waterloo wellington assess and restore framwork – comprehensive

WATERLOO WELLINGTON ASSESS AND RESTORE FRAMWORK – COMPREHENSIVE GERIATRIC ASSESSMENT
1. Screen
(Early Identification)
2. Assess
(Standardized Assessment)
LOW RISK (AUA Score 1-2):
Focus on increasing selfmanagement skills.
Use Caredove, www.caredove.com
to refer to community support
services or rehab services (ie.
Exercise and falls prevention classes)
or refer to CCAC for information and
referral
MODERATE RISK (AUA Score 3-4):
AUA Screening Tool
**See Appendix 1– AUA
Screening Tool**
Consider assessing for Geriatric
Syndromes using the screening
questions in **Appendix 2**.
A referral to a GEM nurse or the
CCAC may be appropriate.
Continue to focus on selfmanagement skills and consider
using Caredove www.caredove.com
or Easy Coordinated Access (ECA)
referral forms to refer to
community-based programs
3. Plan
(Timely Navigation)
Refer patient to Specialized Geriatric
Services www.caredove.com and
CCAC.
Rule out acute medical
condition as the cause of
presentation or functional/
cognitive decline
Does the patient have high
restorative potential?
**See appendix 3 for definition of
restorative potential**
Potential care options for referral:
·
·
·
YES
·
·
·
·
·
Outpatient rehabilitation
Day hospital
Sub-acute complex Medical
Care
Convalescent Care
Restorative Care
Geriatric Rehabilitative Care
Program
Geriatric Assessment Unit
Neuro-behavioural Unit
**See Appendix 4 for definition of
each program**
NO
Potential care options for
referral:
·
Is the person safe to be at
home?
YES
Potential care options for
referral:
·
CCAC
·
Specialized Geriatric
Services
·
·
·
·
·
·
Home with CCAC
support
Ambulatory Care
Community-based
programs
Memory Clinic
Specialized Geriatric
Services
Assisted Living
Retirement Home
RISK ASSESSMENT TO OCCUR ACROSS THE CONTINUUM OF CARE (EVERY TIME A PROVIDER INTERACTS WITH A PATIENT)
Phase
5. Evaluate
(Coordinated Transition)
Care planning based on the
goals of care set by the
client/caregivers
NO
HIGH RISK (AUA Score 5-6):
4. Implement
(Individualized Care)
Reassess status and
goals of patient
compared to initial
assessment
Anticipatory Guidance
The following should be
documented and
communicated with the patient/
family/caregivers and all
community providers involved
in the care of the patient:
·
Identify potential red flags
·
Identify signs and
symptoms to watch for in
the patient/client
·
Identify potential
considerations for followup with the patient/client
in the community.
·
Teaching and education
for patient and
caregiver(s).
·
Advance directives.
Appendix # 1
interRAI Emergency
Department Screener
Appendix # 1
QUESTION LOGIC Appendix # 2
Questions and Simple Tests for General Assessment of Frail Older Patients
Question
Indicator (Scoring applies to
individual domains)
Bathing, dressing, toileting,
transferring, maintaining,
continence, feeding
Using the telephone,
shopping, preparing meals,
housekeeping, doing laundry,
using public transportation or
driving, taking medication,
handling finances
Do you have difficulty driving,
watching television, reading,
or doing any of your daily
activities because of you
eyesight, even while wearing
glasses? (1)
Is your age older than 70
years?
Are you of male gender?
Do you have 12 or fewer years
of education
Did you ever see a doctor
about trouble hearing?
Without a hearing aid, can you
usually hear and understand
what a person says without
seeing his face if that person
whisper’s to you from across
the room?
Without a hearing aid, can you
usually hear and understand
what a person says without
seeing his face if that person
talks in a normal voice to you
from across the room?
Able to complete without assistance;
able but with difficulty; unable to
complete without assistance
Able to without assistance; unable
to complete without assistance
Alternative
Functional Status
Activities of
Daily Living
(ADLS)
Instrumental
activities of
daily living
(IADLs)
Visual
Impairment
Hearing
Impairment
Urinary
Incontinence
Malnutrition
Have you had urinary
incontinence (lose your urine)
that is bothersome enough
that you would like to know
how it could be treated?
Have you lost any weight in
the last (3)
Yes indicated positive screen
Snellen eye chart
1 point
Alternative is
Autoscope (2)
1 point
1 point
2 points
If no, 1 point
If no, 2 points
>3 points; positive screen
Yes indicated positive screen
Loss of at least 5 percent of usually
body weight in last year indicates
positive screen
Appendix # 2
Question
Gait, balance,
falls Δ (10)
Depression◊
Cognitive
Problems
Indicator (Scoring applies to
individual domains)
Have you had any falls in the
past year? (10)
Have you fallen and hurt
yourself since your last
doctor’s visit?
For patients who have not
previously fallen, screening
