Continuity of Care

eHealth Week Berlin 2007

From Strategies to Applications

Continuity of Care

Management of Chronic Diseases

Thursday 19th April ’07

Cillian Twomey

Consultant Physician in Geriatric Medicine

Cork University & St. Finbarr’s Hospitals, Cork


% over 65 years

• 2000 16.1%

• 2025 22%

• 2050 27.5%Future of Healthcare & Care of the Elderly

COM (2001) 723 final


% over 80 years

• 2000 3.6%

• 2025 6%

• 2050 10%Future of Healthcare & Care of the Elderly

COM (2001) 723 final


The Six A’s

1. Acute Assessment


The Six A’s

1. Acute Assessment

2. Appropriate Investigation


The Six A’s

1. Acute Assessment


3. Accurate Diagnosis(es)

4. Access to Consultation

5. Active Rehabilitation


The Six A’s

1. Acute Assessment


3. Accurate Diagnosis(es)

4. Access to Consultation

5. Active Rehabilitation

6. Aftercare


A ‘Comprehensive Specialist Geriatric Service’

– Geriatric Day Hospital

– Multi-Disciplinary Team support involving medical, nursing, occupational therapy, physiotherapy and speech & language services


–‘Rapid response’ GP referral service

–develop specialist clinics such as- Fall / Fracture prevention,

- Heart Failure Management,

- Continence Promotion,

- Stroke Prevention

Ambulatory Care Facility


• An 76 year-old man presented to OPD with a 2-3 week history ofvomiting and retching. He hadanorexia and lost over I stone in weight in the previous six months.

• He denied abdominal pain and his bowel habit was normal

Case 1


Case 1

• He had a long history of increasing pain in his right hip that was restricting his mobility.

• He had been prescribed oral Diclofenac - with some symptomatic relief.


Case 1

• he had hypertension for a number of years that had been controlled on Captopril

• but Valsartan was added to his regime sometime after the Diclofenac was started.


Case 1

• > urinary frequency, nocturia & < flow

• He was a widower living on his own but was becoming more restricted because of his hip problem.


Lab Results

�Hb 13g (N 14-18 g/dL)

�Serum Cr 170�� 129 (N 53-106 µmol/L)

�FOB negative x 3


• Duodenal Ulcer– Rx PPI

• Medications adjusted– Stop NSAID, Rx Paracetamol,

reduce anti-BP Rx

• Discharged home– Plan to review at OPD

Endpoint 1


4 months later

• admitted for elective right total hip replacement.

• 24 hours after his hip surgery he developed acute urinary retention and was catheterised. – Two subsequent trials of voiding failed

– Discharged home, a urinary catheter in place, with a view to urological follow-up


A week later• when getting out of bed he accidentally

dislodged his catheter, developed lower abdominal discomfort and was referred to the Emergency Department, CUH.

• On examination he was once more in acute urinary retention.

• He was also noted to have a swollen left lower limb


• Deep Vein Thrombosis– Anticoagulation Rx

• Benign Prostatic Hypertrophy– Urinary catheter still needed– Refer to Urology

• Discharged home with plans to – see at Geriatric Day Hospital– Urology opinion

Endpoint 2


3 months later• c/o progressive lethargy and listlessness

– °chest pain, °dyspnoea

• readmitted to CUH for further tests

• Afebrile

• early diastolic murmur (L sternal border)

• Repeatedly negative blood cultures, but

• Cardiac ECHO positive

• Rx with IV Antibiotics


Subsequent course…• Over the next 6/52, patient

general health gradually deteriorated

• He developed progressively worsening heart failure


• Infective Endocarditis

–Urinary Tract the likely source of infection

–Treated vigourously

Endpoint 3


• Hypertension• Prostatism• Osteoarthritis of Right Hip

– Symptoms failed to settle with drug Rx and worse he gets a

• Duodenal Ulcer

• Elective Hip Replacement– Develops post-operative acute

urinary retention

Summary 1


• Hypertension• Prostatism• Osteoarthritis of Right Hip

• Duodenal Ulcer• Elective Hip Replacement

• Further catheter problems• Bacteraemia �� Septicaemia ��• Infective Endocarditis ��

• End-stage Heart Failure

Summary 2


Patient’s referralpathways

Blood Pressure Control & IE

Further investigation of hip pain?

Hip Surgery?

Cardiology

Rheumatology / Orthopaedics

Social / Welfare Services

Might need to perform a risk assessment in

patient’s home

GP referral to Geriatrician and back to General

Practitioner

Renal Medicine +/- Urology


Multidisciplinary CarePhysiotherapist

Occupational Therapy

Clinical Nurse Specialist

Clinical Nutrition / Dietetics

Day Centre

Geriatrician / Psychiatry of Old Age

PatientFamily

PHN / C. Care Team

GP / Family Doctor

Speech & Language Therapy

Chiropody / Podiatry

Liaison Nurse / MSW

Ward 4A

Day Hospital


Illness in Older patients–Multiple Pathology–Atypical Presentation–Need for multi-specialist involvement

–An electronic patient record?

Conclusions


“When I’m 64...?”

Continuity of Care

Documents

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