COACH
A Novel Approach for Improving
Access to Care for Frail Seniors in
PEI
Dr. Tim Stultz MD COE,
Kirsten Mallard NP
Provincial Geriatric Program
Making the Connection
Oct. 16, 2015
The Problems of Aging
What is the COACH Team?
Caring for Older Adults in Community and at Home
• Integrated, interdisciplinary expert team with the frail
senior patient/client at the centre
• Created through stronger collaboration of existing
resources in three partner programs (Home Care,
Geriatric Program, Primary Care)
• Does not replace referral to Geriatric Program
• Separate stream for small group of most complex
patients/clients to pilot the team approach
Evidence from Other
Jurisdictions
• Project work began with consideration of best practice
models of care and approaches in other provinces
• Development of COACH Team benefited from learning
from 2 teams
• Integrated Client Care Program (Toronto, ON) – partnership
between Primary Care and Home Care
• Care for Seniors Program (North Perth, ON) – Nurse Practitioner
led partnership between Primary Care, Home Care and Geriatric
Program
Objectives of the COACH
Team
• Improve access to care for frail seniors
• Increase awareness and expertise re: complex geriatric
syndromes
• Improve quality of care for frail seniors and their
family/caregivers
Who is on the COACH
Team?
• Core members:
• Geriatric Program Nurse Practitioner
Role of the Geriatric Program NP
in COACH
The “glue” between the programs and services
• Comprehensive Geriatric Assessment
• 1.5 to 2 hours to complete
• Medical and social history, current meds, physical exam and
functional, cognitive and mood assessments
• Expertise on complex geriatric syndromes
• Strong focus on communication, integration and
collaboration
• Credentials:
• Clinical training with Geriatricians
• Collaborative member of Geriatric Program team
Who is on the COACH
Team?
• Core members:
• Geriatric Program Nurse Practitioner
• Family physician
Role of Primary Care Physician
and NP in COACH
• Maintain lead on medical care for patients
• Provide feedback/input on proposed team model and
processes
• Provide feedback on patients identified to participate in
pilot
• Work collaboratively with the team and share
information on patients
• Provide feedback/input to the evaluation of the pilot
Who is on the COACH
Team?
• Core members:
• Geriatric Program Nurse Practitioner
• Family physician
• Home Care - Care Coordinator
• Collaborating with other members depending
on the needs of the patient/client:
• Primary Care nursing staff (NP, RNs, LPNs)
• Geriatrician
• Allied health or other health care providers
COACH Target Population
• Frail Senior definition
• Client aged 75+, who is assessed or would be assessed as level 3, 4, or 5
with the Seniors Assessment and Screening Tool, and is at significant
risk of institutionalization due to unstable health status and/or living
conditions and/or personal resources
• Phased in approach to eligibility
• Pilot team with small group of common clients initially
• Existing Home Care clients, then expand to new referrals
• Explore expansion across province
Pilot Participants
• Existing Home Care frail senior clients who are also a
patient of Montague Health Centre (approximately 60
total common clients)
• For pilot, focusing on 15 to 20 individuals with highest
complexity, based on:
• Inpatient admissions
• Visits to ER
• Office visits to primary care
• Previous referral to Geriatric Program
• Feedback/input from physicians
Functions of COACH Team
• Comprehensive geriatric assessment
• Home visits
• Connect with patient in hospital and timely post-discharge
follow up
• Facilitating collaborative care planning and Advance Care
Plan
• Sharing of information for smoother transitions of care
• Priority access to enhanced Home Care resources, Geriatric
Program Nurse Practitioner and Geriatrician (collaboration or
consult, as required)
• Teaching/support to client, family/caregivers and health care
providers on complex geriatric syndromes
Other pilot objectives - COACH
Team
• Develop Frail Senior Care Pathway
• Validate team model and processes
• Develop efficient documentation and
communication processes
• Define eligibility criteria and plan for
growth/expansion of COACH post-pilot
Pilot Timelines
• Pilot from January to October 2015
• Preliminary evaluation – April 2015
• Also ongoing evaluation throughout pilot,
using quality improvement approach
• Full evaluation at end of pilot
MY ROLE
First Steps…
• Once identified through Home Care & after
consultation with Family Physicians…
• Phone call to patient and/or caregiver to seek
consent and arrange for initial home visit.
