Selecting Tools for ACAT Assessments. An Introduction to the new ACAT Assessment Tools.

1. Selecting Tools for ACAT Assessments.An Introduction to the new ACAT Assessment Tools. • Assoc Prof Paul Varghese • Geriatrician • Member ECRG • Princess Alexandra Geriatric and Rehabilitation Unit

2. Background 2007 ACAT review • Significant variation in practice • Variation in outcome • A large number of assessment instruments used • Poor consistency across and within ACATs

3. ACAT herding

4. The Task • Review existing Assessment tools • Determine which domains require assessment • Determine which tools are the most suitable for each domain • Determine which tools are suitable for completing ACAT assessments • To not burden assessors with an excessively complex suite.

5. The Process • The ACAP ECRG established June 2009 • Provide advice on tool selection for assessing frail older people • Develop screening items • Determine which core assessments would be performed in every assessment • Janet Sansoni (University of Wollongong) contracted to develop evaluation framework and prepare the final report on behalf of the ECRG • ECRG meets by face to face and teleconference

6. Members of the ACAP ECRG • Dr Susan Hunt (Chair) Senior Adviser, Ageing and Aged Care Division, Department of Health &Ageing • Professor Jenny Abbey Clinical Professor, Faculty of Health Sciences, University of Adelaide, Adjunct Professor, Qld University of Technology, Research Fellow, Menzies Institute, University of Tasmania • Assoc Prof Gideon Caplan Director, Post Acute Care Services, Prince of Wales Hospital PACS Unit, NSW • Dr Terry Finnegan Aged Care and Rehabilitation Department, Royal North Shore Hospital, NSW • Professor Leon Flicker Director, WA Centre for Health and Ageing, Royal Perth Hospital, WA • Ms Therese Gehrig Manager, Aged and Community Care Policy, ACT Health (ACAP Official representative) • Ms Wendy Hubbard Executive Director, Allied Health, Ballarat Health Services, Victoria • Dr Brendan Kay General Practitioner, Jamieson Street Medical, Victoria • Assoc Prof Michael Murray Director, Geriatric Medicine , St Vincent’s Hospital, Victoria • Mr Tony Pyke Manager, Adelaide Metro ACAT, Domiciliary Care South Australia (ACAT Member representative) • Ms Michelle Roffey Director, ACAP Section, Department of Health and Ageing • Assoc Prof Janet Sansoni Associate Professor, Australian Health Outcomes Collaboration, ACT • Ms Trudy Sutton Manager, Business Development, ACH Group, SA • Ms Jenny Stevens Area Director Aged Care WA Country Health Service, WA • Dr Eddy Strivens Regional Geriatrician, Aged Care Health Services, Queensland Health • Assoc Prof Paul Varghese Director, Geriatric &Rehabilitation Unit Princess Alexandra Hospital, Qld • Ms Wendy Venn Aged Care Nurse Practitioner, Aged Care and Rehabilitation Unit, ACT

7. Methodology • Evaluation Framework • Based on the DOMS methodology • Identification of relevant instruments • Selection Criteria • Health Outcomes Instrument review Sheet • Psychometric properties reviewed • Instruments scored and tabulated

8. Psychometric Criteria 1 • Reliability • Internal consistency • Test Retest • Inter-Rater

9. Psychometric Criteria 2 • Validity • Content • Construct • Internal Structure • Correlation with other measures • Discriminant Validity • Interpretability

10. Psychometric Criteria 3 • Responsiveness • Floor and ceiling effects • Sensitivity to change • Applicability – cultural, gender, age appropriateness

11. Tools Reviewed

12. Barthel Katz ADL OARS multidimensional Functional Assessment The Oral Health Assessment Tool InterRAI HC ONI TUG Tinetti Balance Assessment Tool Berg Balance Scale Quickscreen Falls Assessment FRAT MMSE AMTS REPDS (Revised Elderly Persons Disability Scale DSSI (Duke Social Support Index) Nutritional care of the Housebound Elderly DSS Nutrtionally at risk ANSI (Australian Nutritional Screening Iniative) MNA (Mini-Nitrional Assessment) DSQ (Dementia Screening Questionaire) PAS (Psychogeriatric Assessment Scale) KICA (Kimberly Indigenous Cognitive Assessment) incl SKICA –COG IQ CODE Addenbrookes RBANS ADAS FAB Cornell Scale for Depression GDS MADRS CAM DOMS RUDAS NPI-Q HDS CSI (Caregiver Strain Index) ZCBS (Zarit Caregiver Burden Scale) FNHA (Food and Nutritional Health for Adults) Oral Health PAD ReBOC (Reducing Behaviours of Concern) 49 Tools Reviewed

13. Physical ADL IADL Falls Environmental assessment Pain Feeding and Swallowing Nutrition Dental and Oral Health Skin Condition Foot condition Vision Hearing Continence Sleep Lifestyle and health behaviours Self reported health status Cognitive Function Decision Making Capability (capacity) Communication Behavioural and Psychological Depression Behaviours of Concern Delirium Social Loneliness and help availability Neglect/abuse Recent stressors Other Carer referral Domains Identified

