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Interdisciplinary Approach to Management of High Risk Elders

Interdisciplinary Approach to Management of High Risk Elders. GRECC Clinical Demonstration Project VA Greater Los Angeles Healthcare System Host: S Castle (steven.castle@va.gov) M Cirrincione, S Wilkins, A Reinhardt, J Guzman. Overview: Practical Tips. Steven Castle, MD:

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Interdisciplinary Approach to Management of High Risk Elders

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  1. Interdisciplinary Approach to Management of High Risk Elders GRECC Clinical Demonstration Project VA Greater Los Angeles Healthcare System Host: S Castle (steven.castle@va.gov) M Cirrincione, S Wilkins, A Reinhardt, J Guzman vers 2.17.09, VANTS operator: 304-262-7600

  2. Overview: Practical Tips • Steven Castle, MD: • Our focus: who, what and why • Jenice Guzman, GNP • Med Management / Dietary • Michael Cirrincione OTR/L: • OT/PT/KT tools to identify high risk • Stacy Wilkins, PhD • Cognitive, Emotional factors • Jenice Guzman, GNP • Structured decisional capacity • Ashley Reinhardt, MSW • Active case management- who, what, how

  3. 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

  4. Self-Neglect?

  5. 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

  6. Challenges in Defining High Risk Elder: • “Intentionality” obscures responsibility • Understands risk but has demonstrated poor outcomes • Fulmer T JAGS 56:s241-243, 2008 • 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 • 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

  7. 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

  8. 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

  9. Assessing for medication adherence, diet/nutrition Jenice Guzman,RN, GNP-BC, PhD(c) Jenice.guzman@va.gov

  10. 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

  11. Medication evaluation • Evaluation of Adherence: • Medication refill history • Missed doses in pill box • Medication monitoring • Patient response to medications (e.g., low hr if on beta blocker) • Polypharmacy: less than desirable • 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

  12. 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

  13. 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)

  14. Significant Weight Loss 10% in 6 mos 7.5% in 3 mos 5% in 1 mos 2% in 2 week Weight loss BMI: 65 years and older goal is > 23

  15. 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

  16. Functional piece of nutrition: • Shopping for food? • Meal preparation? • Storage of food? • Adherence to dietary restrictions or recommendations/special diets? • Also assessed by OT

  17. Assessing Functional Abilities for Self Care Michael Cirrincione, OTR/L Michael.cirrincione@va.gov

  18. OT: Occupational TherapyEnabling people to do the activities of daily life (ADLs) • “Occupation"-anactivitywhich"occupies"ourtime • OT-skilledtreatmentforindependenceinallfacetsoflife • "skillsforthejobofliving",independentandsatisfyinglives • TheWorldFederationofOccupationalTherapists: • Promoteshealth&well-beingthroughoccupation • 1ogoal:enablepeopletoparticipateintheactivitiesofeverydaylife • Achievedby • Enhancinganindividual'sabilitytoparticipateinADLs, • Modifyingtheenvironment,or • Adaptingtheactivitytobetterfacilitateindependence.

  19. 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.

  20. 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.

  21. 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 • Require another person or device? • Quantifies the need for help and the burden of care. • Translates time/energy another person expends • 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.

  22. Description of Levels of Function & Scores • Independent:other person not required for the activity (NO HELPER) • 7Complete Independence: • 6Modified Independence: • assistive device; &/or more time; &/or there are safety risks • 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. • 3Moderate Assistance: more help than touching, • 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

  23. Capacity - Psychological and Neuropsychological Factors Stacy S. Wilkins, Ph.D., ABPP stacy.wilkins@va.gov

  24. Capacity - Psychological and Neuropsychological Factors • Cognitive • Mental limitations • Emotional • Personality & coping styles • Mood • Psychiatric Diagnoses

  25. 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.

  26. 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 CourseFeature 2: InattentionFeature 3: Disorganized thinkingFeature 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

  27. 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

  28. Dementia • Reduced capacity often seen secondary to: • Poor memory/recall • Executive function/judgment problems • Also can see language or visuospatial deficits

  29. Dementia Evaluation • Minicog • 3 item recall plus clock • MMSE, SLUMS, MOCA • Review (see handouts) • Independent Living Scales (ILS) • Health and Safety Judgment, Finances

  30. Psychiatric Diagnoses • Depression (GDS, PHQ-9) • Low motivation and energy, poor appetite • Psychotic Disorders • Paranoia, delusions • Personality Style • Highly value independence • Substance Abuse

  31. 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

  32. 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?

