Understanding Hospital Utilization Patterns Among Older Adults in Toronto
Exploring the hospital utilization trends in the geriatric population in Toronto, this content showcases the impact of aging on healthcare services. It highlights the prevalence of hospital visits, admissions, and types of care received by seniors aged 65 and above. The data presented underscores the need for specialized geriatric models of care to address the unique healthcare requirements of the elderly population.
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University Avenue Service (MSH/TGH/PMH) Geriatric Medicine Rotation Orientation Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky Chau | Dr. Barry Goldlist | Dr. Rameez Imtiaz Dr. Kristine Kim | Dr. Stephanie Kim | Dr. Guillaume Lim-Fat | Dr. Alanna Miller | Dr. Karen Ng Dr. Richard Norman | Dr. Christina Reppas-Rindlisbacher | Dr. Lindy Romanovsky | Dr. Luxey Sirisegaram Dr. Samir Sinha | Dr. Nathan Stall | Dr. Asenath Steiman Mount Sinai Hospital Suite 475, 600 University Avenue Toronto, Ontario, M5G 1X5 (416) 586-4800 x 7859 4/5/2024
Orientation Outline: Why Geriatrics? Building Better Geriatric Models of Care Our Geriatric Medicine Consultation Service & Clinics Additional Orientation Information Additional Info for Orthopedic & Physiatry Residents
Why Geriatrics? 4/5/2024
Canadas Population 2021 18% = 65 + 4/5/2024
Canadas Population 2031 25% = 65 + 4/5/2024
42% Older Canadians and Hospitalizations 4/5/2024
Older Canadians and Hospital Days 59% 4/5/2024
Ageing and Hospital Utilization in Downtown Toronto Number Age <65 Seniors 65 + % Seniors 75+ Local Population 1,142,469 85% 15% 49% Emergency Room Visits 321,044 79% 21% 62% Acute Hospitalizations 78,025 63% 37% 64% w/ Alternate Level of Care Days 4,263 17% 83% 76% w/ Circulatory Diseases 10,361 32% 68% 65% w/ Respiratory Diseases 5,928 43% 57% 73% w/ Cancer 6,743 53% 47% 54% w/ Injuries 5,809 58% 42% 71% w/ Mental Health 6,161 87% 13% 59% Inpatient Rehabilitation 3,368 25% 75% 66% Toronto Central LHIN, 2006
Longitudinal Study on Aging: Examining Hospital Utilization in the 70+ over an 8 year period Only a small proportion of older adults are consistently extensive users of hospital services Wolinsky et al., 1995
What Defines our Highest Users? Economic & Social Frailty Cognitive & Functional Impairments Multimorbidity
The Hazards of Hospitalization Older adults, especially those who are frail, are particularly vulnerable to the risks of iatrogenic illness and functional decline The pathogenesis of cognitive and functional decline is complex and involves an interaction amongst: The ageing process Comorbid and acute illnesses The hospitalization process
Conceptualizing Functional Decline HOSPIT AL Hostile Environment Depersonalization Bedrest / Immobility Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Acute Illness + Possible Impairment Functional Older Person Depressed Mood, Delirium, and Negative Expectations Physical Impairment and Deconditioning Dys Dysfunctional Older Person functional Older Person Palmer et al., 1998 (Modified)
Trajectories of Functional Decline Baseline Baseline ED Presentation ED Presentation Discharge Discharge 70+ Pts N=2293 57% Stable 45% Stable 65% Discharged with Baseline Function 20% Recovery 12% Hospital Decline 35% Discharged with Worse than Baseline Function 18% Fail to Recover Pre-Hospital Decline 43% Decline 5% Pre-Hospital and Hospital Decline Covinksy et al., J Am Geriatr Soc 2003
Costs of Functional Decline The loss of independent functioning during hospitalization has been associated with: Prolonged lengths of hospital stay Increased readmission A greater risk of institutionalization Higher mortality rates Palmer et al., 1998
Comprehensive Geriatric Assessments (CGA) Hospitalization is an opportunity to provide a beneficial intervention (i.e. CGA) for our older adults CGA is defined as a multidisciplinary diagnostic process intended to determine a frail elderly person s medical, psychosocial, and functional capabilities medical, psychosocial, and functional capabilities and limitations limitations in order to develop an overall plan for treatment and long term follow up Rubenstein, 1982
What is a Comprehensive Geriatric Assessment? Many Other Many Other Specialties Specialties Geriatric Geriatric Medicine Medicine U U V V W X W A A X Y Z Z
