Continuità Assistenziale tra Ospedale e Territorio

Continuità Assistenziale
tra Ospedale e Territorio
per l’Anziano Fragile
Alberto Pilotto
Dipartimento OrtoGeriatria, Riabilitazione e Stabilizzazione
- Livello 3: Area delle Fragilità E.O. Ospedali Galliera
Ospedale di Rilievo Nazionale e Alta Specializzazione
Genova, Italy
Indici Demografici al 1 gennaio 2015
Popolazione
≥ 65 anni
≥ 75 anni
Percentuale Donne
Eu-28
Italia
Liguria
21.4%
10.7%
28.0%
14.7%
742.067.000
60.782.668
51.1%
51.6%
52.7%
152.7
33.7
242.7
46.2
18.4%
7.6%
Indice di Vecchiaia
117.7
Indice Dipendenza Anziani
1.583.263
Regione Liguria
Speranza di Vita alla nascita
80.0 anni (M)
Speranza di Vita a 65 anni
18.8 anni
Speranza di Vita alla nascita
Speranza di Vita a 65 anni
84.9 anni (F)
22.2 anni
ISTAT, Annuario Statistico Italiano
1
Popolazione anziana
anziana ee consumo didi farmaci
farmaci
DATI EPIDEMIOLOGICI
Rapporto OsMed
OsMed 2015
2015 –––
– AIFA ((Agenzia
Agenzia Italiana
Italiana del
del Farmaco
Farmaco)
)
Farmaco ))
Un soggetto di
età ≥ 75 anni
consuma una
farmaci 17 volte superiore
quantità di
rispetto ad un soggetto adulto di 35-44 anni
2
Health Care Services for the Elderly in Liguria Region, Italy
Aging Index 2015: Liguria=243 - Italy=153 - Europe 28=118
Genoa
Nursing Home
Dementia Care Units: Outpatients /day-care facilities
Day-Care Facilities
Home-Care Services (community-based)
ASL: ‘Azienda Sanitaria Locale’
(Local Health Agency)
Acute Geriatrics Unit
Intermediate Care Unit
Home care services (hospital based)
Dementia Care Units: Residential facilities
PostGratuate School in Geriatrics
Dpt. Geriatric Care, OrthoGeriatrics & Rehabilitation
E.O. Galliera Hospital, Genoa, Italy
Continuity of Care for Geriatric Patient
Acute Care
•Geriatrics Unit: 42CGA
beds
•OrthoGeriatric Unit: 9 beds
Ambulatory Clinics
5000 outpatients/year
- C. Cognitive Decline Dementia
- Osteometabolic Center
- Frailty Clinic
- Geriatric Clinic
- Genetic Disability: Down S.
CGA
Post-Acute Care
(in hospital)
•Intermediate Care
Unit : 22 beds
•OrthoGeriatric Rehab.
Unit: 24 beds
•Day Hospital: 2+ 4 beds
GEMU
Geriatrician
Trained Nurse
Social Worker
Home-care
Services
•Home Care Services:
patients in charge 45
•Palliative Care Service:
patients in charge 20
CGA
Long-term Care
Residential Services
•Nursing Home Rehab:
subjects in charge 24
•Alzheimer Unit:
patients in charge 26
CGA
3
MULTIDIMENSIONAL ASSESSMENT
(Comprehensive Geriatric Assessment - CGA)
History,medical visit,
Lab/Rx diagnostics
Health Status
Barthel, ADL
IADL, Tinetti
Cognitive, Functional,
Mood, Motility
Risk of pressure sores
Exton-Smith
Social Network - Cohabitation
Nursing Homes - Income
Biological Risk
Social evaluation
1) Clinical profile
2) Pathological Risk
3) Residual skills
Comorbidity Index (CIRS)
Drug use
SPMSQ, MMSE, GDS
Mini Nutritional
Assessment
Private vs public: home-care,
long-term care services
Individual (personalized)
Care Plan
22 RCT (1984-2010) evaluating 10,315 participants in six countries
Geriatric Evaluation and Management Unit (GEMU)
Ellis et al, The Cochrane Library 2011, Issue 7
4
CGA for older adults admitted to hospital: results
22 RCT (1984-2010) evaluating 10,315 participants in six countries
Results
Reference
1.25
Alive at home 6 months
p=0.0002
1.16
Alive at home 1 year
p=0.003
1.11
Cognition
Institutionalized
Mortality 1 year
0.5
p=0.02
0.79
p<0.0001
0.76
p=0.001
1
1.5
2.0
Ellis et al, The Cochrane Library 2011, Issue 7
Comprehensive geriatric assessment for older
adults admitted to hospital: meta-analysis of
randomised controlled trials
Conclusions
Significantly more older patients are likely to survive admission to
hospital and return home if they undergo CGA. Fewer will experience
deterioration and more will have improved cognitive functioning.