consists of an assessment of
gait and balance (10)
Inquire about gait or balance
problems
Over the past 2 weeks, how
often have been bothered by:
Little interest or pleasure in
doing things?
Feeling down, depressed, or
hopeless?
3-item recall (4)
Any yes response indicates positive
screen.
Clock drawing test(5)
Any of the following errors indicate
positive screen; wrong time, no
hands, missing numbers, number
substitutions, repetition, refusal (5)
Environmental Home safety checklist (6)
Problems
Medication
Periodic "brown bag checkups." Instruct patients to bring
all pill bottles to each medical
visit; bottles should be
checked against the
medication list (12)
Transitions in care, between
hospital and nursing home, or
institutional setting and home,
are a common source of
medication errors and
confusions (12)
A medication review should
consider whether a change in
patient status (e.g. renal or
liver function) might
necessitate dosing
adjustment, the potential for
drug-drug interaction, whether
patient symptoms might reflect
a drug side effect, or whether
the regimen could be
simplified (12)
Response score for each:
0: not at all
1: several days
2: more than half the days
3: nearly every day
Total >3 positive screen
<2 items recalled indicates positive
screen (4)
Alternative
By performing a
multifactorial fall
assessment on a
patient who
screens positive
and then treating
the patient’s
Risk factors for
falling falls can be
reduced by 30% to
40%.
GDS
Instruments for
Primary care SCT,
Mini-cog,MIS,
AMT, SPMSQ,
FCSRT, 7MS, and
IQCODE (11)
The Screening
Tool of Older
Person's
Prescriptions
(STOPP) criteria
were introduced in
2008. The 2003
Beers criteria have
been compared to
the Screening Tool
of Older Person's
Prescriptions
(STOPP),
Appendix # 2
* All except the Snellen eye chart, Audioscope, and evaluation for cognitive problems can be assessed by selfreport using questionnaire.
Questions and response indicators are from the National Health and Nutrition Examination Survey (NHANES)
battery.[7]
Δ Questions and response indicators are from the ACOVE-2 Screener.[8]
◊ Questions and response indicators are from the Patient Health Questionnaire-2.[9]
References:
1. Moore AA, Siu AL. Screening for common problems in ambulatory elderly. Am J Med 1996; 100:438.
2. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary
care. JAMA 2003; 289:1976.
3. Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman RA. Involuntary weight loss in older outpatients.
J Am Geriatr Soc 1995; 43:329.
4. Siu AL. Screening for dementia and investigating its causes. Ann Intern Med 1991; 115:122.
5. Lessig MC, Scanlan JM, Nazemi H, Borson S. Time that tells: critical clockdrawing errors for dementia
screening. Int Psychogeriatr 2008; 20:459.
6. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for
Injury Prevention and Control. Home safety checklists. http://www.cdc.gov/ncipc/falls/FallPrev4.pdf. Accessed
June 9, 2009.
7. Reuben DB, Walsh K, Moore AA, et al. Hearing loss in community-dwelling older persons. J Am Geriatr Soc
1998; 46:1008.
8. Wenger NS, Roth CP, Shekelle PG, et al. Practice-based intervention to improve primary care for falls, urinary
incontinence and dementia. J Am Geriatr Soc 2009; 57:547. Reproduced with permission from: Rueben DB.
Medical care for the final years of life: "When you're 83, it's not going to be 20 years." JAMA 2009; 302:2686.
Copyright © 2009 American Medical Association. All rights reserved.
9. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2. Med Care 2003; 41:1284.
10. David A Ganz MD, MPH, Yeran Boa, MD, Paul G Shekelle, MD PhD, Laurence Z Rubenstein MD, MPH“Will
My Patient Fall?”JAMA 2007:297:1
11. Jennifer S Linn Al, Screening for Cognitive Impairment in Older Adults: A Systematic Review for the Us
Preventative Services Task Force. Annals of Internal Medicine Nov 5 1013 volume 159 number 9.
12. Paula A Rochon, MD, MPH, FRCPC, Kennether E Schmader, MD, H Nancy Sokol, MD Drug prescribing for
older adults, Up to date, Drug prescribing for older adults. http://www.uptodate.com/contents/drug-prescribingfor-older-adults?source=search_result&search=medication+review&selectedTitle=2%7E150#H2
13. Questions and simple test for general assessment of frail older patients, Retrieved from UptoDate April 17,
2014
Appendix # 3
Rehabilitative Care Alliance
Restorative Potential Definition
Restorative Potential means that there is reason to believe (based on clinical expertise and
evidence in the literature where available) that the patient's/client’s condition is likely to undergo
functional improvement and benefit from rehabilitative care. The degree of restorative potential
and benefit from the rehabilitative care should take into consideration the patient’s/client’s:



Premorbid level of functioning
Medical diagnosis/prognosis and co-morbidities (i.e., is there a maximum level of
functioning that can be expected owing to the medical diagnosis /prognosis?)
Ability to participate in and benefit from rehabilitative care within the context of the
patient’s/client’s specific functional goals
Note: Determination of whether a patient/client has restorative potential includes consideration
of all three of the above factors. Neither cognitive impairment, depression, and delirium nor
discharge destination should be used in isolation to influence a determination of restorative
potential.
Appendix # 4
WATERLOO WELLINGTON REHABILITATION/TRANSITIONAL PROGRAM FRAMEWORK
Rehabilitative Care for medically stable patients who do not require 24 hour nursing or medical care will be supported in the community
Medical Stability:





a clear diagnosis and co-morbidities have been established
medical conditions are stable and can be managed within the scope of an RN/RPN and do not require daily reassessments by a physician
all abnormal lab values have been acknowledged and addressed as needed.
all consults and diagnostic tests for the purposes of diagnosis or treatment of acute conditions have been completed and reported or pending test results are not anticipated to dramatically
change the treatment plan. A follow-up plan is in place at the time of the referral and follow-up appointments have been made at the time of discharge from the acute hospital
no acute psychiatric issues limiting the patients’ ability to participate in the program.
REHABILITATION SECTOR
COMPLEX CONTINUING CARE SECTOR
LONG TERM CARE SECTOR
Moderate to High Intensity Rehabilitation
Restorative Care (Moderate to Low Intensity Rehabilitation)
Convalescent Care (Low Intensity
Rehabilitation)
Intensive goal-oriented general rehab program for adults
who require a minimum 60 minutes of total therapy daily.
The Average LOS is goal dependent and is expected to
range between 7 and 40 days as required to improve
strength, endurance, or functioning to support transition
to the community.
Moderate to Low intensity goal-oriented rehab program for adults or seniors who have functional goals and
restorative potential e.g. those who are unable to return home after assessment in acute care, those who meet
eligibility criteria from the community.
The Average LOS is goal dependent (up to 90 days) and focuses on improving strength, endurance, and/or
functioning to ensure a safe transition to the community
Stroke patients are to be referred to Rehab regardless of
the length of stay and the current level of tolerance
Available at Sunnyside
Available at CMH, SJHCG, GRH
Therapeutic Criteria:
Demonstrates potential to tolerate being up in a chair 12 hr, 2-3 times/day
OT, PT is based on a model of a minimum 30-60
WW 555
Available at SJHCG, GRH and Groves (dependent on treatment
plan and client needs)
RAI-HC must be completed prior to
admission
Therapeutic Criteria:
Care plans are individualized and will adjust to the patient’s tolerance level.
Demonstrates potential to tolerate being up in a chair 1-2 hours, 2-3 times/day.
Expanded Role Working Group – February 2014 EP
Appendix # 4
REHABILITATION SECTOR
COMPLEX CONTINUING CARE SECTOR
LONG TERM CARE SECTOR
Moderate to High Intensity Rehabilitation
Restorative Care (Moderate to Low Intensity Rehabilitation)
Convalescent Care (Low Intensity
Rehabilitation)
minutes, 5-7 times per week with a therapist or therapy
assistant
Goals for therapy must be SMART goals
Demonstrates achievement of functionally significant and consistent progress towards the identified goals. Must be
able to follow therapy instructions and participate in therapy.
Patient has demonstrated the potential to attain functional
