Questions to consider• Why do we need a senior friendly  framework?• How or why does change happen?• What sustains change?...
Seniors in Hospitals: the Challenge                    • LOS In Canada:                       – Over 65 6 days longer    ...
Hospitalized seniors lose independencein ADL                                        worse                                 ...
The Challenge                6
RGP Senior Friendly                     Hospital Framework                Emotional &      Ethics in Processes of         ...
Organizational Support•   Strategic priorities•   Organizational leadership•   Accountability•   Policies and procedures r...
Processes of Care• Assessment, diagnosis and management with  special emphasis on age-related conditions• Emphasis on avoi...
Emotional and Behavioural Environment• Attitudes of all staff• Organizational culture• Health care system should be  leadi...
Ethics in Clinical Care and Research•   Autonomy•   Decision-making•   Advanced directives•   Resource allocation
Physical Environment• Enabling maximum independence in  function• Consideration of age-related physiological  changes – se...
Ethics in                             Processes of                                                                     Cli...
“….a focus on geriatrics as the solution,                       not the problem.”                                         ...
The goals of the SFH• Patient / family   – Minimize risk, improve safety   – Maximize functional ability, improve outcomes...
TC LHIN CEO – Hospital CEO Directive• SFH Backgrounder and  self-assessment• Develop a plan for Senior  Friendly Strategie...
The Opportunity• Healthy Communities, Healthy Seniors - 8  strategies aligned with:   – Excellent Care for All Act   – Agi...
Senior Friendly Hospital Care in Ontario• Senior Friendly Hospital self-assessments in 155  organizations across the Ontar...
The Ontario Senior Friendly Hospital Strategy         PHASE 1                   PHASE 2           PHASE 3 - ONGOINGObjecti...
Patient &Care Team                      Hospital                      Priorities           LHIN         priorities        ...
Mobilization of Vulnerable Elders           MOVE iT             MOVE ON           In Toronto          Ontario           • ...
Adverse effects of bedrest•   Atelectasis, aspiration•   Orthostasis•   Thrombosis•   Decubitus ulcers•   Muscle deconditi...
Lying 83% of measured hospital stay spent in bed                                               Sitting Median time spent...
24
Patient-related                   Treatment-related      Illness severity,                Activity order, devices,        ...
Mobilization Algorithm                    26
Mobilization algorithm                 Mobility                                       Level                               ...
Early Mobilization Improvement Plan and       RGP Senior Friendly Hospital Framework                  Emotional &         ...
Selected RCT evidence for early mobilizationSurgical      Many RCTsDxPneumonia      LOS 5.8 vs 6.9 days              (Mun...
Is it feasible tomobilize frailolder patientson medicalunits?                30
First step is to dangle   To Chair
Respiratory ICUIntermountain MedicalCenterSalt Lake City, Utah                        32
Key messages• Senior friendly framework guides improvement  plan• Scalable interventions• High yield• Invest in developmen...
www.seniorfriendlyhospitals.cawww.rgp.toronto.on.caBarbara.liu@sunnybrook.caKen.wong@sunnybrook.ca                        ...
Acknowledgements                                                               SFH LHIN Leads WorkingTC LHIN         TC LH...
