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Community Geriatrics

Community Geriatrics. Dr Rhian Simpson Consultant Community Geriatrician Cambridgeshire Community Services. Summary. Background Role of a Community Geriatrician Models for delivering community based care Evidence base. Background. Appointed in 2003 5 sessions

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Community Geriatrics

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  1. Community Geriatrics Dr Rhian Simpson Consultant Community Geriatrician Cambridgeshire Community Services

  2. Summary • Background • Role of a Community Geriatrician • Models for delivering community based care • Evidence base

  3. Background • Appointed in 2003 • 5 sessions • Second Community Geriatrician locally • No nationally accepted model • Local recognition for more community based models of care

  4. East Cambridgeshire • Rural population 82,300 • 55-64 yrs: 10699 (13%) • 65-74 yrs: 7078 (8.6%) • 75-84 yrs: 4938 (6%) • 85 + yrs : 1646 (2%)

  5. Life expectancy - Males In 2005 – 2007: Source: ONS

  6. Life expectancy - Females In 2005 – 2007: Source: ONS Women in Cambridgeshire can expect to live 3.9 years longer than men but…. …..men’s life expectancy has improved faster than women’s since 1991

  7. 2001 2007 2021 Changes in age structure %

  8. Taiwan Demographics(Wikipedia)

  9. East Cambridgeshire • 1 community hospital • Inpatient beds (21) • Day therapy unit • Outpatient services • 1 Acute hospital • 7 GP practices (primary care) • 9 care homes (320 beds) • 2 Community Matrons (specialist nurses) • Community based teams e.g. rapid response, therapy, social care

  10. Community Services • Intermediate Care services • Community hospital • Day unit • Care Home reviews • Domiciliary Visits • Medical advice to local practitioners • End of life care

  11. Marjorie Warren (1935) • West Middlesex Hospital London • 714 chronic sick “bedridden” “incurables” • Care process • Assessment • Team working • Environmental modifications • Outcome • 514 patients discharged home and ward shut

  12. Comprehensive Geriatric Assessment • 28 RCTs (15 from USA) • Evaluation of “comprehensive geriatric assessment” • Core process in each RCT was MDT assessment and treatment • Best results: Elderly care departments with integrated teams delivering intervention Stuck et al Lancet 1993

  13. Hospital Geriatric Unit vs Alternative Care Stuck et al Lancet 1993

  14. Long Term Conditions (LTC)(BGS 2005) • Geriatricians play key role • 3 level pyramid • Case management • Disease specific care management • Supported self care • Integrated model of care

  15. Management of LTC

  16. Role of Community Geriatrician in management of LTC • Complex multiple LTC • Advice at times of transition • Medical support for assessment process • Leadership role in supporting community teams

  17. Summary • CGA underpins community geriatric practice • Role will depend on local population • Core components • Rehabilitation • Care home medicine • Supporting elderly in their own homes • Palliative Care • Work at interface between primary and secondary care at times of transition • Integrated team working

  18. Models of CareIntermediate Care (IC) DH 2001 • Integrated services • Promote faster recovery from illness • Prevent unnecessary hospital admissions • Support timely discharge from hospital • Maximise independent living

  19. IC:Basic principles of service model • Person centred care • Robust assessment • Partnership working • Timely access to specialist services

  20. Community Hospital ICYoung et al JAGS 2007 • Design: RCT • Setting: 7 community and 5 general hospitals • Participants: 490 patients needing rehabilitation post acute admission • Intervention: MDT care in community hospital • Measurement: NEADL, BI, anxiety and depression score, mortality, discharge destination

  21. Community Hospital IC(O’Reilly et al Age and Ageing 2008) • Results Primary outcome: CH group had significantly better NEADL score at 6/12 compared to general hospital group (p=0.03) Secondary Outcome: No difference in mortality, patient and carer satisfaction, institutional rates, anxiety and depression scores Cost effectiveness similar in CH and GH

