interrai Suite as a Tool for Management of Health Services for the Elderly: An Integrated Screening and Assessment System

Transcription

1 interrai Suite as a Tool for Management of Health Services for the Elderly: An Integrated Screening and Assessment System John P. Hirdes, Ph.D. Ontario Home Care Research and Knowledge Exchange Chair Professor, Department of Health Studies and Gerontology University of Waterloo & Scientific Director, Homewood Research Institute

2 Agenda interrai instruments in Canada Literature on screening and assessment A conceptual framework for use the interrai Instruments interrai Contact Assessment Emergency Department Screener Method for Assigning Priority Levels (MAPLe)

3 The interrai Family of Instruments Home Care + Contact Assessment Nursing Homes Acute Care + ED Screener Mental Health Inpatient Community Emergency Screener Forensic Supplement Prisons Brief Mental Health Screener Intellectual Disability Palliative Care Post-Acute Care-Rehabilitation Community Health Assessment AL supplement Functional supplement MH supplement Deafblind supplement Subjective Quality of Life Long term care Home and community care Mental Health

4 Applications of interrai s Assessment Instruments: One assessment multiple applications Case-mix Single Point Entry Care Plan Resource Allocation Evaluate Best Practices Assessment Prevent Gaming Outcome Measures Patient Safety Quality Improvement Public Accountability Accreditation Quality Indicators

5 Implementation & Testing of interrai Instruments Solid symbols mandated or recommended by govt; Hollow symbols research/evaluation underway DB RAI 2.0 (NH) RAI-HC RAI-MH interrai CMH interrai ESP interrai PC interrai ID interrai ED/AC interrai CA interrai CHA interrai AL interrai SQoL

6 interrai Tools for Screening and Assessment

7 What does the literature say about assessment and screening?

8 What does the literature say about assessment and screening? Comprehensive assessment Can identify unmet needs Can reduce Hospitalization, Institutionalization, Mortality, Morbidity

9 What does the literature say about assessment and screening? Comprehensive assessment Can identify unmet needs Can reduce Hospitalization, Institutionalization, Mortality, Morbidity Preventive Home Visits Some evidence that can reduce costs BUT, not cost effective if used with persons not at risk of major health decline, hospitalization, etc

10 What does the literature say about assessment and screening? Comprehensive assessment Can identify unmet needs Can reduce Hospitalization, Institutionalization, Mortality, Morbidity Preventive Home Visits Some evidence that can reduce costs BUT, not cost effective if used with persons not at risk of major health decline, hospitalization, etc Screening Used to target persons most likely to benefit from intervention Some evidence that fairly simple screens can help to differentiate subpopulations e.g., self-rated health is a strong predictor of mortality in general elderly population

11 Question Some basic questions for service provision In the general population of older persons, who needs a comprehensive geriatric assessment? interrai Solution interrai CA & Assessment Urgency Algorithm Among the people who are assessed, how should we prioritize access to services? Who is at greater risk of adverse outcomes? Who is most likely to benefit from intervention? What will it cost to provide them care? interrai HC & MAPLe CAPs CAPs RUG-III/HC

12 Integrated Screening Methodologies (Compatible assessment, consistency in referral logic) Acute Care Single Point Entry Contact Assessment HC

13 Integrated Screening Methodologies (Compatible assessment, consistency in referral logic) Acute Care ED Screener AC Single Point Entry Contact Assessment HC

14 Integrated Screening Methodologies (Compatible assessment, consistency in referral logic) Acute Care ED Screener AC Single Point Entry Contact Assessment HC Nurse Practitioners CHA

15 Integrated Screening Methodologies (Compatible assessment, consistency in referral logic) Community Acute Care Support Agencies ED Screener AC CHA Single Point Entry Contact Assessment HC Nurse Practitioners CHA

16 Integrated Screening Methodologies (Compatible assessment, consistency in referral logic) Community Acute Care Support Agencies ED Screener AC CHA Single Point Entry Contact Assessment HC Family Physicians Self-report Screener Nurse Practitioners CHA

17 Design Parameters for Contact Assessment

18 Design Parameters for Contact Assessment Aim to identify Clients needing comprehensive assessment (i.e., interrai-hc) Clients needing services urgently Type of clients (e.g., rehab) Expected length of stay Needs of short stay clients who will not received further assessment

