Models of Continence Care: What Works Best? Workshop 27 Tuesday 24 August 2010, 09:00 – 12:00 Time Time Topic Speaker 9:00 9:10 Introduction & General Overview Cara Tannenbaum 9:10 9:35 Continence promotion in the elderly in outpatients Susan Orme 9:35 10:00 The long‐term care model: barriers and indicators of Diane Newman success 10:00 10:25 Delivering continence care through a social enterprise Adele Long model: The Bristol Integrated Continence Service (BICS) 10:25 11:00 Break 11:00 11:25 Measuring the outcomes of continence care Jeffrey Jutai 11:25 12:00 Case studies Cara Tannenbaum & Jeffrey Jutai Aims of course/workshop • To review current models of continence care delivery in the context of patient needs. • To critically appraise the success or failure of various models of care delivery in different countries. • To present a novel model of integrated continence care. • To discuss outcome evaluation of continence care delivery at the individual and health systems level. • To encourage discussion and share lessons learned from around the world. Educational Objectives This workshop will allow practitioners and service providers to discover and discuss some of the latest research on evidence‐based models of continence care. The focus will be on the assessment of patient needs, the process of care delivery and the importance of outcome evaluation. Delegates will learn the advantages and disadvantages of different models of care for meeting patient needs. By the end of the workshop the delegate will be in a position to innovate their own practice if required and will be equipped with a choice of tools to evaluate the outcomes of care delivery. Speakers will also address issues related to different patient populations including patients who self‐manage in the community, patients who seek care in the outpatient setting, and patients who reside in long‐term care. Translational lessons for improved care across these settings will be highlighted. At the health systems level, new information will be presented on the use of national quality indicators for continence care and cutting‐edge triage systems for ensuring appropriate allocation of services. An interactive debate will explore the drivers, enablers and barriers to change in different settings and countries. International Continence Society, 40th Annual Meeting 23 August - 27 August 2010, Toronto, Canada WORKSHOP 27 Models of Continence Care: What Works Best? Chair : Cara Tannenbaum, M.D., M.Sc. Speakers : Dr Susie Orme, BM BS (Hons) MedSci FRCP Diane Newman, ANP-C MSN FAAN Adele Long, MBA(OU) MPhil BSc(Hon) MICR Jeffrey W. Jutai, PhD CPsych ICS WORKSHOP 27: Models of Continence Care: What Works Best? An overview of different models of continence care Cara Tannenbaum MD, MSc The Michel Saucier Endowed Chair in Geriatric Pharmacology, Health and Aging Associate Professor of Medicine, Université de Montréal Many different models of continence care exist. An individual with incontinence may attempt to self‐manage on their own or choose to engage in a doctor‐patient dyad with their primary health care physician. Nurse continence advisors work in tandem with specialty clinics to oversee behavioral or pessary interventions. Urology or urogynecology specialist clinics offer second‐line surgical interventions. Comprehensive geriatric assessment units integrate a multidisciplinary approach using a geriatrician, nurse specialist, physiotherapist and sometimes a pharmacist or social worker. Successful management of incontinence in the hospital or nursing home depends on top‐ to‐ bottom involvement by all personnel from administrators to nursing aides. At the national level, urogynecology triage systems are being implemented. In order to accurately gauge the effectiveness of each model for improving continence at the individual and/or population level, indicators capturing the full impact of the different continence care delivery methods need to be recorded. The use of multiple indicators may provide a more comprehensive picture of effectiveness than a single indicator alone. However, use of indicators raises certain challenges and highlights the complexity of obtaining valid and sustainable measurements of effective continence care over time. The most frequently used model of care is the self‐management model, whereby individuals with incontinence function on their own behalf to effectively manage bothersome urinary symptoms. Fewer than half of all adults experiencing incontinence seek professional care, with the majority preferring self‐help measures to try to control their symptoms (Milne, 2000; Tannenbaum, Drali, Holroyd‐Leduc, & Richard, 2009). Evidence‐based self‐management tools have been created