Incorporating a frailty dimension into LOCUS for seniors in a medical-psychiatry population

Key Findings:

• Services from a psychiatric hospital rather than a general hospital, diagnosis of delirium, use of an antipsychotic or benzodiazepine led to a higher level of care compared to the LOCUS predicted level of health care service.
• Increase in the clinical frailty scale score or treatment for depression predicted a small decrease in the level of care provided as compared to the LOCUS predicted level of health care service.
• Older adults with frailty or depression received LOCUS scores indicating a need for healthcare services higher than the actual level of services provided.

Why was this study needed?

• This is the first study of its kind to evaluate the potential causes of the variance between the LOCUS and actual levels of care received by seniors with mental health disorders and medical co-morbidity.
• Currently there is no available utilization management tool to predict care requirements for these seniors.
• Results suggest that the Clinical Frailty Scale and a few readily available clinical variables can be used to enhance the prediction of the level of psychiatric care required by older adults such that a customized Geri-LOCUS for seniors can be developed to be studied and validated.

Suggestions on how administrators or policy makers could use the findings:

• The development of a customized GERI-LOCUS for seniors could guide the allocation of resources to the primary care setting and support the implementation of an integrated collaborative care model particularly for frail seniors with depression.
• Further analysis of the data is required to understand whether the presence of frailty or depression artificially increases the LOCUS score or whether there are clinician decision making variables or other clinical factors operating.

Brief comment on type of study:

• Between September 2015 and June 2016 the LOCUS score for 398 elderly patients who received services from the seniors mental health services at THP was obtained during routine clinical care and for a small minority was obtained retrospectively from chart reviews.
• Additionally, the LOCUS score 200 elderly patients who received services from the geriatric mental health services at CAMH was obtained via a retrospective chart review.
• In addition to LOCUS, the Clinical Frailty Scale and multiple frailty dimensions were documented for each patient including, but not limited to age, gender, delirium, dementia, depression, alcohol abuse, and socially disconnectedness
• We then analyzed which variables predicted any variance between the LOCUS predicted level of healthcare service required vs. the actual level of healthcare service that was provided.

Key Findings:

• Services from a psychiatric hospital rather than a general hospital, diagnosis of delirium, use of an antipsychotic or benzodiazepine led to a higher level of care compared to the LOCUS predicted level of health care service.
• Increase in the clinical frailty scale score or treatment for depression predicted a small decrease in the level of care provided as compared to the LOCUS predicted level of health care service.
• Older adults with frailty or depression received LOCUS scores indicating a need for healthcare services higher than the actual level of services provided.
• We found 413 articles that identified participants as frail without measuring frailty, and 204 articles that measured frailty.
• The majority (81%) of research that measured frailty were observational studies.
• Most (60%) of the reported frailty measures were developed to measure frailty; however, 27% of frailty measures used operational definitions for the purpose of that study and 2% defined frailty using clinical judgement.
• The Clinical Frailty Scale, Frailty Index, and Frailty Phenotype were the most commonly reported scales.
• 44% of studies used frailty to predict adverse health outcomes, 20% used frailty as an inclusion and exclusion criterion, and 4% used frailty as an outcome measure. One third of studies used frailty for descriptive purposes only.
• Most studies showed that frailty tools are predictive of adverse health outcomes, specifically mortality (84% of cases) and institutionalization (93% of cases).

Why was this study needed?

• This is the first study of its kind to evaluate the potential causes of the variance between the LOCUS and actual levels of care received by seniors with mental health disorders and medical co-morbidity.
• Currently there is no available utilization management tool to predict care requirements for these seniors.
• Results suggest that the Clinical Frailty Scale and a few readily available clinical variables can be used to enhance the prediction of the level of psychiatric care required by older adults such that a customized Geri-LOCUS for seniors can be developed to be studied and validated.

Brief overview of the methodology:

• Between September 2015 and June 2016 the LOCUS score for 398 elderly patients who received services from the seniors mental health services at THP was obtained during routine clinical care and for a small minority was obtained retrospectively from chart reviews.
• Additionally, the LOCUS score 200 elderly patients who received services from the geriatric mental health services at CAMH was obtained via a retrospective chart review.
• In addition to LOCUS, the Clinical Frailty Scale and multiple frailty dimensions were documented for each patient including, but not limited to age, gender, delirium, dementia, depression, alcohol abuse, and socially disconnectedness
• We then analyzed which variables predicted any variance between the LOCUS predicted level of healthcare service required vs. the actual level of healthcare service that was provided.

Remaining knowledge/research gaps:                                                                              

• The development of a customized GERI-LOCUS for seniors could guide the allocation of resources to the primary care setting and support the implementation of an integrated collaborative care model particularly for frail seniors with depression.
• Further analysis of the data is required to understand whether the presence of frailty or depression artificially increases the LOCUS score or whether there are clinician decision making variables or other clinical factors operating.

CFN Webinar (September 13, 2017): Incorporating a frailty dimension into LOCUS for seniors in a medical-psychiatry population