  33. Assessing decisional capacity Jenice Guzman, RN, GNP-BC, PhD(c)

  34. Decision-Making Capacity • Competency – legal state, not medical; • Presumed competent unless adjudicated otherwise by court • Determination of incompetence - only by a court. • Capacity – ability to make an informed consent; • 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

  35. Decision-Making Capacity • Primary issue in evaluation: • What is process of making the decision, not decision itself • Decision-specific • Threshold for incompetence • 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

  36. 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

  37. MacCAT Tool • Functional decision-making steps: • Ability to understand relevant information • r/t memory, previous knowledge • Ability to appreciate the significance of the information for one’s own situation • 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

  38. 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

  39. 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

  40. Social Assessment of High Risk Elders Ashley Reinhardt, M.S.W. Ashley.reinhardt@va.gov

  41. 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

  42. Criteria for High Risk ElderlyFollow up ‘Active’ Case Management If 2 or more of the following: • Lives alone • Inadequate social support • caregiver/family members live far, • and/or cannot provide care regularly • Demonstrates poor judgment or insight that leads to poor outcomes • 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

  43. 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?

  44. 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

  45. Social Work High-Risk Follow up Care for Veterans Flow Map: From GEM Admission to Discharge Home or Other Level of Care Veteran referred to higher level of care Yes: IDT Safety Risk Profile of safety & self-care and rec’s for identified deficits Provide interventions & resources (footnote 2) Discuss: o recommendations with veteran & family. o Negotiate- what rec’s/ changes willing to make. Criteria for high risk of self- neglect? (footnote 1) New GEM admission/ social work assessment • Footnotes (continued): • 2. Interventions post D/C to home: • o VA/non-VA affiliated resources • Refer to Senior Center • Refer 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 Evaluate: -Need for active follow up -Troubleshoot gaps in service Contact veteran &/or family members 2-5 days after discharge and review status of discharge plan Yes:-Add to High Risk Elderly (HealthE Vet) -Continue monthly phone calls/chart review - GRECCclinic F/U • Footnotes: • 1. Criteria for High Risk (>2 of following): • Lives alone • Inadequate social support (caregiver/family can’t provide care daily or regularly; distance, time) • Poor judgment or insight that leads to frequent ER visits and hospitalizations, etc. • Resides in unsafe living conditions/environment NO: 1 more follow up phone call & chart review 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

  46. Social Work High-Risk Follow up Care for Veterans Flow Map: From GEM Admission to Discharge Home or Other Level of Care Veteran referred to a higher level of care Yes: IDT Safety Risk Profile of safety & self-care and rec’s for identified deficits New GEM admission/ social work assessment Criteria for high risk of self- neglect? (footnote 1) Provide interventions & resources (footnote 2) Discuss: o recommendations with veteran & family. o Negotiate- what rec’s/ changes willing to make. NO: Proceed with regular GEM discharge If increase help in place, then regular GEM D.C.; 1 f/u call

  47. Post Discharge Options (footnote 2)Active Case Management/Facilitation • Community Resources (VA / non-VA) • 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 • Discuss Need for Appropriate Consults • 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

  48. 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 Evaluate: -Need for active follow up -Troubleshoot gaps in service • 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 Contact veteran &/or family members 2-5 days after discharge and review status of discharge plan 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

  49. Summary: • “Intentionality”obscuresresponsibility:focusonRisk/severity • Decisionmakingabilityisonepieceofpuzzle • IdentifySpecificdeficitsofSelf-CareRequisites(SafetyRiskProfile) • Medical(falls)/Pharmacy/Dietary-riskofharm • Functional:Limitations,Judgment,Support,Environment • Cognitive:impairments,severity • Withdementia,decisionmakingabilitydeclines • Communicatefindings/concerns • FamilyMeetingProcess,Documentation Familymeetingtips -Teamconsensuspriortofamilymeeting -Identifylegaldecisionmaker -Ask“Whatisunderstandingofmedicalstatus,risks” -Defineconsensusplan,differences,concerns ConductingaFamilyConference,Ambuel,B.;Weissman,D.;www.eperc.mcw.edu

  50. 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 Employees immunity from tort claims, • In course of official duty if within scope of employment • Federal Tort Claims Act, Section 2679(d)(1),(2) • 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

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