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 • • • • • • 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 1 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 Angela.Catic@va.gov 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 2 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 • • • • Proxy Patient family Healthcare providers Future geriatricians and palliative care physicians 3 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?? 4