HE HEA LTH I H IN A GI GING G A GE GE FRIENDLY LY HE HEA - - PowerPoint PPT Presentation

HE HEA LTH I H IN A GI GING G – A GE GE FRIENDLY LY HE HEA LTH H SYST STEM S - ? Commo mon s n sens nse

K AT HRYN BORGE NI CHT , M.D. F ACP CHMD

Nothing to disclose

• K

b o rg e nic ht@ g ma il.c o m

What makes this so important – Health in Aging

• NOT

he a lthy a g ing

• L

e a ding c a use of de a th is now multiple c hronic c onditions

• L

ife e xpe c ta nc y – USA on pa r with CUBA, e ve ry othe r ma jor industria l c ountry is hig he r the n us e xc e pt Cyprus, Ire la nd, Portug a l

• Howe ve r, we spe nd more mone y pe r c a pita on he a lth

c a re the n a ny othe r c ountry ($4500/ pe r c a pita )

WHY I IS THIS – ROOT OT C CA USE?

WE HAVE PUT T HE

DISE ASE AT

T HE CE NT E R, RAT HE R T HE N T HE PE RSON SHOUL D BE – WHAT MAT T E RS T O YOU I S

WHATI

S T HE MAT T E R WI T H YOU

Why should health systems want to be age friendly – what’s in it for them

CA SE F FOR A GE GE FRIENDLY LY HE HEA LTH H SY SYTEM S

Re duc e s c o sts a sso c ia te d with po o r q ua lity c a re Suppo rts b undle d pa yme nts I nc re a se d utiliza tio n o f o f c o sts e ffe c tive se rvic e s E nha nc e d re ve nue a nd ma rke t sha re

SO W O WHA HA T DO DOES S THIS LOOK OOK LIKE KE

Ca n b e a pplie d to multiple se tting s Ne e d to a sse ss yo ur o wn se tting Will g ive yo u so me e xa mple s

• Dr. L
• Dr. L

is a 78 yo re tire d pe dia tric ia n who ha s pa rkinsonism, CAD, a nd de pre ssion. Most re c e ntly his ha s ha d some inc re a se d proble ms with swa llowing with one e pisode of c hoking . He a lso ha d a re c e nt fa ll off his e le c tric bike whic h re sulte d in roa d ra sh a nd a bruise to his shoulde r.

• He live s with his ve ry c a ring wife , who wa tc he s him

c lose ly. He ha s fa mily tha t live s ne a rby.

• He ta ke s 8 diffe re nt me dic ine s, a nd multiple vita mins

The 5 e 5 M s M s – Institu tute te of Health th C Care Improvem emen ent – Busi siness c s case se f for becoming an age f e frien endly h hea ealth s system

WHAT MAT T E RS ME DI CAT I ON MOBI L I T Y ME NT AT I ON MUL T I PL E MORBI DI T I E S

WHAT MATTERS

Ma ny mo de ls So little time ? Wha t ha s wo rke d

A DVA VA NCE CA CA RE PLA NNI NING NG

PICK ONE PRE PARE F ORYOURCARE .ORG Ultimate ly c re ate s a doc ume nts BUT first - talk and disc uss With COVID e ve n more important - PC Wisc onsin we b site for re sourc e s

Current care planning Mary Tinetti, M.D.

GE RIPALWE BSIT E T O L IST E N T O HE R DISCUSSION

” CURRENT CARE PLANNING” – Mary Tinetti, MD.

I de ntify pa tie nts prio ritie s – wha t o utc o me s do the y wa nt fro m the ir he a lth 4 a re a s to stre ss

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unc tio ning a nd a uto no my

• Re la tio nships a nd c o mmunitie s
• Ma na g ing yo ur he a lth
• Me a ning ful thing s in yo ur life

Sta rt with o ne g o a l Use pa tie nts o wn o utc o me s a nd pre fe re nc e s ra the r the n the ir dise a se . F

• c us o n func tio n, no t ne c e ssa rily sympto ms

More Tinetti

• Re a lly drill do wn, g e t spe c ific –

wha t is the thing tha t is ke e ping yo u fro m do ing tha t. Wha t the n me dic a lly c a n we he lp yo u with. Are the re o the r a c tivitie s tha t mig ht ma tc h up with wha t yo u a re do ing

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his c a n b e do ne b y a tra ine d fa c ilita to r

• E

x – wha t do yo u mo st wa nt to us fo c us o n _____ (fill in he a lth pro b le m) so tha t yo u c a n do (fill in de sire d a c tivity) mo re o fte n o r mo re e a sily

LET ETS TA TA LK A BOU OUT BUST STER

Sta te me nt A – Yo u ha ve b e e n in a nd o ut

• f de to x 6 time s in the la st ye a r. Yo u

a re n’ t fo llo wing thro ug h with yo ur a ppo intme nts. Yo u b e tte r sto pe drinking

• r yo u will die …

Sta te me nt B – Ho w is yo ur do g Buste r? I kno w he g ive s yo u a re a so n to ke e p g o ing . Whe re do e s he g o whe n yo u a re in the ho spita l. Wha t do yo u sa y we ta lk a b o ut wa ys to sta y o ut o f the ho spita l so yo u c a n ta ke c a re o f Buste r? Wha t ide a s do yo u ha ve a b o ut tha t?

• Dr. L
• Whe n a ske d a b o ut his “living will” b y his physic ia n siste r he

sta te s”

• Ye s, I

ha ve o ne a nd I ha ve disc usse d it with my wife . My kids kno w a b o ut it b ut do no t kno w whe re it is. I ha ve no t lo o ke d a t it fo r pro b a b ly 10 ye a rs

• Wha t a dvic e wo uld yo u g ive him?

