| Project Objectives / Summary:
Case conferences are considered a key strategy in quality aged care but until recently have been rarely used outside specialist settings. New MBS items now fund GPs and specialists to attend case conferences in residential care but there is little evidence on their effectiveness in this setting. The Division assessed the impact of case conferences (involving a GP, a geriatrician, a pharmacist, residential care staff and a representative of the Alzheimer's Association) on residents with complex behavioural or medication problems.
Objectives:
To evaluate the impact of multi-disciplinary case conferences on the management of residents with medication problems and difficult behaviours in high care facilities.
To describe the acceptability and feasibility of implementing multi-disciplinary case conferences in high care facilities.
Ten nursing homes from around Adelaide, South Australia, were recruited. Using a randomised controlled trial design, five facilities were randomly allocated to the intervention and five served as control. One hundred and fifty four residents with medication problems and / or difficult behaviours (pain and dementia related) were chosen by the facility staff (100 residents from intervention and 54 residents from control facilities). Two case conferences were held for each intervention group resident. Twenty seven GPs were recruited.
Selection Criteria:
A resident on multiple (more than five) medications; and / or
A resident who has a difficult behaviour to which the staff would like more attention paid.
Project Collaboration:
The Division would like to acknowledge and thank the participating nursing homes, the patients, carers and family members, GPs, pharmacists, and the Alzheimers Association who participated in the project.
Project Outcomes:
Outcomes were assessed at baseline and three months. The primary outcome was the Medication Appropriateness Index (MAl). It is designed to assess the appropriateness of a medication on 10 scales including: indication, effectiveness, dosage, correct directions, practical directions, drug-drug interactions, drug-disease interactions, duplication, duration and expense. A MAl was completed by an independent pharmacist for all regular medications taken by each resident. Behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale (NHBPS). At the cessation of the project, three focus groups were conducted with GPs and facility staff.
Two multi-disciplinary case conferences were held for each resident in the intervention group. These case conferences were held at the residential care facility and were approximately three months apart.
All facilities in the study, including those in the control group received a half-day workshop looking at the use of a toolkit in the management of behaviours of concern, provided by the Alzheimers Association of South Australia.
The primary analysis was a comparison of changes over the study period between the Intervention group and the Control group. In addition, a secondary analysis was performed comparing the Intervention-Control and Control groups. Changes over the study period were compared using t-tests, Pearson's chi-square and multivariate regression methods.
Upon completion of the project, participating GPs and facility staff were invited to attend one of three focus groups to discuss their views of the project. The focus groups were facilitated by an individual external to the project but with extensive experience in the health sector.
Conclusions:
- Despite a statistically significant difference between the intervention and control groups in the MAI score at baseline (p=0.034), the total MAI score was reduced by 49% in the intervention group compared with 9% in the control group (p<0.001). In the Intervention group, 36% of baseline medications were ceased, compared to 21% in the control group (p<0.001).
- Multi-disciplinary case conferences were an effective way of reducing the inappropriate use of medications for residents in residential care.
- Multi-disciplinary case conferences were a feasible and acceptable approach to managing residents from residential care.
- While no change in behaviour was detected on the Nursing Home Behaviour Problem Scale, comments recorded at the second case conference indicate that the case conferences had some positive effect on behavioural problems.
- A high proportion of GPs will participate in case conferencing when it is organised and there is a clear clinical need.
- Multi-disciplinary case conferences provided a forum to address both the medical and behavioural management of residents with challenging behaviours and enable residential staff to participate in the development of a care plan.
- There was a strong level of support for the use of multi-disciplinary case conferences in residential care from the participants in the study. The participants found them beneficial, both for their residents and for themselves professionally. The major obstacle to using case conferences is the time required to organise such a meeting, and GPs felt it was unlikely that they would be able to organise a case conference themselves.
Lessons:
Comments made at all three of the focus groups indicated that both the GPs as well as the facility staff found that participation in the multi-disciplinary case conferences was very beneficial. While not all of the suggested interventions, both medication and behavioural changes, worked, they stated that it was a process of trial and error. The case conferences resulted in improved communication between GPs, residential care staff and the resident's families, and provided introduction and an on going association with the geriatricians, the pharmacists and the behavioural specialist. Contributions from all participants were appreciated and resulted in a sense of empowerment, particularly for the facility staff. Some concerns were raised about the feasibility of continuing case conferences outside of the research setting, however, most felt that participation had increased the likelihood of this occurring.
Multi-disciplinary case conferences appear to be a feasible and acceptable approach to reducing the use of inappropriate medications in residential care, facilitating communication between the health professionals involved and producing a variety of pharmacological and behavioural recommendations. This is one of the few projects to evaluate the impact of the new Enhanced Primary Care (EPC) Items. The positive findings of this project resulted from the involvement of a true multidisciplinary team able to provide recommendations on both pharmacological and behavioural interventions.
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