Senior Care Coordination:
Geriatric Nursing in an HMO Primary Care Clinic Conference: Unbridled Nursing Innovation and Care for Older Adults, National Gerontological Nursing Association 10/14/2011 4:30-5:30pm
Kaiser Permanente Colorado Mary Jane Carroll BSN, RN-BC, ONC Denise Kiepe BSN, RN Rhonda Martini-Springer BSN, RN, CMC
Kaiser Permanente Colorado – Department of Case and Care Coordination
Objectives List 3 Key Elements used by a Senior Care Coordinator (SCC) to safely transition patients from hospital or SNF to home to decrease the likelihood of readmission Identify 2 assessment tools used by SCC when a patient is referred for memory issues Give 3 examples of interventions in a plan of care for a member identified with dementia Describe 2 tools that SCC use to identify frailty in order to enter diagnosis on the problem list
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Senior Care Coordination at Kaiser Permanente Colorado (KPCO) Service Statement We are specialized registered nurses with expertise in geriatric assessment and care to meet the needs of frail seniors with complex medical and psychosocial concerns. Our goal is to foster and promote independence while maintaining a safe environment. Our service embraces patients families caregivers and other health care providers within the community and Kaiser Permanente.
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The Senior Care Coordination Team
Front row: Janice Michon, Julie Macklin, Kathy Finstad, Bonnie Sasso, Elizabeth (EJ) Jackson Back row: Patty Tantillo, Mary Jane Carroll, Denise Kiepe, Marilyn Duey, Rhonda Martini-Springer, Sachie Ninomiya, Susan Romero, Mary Beth White, Helene Inglethron, Manger 4 September 23, 2011
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Kaiser Permanente Colorado Colorado Kaiser Permanente serves a Medicare population of more than 50,000 29,000 members over 75 years old 23 primary care medical offices Supported by 14 Senior Care Coordinators SCC physically located in primary care clinics
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Who we are Registered Nurses with geriatric expertise Support primary care physicians in the care of their older patients Promote advocacy and support the high risk older member Unique role evolved over past 14 yrs
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How we got here The Evolution of Senior Care Coordination Began 1997 pilot under Ingrid Venohr, PhD RN Director of Senior Programs
Vision of nurses with geriatric expertise as care coordinators assessing the needs of the elderly
Response to HSQ (health status questionnaire)
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Our Focus: Three “buckets” that define Senior Care Coordination Transitions of Care
Dementia
Managing change
Screening
Empowering patients to self-manage
Primary care collaboration
Reducing readmissions
Support caregivers and family
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Frailty Identify those most in need Reducing risk of falls Patient education
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A Comprehensive Care Team Partnering for improved care Supports PCMH by being an active member of patient care team Collaborate with primary care physician (PCP) Support family and caregivers Support the older patient Reduce hospitalizations and rehospitalizations Address quality of life
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What we do: Telephone assessments In person comprehensive geriatric assessments Collaborate with PCP for diagnosis of dementia and frailty Assist with plan of care Coordinate with home care and community resources Facilitate referrals to palliative care and hospice
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Communicating with Providers Benefits of a Shared Electronic Medical Record (EMR) Entire Care team (hospitalist, lab, primary care, SCC) share same EMR; all users can access: Labs, meds, progress notes, hospitalizations, rehab, “real time”, notification of hospital discharges Referrals Hospital notes
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M di ti
Transitions of Care: Managing Change 12 September 23, 2011
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Transitions of Care Focus: •Transition from Hospital to Home •Transition from Skilled Nursing Facility (SNF) to Home Goals: •Reduce hospital readmissions •Actively engage member (patient centered care)
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Building a Process around Transition Care Key Elements Receive immediate notification of hospital discharge Complete medication reconciliation Schedule hospital follow up appt with PCP Ensure home care/DME in place Answer patient/caregiver questions Conduit in care team Patient advocate in a complex system
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Successful Outcomes Collaboration across care settings Reduced Hospital readmission rate Medication reconciliation Satisfied members
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The Future Further partnerships with area hospitals NP home visits to patients at higher risk Collaboration with Specialty Departments
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Dementia Care: Caring for the Cognitively Impaired 17 September 23, 2011
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Dementia An increasingly large and vulnerable population Up to 20% of people 65 years and older have a diagnosis of dementia1 22% of people 65 years and older have mild cognitive impairment (MCI) and 16% of those patients convert to dementia every year2,3 Dementia is the 6th leading cause of death in the United States in 20074 In 2010, Colorado had the 2nd largest increase of Dementia in the nation5
1.
