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Healthcare Information Standards for Frailty: Why, When and How (2 of 5)

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Trillium II /Focus workshop at Informatics for Health2017: Manchester, April 24-27, 2017
Frailty is an age-related state of vulnerability to the risk of adverse health out-comes after a stressor event. The condition predisposes individuals to progressive decline in different functional domains, leading to falls and fractures, disability and dependency on others, hospitalization, institutional placement and ultimately death. We discuss drivers, challenges and opportunities for healthcare information standards related to frailty in old age in an effort to launch a call for coordinated action across research, policy, and academia. Key issues are selected as the back-drop for this discussion: EHR, patient summaries and frailty in a context of coor-dinated care enabled by health IT standards.
Presentation 2 of 5 by Maria Magdalena Bujnowska-Fedak
Wroclaw Medical University, Poland

Published in: Health & Medicine
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Healthcare Information Standards for Frailty: Why, When and How (2 of 5)

  1. 1. COORDINATED HOLISTIC SERVICE APPROACH TO FRAILTY MANAGEMENT Maria Magdalena Bujnowska-Fedak Wroclaw Medical University, Poland INFORMATICS FOR HEALTH 2017 PANEL: HEALTHCARE INFORMATION STANDARDS FOR FRAILTY: WHY, WHEN AND HOW
  2. 2. FRAILTY DEFINITION Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems putting them at greater risk of adverse outcomes after apparently minor events, e.g. a new drug or a minor infection.
  3. 3. FRAILTY COMPLICATIONS Frailty is a common clinical syndrome in older adults that carries a high risk for poor health outcomes including:  increased susceptibility to acute illnesses,  increased susceptibility to stress,  increased susceptibility to side effects of drugs and other medical interventions,  falls,  disability & dependency,  hospitalization,  institutionalization,  and eventually leads to death.
  4. 4. FRAILTY PREVALENCE Around 10% of people over 65 is living with frailty. 65-69 y. : 4% 70-74y. : 7% 75-79 y. : 9% 80-84 y.: 16% 85+: 26%! Prevalence increases with age and is higher in women than in men.
  5. 5. CARE COORDINATION IN FRAILTY The gold standard for the care of people with frailty is Comprehensive Geriatric Assessment (CGA). CGA is a multidimensional assessment, treatment plan and regular review delivered by a multidisciplinary team (MDT) that usually includes doctors, nurses, physiotherapists, occupational therapists and social workers. A core feature of CGA is a holistic medical review.
  6. 6. CARE COORDINATION IN FRAILTY Comprehensive Geriatric Assessment will:  diagnose medical illnesses to optimise treatment and formulate a plan for care  apply evidence-based medication review checklists and take account of personal priorities and severity of frailty to rationalise medications (only appropriate medications are prescribed)  include discussion with older people with frailty and their carers to define the impact of illness and symptoms on a day-to-day life  create an individualised comprehensive care and support plan (CSP). This will summarise who is responsible for doing what! The CSP should describe an optimisation and maintenance plan including the self-care plans, an escalation plan (what to look out for and who to call) and an urgent care plan that may include whether or not hospital care is appropriate/desirable and what alternative plans are in place.
  7. 7. PERSPECTIVES ON CARE COORDINATION Patient/Family Perspective. Care coordination is any activity that helps ensure that the patient's needs and preferences for health services and information sharing across people, functions, and sites are met over time. Patients, their families, and other informal caregivers experience failures in coordination particularly at points of transition. Patients perceive failures in terms of unreasonable levels of effort required on themselves or their informal caregivers in order to meet care needs during transitions among health care entities.
  8. 8. PERSPECTIVES ON CARE COORDINATION Health Care Professional(s) Perspective. Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system. Clinical coordination involves determining:  where to send the patient next (e.g., sequencing among specialists),  what information about the patient is necessary to transfer among health care entities,  how responsibility is managed among all health care professionals (doctors, nurses, social workers, care managers etc.)
  9. 9. PERSPECTIVES ON CARE COORDINATION Health Care Professional(s) Perspective. Health care professionals notice failures in coordination particularly when the patient is directed to the "wrong" place in the health care system or has a poor health outcome as a result of poor handoffs or inadequate information exchanges. They also perceive failures in terms of unreasonable levels of effort required on their part in order to accomplish necessary levels of coordination during transitions among health care entities.
