Disclosures Alzheimer’s Disease Annual Update 11/7/2014 An Advanced Dementia Consult Service:

Alzheimer’s Disease Annual Update
An Advanced Dementia Consult Service:
Integrating Clinical Care and Education
11/7/2014
Disclosures
I have no relevant financial disclosures to report.
Angela G. Catic, MD
Assistant Professor, Department of Medicine
Geriatrics Section
Baylor College of Medicine
Michael E. DeBakey VA Medical Center
Objectives
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Target population
Key interventions
Pilot Study
Educational opportunities
Challenges
Integration of the ADCS
Background
• 1.8 million advanced dementia
• Commonly hospitalized for acute illness
– Costly
– Burdensome
– Limited clinical benefit
• Unique palliative care needs
– Challenges regarding recognition as terminal illness
– Decision making regarding common complications
– Education regarding expected disease course
Morrison SL, et al. N Engl J Med 2009. Meier DE et al. Arch Int Med 2001. Givens
JL, et al. J Am Geriatr Soc 2009. Sachs GA, et al. J Gen Intern Med 2004.
Advanced Dementia Consult Service
• Targets hospitalized patients ≥65 years who
meet two of three criteria of the Global
Deterioration Stage (DGS) stage 7
• Multidisciplinary effort between geriatrics and
palliative care
• Goals
1. Improve acute care
2. Prevent rehospitalization
3. Educate families and caregivers
Key Interventions
• Inpatient consultation
– Utilized standardized consult form
– Meeting between ADCS team and surrogate
within 24 hours of admission
– ≤5 recommendations
• Printed educational materials for surrogate
decision makers
• Post discharge communication
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Alzheimer’s Disease Annual Update
Educational Booklet
11/7/2014
Educational Booklet
• Standardized information regarding advanced
dementia and related issues
– What is advanced dementia?
– Determining the primary goal of care?
– Basic approach to decision making
– Approach to eating problems
– Approach to decisions about hospitalization
– Approach to treatment decisions for infections
– How advanced dementia affects the family
– What is hospice and palliative care
E-mail [email protected] for pdf of the booklet.
Patient Identification
POE Pop-up #1
• Individuals ≥65 years with a prior diagnosis of
dementia within the institution flagged on
admission
• Pop-up appears in the Provider Order Entry
(POE) system asking admitting provider to
determine if the patient meets criteria for
advanced dementia and if they wish to order a
consult
“This patient has a diagnosis of dementia. At
baseline, patients with advanced dementia are:
1. Functionally mute (e.g. cannot verbalize
meaningfully), 2. Non-ambulatory (e.g.
bedbound), and 3. Incontinent of bowel or
bladder. To the best of your knowledge, does
this patient meet at least two of these three
criteria?”
POE Pop-up #2
Consult Request
• Appears if provider answers “yes” to the initial
question
• “Patients with advanced dementia are extremely
vulnerable when hospitalized. Decisions
commonly arise about the use of burdensome
treatments that may or may not be beneficial to
or wanted by these patients. To help you optimize
the care of this patient with advanced, end stage
dementia, please consider obtaining an Advanced
Dementia Service Consult.”
• Provider asked to enter reason for admission,
projected discharge date, and reason for
consult
• Specified reasons for a consult include
– Assistance with defining goals of care
– Decision-making about feeding issues
– Decision-making about other treatments
– Decision-making about hospice
– Other
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Alzheimer’s Disease Annual Update
11/7/2014
Pilot Testing
Patient Data
• Pilot testing November 2011-April 2012
Characteristic
– Identification of subjects but usual care during control
period (n=24)
– Performance of consult during intervention period (n=5)
• Primary outcomes
– Concordance of treatment with the goal of care
– Knowledge scores of proxy
– Quality of communication (QOC) scale to quantify proxies
experience communicating with hospital physicians
– Satisfaction with Care at the End-of-Life in Dementia (SWCEOLD) scale used to assess proxy satisfaction with hospital
care
85.4 ± 6.9
White (%)
72.4
Female (%)
62.1
Place of residence (%)
Nursing home- 58.6
Private home- 34.5
Assisted living facility- 6.9
Alzheimer’s dementia (%)
66.5
BANS-S score
20.1 ± 1.7 (severe functional disability)
Proxy Data
Characteristic
Result
Age
Characteristics of Hospitalization
Characteristic
Result
Result
Age
58.4 ± 10.5
Length of stay- mean days (SD)
4.6(3.8)
White (%)
65.5
Admitting service (%)
Female (%)
79.3
Relationship to patient (%)
Children- 69.0
Other family or friend- 17.2
Spouse- 6.9
Legal guardian- 6.9
General medicine/Hospitalist- 75.9
Geriatric Medicine- 17.2
Other- 6.9
Primary discharge diagnosis (%)
Lives with patient (%)
13.8
Infection- 48.2
Transient mental status change- 13.8
Metabolic disturbance/dehydration- 13.8
Cardio-pulmonary- 13.8
Other- 10.4
Hours providing direct care to patient per
week (%)
>7 hours- 55.2
1-7 hours- 37.9
None- 6.9
IV antibiotics (%)
86.2
Reported understanding disease course (%)
58.6
Believed patient had <6 months to live (%)
20.7
Comfort main goal of care (%)
86.2
Radiologic exam (%)
96.6
Goals of care discussion documented (%)
Control- 70.8
Intervention- 100
Discharged on hospice (%)
Control- 12.5
Intervention-20.0
One Month Follow Up
• 7 (24.1%) of patients had died
– 6 in control group
– 1 in intervention group
• 8 (27.6%) referred to hospice
– 6 (25%) in control group
– 2(40%) in intervention group
• 24.1% rehospitalized  All from control group
• 4 feeding tubes inserted  All from control group
• Quality-of-communication and satisfaction-with-care
scores higher in intervention group
Educational Opportunities
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Proxy
Patient family
Healthcare providers
Future geriatricians and palliative care
physicians
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Alzheimer’s Disease Annual Update
Challenges
• Accurate identification of patients
– EMR
– Nursing history
– Other
• Timing of intervention
– On admission (ED, ICU)
– At discharge
• Educating providers regarding utility of the
consult
• Selling model of care to hospital leadership
11/7/2014
Business Case for ADCS
• Valuable service for hospital and
patients/proxies
– Lower readmission rate
– Increased hospice referrals
– Improved proxy satisfaction
– Increased education of care providers and trainees
regarding advanced dementia
– Feasible to roll into geriatric or palliative care
consult service
– Keeping with goals of Affordable Care Act
Summary
• ADCS developed to address issues specific to
patients ≥65 years meeting criteria for GDS 7
• Practical challenges included identifying
patients and optimizing timing of consult
• Pilot data suggests patients are less likely to
be rehospitalized and higher proxy satisfaction
• Practical model that can be reproduced in
other institutions
??Questions??
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