Development of an Assess and Restore Mobile Team (ARMT)
AGING 2015 OGA/ RGP 34th Annual conference April 21, 2015
P. FORD, C. GOSSE, J. LONCKE, S. CHATLAND, J. ADMIRAL, V. HASLAM, A. HOLDING, O. KAPELJ, K.REYES, D.CZAJKOWSKI, S. MULLAN, M.PRINCE, L. CAMPOSILVAN, P. PRACSOVICS
BACKGROUND
• St. Joseph’s Healthcare Hamilton was awarded one time funding from the HNHB LHIN for a 3 month pilot program to develop a mobile assess & restore intervention model . This time limited intervention was targeted to high risk seniors who had experienced or were at risk of functional loss due to acute illness • The model was directed at increasing strength, activities of daily living abilities and mobility in an effort to decrease deconditioning, and the subsequent potential for decreased length of stay and decreased requirement for admission to Long Term Care Home • In late December 2013 to early January 2014, discussions and consultations were held with expert informants to determine model development, proposed staffing, work processes, outcome measures/ metrics and communication tools
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MODEL DEVELOPMENT 3
• Team formation and development: Dedicated full time 7days/week inter-‐professional team consisting of: nurses, social workers, occupational therapists, physiotherapists, rehabilitation assistants, pharmacist • Tool development for Case Finding (screening tool) • Metrics identified • Workload Capacity: it was determined that in order to effectively provide increased therapy treatments, the caseload would be a maximum ten patients at any given time • Communication: intra and inter-‐teams (updating care plan daily, e-‐
board, attending rounds when needed)
• Documentation: Therapeutics staff members completed standardized documentation WORK PROCESS 7 DAYS PER WEEK •
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Case finding: all patients over 65 years of age and who were admitted to General Internal Medicine through the Emergency Department/Medical Surgical Assessment Unit were screened by the ARMT nurse. Patients who were screened positive for the ARMT intervention were those at risk of functional loss, with the anticipated plan for them to discharge home. Patients admitted to ARMT: Star sticker placed on patient’s chart to notify all staff of designation
Primary medical team informed, order obtained/ approval from primary team Patient accepted and listed on team roster
ARMT notified of new admission by ARMT nurse
Initial assessment completed by interprofessional team Daily frequent patient encounters, interventions, discharge planning meetings with families Daily ARMT huddles to review and evaluate progression towards goals
Maintenance of patient roster and care plans completed collaboratively each day by all ARMT members Daily communication with primary health care team
PATIENT / FAMILY EDUCATION 5
• Patients (and families) accepted into ARMT provided with information about the service and its purpose
• Weekend availability of interprofessional team facilitated discharge planning, family meetings, and follow through of interventions and discharges
PATIENT DEMOGRAPHICS • Male: 45 Female:
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• Mean Age: 81 (R: 65 to 95)
• Common diagnosis :
Diagnosis
Percentage
Cardio-‐Resp(Pneumonia, CHF, COPD)
52.4
Falls / Syncope
16.7
Delirium/ Dementia
11.9
Nonspecific weakness
8.3
Infections 5.9
RESULTS
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• Total # patients > 65 years screened 422
• Total AMRT enrollment 84
• AMRT-‐Average Length of Stay 5.7days ( R: 1-‐21)
• Referred for comprehensive geriatric assessment 9.5% • Weekend Discharges
10/17.2%
• Monday Discharges 9/ 15.5%
COMPARISON OF ARMT TO USUAL CARE 8
FY2013 Q4 (Jan – Mar)
# of Cases
Total LOS Days
Average LOS Days
Total ALC Days
Average Total ALC Days
ACU Days
Average ACU Days
Average RIW
Arrhythmia wo Cor Angio
4
16
4.0
0
0.0
16
4.0
1.1
Chronic Obstructive Pulmon Dis
7
61
8.7
12
1.7
49
7.0
1.6
General Symptom/Sign
4
12
3.0
0
0.0
12
3.0
1.2
Heart Failure wo Cor Angio
10
86
8.6
0
0.0
86
8.6
1.4
Inflamm & Reactive Arthrop
4
22
5.5
0
0.0
22
5.5
0.8
Renal Failure
4
21
5.3
0
0.0
21
5.3
1.3
Viral/Unspecified Pneumonia
6
59
9.8
6
1.0
53
8.8
1.5
Overall for CMG Comparison Group
39
277
7.1
18
0.5
259
6.6
1.3
All ARMT Patients
84
ARMT Patients
CMG Category
Arrhythmia wo Cor Angio
8.4
92
1.1
616
7.3
1.4
282
5.0
30
0.5
252
4.5
1.0
133
1398
10.5
335
2.5
1063
8.0
1.8
General Symptom/Sign
55
362
6.6
124
2.3
238
4.3
1.2
Heart Failure wo Cor Angio
97
868
8.9
161
1.7
707
7.3
1.5
Inflamm & Reactive Arthrop
14
54
3.9
0
0.0
54
3.9
0.8
Renal Failure
51
473
9.3
37
0.7
436
8.5
3.2
106
944
8.9
161
1.5
783
7.4
1.9
Chronic Obstructive Pulmon Dis
All Patients
708
56
Viral/Unspecified Pneumonia
Overall CMG Comparison Group
512
4381
8.6
848
1.7
3533
6.9
1.7
All Patients
1365
15355
11.2
5595
4.1
9760
7.2
1.9
INTENSITY OF TREATMENT Team Member 9
Number of attendances Nursing Time spent( hours ) in direct patient contact
472 hours Physiotherapy
