Specialist Collaborative Models RGPs of Ontario Perioperative - - PowerPoint PPT Presentation

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Specialist Collaborative Models RGPs of Ontario Perioperative - - PowerPoint PPT Presentation

Apr 11, 2023 121 likes •511 views

Optimizing Outcomes For Frail High Risk Seniors Through Specialist-Specialist and Primary Care- Specialist Collaborative Models RGPs of Ontario Perioperative Surgical Home For The Frail Elderly Dr. Daniel McIsaac The Ottawa Hospital RGPs of

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Optimizing Outcomes For Frail High Risk Seniors Through Specialist-Specialist and Primary Care- Specialist Collaborative Models

RGPs of Ontario

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Perioperative Surgical Home For The Frail Elderly

  • Dr. Daniel McIsaac

The Ottawa Hospital RGPs of Ontario

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Intraoperative Preoperative Postoperative

PERIOPERATIVE SURGICAL HOME FOR THE FRAIL ELDERLY

Daniel I McIsaac MD, MPH, FRCPC

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“…multidisciplinary, team-based approach to patient-centered care that aims to reduce variability, provide continuity…ensure best-practice across the perioperative continuum of care”

PERIOPERATIVE SURGICAL HOME (PSH)

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No conflicts of interest

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Program funding:

  • Canadian Frailty Network
  • University of Ottawa Department of Anesthesiology
  • TOHAMO
  • Canadian Anesthesiologists’ Society
  • International Anesthesia Research Society

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Collaborators

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  • Paul Beaule
  • Gregory Bryson
  • Alan Forster
  • Sylvain Gagne
  • Allen Huang
  • John Joanisse
  • Claire Kendall
  • Manoj Lalu
  • Luke Lavalee
  • Colin McCartney
  • Hussein Moloo
  • Julie Nantel
  • Janet Squires
  • Monica Taljaard
  • Carl van

Walraven

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THE PERIOPERATIVE HEALTHCARE SYSTEM

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Intraoperative Preoperative Postoperative

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A COMPLEX SYSTEM

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Intraoperative Preoperative Postoperative

  • Diagnosis
  • Evaluation
  • Decision making
  • Care planning
  • Optimization
  • Anesthesia
  • Surgery
  • Pain management
  • Acute monitoring
  • Pain management
  • Recovery/rehabilitation
  • Sub-acute monitoring
  • Transition to community
  • Return of normal

function

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A COMPLEX SYSTEM

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Intraoperative Preoperative Postoperative

  • Diagnosis
  • Evaluation
  • Decision making
  • Care planning
  • Optimization
  • Anesthesia
  • Surgery
  • Pain management
  • Acute monitoring
  • Pain management
  • Recovery/rehabilitation
  • Sub-acute monitoring
  • Transition to community
  • Return of normal

function Continuum of Care

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Preoperative frailty predicts

  • Mortality
  • Morbidity
  • ICU admission
  • Length of stay
  • Institutional discharge
  • Self reported new disability

PERIOPERATIVE FRAILTY

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SO, YOU’RE NOT SURPRISED

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PERIOPERATIVE CARE

JAMA Surgery, 2016

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The Association of Frailty with Outcomes and Resource Use After Emergency General Surgery: a Population-Based Cohort Study

Daniel I. McIsaac, Husein Moloo, Gregory L. Bryson, Carl van Walraven

Anesthesia & Analgesia, accepted

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  • 1. Early mortality risk
  • Day 1 20-30 times higher
  • Day 3 15-20 times higher
  • Markedly elevated for ~3 months after surgery

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  • 2. Loss of independence
  • 30-50% discharged to an institution
  • All community dwelling before surgery
  • 2-6 times increased relative risk

2 KEY OUTCOME MESSAGES

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Intraoperative Preoperative Postoperative

  • IDENTIFY
  • RISK STRATIFY
  • DECISION SUPPORT
  • OPTIMIZATION
  • ENHANCED CARE

PATHWAYS

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Intraoperative Preoperative Postoperative

  • IDENTIFY
  • RISK STRATIFY
  • DECISION

SUPPORT

  • OPTIMIZATION
  • ENHANCED

CARE PATHWAYS

  • DECREASE

VARIATION

  • SUPPORT BEST

PRACTICE

  • RISK RE-

STRATIFICATION

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Intraoperative Preoperative Postoperative

  • MONITOR (pre-

and post-discharge)

  • ENHANCED

RECOVERY

  • IMPROVE

CONTINUITY AND TRANSITIONS

  • IDENTIFY
  • RISK STRATIFY
  • DECISION

SUPPORT

  • OPTIMIZATION
  • ENHANCED

CARE PATHWAYS

  • DECREASE

VARIATION

  • SUPPORT BEST

PRACTICE

  • RISK RE-

STRATIFICATION

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STRENGTHS WEAKNESSES OPPORTUNITIES & THREATS

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S W O T

Who Is Involved

WEAKNESSES

  • Insufficient patient

engagement STRENGTHS

  • Multidisciplinary
  • MDs
  • RNs
  • KT/Imp Sci
  • Scientists

THREATS

  • Competing priorities
  • Who’s patient is this?