Components of a CGA use the templates as a guide ID/RFR Labs & Investigations PMHx Confusion Assessment Method (CAM) Mini Mental Status Exam (MMSE) Montreal Cognitive Assessment (MoCA) Rowland Universal Dementia Assessment Scale (RUDAS) Geriatric Depression Scale (GDS) Mood & cognition Vision & hearing Falls Dysphagia Physical Examination HPI Activities of Daily Living (ADLs) Activities of Daily Living (ADLs) D D ressing E E ating A A mbulating T T oileting/transfer H H ygiene S S hopping H H ousekeeping A A ccounting F F ood Prep/Meds T T ransportation /Telephone CGA Weight loss Bladder & bowel Cognitive Assessment incontinence Pain Sleep Medications Current living situation Family & community supports Advance care directives Powers of attorney General financial situation Geriatric Review of Systems Functional History Social History
An Opportunity for Intervention During Hospitalization 29 RCTs, 13 766 participants aged 65+ older, 6 countries, admitted to hospital (in emergency) who underwent CGA vs. usual care OUTCOMES: OUTCOMES: More likely More likely to be living at home (alive and in their own home) in 3-12 months (RR 1.06, 95% CI 1.01 to 1.10; 16 trial, 6799 participants, high certainty evidence) Less likely Less likely to be admitted to a nursing home in 3-12 months (RR 0.80, 95% CI 0.72 to 0.89, 14 trial, 6285 participants, high certainty evidence) Ellis et al. 2017
Building A Continuum Of Geriatric Care 4/5/2024
OUTPATIENT MODELS COMMUNITY MODELS INPATIENT MODELS EMERGENCY DEPARTMENT MODELS 4/5/2024
Our Geriatric Medicine Consultation Service 4/5/2024
University Avenue Inpatient Geriatric Medicine Consultation Service The University Avenue Consultation Service provides geriatric medicine coverage across 3 hospital sites: Mount Sinai Hospital (MSH) Toronto General Hospital (TGH) Princess Margaret Hospital (PMH) Interprofessional Team Supports CNS: Rebecca Lemieux, 416-723-8864 Geriatric Pharmacist ICCP TC-LHIN Care Coordinator: Jennifer Thomas (Mondays) House Calls Team: Stacey Pustowka or Natalie Leventhal, SW (Wednesdays) Circle of Care Team: Natalie Zabolotsky or Sherin Surenthiran (Thursdays)
Referrals Common Reasons Common Reasons Other Other Reasons/Sources Reasons/Sources Delirium & Dementia Orthogeriatrics Service Managing Functional Decline and Falls Surgical ACE patients Diagnostic/Treatment Challenges House Calls (HC) Advice to Support Transitions to Outpatient, Community & Home-Based Services (House Calls/Community Outreach Team) Integrated Client Care Program (ICCP) Geriatric Emergency Management (GEM) Flags Goals of Care & Disposition Planning Geriatric Psychiatry
MSH Orthogeriatrics Service A collaborative Orthopedic, Hospitalist, & Geriatric Medicine Co-Management Model We provide daily Automatic Geriatric Consultation for ALL Automatic Geriatric Consultation for ALL patients 65 years old with patients 65 years old with hip fractures hip fractures Referrals Referrals Staff Receive Automatic E-mail Notification every Morning and Informs the Team
A Reactive Proactive Strategy 1. 2. 3. 4. 5. 6. 7. 8. Adequate CNS Oxygen Delivery Fluid/Electrolyte Balance Treatment of Severe Pain Elimination of Unnecessary Medications Regulation of Bowel/Bladder Function Adequate Nutritional Intake Early Mobilization and Rehabilitation Prevention, Early Detection, and Treatment of Major Postoperative Complications Appropriate Environmental Stimuli 10. Treatment of Agitated Delirium n=126 admitted hip# patients 65 yo Geri Consult pre-op or <24h post-op Daily visits to follow 10 parameters Incident delirium 50 vs. 32% (ARR 18% NNT~6) 9. Marcantonio et al, 2001; Siddiqi et al., 2016; Eamer et al, 2018
Co-Managing Patient with Hip Fractures Geriatrics Geriatrics Hospitalist & Med Consults Hospitalist & Med Consults Mental status Delirium Pre-admission cognition Mood Falls Bone Health Pain and Nausea Constipation Medication Rationalization Disposition Planning Perioperative Risk Assessment Respiratory issues requiring close frequent monitoring Management of: Anticoagulation Blood Glucose Electrolyte Abnormalities Acute Kidney Injury However, collaborativeco-management careis often provided
(HC) Provides Home-based Primary Care For Homebound Elders living within the Toronto Central LHIN catchment area SH/UHN Geriatric Medicine Consultation Service provides Acute Care support when HC patients are admitted to hospital and helps assess patients in hospital for House Calls program enrollment Types of House Calls Consultations: Types of House Calls Consultations: New Patient Referral to House Calls New Patient Referral to House Calls Complete & Fax HC s Referral Form (including Geriatrics Consultation Note & Inpatient Discharge Summary) Existing HC patients who are admitted to MSH Existing HC patients who are admitted to MSH Staff receive E-mail notification when HC patient arrives to the ED Liaise with Admitting team and offer Co-management & Support Upon discharge, fax Discharge Summary and Geriatric Notes to HC www.seniorshousecalls.ca