• CGA’s completed on every COACH patient
over the first few months.
First Steps…
Prior to visiting home:
Review Paper chart from clinic looking at PMHX,
medications, resources in home if any.
Review ISM (Home Care Chart), Drug information
system (DIS), Cerner for blood work, recent hospital
documents related to admissions, ER visits, specialty
consultations.
Communicate with team members involved.
Comprehensive Geriatric
Assessment (CGA)
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Listen!!! HPI…
Review of medical and social history
Chronic diseases
Current medications
Physical examination
Functional assessment (ADL’s & IADL’s)
Cognitive assessment
Mood assessment/Sleep/Appetite
Home Supports/Resources
Discussion around Advanced Care Planning
Focus…
Complex Geriatric Syndromes such as delirium,
depression, varying stages of dementia (BPSD), falls,
de-conditioning, mobility, incontinence, functional
decline, medications.
Guidelines (HTN, Diabetes)
Recommendations often around symptom
management, sleep disturbance, medications,
community resources, Home Care Services,
Catastrophic drug plan, etc.
All This Info…..
Focus is to really look at the information
collected and stick to the objectives of
COACH which is to…
• Improve access to care for frail seniors
• Increase awareness and expertise re: complex geriatric
syndromes
• Improve quality of care for frail seniors and their
family/caregivers
Integrated Team
As Part of This Project…
• Consulted collaborating Geriatrician as needed.
• Really made an effort to connect with the Family
Physician to collaborate & discuss recommendations.
• Jointly with Home Care Coordinator created the plan
of care.
• Patient/Care Giver involved in decision making
process and care plan.
• Ongoing Support to Patient & Family
COACH
• The NP works with other sectors across the
continuum to coordinate care and support
patients as they transition between sectors,
including home, emergency, acute care,
community care, LTC, Respite, Restorative.
(Dr. Prasad et al., 2013)
• Use SBAR to communicate.
COACH
CASE – Mrs. J
Mrs. J
o 79 year old lady, lives with spouse, who is currently
on dialysis. Assessed by Geriatrics in the past and
diagnosed with Mixed Dementia in 2012. Noted
Functional decline since then & today has findings of
low mood & mild agitation. Also congested cough
present.
o Collateral information from son who is the primary
caregiver. No other family on Island.
Functional Status
o She sponge bathes herself twice a week (?) and feels
she does not need anymore assistance.
o Tried home support and inconsistent with service.
Declined Day Program.
o Incontinent of urine at times.
o Unsteady on feet, has had 2 falls 6-12 months and
now uses a walker. Increased difficulty transferring
from sitting to standing.
o All IADL’s by caregiver. Prompting with ADL’s
PMHX
o
o
o
o
o
o
o
Epilepsy (1945) ?
Hypothyroidism – resolved
HTN
Chronic Vertigo
Osteoporosis
Mild COPD
Appendectomy, Tubal Ligation, Rt. & Lt.
Cataract removed, thoracic kyphosis, ? Parkinsons
2011
Medications
o
o
o
o
o
o
o
o
Apo-Cal
Teva –Betahistine 12 mg daily
Vitamin D
Amlodipine 2.5 mg daily
Donepezil 10 mg daily
Irbesartan 10 mg daily
Indapamide 1.25 mg daily
Multivitamin daily
Physical Exam
Afebrile, B/P sitting 130/70, HR 80 reg, Standing
120/70, no postural symptoms.
Noted to have congested cough, Air entry decreased to
base of lungs bilaterally, no crackles, some wheezing
noted throughout.
Pedal edema noted bilaterally. Feet dependant.
Narrow based gait with imbalance, slight stooped
posture, using a walker.
Cognition- Agitated mood, wasn’t feeling well but did
do a MMSE – 20/30 , trouble with clock.