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Dr. barbara liu senior friendly hospitals

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Dr. barbara liu senior friendly hospitals

  1. 1. Senior Friendly Hospitals:A win-winDeGroote Interprofessional Health Leadership ConferenceOctober 2011Barbara Liu, MD, FRCPCExecutive DirectorBarbara.liu@sunnybrook.ca 1
  2. 2. Outline • The Challenge • Addressing the Challenge: RGP Senior Friendly Hospital Framework • The Opportunity – TC LHIN experience – Provincial roll out • Bringing the framework to the bedside - An example of an improvement plan 2
  3. 3. Questions to consider• Why do we need a senior friendly framework?• How or why does change happen?• What sustains change?• When geriatric care is such a epidemiologic imperative, why are we so challenged to monitor and measure progress? 3
  4. 4. Seniors in Hospitals: the Challenge • LOS In Canada: – Over 65 6 days longer – Over 85  14 days longer • In Ontario: – average 53 hospital days awaiting placement in LTC – 16% of inpatient beds utilized for ALC • Senior Friendly Hospital approach is needed to mitigate these system challenges and help older adults age at home 4
  5. 5. Hospitalized seniors lose independencein ADL worse than baseline n=769 Covinsky KE et al. JAGS 2003;51:451
  6. 6. The Challenge 6
  7. 7. RGP Senior Friendly Hospital Framework Emotional & Ethics in Processes of Organizational Physical Behavioural Clinical Care & Care Environment Support Environment ResearchWhat we do How Who Why Where 7
  8. 8. Organizational Support• Strategic priorities• Organizational leadership• Accountability• Policies and procedures reviewed and revised through a senior friendly lens
  9. 9. Processes of Care• Assessment, diagnosis and management with special emphasis on age-related conditions• Emphasis on avoiding hazards of hospitalization• Adoption of best practices and tools• Building new models of integrated care across sectors
  10. 10. Emotional and Behavioural Environment• Attitudes of all staff• Organizational culture• Health care system should be leading change in society to counter ageism
  11. 11. Ethics in Clinical Care and Research• Autonomy• Decision-making• Advanced directives• Resource allocation
  12. 12. Physical Environment• Enabling maximum independence in function• Consideration of age-related physiological changes – sensory comfort• Internal and external physical structure• More than accessibility
  13. 13. Ethics in Processes of Clinical Care & Care Research Organizational Support Emotional & Ethics inProcesses of Organizational Physical Behavioural Clinical Care & Care Support Environment Environment Research Emotional & Physical Behavioral Environ-ment Environ-ment
  14. 14. “….a focus on geriatrics as the solution, not the problem.” 14
  15. 15. The goals of the SFH• Patient / family – Minimize risk, improve safety – Maximize functional ability, improve outcomes – Improve care experience & satisfaction• Staff – Enabled to deliver best practice – Improve satisfaction• Hospital Strategic Alignment – Improve quality – Reduce adverse events & iatrogenic complications – Improve capacity for independent living – Reduce LOS and readmissions 15
  16. 16. TC LHIN CEO – Hospital CEO Directive• SFH Backgrounder and self-assessment• Develop a plan for Senior Friendly Strategies• Obligation to appear in future HSAA
  17. 17. The Opportunity• Healthy Communities, Healthy Seniors - 8 strategies aligned with: – Excellent Care for All Act – Aging at Home as it contributes to reducing ALC – Health equity• Senior Friendly Hospital Strategy – Offers a concrete quality improvement strategy that could become part of the hospitals first Quality Improvement Plans. 17
  18. 18. Senior Friendly Hospital Care in Ontario• Senior Friendly Hospital self-assessments in 155 organizations across the Ontario• RGPs of Ontario worked with LHINs to generate 14 SFH summary reports and individualized feedback letters• provincial summary report describing SFH care across Ontario with recommended action plans for short to intermediate term 18
