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Interdisciplinary Approach to Management of High Risk Elders GRECC Clinical Demonstration Project VA Greater Los Angeles Healthcare System Host: S Castle ([email protected]) M Cirrincione, S Wilkins, A Reinhardt, J Guzman vers 2.17.09, VANTS operator: 304-262-7600 Overview: Practical Tips Steven Castle, MD: Jenice Guzman, GNP Cognitive, Emotional factors Jenice Guzman, GNP OT/PT/KT tools to identify high risk Stacy Wilkins, PhD Med Management / Dietary Michael Cirrincione OTR/L: Our focus: who, what and why Structured decisional capacity Ashley Reinhardt, MSW Active case management- who, what, how Goal of Presentation Practical Processes of Care Identification of High Risk Interdisciplinary Team Assessment of Self Care Requisites: Instruments/Mitigation measures Decision Making Ability Related to High Risk Status Communication of Findings/Recommendations/Family Meeting Active Case Management Each discipline will introduce self/ discuss content Handouts included: Safety Risk Profile worksheet, Process Flow Chart, FIM Script for determining Decisional Capacity Neuropsychiatric tools: Mini Cog, MOCA, SLUMS, GDS, PHQ-9, DSMIV criteria for dementia, depression Self-Neglect? Criteria/Defining High Risk Elder “Elderly who Lack access or refuse needed support, Frequently live in squalor, With advanced, untreated diseases” Dyer CB JAGS 56:s369-240, 2008 Self-Neglect Severity Scale Overall rating of risk to Health &/or Personal Safety without intervention: none, moderate, severe 3 domains: Personal appearance, Functional status, Environment Poor correlation between domains Kelly PA JAGS 56:S253-260,2008 Challenges in Defining High Risk Elder: “Intentionality” obscures responsibility Self Neglect: US Society: presumptively responsible for self care When does responsibility for care shift? Connolly MT JAGS 56:s244-252, 2008 Medical Comorbidity / Disease Management: where it hinges Understands risk but has demonstrated poor outcomes Fulmer T JAGS 56:s241-243, 2008 Risk of serious outcome without intervention Falls, Medication adherence Readmission/ER visit for CHF, HTN, Diabetes, COPD Our Approach for Defining/Active Case Management Focus: are supports for deficits in self-care/disease management in place? Recognizes but is independent of decision making ability/capacity Reviewed later by Ashley Reinhardt: Criteria for High Risk Elderly: 2 or more Lives alone Inadequate social support Poor judgment with poor outcomes Decision making ability for risk is only one of many variables Resides in unsafe living conditions Based upon experience, literature review, expert panel Safety Risk Profile (handout): self care deficits Medical Complexity/Disease Management: Risk of serious outcome without intervention Falls Risk/ Disease management Objective measures Pharmacy: MEDICATION MANAGEMENT Dietary/Nutrition Function beyond ADLs Functional Independence Measure- reference point “Limitation Judgment” Look at interaction of resident, caregiver, environment, disease Cognitive changes, judgment, personality Social support / risk, red flags Assessing for medication adherence, diet/nutrition Jenice Guzman,RN, GNP-BC, PhD(c) [email protected] Medications Marian Rofail, PharmD Medication Adherence: Ability to self medicate or availability of caregiver. Indicators of the Inability to Self-Medicate: Cognitive impairment >5 prescriptions Inability to read prescription & auxiliary labels Difficulty opening non-child-proof containers Inability to discriminate between medication colors/shapes Medication evaluation Evaluation of Adherence: Polypharmacy: less than desirable Medication refill history Missed doses in pill box Medication monitoring Patient response to medications (e.g., low hr if on beta blocker) Unclear indication/duration, adverse effects, drug or disease interactions Duplication, inadequate attention to pharmacokinetics vs. Polymedicine: appropriate/monitored Effective, Appropriate Dosage, monitored for side effects Nutrition - Jennifer Krohn, MS, RD Nutrition Screening & Assessment - Age & sex Dx/ PMH Diet Rx, diet intake /exercise history Height & weight, weight history UBW (usual body wt) BMI (body mass index: kg/m2) IBW (specific for height,frame, sex, & geriatric) Pertinent medications, herbal supplements Nutrition related labs Psychosocial factors Age related factors Key Indicators for Nutrition Risk Disease & chronic conditions that interfere with intake Eating poorly Tooth loss/mouth pain Economic Hardship Reduced social contact Multiple medicines Involuntary weight loss/gain Needs assistance in self care Elder years (especially above 80 yrs) Weight loss Significant Weight Loss 10% in 6 mos 7.5% in 3 mos 5% in 1 mos 2% in 2 week BMI: 65 years and older goal is > 23 Labs for Nutrition Evaluation Serum albumin Pre-albumin C-Reactive protein Glucose/Hemoglobin A1C Cholesterol/HDL/ LDL/Triglycerides BUN/Creatinine – BUN: Trends higher in older adults (prone to dehydration: decreased thirst & poor concentration of urine - Creatinine: Slightly lower value due to decreased muscle mass Functional piece of