1. Specialised Geriatric Services Heather Gilley Sharon Straus

2. Learning Objectives To review the evidence around specialised geriatric assessment in the community To outline the SMH Geriatric Outreach Program

3. What is a specialised geriatric service? Spectrum of services available including community-based, ambulatory, acute care, long-term care, rehabilitation Different models of care Chronic care management focused on frail elderly

4. Who does this? Geriatricians  <150 in Canada  0.5 geriatricians/10000 Canadians aged 65 and greater  10000 in US – but it’s largely a primary care specialty

5. What’s the evidence? RCT of primary prevention of disability (impairment in IADLs or ADLs) or LTC Home admission in community dwelling persons age 75 and older Carried out mainly by NPs with support of geriatricians Intervention effective in reducing disability and LTC home admissions Not targeted to high risk group No effect on acute hospital admissions Intervention group had more MD visits overall NEJM 1995;324:1184-90.

6. What’s the evidence? Systematic review and meta-analysis of randomised trials of community based, multifactorial interventions in elderly people living at home with at least 6 months of follow up 89 trials with 98000 people Decreased risk of:  not living at home RR 0.95 (0.93 to 0.97)  LTC admission RR 0.87 (0.83 to 0.90)  Hospital admission RR 0.94 (0.91 to 0.97) No impact on death RR 1.0 (0.97 to 1.02) Lancet 2008;371:725-35

7. But Very different  Interventions  Intensity  Site of care Largest effect sizes seen in studies done prior to 1993!

8. What’s the evidence? In a more focused systematic review of randomised trials of older patients in preventive home visit programs 21 studies included Trend for decreased mortality OR 0.92 (0.80 to 1.02) Trend for decreased NH admissions OR 0.86 ( 0.68 to 1.1) J Gerontol A Biol Sci Med Sci 2008;63A:298-307.

9. But Heterogeneity present in  Interventions  Populations  Care setting

10. Summary Consider targeting patients at high risk  Less impact in primary prevention CGA is a complex intervention  What are the active ingredients?  What’s the dose/formulation? Follow up on the recommendations made Consider the resources necessary

11. St. Michael’s Team: August 2009 Interprofessional: Full Time Advanced Practice Nurse (Gerontology) Part Time Physiotherapy, Occupational Therapy, Social Work, Administrative Assistant, Clinical Manager 2 Physicians – 1 Psychiatrist, 1 Geriatric Medicine 1 “Intensive Case Manager” from COTA Health 1 CCAC Care Coordinator

12. Data from August 2009-March 2010 251 referrals, 174 new patients seen over 683 visits  Reasons not seen: out of catchment, dead, admitted to hospital, patient refused, needs another type of service Referrals from ED (43), Acute Care (58), Primary care (64) Team involved on average 3.5 weeks Patient profile:  53% have mental health issues – dementia, behaviour problems, delusions/hallucinations, depression, ….  51% moderately or severely frail (5-7/7)using Clinical Frailty Scale  16% do not have a family MD, much higher percentage have a family MD whom they cannot see  2/3 female Team MD sees patient about 25% of time Client satisfaction high based on brief 5-item survey

13. Clinical Frailty Scale 1 – very robust 2 – well – no active disease but less fit than 1 3 – well with treated comorbid disease 4 – apparently vulnerable 5 – mildly frail; limited dependence on others for IADLS 6 – moderately frail; help needed for IADLs and ADLs 7 – severely frail; completely dependent on others, terminally ill CMAJ 2005;173(5)

14. Centre for Aging Research and Education CARE will:  Create generalisable knowledge: Develop a research program to create and evaluate innovative models of generalist and specialty care along the continuum of care and across the transition points  Create capacity: Develop an applied educational research program to create and evaluate innovative models of education for the provision of high quality care  Implement knowledge: Build on existing LKSKI strengths and collaborations to translate the generalisable knowledge to optimise care and transform health systems

15. CARE “PRODUCTS”: New knowledge about high quality care for older persons Commercial tools and products Educational interventions for informal care givers Innovative training models Evidence-based educational strategies Transformative Research Program An interprofessional network conducting clinical research that will create and evaluate new interventions Applied Education Research Program An internationally recognized program integrating evidence- based education with clinical practice and decision making OUTCOMES: Enhanced interprofessional capacity in caring for older persons Better delivery of high quality of care for older persons Engaged and informed older persons and informal caregivers Cost effective strategies that can be applied to healthcare systems worldwide Knowledge Translation across the Continuum Older persons age with dignity, independence and vitality Knowledge Translation across the Continuum Centre for Advanced Research and Education (CARE)