COMPREHENSIVE GERIATRIC ASSESSMENT IN A FRONTIER MONTANA HOSPITAL

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COMPREHENSIVE GERIATRIC ASSESSMENTIN A FRONTIER
MONTANA HOSPITAL

• Presented To
• CHAMPIONS FOR QUALITY CONFERENCE
• ROMAN M HENDRICKSON, MD
• CERTIFIED FAMILY PRACTICE GERIATRICS
• RUBY VALLEY HOSPITAL
• SHERIDAN, MONTANA
• JULY 19, 2008

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WHAT IS COMPREHENSIVE GERIATRIC ASSESSMENT?

• A process utilizing healthcare providers in
  multiple disciplines, to comprehensively evaluate
  the medical, functional, and psycho-social needs
  of a Frail Elderly Patient, so as to maximize the
  patients functional capabilities and quality of
  life.

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WHO IS IT INTENDED FOR?

• Elders who are Failing in their current
  environments
• Elders who are Just Not Doing Well
• Elders who have had a progressive overall
  deterioration in their condition
• Elders whose condition has deteriorated to the
  point where serious consideration has been given
  as to whether they can remain in their own home
• Elders with Mobility, Balance, and or Cognitive
  Problems
• Elders in a nursing facility or assisted living
  facility who have made a progressive or acute
  deterioration in their normal functional
  capabilities.

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WHY DO COMPREHENSIVE GERIATRIC ASSESSMENTS?

• It is the best way to assure that all available
  and appropriate resources are utilized for the
  benefit of the elder not simply medications.
• You cant necessarily understand all that is
  capable of being improved with a patient unless
  you use all available resources to evaluate the
  most complicated patients.

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• Utilizing multiple health care disciplines to
  identify patient functional deficits,
  psycho-social, and medical problems improves the
  likelihood of instituting a care plan that will
  address and improve the patients overall
  functionality and quality of life.

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WHAT IS THE COMPREHENSIVE GERIATRIC ASSESSMENT
PROCESS?

• 1. High Risk Elders are identified or referred
  for evaluation.
• 2. Prior to evaluation by healthcare providers,
  the patient has lab work and an EKG done unless
  already obtained within the preceding 6-12 months.

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• 3. A comprehensive health questionnaire is
  completed by the patient or care giver.
• 4. Appointments for the participating
  healthcare providers are made through the primary
  physicians office.

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• The participating healthcare providers include
• PHYSICAL THERAPY
• OCCUPATIONAL THERAPY
• OPTOMETRY
• PA/NP
• PHYSICIAN
• Some providers are only available once a month,
  while others are available more often.
• Each discipline utilizes a standardized
  Screening Instrument to evaluate the patient.

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• A dictated/transcribed report from each
  discipline is forwarded to the physician within
  several days after the patient is evaluated
  outlining problems identified in their domain,
  and recommendations for further evaluation,
  intervention, or therapy.
• Once all evaluations are completed (usually
  over a 5-10 day period of time), the patient is
  scheduled to see the physician.
• After a complete review of all the
  multi-disciplinary medical reports, the physician
  performs a complete physical examination.

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• Preliminary findings and recommendations are
  then discussed with the patient. Significant
  others can be present if the patient chooses.
• Arrangements are then made for additional
  evaluations needed to initiate indicated therapy.
  
• Goals are set, discussed, and follow-up with
  the physician and other disciplines is scheduled.

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WHAT DO EACH OF THE DISCIPLINES DO?

• PHYSICAL THERAPY The patient is scheduled for a
  one hour appointment. During the appointment the
  patient is assessed comprehensively including the
  use of Get Up And Go test and the Tinnetti
  Balance assessment to evaluate strength,
  mobility, and balance capabilities. A written
  report of the findings and recommendations is
  generated and sent to the physician within two
  days.