nutrition: - - - Shopping for food? Meal preparation? Storage of food? Adherence to dietary restrictions or recommendations/special diets? Also assessed by OT Assessing Functional Abilities for Self Care Michael Cirrincione, OTR/L [email protected] OT: Occupational Therapy Enabling people to do the activities of daily life (ADLs) “Occupation" - an activity which "occupies" our time OT-skilled treatment for independence in all facets of life The World Federation of Occupational Therapists: "skills for the job of living", independent and satisfying lives Promotes health & well-being through occupation 1o goal: enable people to participate in the activities of everyday life Achieved by Enhancing an individual's ability to participate in ADLs, Modifying the environment, or Adapting the activity to better facilitate independence. KT Kinesiotherapy: Based on exercise principles Applied to deconditioning/ cardiac rehabilitation Adapted to enhance the strength, endurance, and mobility Within context of functional limitations or Requiring extended physical conditioning. PT Physical therapists (PTs) Diagnose and treat limited ability to perform functional activities As a result of health-related conditions Examine & develop a plan using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. Functional Independence Measure FIM An indicator of severity of disability, for components of ADL tasks Quick, for large groups of people Changes during rehabilitation/ Disease progression Major gradations: dependence to independence (7 levels) ADLs: independently vs. need for assistance Translates time/energy another person expends Require another person or device? Quantifies the need for help and the burden of care. To provide dependent needs of the disabled individual To achieve and maintain a certain quality of life, safety. A measure of disability, not impairment. Measures what person with disability actually does, Whatever the diagnosis or impairment, Not what he or she ought to be able to do, or might be able to do if certain circumstances were different. Description of Levels of Function & Scores Independent: other person not required for the activity (NO HELPER) 7 Complete Independence: 6 Modified Independence: Dependent: supervision or physical assistance (REQUIRES HELPER) 5 Supervision or Set up: Standby, cueing, coaxing, no physical contact, or Help with orthoses or assistive/adaptive devices. 4 Minimal Contact Assistance: touching only, Patient expends >75% effort to complete the task. 3 Moderate Assistance: more help than touching, assistive device; &/or more time; &/or there are safety risks Expends > 50%; but <75% of effort. Complete Dependence: Max or total assistance is required 2 Maximal Assistance: Expends >25% of effort but <50% to complete task 1 Total Assistance: Subject expends <25% of effort to complete task Capacity - Psychological and Neuropsychological Factors Stacy S. Wilkins, Ph.D., ABPP [email protected] Capacity - Psychological and Neuropsychological Factors Cognitive Mental limitations Emotional Personality & coping styles Mood Psychiatric Diagnoses Cognitive Influence Delirium Rapid Onset, not due to other mental disorder Reduced capacity due to confusion and altered attention Prevalence 30-40% of hospitalized patients older than 65 years 30% of patients in surgical and cardiac intensive care units 40-50% of patients recovering from surgery for hip fracture Factors associated with a higher risk of delirium include advanced age, pre-existing brain compromise, alcohol dependence, diabetes mellitus, cancer, sensory impairment (eg, blindness or poor hearing), malnutrition, and a history of delirium. Assessment for Delirium Digit Span Normal forward is 7 +/- 2 Backwards span should be 2 less than forward CAM (confusion assessment method) Feature 1: Acute Onset and Fluctuating Course Feature 2: Inattention Feature 3: Disorganized thinking Feature 4: Altered Level of consciousness The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4. Inouye S, Ann Intern Med 113:941-8, 1990 Dementia Diagnosis Dementia Diagnosis requires: Acquired persistent decline in Memory One other cognitive domain language, visuospatial skills, executive function Plus – decline in functioning, must effect their lives Dementia Reduced capacity often seen secondary to: Poor memory/recall Executive function/judgment problems Also can see language or visuospatial deficits Dementia Evaluation Minicog MMSE, SLUMS, MOCA 3 item recall plus clock Review (see handouts) Independent Living Scales (ILS) Health and Safety Judgment, Finances Psychiatric Diagnoses Depression (GDS, PHQ-9) Psychotic Disorders Paranoia, delusions Personality Style Low motivation and energy, poor appetite Highly value independence Substance Abuse Interdisciplinary Meetings: putting it together Medical Management limitations/medications Simplify/ train Meds, need for evaluation, reversibility Maintain nutrition, special diets Functional deficits/recognition of limits Caregiver training response Recommended support/Care needs Cognition and mood Screened by MDs, Psychology findings Capacity: all disciplines