These benefits might be cost effective.
Policy implications
All frail elderly patients admitted to hospital should have access to CGA.
The provision of geriatric services needs reviewed by healthcare providers
Who should receive specialist services and which forms of CGA are most
appropriate to which inpatient setting (acute or post-acute) are a priority
of additional research.
Ellis et al, BMJ 2011;343:d6553 doi: 10.1136/bmj.d6553
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Ospedale-Territorio
La continuità assistenziale per l’anziano fragile ed
il “percorso di cura” nella rete dei servizi
Multidimensionale/Interdisciplinare/Multiprofessionale
UVGO
Dipartimento Cure Geriatriche, OrtoGeriatria e Riabilitazione
Livello 3 “Area delle Fragilità”
E.O. Ospedali Galliera
Ospedale di Rilievo Nazionale e Alta Specializzazione
Cartella VMD, informatizzata, «integrata»
VMD
MPI
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The Multidimensional Approach to the Older
Patient with Chronic Kidney Disease
Alberto Pilotto, Daniele Sancarlo, Marilisa Franceschi,
Massimiliano Copetti, Piero D’Ambrosio,
Carlo Scarcelli, Luigi Ferrucci
A Multidimensional Prognostic Index (MPI) based on a
comprehensive geriatric assessment predicts short- and
long-term all-cause mortality in older hospitalized
patients with transient ischemic attack
Daniele Sancarlo • Andrea Pilotto • Francesco Panza •
Massimiliano Copetti • Maria Grazia Longo • Piero D’Ambrosio •
Grazia D’Onofrio • Luigi Ferrucci • Alberto Pilotto
J Neurol 2012; 259 (4): 670-678
Multidimensional Prognostic Index Based on a Comprehensive Geriatric
Assessment Predicts Short-Term Mortality in Older Patients With Heart Failure
Alberto Pilotto, Filomena Addante, Marilisa Franceschi, Gioacchino Leandro,
Giuseppe Rengo, Piero D’Ambrosio, Maria Grazia Longo, Franco Rengo, Fabio
Pellegrini, Bruno Dallapiccola and Luigi Ferrucci
Circ Heart Fail 2010; 3: 14-20
Yourman et al, JAMA 2012, January 11, 2012 ; 307: 182-192
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** Theoretical range 0-14. Higher scores indicate higher quality.
Warnier et al, J Nutr Health Aging2016;20(2):218-30
Optimal setting and care organization in the
management of older adults with hip fracture:
a narrative review
On the basis of available studies, it seems that services characterized by a multidisciplinary
approach with a co-leadership (geriatrician and orthopedic surgeon)
or a geriatrician
leadership demonstrated to produce better outcomes compared to the traditional models.
Giusti et al, Geriatric Care 2015,Vol 1: 5602:9-16
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OrtoGeriatria Livello 2/3: Attività 2015
OTG Livello 2
OTG Livello 3
359
84,5 ± 7,6
9,4 ± 6,3
2,7 ± 2,6
6,9 ± 5,5
96%
4%
463
79,9± 10,3
16,46 ±8,7
Frattura Femore 62%
Protesi anca/gin. 29%
OTG Livello 3
80.8%
-
RSA
8.6%
28,3%
Cure Domiciliari
1.4%
9.3%
Domicilio
4.7%
55.5%
Decesso
2.2%
1.3%
Soggetti con frattura femore
Età media (± SD)
Degenza media (gg) (± SD)
Degenza pre-operatoria (gg) (± SD)
Degenza post -operatoria (gg) (± SD)
Trattamento chirurgico (%)
Trattamento conservativo (%)
-
Esito
Dipartimento Cure Geriatriche, OrtoGeriatria & Riabilitazione
Livello 3 – Area delle Fragilità
E.O. Ospedali Galliera, Genova, Italy
Continuità delle Cure per l’Anziano Fragile: 2015
Cure Domiciliari + Cure Palliative
No. 75 Età media=87.1±5.8
No. 18 Età media=87.1±5.8
MPI
6.6%
Domicilio
65.2%
No. 739
19.6%
VMD
SC Geriatria 10.1%
UVGO SSD Cure
per Acuti
Intermedie
Geriatra
No. 1134 dimessi
Età media=86.1 ± 5.9
18.1%
VMD
No. 115
Assist. Sociale
Età
media=85.6
± 5.1
Infermiere
6.0%
No. 7
Domicilio
47.8%
No. 44
32.6%
MPI
RSA (Residenze Sanitarie Assistenziali)
