The 15-minute Geriatric Visit

1. The 15-minute Geriatric Visit David B. Reuben, MD David Geffen School of Medicine at UCLA

2. Overview of Next 55 Minutes • General background • Individual approaches • Approach to redesigning practice to manage geriatric conditions (eg, falls, incontinence) • An example of how this might work • Costs of implementing change

3. Slides and Supporting Materials http://www.geronet.ucla.edu/centers/acove/index.htm What’s inside • Slides and reprints • Office forms • Physician education • Patient education

4. Ground rules (assumptions) • Follow-up visit cannot take more than 15 minutes • General medical care cannot be compromised • No electronic medical record • Office staff can provide some help

5. Goal: comprehensive care of older personsThe problem: too much to do, too little time • Aggravating factors: two separate, sometimes competing agendas -the patient’s and the physician’s • Inadequate resources - office staff and other professionals • Business as usual

6. Background • Assessing Care of the Vulnerable Elderly (ACOVE) project • identified vulnerable elders, • created a a set of quality indicators based on literature review and expert panel for 22 conditions that affect older persons • examined the process of care (by chart review and structured interview) for each condition

7. Background-II • ACOVE findings • Overall, 54% of QIs met • High numbers of QIs met for common diseases in older persons (e.g., hypertension, diabetes) • Low numbers ( 29-41%) of QIs met for geriatrics conditions (e.g., urinary incontinence)

8. Background-III • Previous research has identified barriers to effective management of geriatric conditions • Inadequate case recognition • Lack of physician knowledge • Poor patient adherence to treatment plan • Inadequate follow-up • Lack of time and resources to address issues

9. Individual Approaches • Advantages • One person can initiate • Doesn’t take much time to get going • Can borrow or adapt existing instruments • Disadvantage: • Only a partial step

10. Strategies for Saving Time in Clinical Practice 1) Delegate data collection

11. Physician-Patient Encounter $$$$ Out-of-Office Preparation Office Visit $$ $ • Reduce time but increase effectiveness/efficiency of the inner circle • Always push to outermost possible circle whenever possible

12. Pre-visit Questionnaire 1. Past medical history- Current medications- Drug allergies- Surgical & medical hospitalization- Social history (habits, sociodemographics)- Preventive services, including lifestyle 2. Home safety checklist 3. Advance Directives

13. Pre-Visit Questionnaire • Specific questions on: • Vision • Hearing • Dentition • Falls • Urinary incontinence • Nutrition • Depressive symptoms • Functional status

14. Obstacles to Delegating Screening/Case-finding to Office Staff • Cost • Training • Capability of acting on results

15. Strategies for Saving Time in Clinical Practice • ) Delegate data collection • ) Minimize data recording time • Dictation • Templates • Word processing programs • Computerized medical records

16. Strategies for Savings Time in Clinical Practice • ) Delegate data collection • ) Minimize data recording time • ) Keep information needed for decision- making readily available • Pocket guides • PDA programs • Useful books • Computer retrieval system

17. Strategies for Savings Time in Clinical Practice • ) Delegate data collection • ) Minimize data recording time • ) Keep information needed for decision- making readily available • ) Delegate plan execution • Network of health professionals • Health educators

18. The Bottom Line • Individual approaches: • can improve efficiency in recognizing geriatric problems • may not do much for managing detected conditions • are a start in the right direction

19. The Next Step • To improve care, change must focus on three key levels • patient • provider • practice • Does not need to be expensive • Should follow the Chronic Care Model

21. Redesigning Care for Chronic Geriatric Conditions • Fundamentally changes the office visit • Consistent with Chronic Care Model • Draws upon many resources (office, community, patients, families) • Can address both recognition and management • Principles can be adapted to many conditions

22. Redesigning Care for Chronic Geriatric Conditions-II • Identify a target population (e.g.,outpatients 75+ years) • Case-finding for untreated conditions • urinary incontinence • falls • Standardized multi-component intervention

23. Multi-component Intervention-I • Efficient collection of condition-specific clinical data, including information collected by non-physicians and automatic orders for simple procedures • Medical record prompts to encourage performance of essential care processes