  22. Community Hospital ICGarasen et al BMC Public Health 2007 • Design: RCT • Setting: Community hospital vs general hospital IC • Participants:142 patients > 60 yrs • Intervention: MDT in community hospital setting • Measurements: hospital admission rates, ADL, mortality, institutional care

  23. Community Hospital IC

  24. Day Unit IC Cochrane review Foster et al 2008 • 13 RCTs with 3007 participants • 5 RCTs Day hospital vs elderly care • 5 RCTs Day hospital vs domiciliary care • 3 RCTs Day Hospital vs no elderly care • Conclusions • Day unit care more effective than no intervention • No clear advantage over other models of elderly care • No evidence to support admission avoidance

  25. Hospital at Home ICCochrane review Shepperd et al 2009 • 26 RCTs with n=3967 participants • Compared early discharge schemes at home with in patient hospital care • Readmission rates were significantly higher for elderly with multiple LTC (n=705) • Increased patient satisfaction for early discharge schemes • No evidence for cost savings • Elderly with LTC and stroke patients were less likely to be in residential care at 6/12 (7 trials)

  26. Care Home ICFleming et al Age and Ageing 2004 • RCT n= 165 frail hospitalised elderly • Intervention: IC in care home vs usual care • Outcome: institutionalisation, Barthel index, mortality. • Results: No significant differences between intervention and control group

  27. IC Conclusions • No clear evidence base for IC service models based on current evidence • More research is needed • Best practice needs to be evaluated

  28. Care Home Medicine • Care Home • 24 hour access to care • Spectrum of care • Residential care • Nursing home • Dementia units • Cost of care • 75% of places funded by government • Range of cost (£300 - £1000)

  29. National census of care homeresidents in UK • N= 15,483 (25% residential) in 244 care homes • 90% admitted due to medical morbidity or disability • > 50% had dementia, CVA or PD • 76% needed assistance with mobility • 71% were incontinent • 78% had mental impairment Bowman et al (2004) Age and Ageing 33:561

  30. The Health and Care ofOlder People in Care Homes • Interdisciplinary approach to assessment, care planning and care delivery • Development of the nurse as the lead practitioner • Service delivery needs to engage general and specialist aspects of medical practice • Practitioners should have appropriate education and training Report of a Joint Working Party. RCP, RCN, BGS (2000)

  31. Resource Implications • Gerontological nurse specialist • Specialist GP service • Specialist pharmacist • Increase input from professions allied to medicine • Regular MDT consultant sessions and visits to homes • Improve care planning • Develop teaching nursing homes

  32. Care home medicine in the UK -in from the cold • Hallmark of caring society is how we care for weakest members • Complex patients • National guidelines (2000) • Finding local model that meets criteria Donald IP et al Age and Ageing, 2008.

  33. Integrated primary and secondarycare model in Manchester UK • 9 homes n=400 • Care home team • Advanced nurse practitioner • GP • Consultant community geriatrician • Anticipatory care • End of life planning • Audit (unpublished) • 35% decrease in emergency admissions • 68% reduction in emergency bed days • 56% decrease in hospital LOS for those admitted to hospital

  34. Domiciliary Visit • 3 components • Advice on treatment and diagnosis • Patient unable to attend hospital • GP present • 60% of my outpatient work comprises DVs • (2/3 of these are in care homes) • Evidence base (Crome et al JRSoc Med 2000) • Valued by GPs • Variable practice • No evidence to show that it decreases hospital admission rates

  35. Conclusions • Role of a Community Geriatrician • LTC in the community • Rehabilitation • End of life care • Team working and integration with other services essential • Local model will depend on population and links with acute units

  36. Conclusions • Evidence base underpinning practice is the Comprehensive Geriatric Assessment • Evidence base for service models and best practice • Intermediate care

  37. Conclusions • More research needed to evaluate best practice • Holisitic care and encompasses all aspects of geriatric medicine • Future of geriatric medicine is in the community

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