19 Design Parameters for Contact Assessment Aim to identify Clients needing comprehensive assessment (i.e., interrai-hc) Clients needing services urgently Type of clients (e.g., rehab) Expected length of stay Needs of short stay clients who will not received further assessment Used with all intakes Hospital and community Telephone and in-person

20 Design Parameters for Contact Assessment Aim to identify Clients needing comprehensive assessment (i.e., interrai-hc) Clients needing services urgently Type of clients (e.g., rehab) Expected length of stay Needs of short stay clients who will not received further assessment Used with all intakes Hospital and community Telephone and in-person Compatible interrai HC NOT a replacement for interrai HC Contains a standardized set of interrai items

21 Design Parameters for Contact Assessment Aim to identify Clients needing comprehensive assessment (i.e., interrai-hc) Clients needing services urgently Type of clients (e.g., rehab) Expected length of stay Needs of short stay clients who will not received further assessment Used with all intakes Hospital and community Telephone and in-person Compatible interrai HC NOT a replacement for interrai HC Contains a standardized set of interrai items Consistent with MAPLe

22 Design Parameters for Contact Assessment Aim to identify Clients needing comprehensive assessment (i.e., interrai-hc) Clients needing services urgently Type of clients (e.g., rehab) Expected length of stay Needs of short stay clients who will not received further assessment Used with all intakes Hospital and community Telephone and in-person Compatible interrai HC NOT a replacement for interrai HC Contains a standardized set of interrai items Consistent with MAPLe Decision support vs automated decision making

23 Assessment Urgency Algorithm Long Stay/Clinically Complex Self reliance indicator Self-reliant Impaired Self-rated health excellent or good Family overwhelmed No Yes No Yes Dyspnea or unstable condition or flareup Unstable condition or flareup Self-rated mood: sad, depressed, hopeless 6 86% No Yes Yes No Yes No 2 38% 4 63% 3 50% 1 20% 6 85% Personal hygiene ADL Yes No 5 79% 3 53%

24 Percentage of clients rated as requiring interrai HC by Assessment Urgency algorithm, study sample (n=408) and provincial data (n=22,410) % Assessment Urgency Score Derivation Sample Provincial Data

25 Actual length of stay of home care clients by Assessment Urgency score at intake, n=408 Algorithm level D/C within 14 days D/C within 60 days Case open over 60 days 5,6 (likely long stay) 3% 33% 64% 3,4 9% 42% 49% 1,2 (likely short stay) 19% 43% 37%

26 interrai Emergency Department Screener

27 Functions of interrai ED Screener

28 Functions of interrai ED Screener Screener for elderly patients in acute care based on CA

29 Functions of interrai ED Screener Screener for elderly patients in acute care based on CA Identify complex patients requiring specialized geriatric assessment and interventions May already have a problem (e.g., delirium, ADL imp) o Needs are often under-detected May develop problems during acute hospital stay

30 Functions of interrai ED Screener Screener for elderly patients in acute care based on CA Identify complex patients requiring specialized geriatric assessment and interventions May already have a problem (e.g., delirium, ADL imp) o Needs are often under-detected May develop problems during acute hospital stay Improve management of frail elderly in acute care to reduce risk of: Bad patient outcomes (e.g., falls, delirium, functional decline) Bad administrative outcomes (long hospital stay, NH placement, readmissions)

31 Functions of interrai ED Screener Screener for elderly patients in acute care based on CA Identify complex patients requiring specialized geriatric assessment and interventions May already have a problem (e.g., delirium, ADL imp) o Needs are often under-detected May develop problems during acute hospital stay Improve management of frail elderly in acute care to reduce risk of: Bad patient outcomes (e.g., falls, delirium, functional decline) Bad administrative outcomes (long hospital stay, NH placement, readmissions) Screener used to trigger interrai Acute Care assessment for admissions to hospital Referral to home care and interrai HC assessment if not admitted

32 Comprehensive Assessment Required Odds Ratio c Stat (95% CL) interrai ED Screener 1 High Risk 6.84 ( ) Medium Risk 3.12 ( ).71 Admitted to Acute Care from Emergency Room Odds Ratio (95% CL) c Stat 3.18 ( ) 1.30 ( ).63 Long Stay/ALC Patient, if Admitted to Acute Care Odds Ratio (95% CL) c Stat 4.90 ( ) 4.08 ( ).63 ISAR ( ) ( ).61 Not Significant TRST ( ) ( ).53 Not Significant [1] interrai ED Screener results based on the interrai Assessment Urgency algorithm.