goals, have the ability to participate, and readily integrate new
learning into daily life, based on clinical expertise and
evidence in the literature.
Staffing Ratios
Realistic Discharge Plan Initiated:
Discharge dependant on goal attainment and/or functional
plateau. Initiated discharge plan to the community (e.g.
previous living arrangement such as: home, RH, supervised
living, independent living) from sending site.
Applicable Legislation
Public Hospital Act
WW 555
Palliative clients with a longer life expectancy should be considered within the admission criteria as long their
medical treatment plan does not limit participation in the therapy program.
LTC patients who resided in LTC prior to admission should return to LTC to receive rehabilitative care
OT, PT is limited (based on the model of 15-30 minutes of therapy up to 5 days per week) within an
interdisciplinary therapeutic setting that includes nursing rehabilitation, a community dining room, and
opportunities for socialization.
SJHCG
GRH
Sunnyside
PT: 0.5:15
PT: 1:32 patients Mon-Fri
PT: 0.7:25 patients Mon-Fri
OT: 0.5:15
OT: 1:32 patients Mon-Fri
OT: by consultation
TA: 0.9:15
TA: 1:21 patients Mon-Fri
TA: 1:25 patients Mon-Fri
SLP: 0.3:15
SLP: 0.2:32 patients
SLP: by consultation
SW: 0.6:64
CDA: 0.2:32 patients
CDA: n/a
Recreation: 0.2:32 patients
SW: 0.6:25
Nursing:
3.78 hrs/day (RN/RPN/PSW)
Elder Life Specialist 1:32 patients
Recreation: 0.3:25
2.06 hrs/day ( RN/RPN)
Nursing: 3.5 hrs/pt/day (RN/RPN)
Nursing:
1.8 hrs/pt/day (RN/RPN)
1.9 hrs/pt/day (PSW)
Realistic Discharge Plan Initiated:
Discharge is dependent on goal attainment and/or functional plateau.
A realistic and viable discharge plan the community (e.g. previous living arrangement such as: home, RH,
supervised living, independent living) has been initiated and has been discussed with the individual.
Discharge planning will follow the Home First Philosophy.
Applicable Legislation
Public Hospital Act
Expanded Role Working Group – February 2014 EP
Applicable Legislation
Long Term Care act 2007
Appendix # 4
The guideline below has been developed to assist in determining which program would be most suitable for patients’ to be
referred; keeping in mind that emphasis is to be placed on the individual’s unique needs.
Geriatric Assessment Unit
Neurobehavioral Unit
Complex Continuing Care
Program
Complex Continuing Care Program





Mild cognitive decline with
multiple co-morbidities
Physical/Functional decline (i.e.
polypharmacy, falls)
No serious/persistent mental
health illness complicated by
aging, mild cognitive issues, comorbidities
No definitive cognitive related
diagnosis – requires an
initial/full assessment of
cognitive impairment
Not a risk to self or others
Exclusion Criteria:




Those exhibiting physically
responsive behaviours
In need of high flow oxygen
(>4L/min)
Exacerbation of a chronic
psychiatric diagnosis
Formed patients
Seniors Specialized Mental
Health
Schedule 1 Psychiatric Unit



Diagnosis of mild-moderate
cognitive impairment associated
with dementia or
neurodegenerative disorder
Medical and neuropsychiatry comorbidities related to dementia
including agitation, resistance and
BPSD
Persistent delirium – evaluation
and treatment of
Exclusion Criteria:




Those exhibiting physically
responsive behaviours
In need of high flow oxygen
(>4L/min)
Exacerbation of a chronic
psychiatric diagnosis
Formed patients





Established diagnosis of
moderate to severe cognitive
impairment, typically related to
dementia significantly affecting
functional ability
Medical issues stable and well
defined
Acute psychiatric issues
relatively managed and stable
Behaviours may pose risk to
self or others
Has not responded to recent,
less intensive interventions
and supports.
Exclusion Criteria:

Axi 1 diagnosis; not
dementia; not medically
stable