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• OCCUPATIONAL THERAPY The patient is scheduled
  for a one hour appointment. OT is only available
  for appointments ½ day per week. The main office
  is 35 miles away in Dillon, but the evaluation is
  performed at Ruby Valley Hospital.
• During the appointment, the patient is given a
  comprehensive functional assessment including the
  use of the Katz ADL and IADL scales.
• If significantly abnormal, the OT performs a
  Home Safety Inspection.
• A written report with all findings and
  recommendations is generated. The report is sent
  to the physician within two days.

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• OPTOMETRY An appointment is scheduled with the
  Optometrist who is available two days per month.
  The Optometrist evaluates near and far vision,
  the need for eyeglasses, or to revise existing
  eyeglass prescriptions. A dilated eye exam is
  performed for metabolic diseases and tests are
  done of intraocular pressure to screen for
  Glaucoma. A written report is sent to the
  physician.

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• PA/NP A one hour appointment is scheduled with
  the PA/NP. During the appointment the patient is
  evaluated for depression and cognitive impairment
  utilizing the Geriatric Depression Scale 15
  question version and the Mini Mental Status Exam,
  Audiometry, and a complete Physical Exam is
  performed.
• A written report is generated documenting the
  findings and available to the physician within
  two days.

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• PHYSICIAN A one hour appointment is scheduled
  with the physician. Prior to the visit the
  physician reviews all written reports from the
  other disciplines, updated patient history
  focusing on functional, and psycho-social issues
  completed by the patient or their family in
  advance of the visit. If necessary, he speaks
  with the other providers. During the visit, the
  physician performs a focused physical examination.

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• After the examination, the physician reviews
  the evaluations of all disciplines and the
  physical findings with the patient and if they
  choose, their significant others. A complete
  written summary is later mailed to the patient
  and their family for their records and review.
• A written report will include any
  recommendations made for further evaluation,
  referral to a sub-specialist, revision of
  medications, or initiation of therapy.
  Adjustments in the home environment, the use of
  assistive devices, hearing aids or eyeglasses may
  also be discussed.

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• The most important part of the process is to
  assure ongoing follow-up and management of any
  recommendations.
• Geriatric Assessment is an ongoing process,
  with the patients optimal outcome a moving
  target.
• Any need to discuss alternative placement is
  usually deferred to a later follow-up appointment.

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WHO ARE WE?

• The Ruby Valley Hospital and Rural Health Clinic
  is a 10 bed critical access hospital located in
  Sheridan, Montana. Sheridan has a population of
  800 and a service population of approximately
  3500 within Madison County. There is a
  population density of about one person per square
  mile.
• There are two physicians and 2 mid-levels
  providing services at the facility. Both
  physicians are Board Certified Family Physicians
  and one is also certified in Geriatrics.

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Of the first 20 patients evaluated

• 4 new diagnosis of Parkinson's were made
• 5 patients had no change in diagnosis or therapy,
  reassured patient and family there was no
  evidence of Alzheimers disease
• 8 referrals for PT with marked improvement in
  gait and balance
• 3 were prescribed walkers
• 2 patients should have been placed in a nursing
  home, but improved enough to avoid nursing home
  placement for six more months
• 4 were placed in the nursing home, 1 was later
  improved enough to return to a home environment.

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• 2 patients moved to a assisted living facility
  from home
• 6 new diagnosis of Dementia were made
• 12 patients had new medications prescribed or
  other medication doses adjusted

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PROBLEMS AND FUTURE OPPORTUNITIES

• Difficulty identifying appropriate at risk
  patients and getting them to be evaluated
• Lack of Perceived Need or Benefit by Family,
  Patients, Community
• Lack of Buy in by other physicians
• Logistics, Travel
• Timely standardized transcribed reports
• Lack of Social Services support system
• Turnover of provider disciplines requiring
  constant re-invention of the wheel

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• Montana is a state of widely dispersed
  populations with limited access to subspecialty
  care geographically proximal to at risk geriatric
  patients. Screening of at risk patients must,
  therefore, occur at the local level. This is
  best done by the local primary care physicians
  and other health care disciplines to allow
  timely, and comprehensive identification of
  patient impairments and opportunities to improve
  patient function. We must do this is to maintain
  the highest quality of life, and allow the
  patient the longest possible independent living
  status.

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