641
575
Occupational Therapy 411
354
Social Work 345
334
Pharmacy 168
PATIENT OUTCOMES • Home 10
60
• Change in Destination 6
• Became Clinically unstable 7
• Palliative 3
• Died 1
• Returned to usual care end of project 8 LESSONS LEARNED 11
• Rapid Team formation demands experienced , flexible , adaptable clinicians
• Initial Emergency Department contact provided upfront information, support , education , partnership and goal setting with patients and families • Weekend process allows greater team face time with patients and families • Limited community resources available on weekends
• Huddles invaluable for priorizing and communication • Overlap scheduling allowed crossover and carryover • Importance of communication with MRP Team
• Greater patient activity, ambulation and independence
NEXT STEPS 12
• Recommendations for incorporation of approach into daily practice
• Dissemination at the local , provincial and national levels • Inclusion of Pilot Project findings to further other provincial working groups (Senior Friendly Hospital strategies and Rehabilitative Care Alliance for Frail seniors and Medically complex Task group ) NEXT STEPS 2014-‐ 2017
EXPRESSION OF INTEREST •
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Proposal Submitted & Approved for Assess and Restore Funding :
The Ministry approved a $10.7M
funding investment for all 14 LHINs in
each of 2014-15, 2015-16,and 201617 to implement the Guideline.
5 awarded to organizations within the
HNHB LHIN
IMPLEMENTATION
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LHIN Wide Consultations with the 5
organizations awarded funding : including
Niagara Health Systems , Hamilton
Health Sciences , Brant County , Joseph
Brant Memorial Hospital and ours.
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GIM Program Implementation: hiring ,
training,communicating with all
stakeholders, PDSA CYCLE with 1
teaching medical team with goal to
include all teaching teams .
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PROPOSAL 2015
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SMART TEAM •
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Physiotherapist Occupational therapist Rehab Assistants
Social Worker
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PT/ rehab assistant sees patient’s twice a day
OT/rehab assistant sees patient once a day
SW l completes the screening and manages the SMART roster to admit patients into the program
Patient numbers on SMART team will be capped at 10-‐15.
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OUTCOME MEASURES • Clinical : Barthel • Discharge Destination • Patient experience Survey • Metrics : LOS , duration on service , CMGs, RIW
• Metrics will be reported to the LHIN on a monthly basis (by SMART steering committee)
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ELEMENTS OF SMART •
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Early screening
Assessment
Navigation and Location
Facility based A&R intervention
Transition home
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SCREENING TOOL 18
NEW SMART BEGINNINGS FOR 2014-‐2017 CYCLE015
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SMART roll out April 7, 2015
PDSA Trial run in GIM, under Team B
SW screens all Team B patients over 65 (will be done in ED/MCU/units)
Off-‐service Patients under Team B will to be included later Allied Health reviews and determines which positive screens will be accepted into program PT working weekends starting April 11/15, OT and SW still determining staffing model
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WORK TO DATE •
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17 screened (from April 7-‐18)
4 patients enrolled 2 discharged home a few patients met partial criteria for SMART, but discharged within 2-‐3 days, hence disqualified.
REFERENCES
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Bakker , F. Robben, S.H. Olde Rikkert, M.( 2011) Effects of hospital wide interventions to improve care for frail older inpatients : a systematic review . BMJ10:1136
Frail Seniors and Medically Complex Task Group, Rehabilitative Care Alliance, MOHLTC, 2013-‐2014. Personal Communication .
Government of Ontario. Assess and Restore (A&R) Program Policies . (2013) Ministry of Health & Long-‐Term Care. Harari,D. Martin,F.C. Buttery,A. O’Neill,S. Hopper,A. (2007) The older person’s assessment and liaison team “OPAL”: evaluation of comprehensive geriatric assessment in acute medical inpatients. Age and Aging. 36:670-‐675.
Martin , F . (2010) Comprehensive Assessment of the Frail Older Patient. Retrieved ww.bgs.org.uk/index.php/topresources/publicationsfind/goodpractices/195-‐
gpgcgass.
Sinha, S.(2012) Living Longer, Living Well . Seniors Strategy. MOHLTC & Ministry for Seniors . Government of Ontario, Toronto
CONTACT INFORMATION 22
• Patricia Ford, RN-‐EC, BA(N). MHSC. CGNc. NP, Geriatric Services . ([email protected])
• Carolyn Gosse, RPH. ACPR. PharmD. Clinical Director of Medicine , Geriatric services . ([email protected])