Recommendations
(Based on First Visit)
o Discussed Assessment with Family Physician
o Puffers for COPD, HCN involved in teachingcaregiver to administer.
o Trial of citalopram (mood, support frontal lobe fx)
o Home Care Coordinator looking into resources (home
support, meals on wheels, day program, home
physio, OT)
Following Visits…..
Through the COACH Pilot over time..
Pedal edema worsened, dependant feet day & night.
Didn’t like her bed. Preferred the chair in living room
which was not ideal…Reduced amlodipine, mobility
worsened, difficulty getting to bathroom. Declined
compression stockings. Started on lasix.
By this time she was receiving daily home support and
regular nursing visits along with having OT and
Physio heavily involved.
Home Care Coordinator very involved working with
Caregiver in an attempt to control her edema.
Fell in the bathroom, injured her leg which impacted her
mobility. Family physician away. Visit to Emerg for xray and rule out fracture.
But…
Able to send an SBAR to Emergency doc with update to
communicate issues. Was admitted.
Able to make some medication adjustments with some
improvement and then discussed taking a
Restorative Approach
Different covering physician. Agreed to plan, family
consented. Contacted another physician to see if he
would accept the transfer to Colville…she was then
transferred for Respite specifically for a restorative
approach.
Team from LTC, Home Care, Family met at the facility,
reviewed function and goals of care.
Able to get her measured for compression hose. Noted
BIG improvement to her lower legs/feet. Reduced
lasix. Mobility improved substantially. During her
respite able to have equipment put in at home and
caregiver was rejuvinated. Discharged home in two
weeks.
Other Examples….
• Medication changes/adjustments in consultation with GP’s....educating
families, staff on side effects and routine follow up. Did it
improve/decrease symptoms?
• Regular contact with Care Coordinator – knowing who to call.
• Mrs. C with very vascular presentation of dementia, challenging
symptoms. Team involved to organize increased service to avoid
hospitalization following an arm fracture.
• Mr. C patient in his early 90’s living with his sister who has
dementia…he was adamant about staying home, difficult to get him to
see his GP, team collaborated heavily.
• Mr. H caregiver indicated that before COACH he was admitted
monthly to hospital. She is feeling supported and this has not
happened since the pilot began.
• Team has identified that patients have little awareness around
Catastrophic drug plan so was able to introduce this (coverage for
diabetic meds, antipsychotics, dementia meds, etc.)
Ongoing Support
• Regularly followed by care coordination and home
care services.
• Updates provided to Family Doctors.
• Rounds every Weds morning with Team to discuss
Coach patients and Care Plans. Access to
Geriatrician.
• Family supported.
• Connect with Acute Care for inpatient assessment &
discharge follow up. Involved in Care Planning.
Other Benefits
• Staff education around complex Geriatric Syndromes
and use of medications. Importance of CGA.
• Family education regarding Dementia & common
Geriatric conditions.
• Continuity of Care.
• Email Alert of Acute Care Admission
• Team Support - Collaboration!
Identified Challenges
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Admin/office/charts
Communication/Documentation
Lack of shared electronic chart
COACH NP or Family Physician role with patient
health issues.
• Availability
• Identified that if we are going to support these frail
older adults at home, more Home Care resources are
needed (respite, access to evening & night cares)
As Part of This Project…
• Consulted collaborating Geriatrician as needed.
• Really made an effort to connect with the Family
Physician to collaborate & discuss
recommendations.
• Jointly with Home Care Coordinator created the
plan of care.
• Patient/Care Giver involved in decision making
process and care plan.
• Ongoing Support to Patient & Family
Evaluation
Evaluation
• Overwhelmingly positive
• Reductions in drugs- improved
physical and mental wellbeing
• Home visit repeatedly cited as key
feature of the program
• Skills of NP were exceptional
Evaluation
• Only recommendations:
• More NP’s
• More respite
Donepezil$40/month
Rollator Walker$300
Having COACH come to your HOME -
PRICELESS!!
Currently
Geriatricians
NP Geriatrics
Restorative
care west
COACH Queens
COACH Prince
Vision
Integrated
Seamless
Acute care
Restorative care
COACH
Restorative
Home care
care east
Palliative care
Restorative
care PCH
Restorative
care PE
Home
COACH Kings
Questions?