24. Multi-component Intervention-II • Patient education materials and active patient role in follow-up • Physician decision support and education

25. So, how does this work?(an example)

26. The ACOVE-2 Intervention • Recently implemented in two group practices in California • Real doctors, real patients • Evaluated as part of a clinical trial

27. Case Finding • Brief screening questions to patient or proxy to identify bothersome incontinence, cognitive impairment/dementia,and falls or fear of falling • Questions administered by office staff (in person or by telephone) prior to visit • Patient (or proxy) responses are given to provider at clinic appointment

28. Case-finding Questions-I • Bothersome incontinence • Had a problem with losing your urine that is bothersome enough that youwould like to know more about how it could be treated

29. Case-finding Questions-II • Memory loss • 3-item recall • Recently had more trouble than in the past with memory for day-to-day happenings around the house, such as remembering where he/she put things, recalling recent events, forgetting what you told him/her, or what he/she told you, remembering plans, appointments or phone calls? (surrogate)

30. Case-finding Questions-III • Falls or fear of falling • Fallen 2 or more times? • Fallen 1 time and hurt yourself or needed to see a doctor because of the fall? • Been afraid that you would fall because of balance or walking problems?

31. Initiating the Intervention • If case-finding is positive, condition-specific materials are attached to the chart • Structured visit note (or sticker) • Visit follow-up sheet • Physician can also initiate the intervention • If multiple conditions are triggered, may need to schedule a “planned” visit

32. Structured Visit Note (or sticker) • History items and simple procedures (completed by the intake office staff) • More detailed historical and exam elements, and ordering diagnostic tests (completed by physician) • Impression and plan (completed by physician)

34. Patient educational materials • Assembled for each condition • Include community resources • Readily available to the clinician to facilitate treatment • Include follow-up visit sheet

35. Visit follow-up sheet • Condition-specific • Prompts the patient to: • monitor the response to treatment • report problems or complications (including inability to adhere to the recommended treatment) to the clinician • Patients are encouraged to bring follow-up sheet to appointment to stimulate discussion

36. Decision Support-Physician Education • Small group educational sessions aimed at practical approaches to each of the four conditions within the context of a busy practice (1 initial, 1 follow-up) • Written decision support briefs that describe the management of the condition (http://www.geriatricsatyourfingertips.org/) and community resources to help in management

37. Flexibility • Intervention group practices must address all conditions using all components of the intervention • Flexibility in how the components are administered and the content of components • Decide how much of the intervention is performed by office staff rather than physicians • Can modify content and supporting materials

38. So, you can do this. Does it work?

39. Quality Scores after Interventionfor Dementia, Falls & Incontinence * p<0.001 for difference in QIs passed between I and C groups.

40. Scores for Falls Care

41. Scores for Incontinence Care

42. Scores for Dementia Care

43. Patient Report of Receipt of Educational Material: Falls

44. Patient Report of Receipt of Educational Material: Incontinence

45. Change in Physician Knowledge about Dementia, Falls and Incontinence* *21-item knowledge test on geriatric care of falls, dementia and incontinence.  † p=0.05 for difference comparing Intervention and Control groups.

46. Physician Perceptions:Relevance, Confidence and Frustration *5-point scales, 1=Not at all, 5=Extremely. † p<0.05 comparing difference between I and C.

47. Summary of main findings • Screening can identify a large number of older patients with falls/gait impairment and incontinence. • A practice-based, low tech intervention can improve care, though not satisfaction, for falls and incontinence among older, community-dwelling patients. • The intervention’s effectiveness was only moderately effective.

48. Why wasn’t ACOVE-2 more effective? • Failure to delegate data collection? • Not enough recognition of inadequate practices with subsequent modification? • Not enough patient empowerment? • Physician priorities? • Obstacles to providing quality care?

49. Costs of Mounting this Practice Change • Start-up ($3,330 per 10 physician practice) • establishing a screening mechanism • customizing forms • identifying condition-specific local community-based resources • training physicians and office staff • installing clinic materials

50. Costs-II • Maintenance • time spent administering screens (3 minutes) • additional staff time needed for the historical and examination components that are delegated to office staff (3 minutes per positive screen), • costs of stocking and updating the forms