  10. 10. PERSPECTIVES ON CARE COORDINATION System Representative(s) Perspective Care coordination is the responsibility of any system of care to deliberately integrate personnel, information, and other resources needed to carry out all required patient care activities between and among care participants. Failures in coordination that affect the financial performance of the system will likely motivate corrective interventions. System representatives will also perceive a failure in coordination when a patient experiences a clinically significant mishap that results from fragmentation of care.
  11. 11. CARE COORDINATION CIRCLE Care coordination ring Care coordination Measures Atlas Update. Chapter 2. What is care coordination? AHRQ Publication No. 11-0023-EF, 2010.
  12. 12. STRATEGY FOR THE CARE OF OLDER PEOPLE WITH FRAILTY The strategy for the care of older people with frailty is usually built on the following three pillars:  Ageing well and staying well at home  Extending primary and community support  Integrated care in acute settings
  13. 13. STRATEGY FOR THE CARE OF OLDER PEOPLE WITH FRAILTY  Ageing well and staying well at home The ideal scenario for patients and health professionals alike is supporting older people with frailty to stay well and out of hospital. People want to continue to lead their normal lives for as long as possible. Remaining at home is a critical part of this, and has a profound impact on their overall well-being and health outcomes. Proactive care to support early identification, prevention and forward planning is also vital for an efficient care of frail patients.
  14. 14. STRATEGY FOR THE CARE OF OLDER PEOPLE WITH FRAILTY  Extending primary and community support Older people with frailty are susceptible to health crises and need acute care when a crisis occurs. They want to remain at home if they possibly can, and developing urgent care responses delivered at home or in a community setting often gives better outcomes than in hospitals. Successful delivery requires collaboration across a wide range of health, social and voluntary sector organizations, working together with patients, families and caregivers. The fruitful and efficient interaction between all these entities is crucial.
  15. 15. STRATEGY FOR THE CARE OF OLDER PEOPLE WITH FRAILTY  Integrated care in acute settings Inevitably, there are times when care can only be delivered in an appropriate and timely manner in a hospital setting (e.g. the person is very unwell or unstable or needs investigation or treatment which is best delivered in an acute setting). Older people with frailty are particularly vulnerable when under the strain and stress of being admitted to hospital. In these instances, the aim of care providers is to minimise the impact this has on the patient’s health by delivering tailored acute care, supporting a timely discharge and facilitating smooth transitions between care settings.
  16. 16. CARE TRANSITION Transitional care is defined as ‘a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location’ (Coleman EA, Boult C. American Geriatrics Society Health Care Systems C. Improving the quality of transitional care for persons with complex care needs. J AM Geriatr Soc 2003;51:556-7) Transition types include transfers from home-to-hospital, hospital-to-home, hospital-to-skilled care facility (e.g. rehabilitation unit), and skilled care facility-to-home and/or homecare.
  17. 17. CARE TRANSITION Transition types include transfers from home-to-hospital, hospital-to-home, hospital-to-skilled care facility (e.g. rehabilitation unit), and skilled care facility-to-home and/or homecare.
  18. 18. CARE TRANSITION People are more vulnerable to risks that may affect their health during transitions and so the quality of care related to transitions is important. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex care management, as well as for their family carers.
  19. 19. CARE TRANSITION BARRIERS  Delayed transfer of care (when a patient is still occupying an acute hospital bed but is clinically ready and safe for transfer)  Organisational barriers including system inflexibility, healthcare system fragmentation and lack of standardised processes  Lack of capacity in community health and social care provision perceived as an on-going barrier to transitions from acute wards  Deficits in communication and information transfer at hospital discharge with no established process for information exchange between settings; lack of timely, accurate and complete communication between services  Lack of effective communication within the interprofessional team  Lack of effective communication with the patient, the family; lack of communication with caregivers
  20. 20. CARE TRANSITION BARRIERS
  21. 21. MEASURES OF EFFECTIVE CARE TRANSITION  reduction in hospital LOS and reduced emergency re- admission rate,  high quality of life,  restoration or maintenance of function in keeping with increasing age,  reduction of family/carer burden,  delayed transfer for nursing home care.
  22. 22. KEY POINTS OF CARE TRANSITION  High-quality transitional care is especially important for older adults with multiple chronic conditions and complex care management, as well as for their family carers.  A key element is effective communication and smooth transfer of relevant information with relatives, carers and community service providers including the primary care physician.  To truly understand intervention effectiveness, multilevel program evaluation of implementation strategies is needed.
  23. 23. Thank you for your attention! COORDINATED HOLISTIC SERVICE APPROACH TO FRAILTY MANAGEMENT

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