Geriatric Psychiatry Service Delivery: South Island - Island Health

Transcription

1 Geriatric Psychiatry Service Delivery: South Island - Island Health Dine and Learn: Victoria Division of Family Practice November 23, 2015

2 Learning Objectives The Division of Geriatric Psychiatry South Island: Membership Geographical Area Served Service Delivery Review of Our Programs Admission Criteria Referral Process

3 Division of Geriatric Psychiatry South Island Membership: 6 FTE Geographical Area Served: South of the Malahat, Western Communities, Victoria, and Saanich Peninsula and the Gulf Islands.

4 Service Delivery We work with Interdisciplinary teams in all of our programs. Community: Residential Care, Senior s Outreach Team (Home and Community Care Sites). Senior s Outpatient Clinics: RJH and PHU. Acute Care C/L: RJH, VGH and SPH GEM teams. Inpatient: RJH 2SE. Tertiary Care: RJH 2SW and Sandringham.

5 Program Admission Criteria 75 years and older exceptions are made for patients with early onset dementias and older patients with mental illness and significant frailty. Dementia complicated by neuropsychiatric symptoms. Late onset mental illness. Community assessment reserved for those that cannot/will not come into a clinic

6 Referral Process Seniors Health Intake: Senior s Health Referral Form: Fax: Phone: What is required?: Patient data Reason for referral Clinical features _ suicidality, cognitive impairment, neuropsychiatric symptoms, substance abuse, mobility issues, medical illness and current medicines.

7 Residential Care Consultation: Facility Organization and Care in BC Residential Care Facilities Governance: The Hospital Act (IH) and The Community Care and Assisted Living Act (Affiliates). Other Legislation: Mental Health Act, OPGT etc. The Culture of Care: Medical Director, Director of Care and Staff.

8 What is the level of dementia and frailty in BC Residential Care Facilities? 30,000 residential care beds in BC. 75% of residents have a diagnosis of dementia. 20% of the resident population dies in the course of a year. Average length of stay of residents 14 months. 40% of new admits die within 1 year 20% of this group die in the first month. 90 % of residents die in place.

9 Neuropsychiatric Symptoms (NPS) In Dementia I Most prevalent: apathy, irritability, agitation, depression & anxiety Least prevalent: delusions, hallucinations, disinhibition, aberrant motor behavior & euphoria

10 Other Causes of Behavioral Disturbance in Dementia Delirium Drugs Pain/discomfort Disability Relocation/Change in Routine Over/Under Stimulation Pre-existing Psychiatric Illness

11 P.I.E.C.E.S. The P.I.E.C.E.S. approach/assessment provides a framework for the treatment team: to understand the meaning behind a person s behavior, and; to formulate a care plan. Physical Intellectual Emotional Capabilities Environment Social

12 The Nonpharmacological Management of NPS Activities. Caregiver Education and Support. Communication. Simplify the Environment. Simplify the tasks.

13 PharmacologicalIntervention Detect Indication (what is being treated?). Select symptom set (what are the target symptoms?). Effect monitor for response and side effects.

14 Are there behaviors that do not respond to medication? Aimless wandering. Inappropriate urination/defecation. Inappropriate dressing/undressing. Annoying perseverative behavior or calling out. Hiding/hoarding. Eating Inedibles. Tugging at/removal of restraints.

15 Conclusions The keys to successful intervention in residential care include: Becoming familiar with the facility culture; Developing a cogent understanding of the problematic behavior(s); Utitizing nonpharmacological and, where indicated, pharmacological treatments: and, Following up to monitor the resident s response to interventions.

16 Inpatient Services Secondary Care Geriatric Psychiatry Inpatient Unit (2SE) Tertiary Care (2SW, Sandringham)

17 Geriatric Psychiatry Inpatient Unit (2S) Royal Jubilee Hospital

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20 Geriatric Psychiatry Inpatient Unit (2SE) (Secondary Care) Geographical Area Served: South of the Malahat, Western Communities, Victoria, and Saanich Peninsula and the Gulf Islands. Program admission Criteria 75 years and older exceptions are made for patients with early onset dementias and older patients with mental illness and significant frailty. Dementia complicated by neuropsychiatric symptoms. Late onset mental illness.