OPPORTUNITIES

  • People care about frailty
  • System and Pt outcomes
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S W O T

Funding Sustainability

WEAKNESSES

  • No institutional

program funding STRENGTHS

  • Growing

external/internal research funding THREATS

  • QBPs (procedure, not

patient-centered) OPPORTUNITIES

  • MOHLTC Innovation

funding

  • The iron is hot
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S W O T

Policy Support

WEAKNESSES

  • No standard

hospital or ministry policy STRENGTHS

  • Evidence-based

framework and focus

  • Best practice guidelines

(ACS/AGS/BGS) THREATS

  • Frailty isn’t woven into

healthcare policy-yet OPPORTUNITIES

  • Novel area of research
  • Emerging team based and

comprehensive care models

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S W O T

Setting

WEAKNESSES

  • Silos
  • Acute hospital-

transition gap STRENGTHS

  • Buy in from clinical leads
  • Motivated program lead

THREATS

  • Competing interests

OPPORTUNITIES

  • Evaluation hotbed
  • Built into hospital data

systems

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S W O T

Decision-Making

WEAKNESSES

  • No Shared Decision

Making integrated to date STRENGTHS

  • Pt-oriented focus

THREATS

  • High prevalence of frailty

OPPORTUNITIES

  • Ottawa-Decision making

leadership

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S W O T

Patient Selection

WEAKNESSES

  • High-prevalence of

frailty (40-50%) STRENGTHS

  • High prevalence of frailty
  • Poor patient-centered
  • utcomes

THREATS

  • Resources needed to

support some interventions for high risk frail elders OPPORTUNITIES

  • Data to establish criteria
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S W O T

AGS Person-Centred Care

WEAKNESSES

  • Co-ordination a work in

progress

  • How to ‘force’ care plan

and goal review STRENGTHS

  • Patient centered outcomes

and processes

  • Infrastructure for

information flows THREATS

  • Who’s patient is this?
  • Outcome overload

OPPORTUNITIES

  • Inter-professional team

engaged

  • KT/Imp Sci experts from

day 1

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  • Everyone seems to ‘get’ frailty

– Surgeons, other MDs, patients, …

  • People are eager to get on board
  • Research funders are engaged
  • Momentum

– For our local project – For improved care of frail and older patients generally – Comprehensive care models FACILITATORS-A SUMMARY

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  • How do YOU define frailty?

– How frail do you need to be for focused intervention

  • $

– Continued research funding – Institutional funds for long-term implementation

  • Competing interests of collaborators
  • Patient engagement
  • Massive variations in care
  • Designing a process for a continuum of care

currently built in silos

CHALLENGES-A SUMMARY

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THANK YOU

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WHO IS INVOLVED

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STRENGTHS Multidisciplinary

Anesthesiologists Geriatricians Surgeons Family Physicians Scientists Methodologists Nurse Specialists KT/Implementation Science

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WHO IS INVOLVED

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STRENGTHS Multidisciplinary

Anesthesiologists Geriatricians Surgeons Family Physicians Scientists Methodologists Nurse Specialists KT/Implementation Science

WEAKNESSES Pt engagement Just starting Complexities

Competing interests

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WHO IS INVOLVED

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STRENGTHS Multidisciplinary

Anesthesiologists Geriatricians Surgeons Family Physicians Scientists Methodologists Nurse Specialists KT/Implementation Science

WEAKNESSES Pt engagement

Just starting

Complexities

Competing interests

OPPORTUNITIES PEOPLE CARE

Frailty makes sense

Pt engagement

The iron is hot

Outcomes speak

PROMs

KT approach

Theory guided

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WHO IS INVOLVED

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STRENGTHS Multidisciplinary

Anesthesiologists Geriatricians Surgeons Family Physicians Scientists Methodologists Nurse Specialists KT/Implementation Science

WEAKNESSES Pt engagement

Just starting

Complexities

Competing interests

OPPORTUNITIES PEOPLE CARE

Frailty makes sense

Pt engagement

The iron is hot

Outcomes speak

PROMs

KT approach

Theory guided

THREATS Engagement

Competing priorities

Who’s Pt is it?

The silos again

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SUSTAINABLE FUNDING

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STRENGTHS External

Consistent & growing x 3 years

Internal

Research funding

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SUSTAINABLE FUNDING

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STRENGTHS External Consistent & growing x 3 years Internal Research funding WEAKNESSES Research funding No program or institutional funds

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SUSTAINABLE FUNDING

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OPPORTUNITIES Innovation funding

Translation to clinical care

Pt engagement

We’re working on it

Population dynamics

Ageing population

SUSTAINABLE FUNDING

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STRENGTHS External Consistent & growing x 3 years Internal Research funding WEAKNESSES Research funding No program or institutional funds

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THREATS If the research $ dries up

Increased challenge

Clinical budgets

QBPs Decreased global budgets

SUSTAINABLE FUNDING

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OPPORTUNITIES Innovation funding

Translation to clinical care

Pt engagement

We’re working on it SPOR

Population dynamics

Ageing population

SUSTAINABLE FUNDING

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STRENGTHS External Consistent & growing x 3 years Internal Research funding WEAKNESSES Research funding No program or institutional funds

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LOCUS OF CONTROL

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STRENGTHS Buy in from clinical leads Motivated leader

I guess that’s me

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WEAKNESSES The silos Shared patients Surgeon, Anesthesiologist, +/- Geriatrician No SDM

LOCUS OF CONTROL

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STRENGTHS Buy in from clinical leads Motivated leader

I guess that’s me

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OPPORTUNITIES SDM

Ottawa PtDA research group

Momentum of continuum of care

Emerging concept in perioperative care

Team buy in

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WEAKNESSES The silos Shared patients Surgeon, Anesthesiologist, +/- Geriatrician No SDM

LOCUS OF CONTROL

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STRENGTHS Buy in from clinical leads Motivated leader

I guess that’s me

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THREATS Loss of momentum

Increased challenge

Transitional care

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OPPORTUNITIES SDM

Ottawa PtDA research group

Momentum of continuum of care

Emerging concept in perioperative care

Team buy in

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WEAKNESSES The silos Shared patients Surgeon, Anesthesiologist, +/- Geriatrician No SDM Too in-hospital

LOCUS OF CONTROL

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STRENGTHS Buy in from clinical leads Motivated leader

I guess that’s me