assess as a part of evaluation Concerns discussed at team meetings, Degree, reversibility of deficits/ evaluation Mitigation options (all team members) Patient Input Patient Declines Services…. I’ll be fine, just send me home. I’ve always managed to take care of myself. I don’t need help from anybody! NOW What? Assessing decisional capacity Jenice Guzman, RN, GNP-BC, PhD(c) Decision-Making Capacity Competency – legal state, not medical; Capacity – ability to make an informed consent; Presumed competent unless adjudicated otherwise by court Determination of incompetence - only by a court. Any licensed clinical provider may determine capacity. Other thoughts: A competent person chooses to run risks; an incompetent person simply allows the risk to happen. Bad choice ≠ incompetent. Competency’s connotation is ‘all or nothing’. Capacity implies varying ability on various decisions. Cooney et al., 2004; Resnick & Sorrentino, 2006 Decision-Making Capacity Primary issue in evaluation: Decision-specific Threshold for incompetence What is process of making the decision, not decision itself Depends on degree of harm associated with probable choice; Benefit vs risk. Decision-making demands fluctuate Depends on match between functional demand and patient’s ability Cooney et al., 2004; Grisso & Appelbaum, 1998; Kim, Karlawish, & Caine, 2002 Decision-Making Capacity Society values self-determination, Must show proof of poor decisional-capacity to remove it Expert-judgment: variability in training/ response Kim SYH, Psychosomatics 47:325-329, 2006; doi: 10.1176/appi.psy.47.4.325 Structured “capacity interview” assessing decisional abilities MacCAT-T (MacArthur Competence Assessment Tool for Treatment) Applied to decision about self care/home situation Assumption of MacCAT-T: Criteria applied to determine capacity for any tasks/decisions are similar at core. Grisso & Appelbaum, 1998 MacCAT Tool Functional decision-making steps: Ability to understand relevant information Ability to appreciate the significance of the information for one’s own situation r/t memory, previous knowledge e.g, probable consequences Ability to reason & engage in a logical process of weighing treatment options/recommendations Ability to express a choice See sample script MacCAT tool available at: http://www.prpress.com/books/mactfr.html Grisso & Appelbaum, 1998 Patient found to lack capacity: Confusion or Delusional thinking Illogical beliefs Watch for cultural context… Affective states related to mental disorder Inability to manipulate information rationally or to verbalize consequences Inability to communicate IF Patient found to lack capacity: Then Suggested Alternative approaches: Improve functional abilities E.g., use of reminder system (white boards); Recommending use of hired caregiver Decrease polypharmacy Decrease decision-making demands of the situation (e.g., meals on wheels) Safety Net: HBPC, Home health, APS, active telephone follow up Social Assessment of High Risk Elders Ashley Reinhardt, M.S.W. [email protected] Social Work: Assessment Guide for High Risk Elders Assessment Guide: Financial Resources: Medicare, Medicaid (Medi-cal), Social Security, Service Connected Compensation or VA Pension Social Network: Primary Caregiver, Assess Other Social Supports Identify Durable Power of Attorney in Health Care (Review Advance Directive) Values & Context based upon culture and family Access to available services: Transportation and Meals Criteria for High Risk Elderly Follow up ‘Active’ Case Management If 2 or more of the following: Lives alone Inadequate social support Demonstrates poor judgment or insight that leads to poor outcomes caregiver/family members live far, and/or cannot provide care regularly e.g. frequent ER visits and hospitalizations Decision making ability is one of many variables assessed Resides in unsafe living conditions Based upon experience, literature review, expert panel Social Work Assessment of High Risk Elders What are the veteran’s goals? Patient-centered care What are the needs of the veteran based on the findings of the interdisciplinary team? What resources are available to match the veteran’s goals, his needs, and his access to appropriate care? Process Steps: Social Work Active Case Management Flow Map of Follow-up Care Note: followed if high risk regardless of capacity Addresses challenge of when “Intentionality” obscures responsibility Fulmer T JAGS 56:s241-243, 2008 Social Work High-Risk Follow up Care for Veterans Flow Map: From GEM Admission to Discharge Home or Other Level of Care New GEM admission/ social work assessment Criteria for high risk of self- neglect? (footnote 1) Yes: IDT Safety Risk Profile of safety & self-care and rec’s for identified deficits Discuss: o recommendations with veteran & family. o Negotiate- what rec’s/ changes willing to make. Contact veteran &/or family members 2-5 days after discharge and review status of discharge plan Footnotes: 1. Criteria for High Risk (>2 of following): o Lives alone o Inadequate social support (caregiver/family can’t provide care daily or regularly; distance, time) o Poor judgment