21 Geriatric Psychiatry Inpatient Unit (2SE) (Secondary Care) 18 Beds (4 double occupancy, 10 private) Multidisciplinary Team Psychosocial Rehab Model

22 Geriatric Psychiatry Inpatient Unit (2SE) (Secondary Care) Reason s for admission: Psychiatric Illness: Depression Bipolar Disorder Psychotic Disorder Anxiety Disorder Dementia with related Behavioural/Psychological symptoms Requires the expertise and security provided on 2SE

23 Geriatric Psychiatry Inpatient Unit (2SE) (Secondary Care) Requires a referral by a Geriatric Psychiatrist Community (Outpatient clinic / SORT) Acute Care ER LTC

24 Geriatric Psychiatry Inpatient Unit (2SE) (Secondary Care) Patient Population: Diagnosis (current) Depression 21% Bipolar Disorder 5% Psychotic Disorder 47% Dementia with BPSD 74% Age (past year) % % % %

25 Geriatric Psychiatry Inpatient Unit (2SE) (Secondary Care) Disposition Home Assisted Living / Long Term Care Tertiary Care

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28 Inpatient Services Geriatric Psychiatry Inpatient Unit (2SE) Tertiary Care (2SW, Sandringham)

29 Inpatient Services: Tertiary Care (2SW, Sandringham) Island wide service: 2SW Sandringham Cowichan Lodge (Duncan) Lodge on Fourth (Ladysmith) New Horizons (Campbell River)

30 SENIORS MENTAL HEALTH TERTIARY TRIAGE TOOL - March 2015 The following criteria are considered in choosing a suitable care location. The criteria also highlight when an area is not appropriate and the patient should move to a different care location. CRITERIA Acute Tertiary 2SW PSYCHIATRIC: Late onset mental disorder of chronic MH Illness complicated by age. At imminent risk of harm to self or others Complex psychiatric diagnostic and treatment issues Tertiary Rehabilitation Code White) Cowichan Lodge (with Tertiary Residential & Rehab. Sandringham, Lodge on 4 th & New Horizons Very High Low - Medium Low - Medium Very High Medium - High Medium COGNITIVE: Age related progressive dementia with psychiatric complications or non-cognitive symptoms of dementia Psychiatric Complications Very High High Medium Addictions Issues Very High Medium Low Progressive dementia amenable to rehab care plan SAFETY/RISK ISSUES: Responsive behaviors: Cannot be mitigated with CP. OTR needed Unsafe Intrusiveness Very High Mod-High Low - Medium Very High High Medium-High (Code White response) Medium-High (Code White response) Low - Medium Unmanageable wandering behavior Very High High Low - Medium FUNCTIONAL CRITERIA: Maximum Care Staff Required for Personal Care (3 or more) ENVIRONMENTAL ISSUES: Need for a small, low stimulation dementia care unit Very High Very High High High Low Low - limited capacity to use 3 staff at weekly bath times, etc. Any other patient specific information that would be needed to be considered for an acceptance to tertiary care. (e.g. medical acuity, biomedical risk factors, dangerous cohort, etc.)

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33 Tertiary Care (2SW) Requires a referral by a Geriatric Psychiatrist Acute Care (Throughout the Island) ER LTC Community (Outpatient clinic / SORT) (less common)

34 Tertiary Care (2SW) 9 Beds (1 double occupancy, 7 private) Multidisciplinary Team Psychosocial Rehab Model Higher staff:patient ratio than 2SE Low-stimulation environment

35 Tertiary Care (2SW) Patient Population: Diagnosis (current) Dementia (severe) 100% Age (current) % % % %

36 Dispostion LTC Tertiary Care Tertiary Care (2SW)

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41 Combined Stats for 2S Duration of Care (this year): Acute: ALC: 61.9 days days ALC rate (this year): 34%