33 Distribution of Canadian Triage Assessment Scale (CTAS) and Assessment Urgency Scores Among ED Patients Aged 75+

34 Method for Assigning Priority Levels (MAPLe)

35 Development of MAPLe Decision support tool for interrai HC to establish priority for access to community and nursing home services Developed to predict three key outcomes Caregiver distress Nursing home placement Person considered better off elsewhere MAPLe can also be derived from interrai AC, CHA & CMH

36 Variables used in MAPLe Algorithm ADL Hierarchy Scale Cognitive Performance Scale Behaviour Disturbances: Wandering Verbal abuse Physical abuse Socially inappropriate Resists care Worsening of decision-making Medication management Pressure or stasis ulcers Environment: Bathroom Kitchen heating/cooling Personal safety Access to home Falls Few meals Meal preparation Swallowing Geriatric Screener NH Risk CAP

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38 Rate of Nursing Home Admissions Within 90 Days of Assessment by MAPLe Level, Ontario, Derivation Sample % Low Mild Moderate High Very High MAPLe Level

39 Relationship between MAPLe and signs of caregiver stress in selected Canadian Provinces

40 Distribution of MAPLe Scores, by Diagnosis, Ontario Home Care Clients

41 Rates of Any Indicator of Caregiver Distress by MAPLe Score and Diagnosis, Ontario CCAC Clients

42 International Differences in Access to Home Care: Distribution of MAPLe Levels by Country % low mild moderate high very high MAPLe Level Sweden Denmark Iceland Netherlands Norway Finland Winnipeg Ontario UK Germany Czech Rep France Italy

43 Rate of Caregiver Distress by Percentage of Clients with MAPLe Level 4 or 5, by Country PAPHR SW DK IS FI NO WRHA ON UK NL CZ NS GE FR Pearson s r=0.82

44 Using MAPLe for Matching Services to Needs MAPLe Low Expected Service Type I & R Mild Moderate Home Care High Very High LTC Facility

45 Using MAPLe for Matching Services to Needs MAPLe Low Expected Service Type I & R Mild Moderate Home Care High Very High LTC Facility

46 Using MAPLe for Matching Services to Needs MAPLe Low Expected Service Type I & R Mild Moderate Home Care High Very High LTC Facility

47 Using MAPLe for Matching Services to Needs MAPLe Low Expected Service Type I & R Mild Moderate Home Care High Very High LTC Facility

48 Using MAPLe for Matching Services to Needs MAPLe Low Expected Service Type I & R Mild Moderate Home Care High Very High LTC Facility

49 Using MAPLe for Matching Services to Needs MAPLe Low Mild Moderate High Very High Expected Service Type I & R Home Care LTC Facility Case Manager Review Self-rated health Poor stamina Prior hospitalizations Emergency visits Caregiver needs Hrs of informal care Hrs of formal care Family Preferences Client Preferences CHESS Score 24 hr supervision

50 Using MAPLe for Matching Services to Needs MAPLe Expected Service Type Case Manager Review Actual Service Type Low Mild Moderate High Very High I & R Home Care LTC Facility Self-rated health Poor stamina Prior hospitalizations Emergency visits Caregiver needs Hrs of informal care Hrs of formal care Family Preferences Client Preferences 24 hr supervision I & R Homemaking Personal Care Home Care LTC Facility CCC Facility

51 Nursing Home Placement Among Home Care Clients by MAPLe Level, Ontario & Winnipeg Regional Health Authority Ontario Winnipeg

52 Nursing Home Placement Among Home Care Clients by MAPLe Level, Ontario & Winnipeg Regional Health Authority Ontario Winnipeg

53 Concluding remarks interrai family of instruments provide evidence based approach to screening, assessment and prioritization of clinical services Can be used at individual level to match needs to services but also at the population level to benchmark quality of care and evaluate performance of services for the elderly

54 Thank you!