Alzheimer's Association, 2010 Alzheimer's Disease Facts and Figures; Johnson DK, et al 2009
2.
Arch Neurol. 2003;60:1385-1389.,Lopez et al, 2003
3.
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N Engl J Med 2005; 352:2379-2388, June 9, 2005, Petersen RC, et al
4.
CDC: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf
5.
L.E. Hebert, P.A. Scherr, J.L. Bienias, D.A. Bennett and D.A. Evans, State-specific projections through 2025 of Alzheimer’s disease prevalence,Neurology 62 (2004), p. 1645.
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Facing the Challenge Behavioral and Psychological Symptoms of Dementia Patients with dementia often experience at least one of the following: Hallucinations
Depression
Delusions
Anxiety
Agitation
Aggression
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Evolution of Dementia Care Building processes to improve patient support Beginning: •Training/Education (weekly): •Geriatricians •Case reviews •Alzheimer’s Association •Care Management Institute •Tools included: MMSE and Clock drawing, GDS •Dementia vs delirium vs depression •Comprehensive Geriatric Assessment
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Expansion: •Gaining expertise •Neuro-psychiatrist •Types of dementia and diagnostic process •Book reviews •Behavioral education and treatments •Additional screenings: trails B, animal naming, alternating triangles and squares &reverse arrow, 7 min screen •Telephone and “in person” assessment
Today, Comprehensive Dementia Processes: •Gero-psychiatrist education •Expand knowledge •Comprehensive Geriatric Assessment •More Tools: SLUMS, PHQ-9 •Memory clinic •Virtual Gero consults
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Connecting to Our Patients What we do
Ongoing Support And Primary Care Partnership
Primary Care
Member Centered Care Comprehensive Geriatric Assessment Plan
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The Comprehensive Geriatric Assessment
Chart review Social history and support Functional status Medical history and medication review Nutritional/weight status Depression/mood status Cognitive/memory assessment Advanced directives Assessment tools Member Centered Care Plan
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Other Assessment Tools Activities of daily living (ADL’s) Instrumental activities of daily living (IADL’s) Functional Activities Questionnaire (FAQ) Geriatric Depression Screen (GDS) PHQ-9 Depression Screen
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Cognitive Assessment SLUMS (Saint Louis University Mental Status) Examination Cognitive/memory issues and history: – short term memory issues – difficulty with orientation – impaired visuospatial – difficulty with language skills – difficulty with word finding – repeating self – caregiver reporting personality changes, hallucinations, delusional thoughts, paranoid ideations, behavioral changes 24 September 23, 2011
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The Member Centered Care Plan Education Coping
Home Care
Caregiver Support
Home Safety
Advance Directives
Medication Safety
Member
Physical Activity
Placement Alzheimers Assoc. 25 September 23, 2011
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Community Resources
Driving
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Outcomes Empowerment of Members/Caregivers living with dementia – Decrease caregiver stress – Improved quality of life
Creation of coordinated care team around the dementia patient Provider, Member, Caregiver satisfaction
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Making Strides Continuing to make a difference in the lives of dementia patients
Case conference at ED discharge Memory Clinic Collaborate with Alzheimer’s Association to offer classes Advocate the use of MiniCog in Primary Care Quantify the outcomes
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Frailty: Balancing Care and Compassion 28 September 23, 2011
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What is Frailty?
“Weakness, fragility, lack of balance or endurance, sarcopenia, immobility, wasting”
-Tabers Medical dictionary, 21st edition
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What is Frailty?
“Persons with a high probability of dependency on others within the next 12 months”
-Nicole Hill, Kaiser Permanente Center for Health Research, January 2002
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What is Frailty?
