1. Evidence of HELP Effectiveness Hamilton Health Sciences HELP Workshop, December 10, 2013

2. Ontario Context: Why HELP? Aging population- 14.2% at present, 23.6 % by 2036 Excellent Care for All – patient experience Provincial Senior Friendly Hospital Initiative- delirium and functional decline indicators Fiscal Environment 2

3. Common Geriatric Syndromes Fx decline, Falls Polypharm Delirium Dementia Depression Malnutrition, dehydration

4. Shared Risk Factors Geriatric Syndromes 4 Shared risk factors – older age, cognitive impairment, functional impairment and impaired mobility Inouye S. et al. J Am Geriatr Soc. 2007 May; 55(5): 780–791.

5. Before HELP: The Yale Geriatric Care Program OBJECTIVE: A nursing-centered intervention to prevent functional decline among hospitalized elderly medical patients. DESIGN: Prospective matched cohort study on medicine wards PATIENTS: 216 patients aged ≥70 years (85 intervention and 131 control patients). INTERVENTION: identification and surveillance of frail older patients, twice- weekly rounds of the Geriatric Care Team, and a nursing educational program. RESULTS: reduction in functional decline in high risk from 64% in controls to 41% in the intervention group 5 Inouye, Sk et al, A controlled trial of a nursing-centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program.. J Am Geriatr Soc. 1993;41(12)

6. Yale Geriatric Care Program- Resources 2-4 Geriatric Resource Nurses- ward staff with extra training CNS, Gerontology Geriatrician 6

7. .. The Yale Geriatric Care Program: Challenges initial difficulties with recruitment and retainment of geriatric resource nurses (due to high nursing turnover and the increased time commitment required), breakdown in communication and carryover of recommendations between nursing shifts, and obstacles to communication between the nursing and medical staff. compliance 7

8. Yale Delirium Prevention Trial, 1999 Controlled intervention trial N= 852 admissions to acute medical wards Standardized protocols targeting delirium risk factors: Cognitive Impairment Sleep Deprivation Immobility and new onset functional deficit Vision Impairment and Hearing Impairment Dehydration Inouye SK, et al. N Engl J Med 1999;340:669-76 8

9. Elder Life Program Interventions 9 Reality orientation Therapeutic Activities Program Cognitive Impairment Vision/Hearing Aids Adaptive Equipment Vision/Hearing Impairment Early Mobilization Minimizing immobilizing equipment Immobilization Nonpharmacologic approaches to sleep/anxiety Restricted use of sleeping medications Psychoactive Medication Use Early recognition Volume repletion Dehydration Noise reduction strategies Sleep enhancement program Sleep Deprivation Risk Factors Intervention

10. HELP Resources Elder life Specialist Volunteers - 3 x day, 7 days week Elder life Nurse Specialist Geriatrician Administrative support The Hospital Elder Life program (©2000,Sharon K. Inouye,MD,MPH) 10

11. Yale Delirium Prevention Trial Significant reduction in the development of delirium (9.9% of intervention patients vs. 15% of usual care patients, odds radio = 0.60, P=0.02). Significant reduction in total number of days with delirium (105 vs. 161 in usual care, P=0.02). Significant reduction in functional decline and nursing home placement Inouye SK, et al. N Engl J Med 1999;340:669-76 11

12. Other Hospital Elder Life Program Interventions Geriatric nursing assessment and intervention Interdisciplinary rounds Geriatrician consultation Interdisciplinary consultation Provider education program Community linkages and telephone follow-up 12 The Hospital Elder Life Program (©2000,Sharon K. Inouye,MD,MPH)

13. Delirium Prevention Trial: Significance First demonstration of delirium as a preventable medical condition Targeted multicomponent strategy works Significant reduction in delirium and total delirium days No significant effect on delirium severity or recurrence Primary prevention of delirium likely to be most effective treatment strategy Effectiveness and cost-effectiveness of the program has been demonstrated in multiple studies. The Hospital Elder Life Program (©2000,Sharon K. Inouye,MD,MPH) 13