  19. 19. The Ontario Senior Friendly Hospital Strategy PHASE 1 PHASE 2 PHASE 3 - ONGOINGObjective Objective• Identify current • Monitor and sustain hospital state Objective and system improvements • Close the gapPlan Future State• Hospital self- Plan • Prevent functional decline assessments • Implement hospital • Improve patient experience• LHIN-level roll-up improvement plans • Enable hospital staff• Provincial roll-up • Develop key enablers • Improve equity 19
  20. 20. Patient &Care Team Hospital Priorities LHIN priorities Provincial Improvement Priorities 20
  21. 21. Mobilization of Vulnerable Elders MOVE iT MOVE ON In Toronto Ontario • B Liu (PI) • MOVE iT plus • D Brown-Farrell • Kelly Milne • S Straus • Stephanie Amos • M Zorzitto • Sharon Marr • Dorothy Knights • Barry Lumb • T Izukawa • J Ritchie • S Sinha • R. Ramsden • et al. 21
  22. 22. Adverse effects of bedrest• Atelectasis, aspiration• Orthostasis• Thrombosis• Decubitus ulcers• Muscle deconditioning, joint contracture• Bone demineralization• Sensory deprivation 22
  23. 23. Lying 83% of measured hospital stay spent in bed Sitting Median time spent standing or walking Walking = 43 minutes or 3% of dayBrown, C et al JAGS 2009;57:1660 23
  24. 24. 24
  25. 25. Patient-related Treatment-related Illness severity, Activity order, devices, Processes of Processes of comorbidity, medications Care Care pain, delirium Barriers to Mobilization Institution-related Attitudinal factorsStaffing, time constraints, Organizational Physical Ethics in Patient or staff, & Emotional equipment Clinical Care & Behavioural Support Environment expectations, concern Research Environment fallingBrown, C et al J Hosp Med 2007;2:305 25
  26. 26. Mobilization Algorithm 26
  27. 27. Mobilization algorithm Mobility Level Corporate Standard of Practice• Can they respond to verbal stimuli?• Can they roll side to side? C• Can they sit at edge of bed?• Can they straighten one or both legs?• Can they stand? B• Can they transfer to a chair?• Can they walk a short distance? A 27
  28. 28. Early Mobilization Improvement Plan and RGP Senior Friendly Hospital Framework Emotional & Ethics in Processes of Organizational Physical Behavioural Clinical Care & Care Environment Support Environment ResearchWhat we do How Who Why Where Mobilization Culture training Corporate assessment Priority setting standard of Clutteralgorithm and Ageism care; Strategic in rounds initiativecare pathway Awareness theme 28
  29. 29. Selected RCT evidence for early mobilizationSurgical Many RCTsDxPneumonia  LOS 5.8 vs 6.9 days (Mundy Chest 2003;124:883-889)Stroke  Barthel Index at 3 months Earlier return to walking 3.5 vs 7 days P=0.03 (Cumming TB Stroke 2011; 42 :153)Cochrane  Discharge to home, NNT=16Review (2009)  LOS by 1.08 days (-1.93 to -0.22) 29
  30. 30. Is it feasible tomobilize frailolder patientson medicalunits? 30
  31. 31. First step is to dangle To Chair
  32. 32. Respiratory ICUIntermountain MedicalCenterSalt Lake City, Utah 32
  33. 33. Key messages• Senior friendly framework guides improvement plan• Scalable interventions• High yield• Invest in development of knowledge, skills, attitude• Geriatric issues require an interprofessional approach 33
  34. 34. www.seniorfriendlyhospitals.cawww.rgp.toronto.on.caBarbara.liu@sunnybrook.caKen.wong@sunnybrook.ca 34
  35. 35. Acknowledgements SFH LHIN Leads WorkingTC LHIN TC LHIN SFH Taskforce Group of ON• C Orridge • J Bennett (Co-Chair) • MK McCarthy • B Liu (Co-Chair) • J Merkley A Anderson A Marcuzzi• V Sakelaris• R Cook • M Codjoe • C Millar J Girard B Laundry• T Martins • C Cotton • J O’Neill G Whitson Shea, C Russell• G Whitehead • S VanDeVelde-Coke • J Walsh S Isaak C LeClerc• S Smit • P Cripps-McMartin • C Ross S Stewart P Istvan • L Dess • K Velji • C Levy N Jaffer S Colwell H Willis M AuchinleckRGPs of ON• K Wong T Martins B Villella• D Jewell K Tasala• K Milne• E Plain • The Senior Friendly Hospital Strategy is an initiative of• E McCarthy Ontario’s Local Health Integration Networks• K Rossi• M Awad• D Ryan 35

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