“State of vulnerability that carries an increased risk of poor outcomes in older adults”
-Cleveland Clinic Journal of Medicine, December 2005
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The Frail Population Most frail older adults are women* The incidence of frailty increases over 80 years of age* The number of frail older adults is increasing every year* *source: JAMA 2006:296(18);2280.doi10,1001/jama296.18.2280 32 September 23, 2011
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Potential Trajectory of Frailty
Source: http://www.scribd.com/doc/62935247/Aging-Successfuly-Spring-2010
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Causes and Outcomes of Frailty
Source: http://www.scribd.com/doc/62935247/Aging-Successfuly-Spring-2010 34 September 23, 2011
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Defining the Challenge
Frailty is difficult to define as it is not a disease, but rather, a condition reflected by the combination of the aging process and a variety of medical problems. As geriatric nurses, we may not always agree on exactly what it is, but we know frailty when we see it.
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Working from a Common Ground Characteristics of the Frail
Weakness Complex medical conditions Less able to tolerate the stress of illness, hospitalization and immobility Impaired cognitive function Need assistance with activities of daily living (dressing, eating, toileting and mobility). 36 September 23, 2011
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Clinical Challenges
Malnutrition
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Social Isolation
Fall Risk due to Impaired Balance
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Risks to Frail Population Disability Hospital admission Chronic illness Increased likelihood of infection with serious complications Loss of independence
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Facing the Challenge: How KPCO Senior Care Coordinators work with the frail population Plan
Document
Increase awareness of frailty across entire Care Team
Use of diagnosis code (D797) Screen Standardized screening tools used by staff Identify All patients contacted are assessed for frailty
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Frailty Assessment Using the telephone to accurately identify the frail
Three standardized questions asked during all telephone assessments and documented in the electronic medical record: 1. In the past year, have you had weight loss of 5% or more? 2. Are you unable to rise from a chair 5 times without using arms? 3. Over the last week, have you not felt full of energy?
A positive response to at least two of these questions indicates a diagnosis of frailty.
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Frailty Wheel
1. 2. 3.
Developed by the Kaiser Permanente Center for Health Research in 2001*. Based on the validated methodology from the Health Status Questionnaire (HSQ) to identify persons with a high probability of dependency on others for daily care. The Frailty Wheel addresses three questions: Because of a disability or health problem, do you need or receive help from another person for taking your MEDICATIONS? Do you need or receive BATHING ASSISTANCE including sponge baths? Do any of your HEALTH CONDITIONS interfere with your daily activities?
*Sources: Brody, Kathleen K., Johnson, Richard E., Ried, L. Douglas, Carder, Paula C. & Perrin, Nancy A Comparison of Two Methods for Identifying Frail Medicare-Aged Persons. Journal of the American Geriatrics Society 50 (3), 562-569. doi: 10.1046/j.1532-5415.2002.50127.x Brody, KK, Johnson, RE, Douglas Ried, L Evaluation of a self-report screening instrument to predict frailty outcomes in aging populations Gerontologist 1997 37: 182-191
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Case Studies The Frailty Wheel in practice
Elizabeth---77 years old, states that she does need assistance with her medications, but does not need help with bathing. Her health conditions do not interfere with her daily activities. Elizabeth is not frail. George---80 years old, states that he does need medication assistance and requires standby assistance with bathing. His health conditions interfere with his daily activities. George is frail.
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Preventing the onset of frailty in older persons
F R A I L T Y
ood intake maintained esistance exercises therosclerosis prevention solation avoidance imit pain ai Chi or other balance exercises early check for testosterone deficiency
Source: Abellan van Kan G, et al. Frailty: Toward a clinical definition. J Am Med Dir Assoc 2008 Feb;9(2):71-2 43 September 23, 2011
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The focus of a gerontological nurse is to promote advocacy and support for the high risk elder member in an integrated primary care model.
1. 2. 3.
Care transition after hospital or skilled nursing home discharge to home Dementia identification and management Frailty/falls with proactive assessment and intervention
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For more information Mary Jane Carroll BSN, RN-BC, ONC Email:
[email protected] Office Number: 303-850-2143 Denise Kiepe BSN, RN Email:
[email protected] Office Number: 303-678-3226 Rhonda Martini-Springer BSN, RN, CMC Email:
[email protected] Office Number: 303-457-6638
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Questions
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