Download PowerPoint - GRECC Audio Conferences

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
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Steven Castle, MD:
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Jenice Guzman, GNP
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Cognitive, Emotional factors
Jenice Guzman, GNP
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OT/PT/KT tools to identify high risk
Stacy Wilkins, PhD
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Med Management / Dietary
Michael Cirrincione OTR/L:
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Our focus: who, what and why
Structured decisional capacity
Ashley Reinhardt, MSW
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Active case management- who, what, how
Goal of Presentation
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Practical Processes of Care
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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
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Each discipline will introduce self/ discuss content
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Handouts included:
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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
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“Elderly who
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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:
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none, moderate, severe
3 domains: Personal appearance, Functional
status, Environment
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Poor correlation between domains
Kelly PA JAGS 56:S253-260,2008
Challenges in Defining High Risk Elder:
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“Intentionality” obscures responsibility
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Self Neglect:
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US Society: presumptively responsible for self care
When does responsibility for care shift?
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Connolly MT JAGS 56:s244-252, 2008
Medical Comorbidity / Disease Management: where it hinges
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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
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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
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Lives alone
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Inadequate social support
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Poor judgment with poor outcomes
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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
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Medical Complexity/Disease Management:
 Risk of serious outcome without intervention
 Falls Risk/ Disease management
 Objective measures
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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
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Marian Rofail, PharmD
Medication Adherence:
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Ability to self medicate or availability of caregiver.
Indicators of the Inability to Self-Medicate:
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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
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Evaluation of Adherence:
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Polypharmacy: less than desirable
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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
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Effective, Appropriate Dosage, monitored for side effects
Nutrition
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Jennifer Krohn, MS, RD
Nutrition Screening & Assessment
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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
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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)
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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:
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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)
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“Occupation" - an activity which "occupies" our time
OT-skilled treatment for independence in all facets of life
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The World Federation of Occupational Therapists:
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"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
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Enhancing an individual's ability to participate in ADLs,
Modifying the environment, or
Adapting the activity to better facilitate independence.
KT
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Kinesiotherapy:
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Based on exercise principles
Applied to deconditioning/ cardiac rehabilitation
Adapted to enhance the strength, endurance, and mobility
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Within context of functional limitations or
Requiring extended physical conditioning.
PT
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Physical therapists (PTs)
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Diagnose and treat limited ability to perform functional activities
As a result of health-related conditions
Examine & develop a plan using treatment techniques
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to promote the ability to move,
reduce pain,
restore function,
and prevent disability.
Functional Independence Measure FIM
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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
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Translates time/energy another person expends
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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,
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Whatever the diagnosis or impairment,
Not what he or she ought to be able to do, or might be able to do
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if certain circumstances were different.
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Description of Levels of Function &
Scores
Independent: other person not required for the activity (NO HELPER)
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7 Complete Independence:
6 Modified Independence:
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Dependent: supervision or physical assistance (REQUIRES HELPER)
 5 Supervision or Set up:
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Standby, cueing, coaxing, no physical contact, or
Help with orthoses or assistive/adaptive devices.
4 Minimal Contact Assistance: touching only,
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Patient expends >75% effort to complete the task.
3 Moderate Assistance: more help than touching,
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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
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Cognitive
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Mental limitations
Emotional
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Personality & coping styles
Mood
Psychiatric Diagnoses
Cognitive Influence
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Delirium
 Rapid Onset, not due to other mental disorder
 Reduced capacity due to confusion and altered attention
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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
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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
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Digit Span
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Normal forward is 7 +/- 2
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Backwards span should be 2 less than forward
CAM (confusion assessment method)
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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
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Dementia Diagnosis requires:
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Acquired persistent decline in
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Memory
One other cognitive domain
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language, visuospatial skills, executive function
Plus – decline in functioning, must effect their lives
Dementia
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Reduced capacity often seen secondary to:
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Poor memory/recall
Executive function/judgment problems
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Also can see language or visuospatial deficits
Dementia Evaluation
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Minicog
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MMSE, SLUMS, MOCA
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3 item recall plus clock
Review (see handouts)
Independent Living Scales (ILS)
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Health and Safety Judgment, Finances
Psychiatric Diagnoses
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Depression (GDS, PHQ-9)
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Psychotic Disorders
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Paranoia, delusions
Personality Style
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Low motivation and energy, poor appetite
Highly value independence
Substance Abuse
Interdisciplinary Meetings:
putting it together
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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….
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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
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Competency – legal state, not medical;
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Capacity – ability to make an informed consent;
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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
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Primary issue in evaluation:
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Decision-specific
Threshold for incompetence
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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
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Depends on match between functional demand and
patient’s ability
Cooney et al., 2004; Grisso & Appelbaum,
1998; Kim, Karlawish, & Caine, 2002
Decision-Making Capacity
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Society values self-determination,
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Must show proof of poor decisional-capacity to remove it
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Expert-judgment: variability in training/ response
 Kim SYH, Psychosomatics 47:325-329, 2006; doi:
10.1176/appi.psy.47.4.325
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Structured “capacity interview” assessing decisional abilities
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MacCAT-T (MacArthur Competence Assessment Tool for Treatment)
Applied to decision about self care/home situation
Assumption of MacCAT-T:
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Criteria applied to determine capacity for any tasks/decisions are
similar at core.
Grisso & Appelbaum, 1998
MacCAT Tool
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Functional decision-making steps:
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Ability to understand relevant information
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Ability to appreciate the significance of the information for
one’s own situation
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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:
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Confusion or Delusional thinking
Illogical beliefs
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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:
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Improve functional abilities
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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:
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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
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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
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Access to available services:
Transportation and Meals
Criteria for High Risk Elderly
Follow up ‘Active’ Case Management If 2 or more of the following:
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Lives alone
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Inadequate social support
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Demonstrates poor judgment or insight that leads to
poor outcomes
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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
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What are the veteran’s goals?
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Patient-centered care
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What are the needs of the veteran based on
the findings of the interdisciplinary team?
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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
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Flow Map of Follow-up Care
Note: followed if high risk regardless of capacity
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Addresses challenge of when “Intentionality”
obscures responsibility
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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
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Community Resources (VA / non-VA)
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Discuss Need for Appropriate Consults
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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
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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:
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“Intentionality” obscures responsibility: focus on Risk/severity
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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
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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:
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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
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Have confidence in strong IDT/ communication/ documentation

Westfall Act (28 U.S.C. Sec 2679(b)(1)
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Federal Tort Claims Act, Section 2679(d)(1),(2)
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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]