Integrated Client Care Project (ICCP) This program provides Intensive TC-LHIN Home and Community Care Case Management for the most complicated patients (frequent fliers) we see who are living in the community Their TC-LHIN Care Coordinators create close collaboration with Primary Care, ED, Geriatric Psychiatry and Medicine teams Types of ICCP Consultations: Types of ICCP Consultations: Staff receive E-mail notification when ICCP patients arrive in the ED Liaise with admitting team and offer co-management & geriatric support
Surgical ACE Flags Collaboration between Geriatric Medicine and General Surgery Proactively identifies and supports vulnerable older adults aged 75+ admitted urgently or emergently to the General Surgery Acute 75+ admitted urgently or emergently to the General Surgery Acute Surgery (ACS) Surgery (ACS), a dedicated team that admits patients from the emergency department aged Referrals Referrals Flagged Surgical ACS patients are emailed out to the consult email list every morning; weekend/holiday flags are held until next business day
Surgical ACE For flagged patients, review chart and liaise with general surgery as needed to determine appropriateness General Surgery can still consult as usual through locating
GEM Flags Check GEM Flags Daily Review MSH MSH GEM Nursing Notes in Powerchart for GEM flagged patients Open Patient Chart Clinical Notes GEM Nursing notes TGH TGH GEM Nurse (Jane Ren) also sends TGH GEM Flagged patients via the TGH Consults e-mail notification for the team to follow-up Liaise with respective Admitting Team at MSH/TGH and offer Geriatrics Support if needed
Geriatric Psychiatry Consult Service Shared Care for Older Adults with Mental Health Needs: Active Mental Health Illnesses Delirium Co-management Difficult to Manage Behavioural & Psychological Symptoms of Dementia How to access Geriatric Psychiatry? MSH Call x8419 to request a Geripsych consultation TGH Order Inpatient Psychiatry Consult via Epic
Communicating New Consultations E-mail ALL new referrals to the Interprofessional Geriatric Medicine Consultation team at MSH & TGH respectively (Sometimes you will be the On-Call person even if you are assigned to be in clinic)
Completing a Consult Consultation Forms Consultation Forms MSH MSH Use approved PINK PINK Forms approved MSH CGA Templates (General + Hip Fracture) OR MSH UHN UHN Consults are done through EPIC step-by-step instructions on how to process a consult through EPIC EPIC record system. Please see next slides for Record consult date, start (includes chart review times) start, and stop time stop time on your consult note MSH Only: MSH Only: Store completed consults in the Geriatrics Office filing cabinet under the printer (top top drawer) by month File PHOTOCOPY PHOTOCOPY of MSH Consultation Forms Or Or File CARBON COPY CARBON COPY of PINK PINK MSH Consultation Forms
AVAILABLE ONLINE THROUGH TRAINEE WEBSITE AND IN MSH GERIATRIC OFFICE
AVAILABLE ONLINE THROUGH TRAINEE WEBSITE AND IN MSH GERIATRIC OFFICE
Adding TG/PM & PM Geriatrics Team List to your Consult Profile Adding TG/PM & PM Geriatrics Team List to your Consult Profile Handover Lists
Adding Pending Geriatrics Consults to your Consult Profile Adding Pending Geriatrics Consults to your Consult Profile Handover Lists
UHN Epic Consult UHN Epic Consult
MSH Consult Recommendations AVOID using the Consult SUGGEST Orders AVOID using the Consult SUGGEST Orders Creates Miscommunications Creates Delays in Patient Care Always best to communicate consultation recommendations directly to referring team Provides education and rationale Offer to implement suggestions directly - ensures recommendations are completed! EXCEPTION EXCEPTION: Direct order entry for hip fracture co-management patients. Orders still discussed with Hospitalist team.
Sign-out List for University Avenue (includes TGH/PMH Patients) geriatrics *** ALWAYS UPDATE THE SIGN-OUT LIST ***
Outpatient Geriatric Medicine & Specialty Clinics
Sinai/UHN Clinics Please ensure that for UHN training for Dragon is completed and the Dragon Med One Team has granted you access PRIOR UHN, all Please check your schedules & be on time time for your clinic, as patients have been scheduled for you in advance be on PRIOR to starting Contact email is speechcognition@uhn.ca Please ensure you obtain BOTH and UHN UHNDictation Access at the BEGINNING BEGINNING of your rotation BOTH MSH MSH They are NOT THE SAME NOT THE SAME
Sinai/UHN Clinics TRI Outpatient Clinics Ground Floor (Elm Street Entrance) Drs. Alibhai, Berger, Chau, Imtiaz, K. Kim, Lim-Fat Miller, Reppas, Sirisegaram, Steiman Renemae Lopez, RN, Samuel Leite, SW UC Outpatient Physician Clinics Admin (416) 597-3422 x 4200 ucoutpatientphysicianclinics@uhn.ca MSH GIM/Geriatrics Clinic Area 4th floor, Rm 463 Drs. Goldlist, S. Kim, Ng, Norman, Romanovsky, Sinha, Stall GIM-GeriatricsClinic@sinaihealth.ca