to aid individuals in reducing risk factors for incontinence (see poster #x at ICS). Self‐monitoring around pelvic floor muscle exercises, caffeine reduction, weight loss, constipation management and improvement of vision and hearing impairment yields 50% reductions in incontinence in older women with stress, urge and mixed symptoms. A voiding diary is useful as a self‐monitoring outcome measure, though improvements in self‐efficacy and distress can also be documented using the Geriatric Self‐Efficacy Index for Urinary Incontinence and the Urogenital Distress Inventory respectively. ICS WORKSHOP 27: Models of Continence Care: What Works Best? Nurse‐led continence advisor programs appear to have similar efficacy to urology or urogynecology specialty models for conservatively managing incontinence (Borrie, Bawden, Speechley, & Kloseck, 2002; Moore et al., 2003; Williams et al., 2005). Outpatient geriatric assessment units are gaining in popularity (Padros, Peris, Salva, Denkinger, & Coll‐Planas, 2008; Tannenbaum, Bachand, Dubeau, & Kuchel, 2001), and report obtainable dryness rates up to 25% and improvement in an additional 45% of frail elderly patients who consult their service (Harari & Igbedioh, 2009). A number of effective continence interventions are available for nursing home residents, including prompted voiding and correction of reversible precipitating factors (Offermans, Du Moulin, Hamers, Dassen, & Halfens, 2009; Palmer, 2008). However, continence care programs in the long‐term care setting are difficult to implement and sustain (Etheridge, Tannenbaum, & Couturier, 2008). Using continence rates as a quality indicator for long‐term care may be one way of integrating continence management into mainstream healthcare delivery (Palmer, 2008). At the national level, a centrally commissioned clinical audit program to monitor the impliementation of evidence‐based guidelines across England and Wales found disparate standards of care in the community, hospitals and nursing homes (Wagg, Lowe, Peel, & Potter, 2009; Wagg et al., 2008). The climate is ripe with opportunities to improve appropriate training, skills and access to deliver efficient, high‐quality continence care across a variety of settings (Oliver, Thakar, Sultan, & Phillimore, 2009; Stothers, Wilkie, Lieblich, & Wilson, 2008). Selected references: Borrie, M. J., Bawden, M., Speechley, M., & Kloseck, M. (2002). Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ, 166(10), 1267‐1273. Etheridge, F., Tannenbaum, C., & Couturier, Y. (2008). A systemwide formula for continence care: overcoming barriers, clarifying solutions, and defining team members' roles. J Am Med Dir Assoc, 9(3), 178‐189. Harari, D., & Igbedioh, C. (2009). Restoring continence in frail older people living in the community: what factors influence successful treatment outcomes? Age Ageing, 38(2), 228‐233. Milne, J. (2000). The impact of information on health behaviors of older adults with urinary incontinence. Clin Nurs Res, 9(2), 161‐176. Moore, K. H., O'Sullivan, R. J., Simons, A., Prashar, S., Anderson, P., & Louey, M. (2003). Randomised controlled trial of nurse continence advisor therapy compared with standard urogynaecology regimen for conservative incontinence treatment: efficacy, costs and two year follow up. BJOG, 110(7), 649‐657. Offermans, M. P., Du Moulin, M. F., Hamers, J. P., Dassen, T., & Halfens, R. J. (2009). Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn, 28(4), 288‐294. Oliver, R., Thakar, R., Sultan, A. H., & Phillimore, A. (2009). Urogynecology triage clinic: a model of healthcare delivery. Int Urogynecol J Pelvic Floor Dysfunct, 20(8), 913‐917. Padros, J., Peris, T., Salva, A., Denkinger, M. D., & Coll‐Planas, L. (2008). Evaluation of a urinary incontinence unit for community‐dwelling older adults in Barcelona: implementation and improvement of the perceived impact on daily life, frequency and severity of urinary incontinence. Z Gerontol Geriatr, 41(4), 291‐297. Palmer, M. H. (2008). Urinary incontinence quality improvement in nursing homes: where have we been? Where are we going? Urol Nurs, 28(6), 439‐444, 453. Stothers, L., Wilkie, D., Lieblich, P., & Wilson, P. (2008). Developing a continence care centre using an urban/academic model of continence care. Can J Urol, 15(3), 4084‐4090. ICS WORKSHOP 27: Models of Continence Care: What Works Best? Tannenbaum, C., Bachand, G., Dubeau, C. E., & Kuchel, G. A. (2001). Experience of an incontinence clinic for older women: no apparent age limit for potential physical and psychological benefits. J Womens Health Gend Based Med, 10(8), 751‐756. Tannenbaum, C., Drali, R., Holroyd‐Leduc, J., & Richard, L. (2009). Lessons learned: Impact of a continence