42 Sandringham Today Photo Sphere Leave now

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45 SENIORS MENTAL HEALTH TERTIARY TRIAGE TOOL - March 2015 The following criteria are considered in choosing a suitable care location. The criteria also highlight when an area is not appropriate and the patient should move to a different care location. CRITERIA Acute Tertiary 2SW PSYCHIATRIC: Late onset mental disorder of chronic MH Illness complicated by age. At imminent risk of harm to self or others Complex psychiatric diagnostic and treatment issues Tertiary Rehabilitation Code White) Cowichan Lodge (with Tertiary Residential & Rehab. Sandringham, Lodge on 4 th & New Horizons Very High Low - Medium Low - Medium Very High Medium - High Medium COGNITIVE: Age related progressive dementia with psychiatric complications or non-cognitive symptoms of dementia Psychiatric Complications Very High High Medium Addictions Issues Very High Medium Low Progressive dementia amenable to rehab care plan SAFETY/RISK ISSUES: Responsive behaviors: Cannot be mitigated with CP. OTR needed Unsafe Intrusiveness Very High Mod-High Low - Medium Very High High Medium-High (Code White response) Medium-High (Code White response) Low - Medium Unmanageable wandering behavior Very High High Low - Medium FUNCTIONAL CRITERIA: Maximum Care Staff Required for Personal Care (3 or more) ENVIRONMENTAL ISSUES: Need for a small, low stimulation dementia care unit Very High Very High High High Low Low - limited capacity to use 3 staff at weekly bath times, etc. Any other patient specific information that would be needed to be considered for an acceptance to tertiary care. (e.g. medical acuity, biomedical risk factors, dangerous cohort, etc.)

46 Tertiary Care (Sandringham) Requires a referral by a Geriatric Psychiatrist Acute Care (Psychiatric Unit) Tertiary Care

47 Tertiary Care (Sandringham) Reasons for admission: Further stabilization/assessment (Tertiary Rehab) No longer acute but can t be managed in a less supportive environment (Tertiary Residential) Patient Population: More frail/chronic or late onset Psychiatric Illness Patients with more challenging personality traits

48 Tertiary Care (Sandringham) 46 Beds (all private, most have shared bathroom) 23 Tertiary Rehab, 23 Tertiary Residential Multidisciplinary Team Well organized for recreation and rehab efforts Smoking area

49 Disposition: Sandringham LTC AL Home Length of Stay Years Months (less often) Tertiary Care (Sandringham)

50 On Call provision Consultation/Liaison Seniors Outreach Team Seniors Outpatient Clinic

51 On Call provision 24/7 through RJH switchboard RJH, VGH,SPH, and community (GP s, allied services) Primarily telephone based- majority of consultation provided through the C/L service and community teams No dedicated emergency assessment area in ER. Patients with dementia/ >75 excluded from PES

52 Consultation/Liaison service Royal Jubilee Hospital Mon/Wed/Fri 9-5pm Integrated into RJH GEM team 8-12 new assessments/week, 6-8 on caseload Victoria General Hospital Tues/ Fri 9-5pm Integrated into VGH GEM team 4-6 new assessments/week, 6-8 on caseload

53 Service provision Primarily assessment and management of functional psychiatric illness Stabilisation of Dementia associated Behavioural Syndromes MHA/Capacity/Guardianship Act Assistance with formulation and care planning Community Liaison

54 SENIORS OUTREACH TEAM (SORT) Amalgamation of EOS and VISTA Integrated into HCC geographical areas March 2014 Dr Oates (EWHU), Dr Prowse (SPHU), Dr Pakrasi (ROHU), Dr Cotterell (VHU) 2 OT s, RN s, SW s, 5 SORT Physicians Assessment and advisory service Limited to no capacity for case management

55 Clinical focus Referrals come from multiple sources Processed through Seniors Intake Increasingly more involved in abuse/neglect cases Triage/assessment, psychosocial support, short term monitoring In reach into LTC HCC education/support

56 Ave referrals per month Strategy is to advise and up skill HCC to meet rising demand Building capacity for Geriatric Psychiatry assessment in Health Units and at home

57 SENIORS OUTPATIENT CLINIC Primarily based at Memorial Pavilion (RJH) Satellite clinic at SPH ( Dr Pakrasi) RJH supported by 1 full time RPN Limited access to Geriatric Medicine resources Access to Behavioural Neurology (Dr Henri- Bhargava) referrals/m, ave 60d wait 2014/15 (likely 21-28d currently)

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59 Questions?

60 Discussion topics Assessment and management MCI/MNCD Depression in primary care Differentiating depression vs dementia Navigating Guardianship issues