Improving the functional health of at-risk seniors

Providence Health Care (PHC), one of Canada’s largest faith-based health-care organizations, operating 14 health-care facilities in Greater Vancouver, is known for its leading Elder Care Program. The program provides a wide spectrum of services for elderly British Columbians, including residential care, acute geriatric medicine, geriatric psychiatry and rehabilitation.

Each year, 25 per cent of all patients admitted to St. Paul’s Hospital and 50 per cent of those admitted to Mount Saint Joseph Hospital are over the age of 70. Of these, the Elder Care Program’s multidisciplinary teams’ expertise assists complex geriatric patients with acute health-care needs.

“There are critical challenges facing hospitals for the care of seniors nowadays, especially for those at-risk seniors over 70,” says Dr. Janet McElhaney, PHC Physician Program Director for Elder Care. “For that population, we are seeing an increasing number of admissions and related inpatient days,” she adds. Many of these older patients have chronic diseases and multiple complex medical issues and live alone with little support.

One in three patients over 70 years of age admitted to hospital ends up being discharged at a higher level of disability. In response to this concerning trend, in September 2008, PHC began implementing an innovative and unique approach to enhance the care and flow of vulnerable, at-risk elderly patients admitted to the emergency department at St. Paul’s Hospital.

The aim of the Goal Responsive Acute Care for Elders (GRACE) initiative, which spans multiple programs within PHC, is to prevent increasing disability and functional deterioration of at-risk elderly patients as a result of hospitalization. “The GRACE initiative is a key strategy for reducing the significant de-conditioning affects in hospitalized elders associated with bed rest and to support older patients in returning to the setting in which they lived prior to their hospital admission,” says McElhaney, who is the initiative’s physician lead. “This approach allows us to create a near-seamless flow through the patient’s hospital stay by closing existing gaps in access to needed services.”

An inter-professional collaborative practice team was established at St. Paul’s Hospital as part of the broader GRACE initiative. The GRACE clinical team initiates timely patient identification, evaluation, early rehabilitation and effective discharge planning for the target patient population.

The team works closely with the emergency department, acute care staff, community services and family physicians to establish practice links and to facilitate integration of the team’s recommendations into the senior’s ongoing care plan. Though this practice model has been applied elsewhere in Canadian hospitals, this initiative is unique in Canada with respect to the breadth of the GRACE clinical team. The team includes two geriatric emergency nurses, a physiotherapist and six geriatricians.

The team reviews a patient’s previous admission records and checks to see if they have been receiving home support or care at the community level. They perform complete medical, functional and social assessments and tests that include screening for common geriatric problems. Frail patients with mobility issues will have tests to determine if they need a walking aid, are at a higher risk of falls, and whether they need help with daily activities such as getting up and down stairs or in and out of the tub.

The team communicates with ED staff and physicians in decisions about care planning, and makes recommendations regarding admission or discharge. If the patient is admitted to hospital, the team prepares a care plan with recommended treatments and liaises with appropriate geriatric services within the hospital, such as the Geriatric Medicine Outpatient Clinic or the Geriatric Day Program. For patients who are discharged from hospital, they can arrange further assessments by community physiotherapists, occupational therapists or home nurses, who can refer them to services such as the Falls Clinic at St. Paul’s Hospital and advise on choosing and purchasing appropriate mobility aids.

The team members use a patient-centred approach, involving the patient in dialogue around the nature of their hospitalization, recommended treatment options, and goal setting. “Since the GRACE initiative began, we’ve heard from patients who are grateful for the individual approach our team takes to providing comprehensive care,” McElhaney says.

For one such patient with unsteady gait and leg pain, GRACE physiotherapist Anne Leclerc arranged the purchase of a walker and referred her to the St. Paul’s Hospital Geriatric Day Hospital where she is now regularly monitored. The patient continues to live independently and is very pleased to be monitored so closely.

The team members enjoy the satisfaction of helping seniors maintain their independence by working to return them to the setting in which they lived before coming to hospital, thereby avoiding the need for residential care. “I feel I can make a real difference with this group, in helping them maintain or improve their functional mobility and ultimately, their quality of life,” says Leclerc.