14. Overall Schema CORE TOOLS Used with all Assessments Screening Questions Used to determine what further in depth assessments may be needed

15. Core Tools • Cognition • sMMSE (Molloy) • RUDAS for CALD clients • KICA for Indigenous clients from rural or remote • IQ code – for informant interview • ADL • Barthel (Collin scoring) • KICA-ADL for Indigenous clients from rural or remote • IADL • OARS-IADL – based on the Lawton

16. Screening Questions 1 • General and Preliminary Items • Assessor Rated: Is an interpreter required? • Communication • Assessor Rated: Does this person have difficulty in communicating with others? • Self Rated Health Status • In general would you say your health is ? • Excellent • Very Good • Good • Fair • Poor

17. Screeners cont… • Falls • Have you had a fall in the past 12 months • Are you afraid of falling? • If ‘yes’ referral for a falls assessment should be considered.

18. Screeners cont… • Pain • In the past 4 weeks have you had more than mild pain or discomfort? • If ‘yes’ consider using the relevant pain assessment tool (Brief Pain Inventory, Residents Verbal Brief Pain Invetory or Abbey Pain Scale) or consider referral to General Practitioner for diagnosis and treatment.

19. Screeners cont… • Feeding and Swallowing • Do you have problems swallowing? • Nutrition • Have you lost any weight without trying, or had other nutritional concerns, in the past 3 months? • Dental or Oral Health Concerns • Do you have any problems with your teeth, mouth or dentures?

20. Screeners cont… • Skin Condition • Do you currently have any major skin condition? • a. Pressure ulcer • b. Other skin ulcer • c. Healing surgical wounds • d. Other skin tears, cuts or lesions • e. Other skin problems e.g. bruises, rashes, itching, eczema, etc. • Foot Condition • Do your have a foot problem that affects your ability to walk or move about?

21. Screener cont… • Vision • Do you have difficulty with vision, even with glasses? • Hearing • Do you have difficulty hearing, even if you use a hearing aid?

22. Screeners cont… • Continence • [In addition to the bowel and bladder items in the Modified Barthel Index] • Do you have any other bowel or bladder problems (e.g. pain/difficulty in passing stool, frequent diarrhoea, nocturia or frequent urination?) • Sleep • Do you experience any difficulties with your sleep (e.g. difficulty falling asleep, fragmented sleep, insufficient sleep)?

23. Screeners cont… • Environmental Assessment • [For assessments conducted in a community setting]. • Assessor Rated: Does the residential environment have any major safety and health risks?

24. Screeners cont.. • Lifestyle and Health Behaviours • Are you a current smoker? • Is alcohol consumption causing a problem for this person? • If ‘yes’, specify problem: • Mobility problems • Confused at times • Inappropriate behaviour • Personal neglect • Dangerous driving • Nutritional concerns

25. Decision Making Capability • Assessor rated:Are there any concerns regarding the client’s decision making capabilities • If ‘yes’ • Who assists the client in making health and lifestyle decisions ? • a. = No one • b. = Significant Informal Assistance • c. = Power of Attorney • d. = Advance Health Directive • e. = Person responsible or appointed guardian • If the answer is (a) or conflict is apparent, consider referral for specialist assessment. • Who assists the client in making financial decisions? • a. = No one • b. = Significant Informal Assistance • c. = Power of Attorney • d. = Advance Health Directive • e. = Person responsible or appointed guardian • [j1]I used care recipient in the text and I think we should change it to client

26. Behavioural and Psychological Aspects • Depression • Over the past four weeks have you felt down or depressed more than half of the time? • Behaviours of Concern and Delirium Items • The following questions should be asked of an informant. • Does (the person) have behavioural problems for example, aggression, agitation, wandering, socially inappropriate behaviour or sexual disinhibition? • Has there been a sudden change in the person’s mental state recently?

27. Social Aspects • Trigger for Carer referral • Are carer arrangements sustainable without additional services or support? • Loneliness and Help Availability • Would you say that you are often lonely? • During the past 4 weeks, was someone available to help you if you needed and wanted help? • Neglect/Abuse • Is there any evidence that this person has been abused, mistreated, or neglected? • Recent Stressful Events • Has the client experienced one or more major stressful life events over the past 3 months? (These events could include a bereavement or severe illness/ injury of self/family/ friend, separation from partner/family, major financial loss or being the victim of a crime). 

28. Next Steps • Finalise the report • Develop a form • Pilot the tool • Refine the tool • Training • Implementation

29. The Present- complex Triage Information Recordsreview Assessment Interview Collateral Reports ACCR Documentation Recommendations Duplication of Data capture and Data entry

30. A Possible Future Reports ComprehensiveGeriatricAssessment ACCR Electronic HealthRecord Recommendations