or insight that leads to frequent ER visits and hospitalizations, etc. o Resides in unsafe living conditions/environment Evaluate: -Need for active follow up -Troubleshoot gaps in service NO: 1 more follow up phone call & chart review Criteria: (see footnote 3) Provide interventions & resources (footnote 2) Footnotes (continued): 2. Interventions post D/C to home: o VA/non-VA affiliated resources o Refer to Senior Center oRefer to VA Service Connection (if needed) o Discuss Appropriate consults placed: HBPC, Telehealth, Home Care nurse, PT/OT, Home Safety Eval, Social Work Home Health follow up o Facilitate FU appts – 1 GRECC f/u appt if no PCP o Assess need to File APS report If increase help in place, then regular GEM D.C.; 1 f/u call NO: Proceed with regular GEM discharge Comprehensive D/C Plan: - Facilitate consults and appointments -Provide resources -GRECC clinic FU- social work & Attending or Fellow on GEM ward Veteran referred to higher level of care Yes:-Add to High Risk Elderly (HealthE Vet) -Continue monthly phone calls/chart review - GRECCclinic F/U Footnotes (continued): 3. Discharge Criteria from High Risk FU: o Veteran linked into a system of care o Veteran declines care, but demonstrates independence at follow up O Veteran deteriorates and then agrees to a higher level of care Social Work High-Risk Follow up Care for Veterans Flow Map: From GEM Admission to Discharge Home or Other Level of Care New GEM admission/ social work assessment Criteria for high risk of self- neglect? (footnote 1) NO: Proceed with regular GEM discharge Yes: IDT Safety Risk Profile of safety & self-care and rec’s for identified deficits Veteran referred to a higher level of care Discuss: o recommendations with veteran & family. o Negotiate- what rec’s/ changes willing to make. If increase help in place, then regular GEM D.C.; 1 f/u call Provide interventions & resources (footnote 2) Post Discharge Options (footnote 2) Active Case Management/Facilitation Community Resources (VA / non-VA) Discuss Need for Appropriate Consults Meals, Transportation, Emergency Alert Caregiver training/support, Adult Day Care, Senior Centers Eligibility: Assess need for In Home Supportive Services, Aid and Attendance and Homemaker Health Aid Program HBPC vs. Home Health Agency: Medication Management, PT, OT, Social Worker Telehealth (rural/isolated with cognition/motivation) Follow up appointments Post Discharge, one follow up in Geriatrics/GRECC Primary Care Provider Social Work High-Risk Follow up Care for Veterans Flow Map: Follow Up at time of GEM Discharge Comprehensive D/C Plan: - Facilitate consults and appointments -Provide resources -GRECC Clinic FU- social work & Attending or Fellow on GEM ward Contact veteran &/or family members 2-5 days after discharge and review status of discharge plan Evaluate: -Need for active follow up -Troubleshoot gaps in service NO: 1 more follow up phone call & chart review D/C Criteria: (see footnote 3) Footnotes (continued): 3. Discharge Criteria from High Risk FU: o Veteran linked into a system of care o Veteran declines care, but demonstrates independence at follow up o Veteran deteriorates and then agrees to a higher level of care Yes:-Add to High Risk Elderly (HealthE Vet) -Continue monthly phone calls/ chart review -GRECC Clinic F/U -Assess need to report to APS -Review Home health input/status -Consider home telehealth, cognition Ok, lives in remote area Summary: “Intentionality” obscures responsibility: focus on Risk/severity Decision making ability is one piece of puzzle Identify Specific deficits of Self-Care Requisites (Safety Risk Profile) Medical (falls)/ Pharmacy/ Dietary- risk of harm Functional: Limitations, Judgment, Support, Environment Cognitive: impairments, severity With dementia, decision making ability declines Communicate findings/concerns Family Meeting Process, Documentation Family meeting tips -Team consensus prior to family meeting -Identify legal decision maker -Ask “What is understanding of medical status, risks” -Define consensus plan, differences, concerns Conducting a Family Conference, Ambuel, B.; Weissman, D.; www.eperc.mcw.edu Summary: Active follow up regardless of Capacity See that Plan is carried out, Important to have documented what was plan… Detect early decline, need for intervention Have confidence in strong IDT/ communication/ documentation Westfall Act (28 U.S.C. Sec 2679(b)(1) Federal Tort Claims Act, Section 2679(d)(1),(2) Federal Employees immunity from tort claims, In course of official duty if within scope of employment Upon such certification, United States is substituted as defendant Employee has status of a witness If patients refuse or lack ability to comply with safety recommendations; Government liability is unlikely when there is thorough documentation of all efforts made and patient’s response Rita Mendosa, VA Legal Counsel Nurse practitioner: [email protected] Occupational Therapist [email protected] Neuropsychologist [email protected] Social Worker [email protected] Geriatrician: [email protected] 310-268-4671 Pharmacist [email protected] Nutritionist [email protected]