14. HELP Website http://hospitalelderlifeprogram.org http://hospitalelderlifeprogram.org How to materials: HELP manuals, videos Educational materials: on acute hospital care and delirium in older persons for consumers, families, caregivers Reference list: brief list by topic; comprehensive searchable bibliography HELP: general background information and study results The Hospital Elder Life Program (©2000,Sharon K. Inouye,MD,MPH) 14

15. Sustainability of HELP: Will HELP Work in Other Settings? The Hospital Elder Life Program (©2000,Sharon K. Inouye,MD,MPH)

16. HELP at Shadyside -UPMC Shadyside -500 bed community hospital in Pittsburgh Delirium rate: pre HELP 2001: 46% 2008: 18% 2011 –Hospital acquired delirium: less than 4% LOS decreased, delirious and non delirious patients Total patients served: 2008: 7,000 on 6 units Paid staff 7.6, 107 volunteers, 4 medical units, 1 orthopedic unit, 1 neurosurgical Cost savings $2,031,440 annually 16 Rubin FH (2011) J Am Geriatr Soc.

17. HELP in Taiwan Modified hospital elder life program Design: 2200 bed urban hospital, Pre-post comparative 3 HELP interventions (mobility, nutrition and cognitive activities) delivered by a study nurse Participants: 77 usual care, 102 HELP intervention abdominal surgical patients, matched Measures: change in ADL, nutrition and cognitive status from admission to discharge Outcomes: Delirium rate HELP group (0%); control group (16.7%) (p < 0.001). ADL and nutritional decline: HELP group < control (p < 0.001) Chen, C. et al. Nursing Research, 61(2), 2012

18. HELP in Australia Stage 1 Design: Population – Stage 1 pre/post study on one ward: 21 patients usual care, 16 pts HELP interventions delivered by volunteers Stage 1 Outcome: – Delirium rate: HELP 6.3%; control 38% (P = 0.032) Stage 2 Design: – Expanded to 5 wards - sitter use as decreased by 314 hours/month Stage 2 Outcome: – Cost savings: $129,186 annually. Caplan GA. Recruitment of volunteers to improve vitality in the elderly: the REVIVE study. Intern Med J. 2007 Feb;37(2):95-100

19. HELP in Spain Controlled intervention study 542 medical pts, age 70 +, at risk Usual care and HELP interventions Interventions = educational and HELP clinical protocols delivered by nurses, residents and physicians with a CNS monitoring and prompting compliance Outcomes: delirium 11.7% HELP; 18.5 % usual care, P=0.005, Functional decline: 45.5% HELP, vs 56.3% in UC, P=.03 75% adherence Vidan, M., An Intervention Integrated into Daily Clinical Practice Reduces the Incidence of Delirium During Hospitalization in Elderly Patients JAGS 57:2029–2036, 2009 19

20. France: Confucius Study Protocol DESIGN Stepped wedge cluster randomized trial SETTING 3 surgical wards, 3 university hospitals in France (N,360) INTERVENTION: Mobile geriatric teams + some HELP protocols (sensory and orientation) + staff education + case review of delirium OUTCOMES to be measured; delirium rate and severity, LOS, morbidity, mortality 20 Mouchoux, C. et al., BMC Geriatrics, 11(25), 2011

21. HELP at Trillium Health Center Mississagua, Ontario Study Design: Retrospective Cohort within context of a Quality Improvement (QI) Model Control Group – Usual Care: N=72,admitted to medicine within 12 months before HELP Study Group ‐ HELP: N=141 Patients on medicine who met HELP program criteria and participated in program interventions. Results: Delirium rate 22% before HELP, 7 % after Discharged home: 7% more Mortality: 11% less http://www.gerontario.org/documents/B4%20Prevention%20of%20Delirium%20and %20Functional%20Decline%20Among%20Hospitalized%20Elder%20Patients.pdf 21

