1. TRI Orientation Geriatric Rehabilitation
Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky Chau
Dr. Barry Goldlist | Dr. Dan Liberman | Dr. Karen Ng | Dr. Samir Sinha
Toronto Rehabilitation Institute, University Centre Site
550 University Avenue
Toronto, Ontario, M5G 2A2
(416) x 6641

2. Outline Introduction Geriatric consultations Clinics & Programs
Rounds & Education

3. introduction

4. Introduction
Acute medical illness & hospitalization often precipitate functional decline. Many factors additionally contribute to further disability that often impacts rehabilitation.
Disability & Functional Decline
Multiple medical Comorbidities
Frailty
Acute Medical Illness & Hospitalization

5. Conceptualizing Disability
Impairment
Activity Limitation
Participation Restriction
As the diagram indicates, in ICF disability and functioning are viewed as outcomes of interactions between health conditions (diseases, disorders and injuries) and contextual factors.
Among contextual factors are external environmental factors (for example, social attitudes, architectural characteristics, legal and social structures, as well as climate, terrain and so forth); and internal personal factors, which include gender, age, coping styles, social background, education, profession, past and current experience, overall behaviour pattern, character and other factors that influence how disability is experienced by the individual.
The diagram identifies the three levels of human functioning classified by ICF: functioning at the level of body or body part, the whole person, and the whole person in a social context. Disability therefore involves dysfunctioning at one or more of these same levels: impairments, activity limitations and participation restrictions.
Terminology:
Body Functions are physiological functions of body systems (including psychological functions).
Body Structures are anatomical parts of the body such as organs, limbs and their components.
Impairments are problems in body function or structure such as a significant deviation or loss.
Activity is the execution of a task or action by an individual.
Activity Limitations are difficulties an individual may have in executing activities.
Participation is involvement in a life situation.
Participation Restrictions are problems an individual may experience in involvement in life situations.
Environmental Factors make up the physical, social and attitudinal environment in which people live and conduct their lives.
WHO & ICF et al., 2002.

6. Comprehensive Geriatric Assessment

7. Geriatric Rehabilitation
“ … a branch of geriatric medicine concerned with limiting the extent of disability, preventing functional and social decline, and delaying or preventing loss of independence and institutionalization …”
AGS Education Committee. The Training of Geriatric Fellows in Rehabilitation: AGS Education Guidelines

8. A Specialized Focus Frail & medical complex older adults
Holistic vs. Illness (e.g. stroke rehab) approach
All factors that impair function
Multidisciplinary team
Multifactorial & individualized interventions to improve function

9. Outcomes of Geriatric Rehabilitation
At discharge
At Follow Up
 Function
OR 1.75
(95% CI 1.31 to 2.35)
OR 1.36
(95% CI 1.07 to 1.71)
 Nursing Home Admission
RR 0.64 (0.51 to 0.81)
RR 0.84 (0.72 to 0.99)
 Mortality
RR 0.72 (0.55 to 0.95)
0.87 (0.77 to 0.97)
Bachmann et al., BMC 2010.

10. Geriatric consultations

11. Geriatric Consultation Team
You!
Geriatrician
Florence Paat, Nurse Practitioner

12. Geriatric Referrals Automatic Other
Geriatric Rehabilitation Unit (6 South)
Geriatric Psychiatry Unit (5 South)
MSK Unit (7 & 8 South)
Other
Other TRI floors

13. Geriatric Rehabilitation Unit (6 South)
25 bed inpatient unit built on a co-management model
Hospitalist (Dr. Robert Lam)
Geriatrician
Geriatric Nephrologist (Dr. Vanita Jassal)
Geriatric patients & patients with dialysis needs are admitted into Team A, B, or C
Consultations
Karlee Lin sends notifications of new admissions to geriatricians daily
Requests located in geriatrician mailbox on 6S nursing unit

14. Co-Management Focus Geriatrics Hospitalist (MRP) Geriatric Nephrology
Geriatric related issues (e.g. cognition, function, medications, pain, sleep, disposition)
Management of complex medical diseases, if needed
Management of complex medical diseases
Urgent and/or medical emergencies
Dialysis & Dialysis related issues*
* For dialysis patients, we complete a CGA and provide follow up as needed

15. Geriatric Psychiatry Unit (5 South)
Locked unit of patients admitted with dementia related behaviours built upon a co-management model
Hospitalist (Dr. Tazkarji)
Geriatric Psychiatrist (Drs. Iaboni & Keren)
Consultations
Requests obtained via May Seeto

16. MSK (7 & 8 South)
Inpatient rehabilitation unit for patients with MSK conditions and/or those recovering after surgery built upon co-management model between hospitalist & physiatrist
Consultation
All fractured hip patients transferred from MSH/TWH
Geriatricians receive notifications of newly transferred patients

17. Limited Consultation & Follow Up
Provides continuity of care and focused management of geriatric related issues
Cognition (e.g. delirium, depression)
Bone Health
Disposition
Obtain MSH/TWH geriatric consultation, follow up, and sign out notes to assist with your management plan

18. Consult Recommendations
GRU (6S)
Order blood work directly into EPR
Complete respective paper requisition for other investigations (e.g. ECG, CXR, CT Head)
Write medication orders directly on order sheet
MSK (7S & 8S)
Write suggestions in MRP’s black book
Geriatric Psychiatry (5S)
Write suggestions in Dr. Tazkarji’s black book; or
Dr. Tazkarji (MRP) for recommendations

19. Consultation Notes All consultation notes are dictated
Include date, start/end times of consultation
Place written yellow consultation notes (if used) & signed transcribed dictation notes in the chart
* Please ensure you obtain your UHN dictation code at the beginning of your rotation *
Follow up notes written in multidisciplinary progress notes section

20. Sign-out Lists

21. *** ALWAYS UPDATE THE SIGN-OUT LIST ***

22. Ambulatory clinics & programs

23. Ambulatory Clinics
Geriatric Day Hospital Clinic at TRI (2nd Floor South Wing )
Dr. Arielle Berger
Michelle Cordeiro (416) ext. 3065
Geriatric Medicine Clinic at Bickle Centre
Complex Continuing Care
Specialty Clinics, Main Floor, Rm S-217
Geriatric Nephrology Clinics at TGH (12NU Renal Clinics)
Dr. Vanita Jassal
Samantha Ramsammy

24. Programs Falls Prevention Program (2nd Floor, South Wing)
Ramona Gheorghe, RN & Marlee Beallor, PT
X 3777 or 3783
Geriatric Day Hospital Program (2nd Floor, South Wing)
Michelle Cordeiro (416) ext. 3065
Inpatient Dialysis Program (Ground floor, East Entrance)
Pre-arrange with Dr. Vanita Jassal

25. Rounds & Education

26. Weekly Rounds

27. Education
Interprofessional learning with care coordinator (Karlee Lee), NP, wound care NP, OT, PT, Nutritionist, Pharmacist, SW, Recreational therapist
Additional Quality and Risk Safety Rounds (q2nd Thursday of the month)
Weekly article review

28. Resident Office 4th Floor, Room 131 Obtain ID badge for access from:
Tracia Young, Medical Education Coordinator
10th Floor, Room 119
x 3834
Yes, there is a resident’s room at TRI on the 4th floor, Access is via id badge – I usually sign out generic id badges activated for access to that room.  May sends learner to my office to pick up from me once they arrive.

29. Thank You!
Questions?