How to Get There: A Regional Approach to Senior Friendly Hospitals Kathleen Graham RN MN CHE VP Patient Care &

1. How to Get There: A Regional Approach to Senior Friendly HospitalsKathleen Graham RN MN CHEVP Patient Care & CNOQueensway Carleton HospitalOttawa

2. Genesis of the SFH Initiative Ottawa RGAP developed “Vision for Care” Strategic Plan One of the initiatives arising from the plan: “Effective & efficient treatment of the elderly in the hospital”

3. Implementing a Strategy for SFHs • Steering Committee mandated by RGAC to: • Improve patient outcomes • Reduce suboptimal use of resources • Improve patient/family satisfaction • Recruited a chairperson and a consultant to help develop a conceptual framework • Partnered with the Council on Aging to collect information on the broader aspects from consumers & providers with focus groups and a conference

4. 5 Major Elements and Key Questions 1. Physical Environment Is the physical environment sensitive to the capacities of elderly clients and visitors? 2. Emotional/Behavioural Environment Do the staff interact with the elderly client in a respectful, supportive and caring way?

5. Major Elements (con’t) 3. Process of Care Does the care and treatment take into consideration research and evidence regarding the physiology and pathology of aging as well as the social science research? Is the knowledge gained through orientation and education translated into practice?

6. Major Elements (con’t) 4. Organizational Support Does the organization show its support for being a senior friendly hospital in its organizational structures and processes? 5.Ethics in Clinical Care and Research Do care providers, researchers and others ensure that ethical issues are fully addressed with elderly clients or research subjects?

7. Senior Friendly HospitalMajor Elements Process of Care • Assessment and diagnosis with special emphasis on age related changes • Planning emphasis on avoiding hazards of hospitalization • Implementation-use of aids to compensate for sensory losses • Evaluation - consider response to hospitalization, impact of treatment • Emotional and Behavioural • Environment • Courtesy of staff • Respect • Information sharing and listening • Individualized approach to each patient • Culturally and gender sensitive • Ethics in Clinical Care and Research • Confirm patient’s understanding of informed consent • Use of Advanced Directives • Thoughtful discussion of treatment options and palliative care options • Organizational Support • Relevant policies and procedures • Inclusion into program development • Staff recruitment, orientation, ongoing education • Membership and TOR for committees dealing with patient outcomes • Physical Environment • Visual aspects • Physical space including external surfaces/crosswalks,speed bumps, sidewalks / grounds • Sensory Comfort • Furniture

8. Getting Started—Building Organizational Commitment • Letters to CEOs introduced the Senior Friendly Hospital concept • Extended invitation to be involved and have a representative on the Steering Committee • Coincided with introduction of the Accessibility Act • Provided helpful documentation • Strong endorsement received from local and Ottawa Valley hospitals

9. Physical Environment Criteria • Overall Environment • Lighting • Noise / Sound • Décor • Orientation / Wayfinding • Specific Functional Areas • Bedrooms • Telephone • Light Switches • Hallways, Waiting Rooms, Washrooms • Safe Mobility • Flooring • Doors • Other Factors • Large print on written materials • Hearing amplifiers for all staff • Consider nutrition needs • Furniture • Tables • Beds, and bedside tables • Chairs

10. From Theory to Practice… (Embedding the Environment Work) Joanne O’Keefe O.T. developed senior friendly guidelines for physical environment (Geriatrics Today, www.rgapottawa.com) “Free” expert consultation for building plans St. Joseph’s Buying Group Algonquin College Design Program

11. Emotional & Behavioural Environment Patients and their families report a need to improve the way we communicate and demonstrate respect Respect/dignity is an illusive element to measure Clustered around questions in the NRC Hospital Patient Satisfaction Survey Patient Satisfaction Survey Reports will inform quality improvement Built on Accreditation Standards Is there a correlation between the hospital’s patient satisfaction score and the checklist score

12. Merging SFH with Quality OHA Patient Satisfaction Survey Accreditation Standards Hospital specific indicators/balanced score cards Best Practice Guidelines

13. Building on NRC Patient Satisfaction Process of Care • Access • Continuity and Transition • Coordination of Care • Physical Comfort • Overall Impressions • Additional Items • Emotional and Behavioural Environment • Emotional support • Information and education • Respect for Patient Preferences • Involvement of Family • Overall Impressions Ethics in Clinical Care and Research Item not included in NRC(Picker/Smaller World ) Patient Survey • Organizational Support • Additional questions • Physical Environment • Amenities

14. Evaluation Strategies: Building on Existing Tools • Process for Comparative Analysis using OHA Patient Satisfaction Survey • Cluster items that are most senior sensitive • Analysis • Dr S. Amos-RGP and Dr. A. Brown, University of Toronto • Expected Outcomes • Senior Specific Hospital Report Card • Comparison of SFH achievement across the region and provincial hospitals

15. Comparison of Hospital Patient Satisfaction Survey with SFH Guidelines

16. Comparison of Hospital Patient Satisfaction Survey with SFH Guidelines Senior Friendly Guidelines Are staff’s communications senior friendly? Information Sharing/Listening

17. NRC Results • Respect for Patient’s Preferences • 54.2% Had enough to say about their treatment • 80.1% Treated with respect/dignity • Emotional Support • 62.5% All Dimensions combined • 47% Nurse discussed anxieties/fears • 57.9% Ease of finding someone to talk to • Information & Education • 64.8% All Dimensions combined • Continuity & Transition • 58.2% When to resume normal activities • Involvement with Family • 60.9% Amount of information given to family • 62.3% Family had enough recovery information