22. Potential for HELP in Long Term Care OBJECTIVES: To identify potentially modifiable environmental factors and patient vulnerability associated with severity of delirium symptoms DESIGN: Prospective, observational cohort study. SETTING: Seven long-term care (LTC) facilities, Montreal Two hundred seventy-two LTC residents over 65 MEASUREMENTS: Weekly assessments (for up to 6 months) of the severity of delirium symptoms using the Delirium Index (DI), environmental risk factors, and number of medications and baseline vulnerability McCusker,J, Environmental Factors Predict Severity of Delirium Symptoms in LTC Residents with and without Deliirum. JAGS 61:502–511, 2013

23. Results continued RESULTS: Six potentially modifiable environmental factors predicted weekly changes in Delirium Index absence of reading glasses aids to orientation family member glass of water presence of bed rails and other restraints prescription of two or more new medications Residents with dementia appeared to be more sensitive to the effects of these factors CONCLUSION: Six environmental factors and prescription of two or more new medications predicted changes in the severity of delirium symptoms. 23

24. Could Family Deliver HELP interventions? Descriptive, feasibility intervention study of family delivery of HELP protocols 15 patient/family caregiver dyads (42 approached), on HELP Protocols and completion rates: orientation protocol (83.52%) vision protocol (81.48%), therapeutic activities protocol (76.92%,), hearing protocol (73.58%) early mobilization protocol (55.29%) Barriers and Enablers: partnerships, therapeutic relationships, environment J 24 Rosenbloom-Brunton DA et al Gerontol Nurs. 2010 Sep;36(9):22-33;.Gerontol Nurs.

25. Family Delivering Delirium Prevention Strategies in Chile OBJECTIVE: assess the efficacy of family intervention to prevent delirium METHODS: 287 hospitalized patients at intermediate or high risk of developing delirium randomized to receive a non-pharmacological intervention (orientation, sensory support) delivered by family members (144 patients) or usual care (143 patients). RESULTS: delirium rate 5.6% in the intervention group; 13.3% in the control group (relative risk: 0.41; confidence interval: 0.19-0.92; P = 0.027) CONCLUSION: non-pharmacological prevention of delirium delivered by family members reduces delirium risk 25 Martinez FTAge Ageining 2012 Sep;41(5):629-34. 2012 May 15. Preventing delirium in an acute hospital using a non-pharmacological intervention.

26. Challenges and Predictors of Success Challenges in New Program Implementation Strategies for Addressing Challenges 1. Gaining internal support for the program Identify key constituents Develop and target individualized messages 2. Ensuring Effective clinician leadership Identify clinical leaders with credibility with in the hospital Retain clinical leaders with adequate time and budget 3. Integrating with existing geriatric programs Sharing of resources Emphasis on complementing rather than competing 26 Bradley et al, JAGS 2004;52: 1875-1882 Bradley: Survey of 9 US hospitals implementing HELP

27. Challenges and Predictors of Success Challenges in New Program Implementation Strategies for Addressing Challenges 4. Balancing Program fidelity with hospital –specific circumstances Implementing program as designed originally - include all interventions 5. Documenting and publicizing positive outcomes Gather and summarize data Use language that is relative to audience Present data regularly 6. Maintaining Momentum Manage expectations – implementation may take more than one year Plan for staff turnover 27 Bradley JAGS 2004;52: 1875-1882

28. Could HELP work with fewer staff resources? Who in your setting could recruit, train and schedule volunteers? Is there someone else who can deliver on the interventions? Who could screen and enroll patients? Could they be identified automatically on admission? 28

29. Ontario HELP Uptake Ontario HELP Network-22 sites -quarterly teleconference to share ideas, data and challenges Waterloo-Wellington LHIN is supporting five sites to start HELP Trillium and HHS are piloting Family HELP interventions Small hospitals report challenges in resources needed for HELP start up 29

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