M EDI DICA TIONS – some th thoughts ts and i d ide deas

• Me dic ation r

e c onc iliation

• E

valuate patie nts goals r e late d to life e xpe c tanc y and adjust me ds for that

• E

valuate me ds for pote ntially inappr

• pr

iate me ds

• De pr

e sc r ibing

• E

xample – Me di c og

Medication deprescribing 123-ABC

1- Purpo se o f me dic a tio n 2 – Ho w is pa tie nt using 3 - “Ho w’ s tha t wo rking fo r yo u” A – Adve rse e ffe c ts B – Be ne fits/ b urde ns C – Co nve rsa tio n

What if they say no

• SPIKE

S – se tting P – pe r c e ption I – invita tion K – knowle dg e E – e motion S – Summa r ize r e c omme nda tions AND RE PE AT

• Dr. L
• He take s 8 diffe r

e nt me dic ations – lithium, c italopr am, me topr

• lol, r
• suvastatin, Sine me t, r
• pinor
• le , mir

tazapine , Ritalin

• His wife give s him a handful of vitamins in the am
• He has se e n his ne ur
• logist r

e c e ntly who que r e d him about whe the r he notic e d any diffe r e nc e fr

• m his Par

kinson's me ds

• What would you like to make sur

e you do whe n you visit with him?

• How would you addr

e ss his r e c e nt c hoking e pisode ?

MOBILITY

T hink a bout a pa tie nt in the hospita l

T hink a b o ut

T hink a bout PT Me dic a r e r ule s

T hink a b o ut

T hink COVID a nd de lir ium – we ha ve g one ba c kwa r ds

T hink

T hink loss of mobility inc r e a se s r isk of de a th, hospita liza tions, fa lls, de c lining func tiona l sta tus

T hink

M OB OBILITY – CA CA N B BE COM OM PLEX

F ac to r s – balanc e , me ds, se nso r y issue s, fo o twe ar , e nvir

• nme nt,

func tio n Pic k a to o l and use it – T GUG Co mmunic ate

• Dr. L
• Afte r his re c e nt fa ll, he is c onc e rne d a bout g e tting on a

bike a g a in.

• He c ontinue s to pa rtic ipa te in va rious Pa rkinsons mobility

c la sse s, inc luding pila te s, boxing a nd da nc e a lthoug h some of this ha s be e n re stric te d by COVID

• How would you a pproa c h his re c e nt fa ll a nd his de sire to

c ontinue to ride his bike

M ENTA TION

De pre ssio n De me ntia De lirium

THE 3 DS

E ac h de se r ve s a se par ate disc ussion E ac h inte r ac ts with e ac h othe r All have Unde r diagnosis Unde r pr e ve ntion Unde r tr e atme nt

HE HELP – Hospital E l Eld lder Li Life P Prog

• gram
• Dr. Sharon

Inouye

• T

ar ge te d patie nts at r isk for de lir ium

• Pr

e disposing c onditions (c ognitive impair me nt, se ve r e illne ss, visual or auditor y impair me nt

• Hospital ac quir

e d c onditions – me dic ations, pr

• c e dur

e s, be d r e st

• T

e am of tr aine d volunte e r s

Interventions What they provide

• Da ily visito r pro g ra m
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a rg e te d a c tivitie s

• E

a rly Mo b iliza tio n

• F

e e ding a ssista nc e

• He a ring a nd visio n pro to c o l
• No n-pha rma c o lo g ic a l sle e p

pro to c o l

• Orie nt, so c ia lize
• K

e e p c o g nitive ly e ng a g e d

• Wa lking a nd ROM
• Co mpa nio nship a t me a ls
• Ada ptive e q uipme nt
• So o thing e nviro nme nt,

music , he rb a l te a , ha nd fo o t ma ssa g e

• Dr. L
• On que stioning , he ha s be e n on his multiple psyc hia tric

me ds for ye a rs a nd is not willing to c ha ng e the m

• His wife a nd c hildre n ha ve e xpre sse d c onc e rn a bout his

me mory a lthoug h he de nie s a ny issue s

• He re ma ins a n a c tive re a de r a nd is ve ry soc ia lly e ng a g e d
• Would you c ha ng e a nything a t this time

MULTIPLE DIAGNOSES

• AL

L OF T HE ABOVE

• NOT

JUST T RE AT ING ONE DISE ASE , T RE AT ING ONE PE RSON

FOC OCUS A R A REA S A S

• T

RANSIT IONS – hospital, NH, AL F , inde pe nde nt living, home he alth, hospic e

• Annual We llne ss visit – c ove r

s 4/ 5 Ms

• Me ntation – mini Cog
• Me dic ations – me dic ation

r e c onc iliation

• Mobility – ADL

s, IADL s, ?T GUG

• What matte r

s

• Dr. L
• He re ma ins ve ry a wa re of his multiple me dic a l proble ms

a nd how the y a ffe c t his da ily life

• He de c ide d to g ive up driving 6 months a g o
• He c ontinue s to pla y te nnis with his brothe r but ha s

a da pte d his style to fit his mobility ne e ds

• He is a n a vid fishe rma n but now ma ke s sure he doe s not

g o a lone

• “We ’ ve b e e n wro ng a b o ut wha t o ur jo b is in

me dic ine . We think o ur jo b is to e nsure he a lth a nd surviva l. But re a lly it is la rg e r tha n tha t. I t is to e na b le we ll b e ing . And we ll b e ing is a b o ut the re a so ns o ne wishe s to b e a live ”

• Atul Gawande