18. SFH Dimensions of Quality Process of Care • Access • Continuity and Transition • Coordination of Care • Physical Comfort • Overall Impressions • Additional Items • Emotional and Behavioural Environment • Emotional support • Information and education • Respect for Patient Preferences • Involvement of Family • Overall Impressions Ethics in Clinical Care and Research Item not included in NRC(Picker/Smaller World ) Patient Survey • Organizational Support • Additional questions • Physical Environment • Amenities

19. Other Quality Initiatives/Measures Process of Care • Develop and implement Senior Sensitive Protocols Falls, Restraints, Delirium, etc • Adverse Events ( Encon) • Patient / Family Comment Cards, Complaints/Compliments • Utilization: readmission, discharge disposition etc. • Ethics in Clinical Care and Research • Audits for informed consents • Proportion of seniors enrolled in Research projects • Emotional and Behavioural Environment • Comment Cards, Complaints/Compliments • Focus Groups • Organizational Support • Audits of Policies and Procedures to ensure sensitivity to seniors’ needs • Physical Environment • Adherence to Senior Friendly Guidelines • Accessibility Working groups • Focus Groups • Audits

20. More Evaluation Building on Existing Tools • Use other data collection tools and stratify by age • Prevalence reports : Falls, Restraints, Pressure • Incidence reports: Adverse Incidents, • Patient/Family Comment Cards

21. Other Quality Indicators-Skin • Pressure Ulcer Prevalence (PUP) 2002 • 83% of patients are “at risk” • Of these, 65% have a deficit in nutrition • 18% prevalence rate in ulcers • Seniors represent 77% of ulcer population • 37% of ulcers develop within first 7 days after admission • Average LOS 31 days vs 21 days patients with intact skin

22. Other Indicators-Falls and Restraints • Falls – 2003/04 • Of the ~2200 falls, those > 71 yrs. experienced 41% of all falls • Those >71 yrs. had 64% of population with moderate degree of injury Those >71 yrs. had 74% of serious degree of injury • Use of Restraints 2002/2003 • Those >70 yrs. represent 39.4% of population using restraints • Those >70 yrs. 26.4% with both physical and chemical restraints

23. Care Processes • First steps: • Expert Panelconvened Oct 03 • Possible foci for care processes collated, debated, clustered, and priorized • Each member exploring topic e.g. 3D’s • Possible next steps: • Use Steering Committee as focus group • Find champion(s) and support them • Vision: a checklist for best processes for senior friendly hospital care

24. Where to Go From Here? • Continue work on Conceptual Framework Elements • Physical Environment-Completed • Emotional/Behavioural Environment Nov03 • Care Processes-June 04 • Organizational Support- tbd • Ethics in Clinical Care and Research-tbd • Continue Dialogue and Education • OHA- Toronto Nov 03 • Publication of Guidelines

25. Benefits of Being Senior Friendly W.H.O. recommends senior friendly health-care centers Patients receive targeted approaches and best practice care Care providers note increased job satisfaction and morale Impacts on patient safety and functional level (quality and risk) Decreases LOS and cost- in human and financial terms

26. The Pitch To Boards and Administration Seniors are 1/3 of hospital admissions but 2/3 of days ER Readmission rates are 42% in patients >75 years Frail elderly experience further functional decline not related to acute episode but to hospital practices (even when adjusted for age/co morbidity) Frailest elderly ~3% of population use 30% of health-care resources Supports Accreditation Process Seniors are the largest group of foundation donors

27. In Closing…. “Best Practice” depends upon an environment where choices are guided by clinical expertise, developed through education, based on research, and incorporating the wishes of seniors Success requires building on the strengths of our communities, leaders, care receivers and providers We are just beginning, and would welcome other partners

28. Other Initiatives • Vancouver Island Health Authority- “Elder Friendly Hospital” adopted the gerontology perspective for all programs/services • System-wide approach-all levels and types of staff • High-risk screen at admission on all patients • Objectives: • Predict and prevent adverse consequences of hospitalization • Preserve functional ability • Early discharge planning and return to the community

29. Other Initiatives • Edmonton-”Senior Friendly” Toolkit • Sponsored by the Alberta Council on Aging • Targeted the community (retail sector) to direct changes in facilities & services • Guide book, Workshops/seminars, Presenters Kit, Tee shirts, Stickers • Senior Friendly Checkup with manual, checklist & rating scale

30. Senior Friendly HospitalMajor Elements Process of Care • Assessment and diagnosis with special emphasis on age related changes • Planning emphasis on avoiding hazards of hospitalization • Implementation-use of aids to compensate for sensory losses • Evaluation - consider response to hospitalization, impact of treatment • Emotional and Behavioural • Environment • Courtesy of staff • Respect • Information sharing and listening • Individualized approach to each patient • Culturally and gender sensitive • Ethics in Clinical Care and Research • Confirm patient’s understanding of informed consent • Use of Advanced Directives • Thoughtful discussion of treatment options and palliative care options • Organizational Support • Relevant policies and procedures • Inclusion into program development • Staff recruitment, orientation, ongoing education • Membership and TOR for committees dealing with patient outcomes • Physical Environment • Visual aspects • Physical space including external surfaces/crosswalks,speed bumps, sidewalks / grounds • Sensory Comfort • Furniture

31. Remember…A Senior Friendly Hospital… • maintains and/or improves functional abilities • has a safe and comfortable physical and emotional environment • provides respectful and responsive care and services • has staff who ask questions and listen for responses without making assumptions • encourages and supports patients and families having input into decisions