No. 205 Età media=86.6±6.1
No. 30 Età media=87.1±5.6
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Dipartimento Cure Geriatriche, OrtoGeriatria & Riabilitazione
Livello 3 – Area delle Fragilità
E.O. Ospedali Galliera, Genova, Italy
SC Geriatria
Degenza media in rapporto all'esito: Anno 2015
Età Media±DS
Degenza media (giorni)
Domicilio, No. 739
86.0±6.0
10.2 ± 6.5
Cure Domiciliari, No. 75
87.1±5.8
11.3 ± 9.8
RSA, No. 205
86.6±6.1
15.2 ± 11.0
Cure Intermedie, No. 115
85.6±5.1
17.4 ± 11.3
P=0.2 (NS)
P<0.0001
Esito, Numero casi
Cure Intermedie totale = No. 448 (115/448 = 25.6%)
“MPI-TRIVENETO” Project
22 Geriatrics Units, N° patients=1178, F=59.4%, mean age=84.9±6.7 yrs
MPI-1 23,6%, MPI-2 33,7%, MPI-3 42,6%, MPI medio=0,56±0,24
p<0.0001
500
400
300
200
100
0
N°321
N° 413
N° 226
14%
36%
47%
34%
38%
29%
MPI 1
MPI 2
40%
41%
17%
MPI 3
Peggiorato Invariato Migliorato
Adjusted for baseline characteristics of patients
(age,sex, MPI) and diagnosis at discharge: HF,
pneumonia, dementia, respiratory failure, COPD,
arrythmia, CKD
Volpato et al, Rejuvenation Res 2016, in press
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MOdello organizzativo, architettonico, tecnologico di
DImissione PROtetta per soggetti anziani con “dimissione
difficile”. Studio MoDiPro.
Versione 1.0 del 22 ottobre 2015
HELP
As Population Ages, Where Are the Geriatricians?
By KATIE HAFNER, JAN. 25, 2016
“One of the greatest stories of the 20th century was that we doubled the
life expectancy,” said T. Fulmer, president of the Hartford Foundation,
which funds programs to improve the care of older adults.
“Now we
need to have all the supports to assure not just a long life but a high
quality of that long life.”
Phyllis Wolfe, 76, above, with
her geriatrician, Dr. Elizabeth
Eckstrom, in Portland, Ore., in
November. Dr. Eckstrom was a
general
internist
before
completing a fellowship in
geriatrics. “I had no idea ALL
what I didn’t know,” she said.
Credit. Carl Kiilsgaard for The New York
Times
Recent evidence about care provided by geriatrics teams shows that
with the care of such teams, the hospitalization of older adults runs
shorter, costs less and results in fewer complications, including falls,
pressure ulcers and urinary tract infections.
There is an emerging emphasis on training many different health care
professionals - nurses, pharmacists, family physicians, and physical and
occupational therapists - to see older patients through a geriatrics lens.
Mini-fellowships at teaching hospitals to train practicing physicians in
geriatrics have sprung up around the country.
Cardiology, urology,
emergency medicine and other specialties are promoting geriatrics
training within those disciplines.
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Take Home Messages
Continuità Assistenziale tra Ospedale e Territorio per l’Anziano Fragile
Background
- invecchiamento demografico, fragilità e nuove necessità assistenziali
Metodi
- VMD e UVGO: multidimensionale e multiprofessionale
Strumenti
- Cartella Informatizzata-Integrata, VMD
MPI
Risultati
- OrtoGeriatria Livello 2 /Livello 3, (Riabilitazione)
- Geriatria, Cure Intermedie, Cure Domiciliari/ Palliative, RSA
Conclusioni (The New York Times)
- Modelli di Cure Geriatriche basati su evidenze; formazione; ricerca
- Stakeholders: infermieri, medici specialisti, MMG, …decisori…
Dipartimento Cure Geriatriche, OrtoGeriatria e Riabilitazione
Livello 3 “Area delle Fragilità”
E.O. Ospedali Galliera
Ospedale di Rilievo Nazionale e Alta Specializzazione
http://www.mpiage.eu
Download “MPI-calculate” software
iMPI© application for iPhone and iPad on AppStore
available “for free”
Grazie per l’attenzione
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