G.I.F.T. G eriatric I nterdisciplinary F ellowship T raining Program

1. G.I.F.T.Geriatric Interdisciplinary Fellowship Training Program Teri Wurmser, PhD, MPH, RN Director, Ann May Center for Nursing, Meridian Health Chair, Georgian Court-Meridian Health School of Nursing Linda Hassler, MSN Geriatric Program Manager, Ann May Center for Nursing, Meridian Health

2. Purpose The Geriatric Interdisciplinary Fellowship Training (GIFT) program is an eight week summer program to provide medical, nursing and pharmacy students an opportunity to work with an interdisciplinary team to gain clinical experience with older adults across the continuum

3. GIFT Objectives • Use teamwork to meet the diverse needs of geriatric patients in diverse settings • Acquire clinical experience in working with older patients in a variety of settings • Gain an appreciation of the experience of living with chronic and multiple medical conditions associated with aging. • Design an interdisciplinary project that addresses a specific challenge experienced by the older adult patient in the acute care setting

4. TEAMS • One team placed at each of three MH hospitals • Each fellow had a preceptor in his/her own discipline • Preceptors included Geriatric Clinical Nurse Scholars, Clinical Pharmacists and Geriatricians • Experiences included long term care, medical day care, assisted living, palliative care, wound care, rehab, primary care • Eight students: 1 medical, 4 nursing, and 3 pharmacy which formed two teams

5. The program produced excitement and increased collaboration among the pharmacists, nurses and physicians who participated The students reported on evaluation that they gained a better understanding of the work of other members of the interdisciplinary team Many reported that this experience would be the only targeted geriatric education experience that they would receive during their respective educational programs.. GIFT Program Feedback

6. GERIATRIC INTERDISCPLINARY FELLOWSHIP PROJECTS2011

7. NORTH TEAM: Opoid Use and Pain Assessment Nisha Bhide Jennifer Chiu Alexa Greenstein Amber Zebe

8. Pain in Older Adult Patients • High prevalence of pain in older adults • 25-50% community dwelling older adults • 45-80% nursing home residents • 31% females and 19% males over age 75, in the hospital, have reported pain in three or more areas • Older adults not only underreport pain, but also may have difficulties in recognizing and expressing pain due to cognitive impairment Chau DL, Walker V, Pai L, et al. Opiates and elderly: Use and side effects. Clinical Interventions in Aging. 2008:3(2) 273-278. AGS Panel on Older Persons: Pharmacological Management of Persistent Pain in Older Persons . Journal of American Geriatrics Society

9. Pain Assessment Tools • Numeric Rating Scale (NRS) • PAINAD Scale

10. Primary Objectives • Evaluate the appropriate use of pain assessment tools on NICHE units • Assess the use of concomitant sedative medications • Evaluate whether a bowel regimen was added prophylactically to prevent constipation • Develop a tool to educate patients about common side effects associated with opioid medications • Determine patient satisfaction regarding their pain management through follow-up telephone interviews

11. Pain Assessment tools Used

12. Opioid Medication Profile

13. Percent of Sedative Medications

14. Percent of Patients with Prescribed Bowel Regimens

15. Patient Satisfaction Survey To Pain Control • Average grade given for overall pain control experience = 7.25/10 • Average grade given for responsiveness of nurses to pain = 8.31/10 • Average grade given for responsiveness of physicians to pain = 8.25/10

16. In Summary • 4 out of 5 patients with dementia were not assessed using the appropriate assessment tool • 54% of patients were prescribed a concomitant sedative • 22% of these patients were prescribed multiple sedatives • 56% of patients were not prescribed a bowel regimen • Patient satisfaction survey shows positive results

17. Recommendations for Future Practice • Ensure appropriate use of pain assessment tool • Increase awareness for the use of PAINAD scale in patients with dementia • Decrease potential opioid side effects: • Avoid concomitant sedative medications, if possible • Implement bowel regimen at the beginning of opioid therapy • Avoid polypharmacy • Implement “What to Look For: Pain Medication (Opioids)” as an educational tool throughout Meridian Health

18. What to Look for: Pain Medication (Opioids)

19. References • American Geriatrics Society Panel on Older Persons: Pharmacological Management of Persistent Pain in Older Persons. Journal of American Geriatrics Society 57:331-1346, 2009 • Chau DL, Walker V, Pai L, et al. Opiates and elderly: Use and side effects. Clinical Interventions in Aging. 2008:3(2) 273-278. • Gloth FM. Pharmacological Management of Persistent Pain in Older Persons: Focus on Opioids and Nonopiods. The Journal of Pain. 2011:12(3), Suppl 1, S13-20 • Pain Assessment Ad-Hoc Committee. Pain Assessment in the Nonverbal Older Adult with Dementia. Meridian Health. June 2010. • U.S. Census Bureau. State and national population projections. Available at http://www.census.gov/population/www/projections/popproj.html • Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc 2003;4:9-15.   • Potentially Harmful Drugs in the Elderly: Beers List and More. Pharmacist’s Letter/Prescriber’s Letter. 2007. Vol 23. Num 230907 • Goodheart CR, Leavitt SB. Managing Opioid-Induced Constipation in Ambulatory-Care Patients. Pain Treatment Topics. 2006.

20. SOUTH TEAM:Medication Awareness Prior to Discharge Jennifer Collins Robert Gonsalves Kristee Stanley Nicole Payette

21. Our Project • Issue - HCAHPS scores for Medication Communication on 4 North Ocean Medical Center had been inconsistent and low • Problem statement - Providing the patient with an interdisciplinary team approach toward medication education and understanding will increase patient satisfaction, compliance, confidence, and HCAHPS scores. • Evidence-based literature review • “Too often patients with complex acute or chronic conditions are ill-prepared for the transitions that occur during the course of their care, resulting in increased risk for readmission" (California Healthcare Foundation, 2008)

22. OMC 4 North HCAHPS 2011

23. Background • Location: Ocean Medical Center 4 North • ACE UNIT: Acute Care for the Elderly • Goal: Benefit the patient by utilizing an interdisciplinary team approach focused on providing the patient with a better understanding of medications and side effects • Patient and Family Centered Care • Modified Focus: Discharge meeting to help patient understand medication and side effects as well as voice any concerns

24. ProjectDetails • 8 Week Pilot Study • Daily rounds on 4 North • Patient Medication Reconciliation list • Patient Prescriptions • Side effects/ Adverse effects • Discharge Counseling • Medication List/Handouts • One week follow-up call with permission

25. Our Patients • Total patient population = 12* • Discharged to home alone or with caregiver • Acute Care for the Elderly Unit on 4 North • 65 years of age or older • 3 Males and 9 Females • Non-specific diagnoses

26. FinalResults OMC 4 North HCAHPS 2011

27. Recommendations • Continue Interdisciplinary team care • Add team members: Dietician, PT, OT, RT • Continue giving out “Medication Tracker” cards • Continue the take home packet with highlighted side effects • Implement a room poster and handout • Tiger Television Programs

28. References • Darwin, B, & Parrish, M. (2008). Navigating care transitions in california: two models for change. California Healthcare Foundation, Retrieved from http://www.chcf.org/publications/2008/09/navigating-care-transitions-in-california-two-models-for-change • Naylor, M. (2006). Transitional care: a critical dimension of the home healthcare quality agenda. Journal for Healthcare Quality, 28(1), Retrieved from http://www.champ-program.org/static/Naylor.pdf

29. Questions?