Risk Prediction for Adverse Outcomes for Frail Older Persons with Complex Healthcare and Social Care Needs Admitted to a Community Virtual Ward Model

Figures & data

Figure 1 The North Dublin community virtual ward (CVW) assessment and triage process.

Table 1 Health States Measured at 30, 60 and 90 Days After Admission to the Community Virtual Ward

Unstable
Reduced or inadequate oral and/or nutritional intake
Gradual cognitive decline or change in mental state
Functionally unable to undertake their usual/baseline activities of living
Social care needs exceeding supports within the home
Secondary event resulting in above
Deteriorating
Increase in events and episodes
Decrease in function (activities of daily living) from baseline
Decrease in mobility
Deterioration in mental status
Further weight loss in spite of interventions
Stable
Ability to eat and drink returned
Mental status considered normal or back to baseline for those living with dementia
Functionally returning to their usual activities of daily living either independently or with support
Improvements in emotional/psychological state or no evidence of deterioration
No subsequent events within the last 30 days

Table 2 Summary of Data Items and Scales Collected as Part of the Community Virtual Ward (CVW) Model

Domain	Approach (Scale) to Measurement	Definition or Cut-Off Score	Measured at
Frailty	Rockwood CFS	5	Admission, 60 and 90 days
Risk of Hospitalization	ISAR	2	Admission, 60 and 90 days
Falls	Review of records	Within 3 months	Admission, 60 and 90 days
Function	Modified BI	16	Admission, 60 and 90 days
Mobility	Modified FIM	>1	Admission, 60 and 90 days
Mobility	TUG	>13 seconds	Admission, 60 and 90 days
Depression	GDS	>5	Admission, 60 and 90 days
Nutrition	MUST	<1	Admission, 60 and 90 days
Pressure Ulcer Risk	Walsall	>3	Admission, 60 and 90 days
Cognition	MMSE	<30	Admission, 60 and 90 days
Health States	Unstable, Stable, Deteriorated	Defined Table 1	Admission, 30, 60 and 90 days

Abbreviations: CFS, Clinical Frailty Scale; ISAR, Identification of Seniors at Risk tool; BI, Barthel Index; FIM, Functional Independence Measure; TUG, Timed Up and Go test; GDS, Geriatric Depression Scale; MUST, Malnutritional Universal Screening Tool; MMSE, mini mental state examination.

Table 3 Typical Events and Interventions Applied as Part of the North Dublin Community

Event Category	Example	Assessment	Intervention(s)	Monitoring
Clinical	UTI	MSU, oral antibiotics, baseline bloods	Sub-cutaneous fluids	Twice daily monitoring for 3 days
Functional	Fall, functional decline	Functional assessment	Physio/occupational therapy input. Balance and exercise programme, caregiver(s) involvement	4 weeks active monitoring minimum with once weekly review
Nutritional	Weight loss	Assessment: Review fluid and oral intake, meal preparation	Increase home care supports, dietician input, baseline bloods. Dietary monitoring plan	4 weeks active monitoring with once weekly review
Social	Cognitive decline with increase in social care needs	Review current Social supports. Day Hospital Assessment CGA	Assign social worker, MDT Input Day Hospital	Once weekly review for 4 weeks
Behavioural	Wandering at night, aggressive behaviours	Assessed for delirium, medication review ± change. Cognitive, functional, nutritional and social assessment. Geriatrician input	Community step up (intermediate care) bed. Pro-active care planning for long-term care, community psychiatry input	Reviewed 2 days post discharge from step-up bed with once weekly reviews for up to 4 weeks

Abbreviation: CGA, Comprehensive Geriatric Assessment.

Table 4 Characteristics of Patient Included in the Community Virtual Ward

Demographics	Baseline Profile
	Numbers, % and SD
Age	82.83 (SD 6.406)
Gender
Female	58 (65.9)
Male	30 (34.1)
Living Alone
Yes	33 (37.5)
No	55 (62.5)
Sign of Self Neglect
Yes	44 (51.1)
No	43 (48.9)
Signs of Caregiver Frailty
Yes	33 (37.5)
No	51 (58.5)
Number of Home Care Hours	10.98 (SD 8.567)
Number of Comorbidities	2.82 (SD 1.034)
Most Common
Dementia	65 (73)
Hypertension	32 (36)
IHD	25 (22)
Atrial fibrillation	20 (20)
CVA	20 (22)
Osteoporosis	17 (19)
COPD	15 (17)
Charlson Comorbidity Index
−2–5	36 (40.9)
−6–7	39 (44.3)
−8–10	13 (14.8)
Number of Medications	8.24 (SD 3.655)
Number of Falls Risk Increasing Drugs (FRIDs)
–None	16 (18.2)
−1 FRID	35 (39.8)
−2 or more FRIDs	37 (42.0)
Most Common FRIDs
–Beta-blockers	29 (32.9)
–Ace-inhibitors	23 (26.1)
–Diuretics	21 (23.8)
–Antidepressants	21 (23.8)
–Calcium Channel Blockers	19 (21.5)
–Night Sedation	11 (12.5)
–Benzodiazepines	11 (12.5)
–Antipsychotics	11 (12.5)
Incontinence
Yes	64 (72.7)
No	24 (27.3)
Falls Pre (Last 3 Months)
–No Falls	37 (42)
−1 Fall	20 (22.7)
−2 or more	31 (35.2)
Unplanned Care (Last 3 Months)
−1 ED presentation	36 (40.9)
−2 or more ED presentations	31 (35.2)
−1 hospital admission	36 (40.9)
−2 or more hospital admissions	21 (23.9)

Table 5 Multinomial Logit Regression Analysis Factors Associated with Institutionalization

Risk Scores	Stages 1=Admission 2=60 Days 3=90 Days		B (SE)	95 CI for Odds Ratio	Lower		Upper
Home		Risk Scores
Barthel	60 days	6–15 (High–low)	−3.78	p=0.000**	0.023	0.002	0.32
ISAR		0–4	−5.47	p=0.000**	2.64	0.000	0.07
Mobility	60 days	Supervision-Independent	4.51	p=0.001*	0.995	0.001	0.42
MMSE	60 days	18–30	1.92	p=0.003*	0.146	0.041	5.23
Rockwood	On Admission	6	1.95	p=0.017*	0.142	0.028	0.70
Institutionalization
Mobility	60 days	Assistance 1.2, hoist	−1.14	p=0.014*	0.319	0.128	0.79
MMSE	60 days	0–17	−.869	p=0.041*	0.419	0.12	1.42
Rockwood	On Admission	>7	−1.76	p=0.012*	0.171	0.04	0.67

Notes: Chi-Square *p<0.05, **p<0.001.

Table 6 Health States Measured at 30 and 60 Days and Outcomes

Health State	Days CVW	B (SE)	Wald X^2 (1)		OR	Outcome
Stable	30–60 days	0.78	15.23	p<0.001	3.39	Home
Unstable	30–60 days	0.68	7.40	p<0.006	2.09	Institutionalization
Deteriorated	30–60 days	0.55	5.82	p<0.01	1.01	Institutionalization