The Community Assessment of Risk and Treatment Strategies (CARTS) programme
The Community Assessment of Risk (Tool) and Treatment Strategies (CARTS) Programme is a risk intervention strategy, the first of its kind, that aims to identify, quantify, stratify and manage risk of adverse outcomes, frailty and functional decline among community dwelling, older adults. The number and proportion of older adults is increasing and they often present with complex patterns of interacting conditions. Older adults may lack adequate home supports, creating a 'care deficit', that places them at increased risk of adverse outcomes, including institutionalisation, hospitalisation and death. CARTS provides a novel solution towards delivering integrated healthcare in the community.
CARTS and the EIP on AHA
The CARTS programme was selected as an exemplar as part of Irelands sucessful three star reference site bid under the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). CARTS targets the A3 Action, 'Prevention of functional decline and frailty', covering all three pillars. The first, 'prevention, screening and early diagnosis', matches A3: by allowing early identification of community dwellers living at risk, CARTS will allow prompt response and initiation of appropriate management to prevent functional and cognitive decline. CARTS also targets the second and third pillars, providing protocols and training pathways, and in conjunction with ICT, allows new assistive technologies to be trialled and evaluated in clinical practice, see the folowing link for a description of Irelands three star reference site under the EIP on AHA, the COLLaboration of AGEing or COLLAGE http://www.europeangeriaticmedicine.com/article/S1878-7649(15)00088-1/fulltext
The CARTS tools
The Risk Instrument for Screening in the Community (RISC) is a quick (completed in one to two minutes), 'pre-screen', which stratifies patients from minimal to higher levels of risk. It collects demographic data and identifies concern for three core domains: Mental State, Activities of Daily Living and Medical State.
The Community Assessment of Risk Instrument (CARI), a short Comprehensive Geriatric Assessment proforma is completed on patients who screen positive on the RISC. The three core domains are further subdivided into sections and issues. For example, within the domain Mental State, there are four sections: Thinking and Reasoning, Behaviours, Psychiatric, and Other. Each section is subdivided into issues, for example Thinking and reasoning is divided into two issues, Cognition and Insight and Executive function. Each issue is graded in severity, from mild to severe, the effect of the care network is noted, and risk is determined such that: Risk equates to the severity of the concern minus the protective effect of the caregiver network. The CARI also stratifies individuals into low, medium and high risk. The instrument has been developed in conjunction with public health nurses (PHNs) but can be used by other healthcare workers.
The CARTS programme was developed over a six month period of feedback and after the creation of a dedicated training programme, inter-rater reliability (IRR) of the RISC was established. The next phase of the CARTS programme involved the validation of the RISC in a sample of 803 community dwelling older adults in Cork City and County. Screening was be conducted by PHNs trained in the CARTS program. Once individuals were stratified according to their risk, the tool was validated against a validated measure of frailty, the Clinical Frailty Scale (CFS). The one year event rate for adverse outcomes was then determined. The CARTS tools have been used in several countries including Australia, Portugal and Spain with validation near completion in these sites. Intervention strategies have also been developed to complement the introduction of the CARTS programme (CARTS management) and these are now being validated in combination with the CARTS screening and assessment components.
Figure 1. Overview of the Community Assessment of Risk and Treatment Strategies integrated care pathway model.
Overview of Results to Date
Ethical approval was granted from University College Cork and the University Teaching Hospitals in Cork, Ireland. An extensive training program for PHNs and other healthcare workers was then developed.Preliminary data collection began with a review of a risk register of 783 older adults in one public health nurse (PHN) sector, covering c 4000 older adults, in our target area (South Lee, Cork City). The inter-rater reliability (IRR) (n=115 raters) of the RISC was established - trained, “certified” raters were shown to have improved reliability in a sample of Irish and Canadian healthcare workers. To validate the RISC, patients under active follow-up by their PHN (n=803) were screened in two health centres in Cork. Baseline demographics, frailty level (using the Clinical Frailty Scale [CFS]) and perceived risk of adverse outcomes (using the RISC) were measured. At one year, the prevalence rate of the three adverse outcomes was 10.2% for institutionalisation, 17.7% for hospitalisation (at least one) and 15.6% for death. Patients classed as high-risk had a significantly greater risk of institutionalisation (31.3% and 7.1%, p<0.001), hospitalisation (25.4% and 13.2%, p<0.001) and death (33.5% and 10.8% p<0.001) compared to those who scored low-risk. The RISC was more accurate than the CFS in predicting all three outcomes. Secondary analysis of the data revealed that each component, but particularly the caregiver network, had reasonable accuracy in predicting institutionalisation. No subtest or assessment instrument significantly predicted risk of hospitalisation. Perceived risk of institutionalisation correlated most with concern over the ability of caregiver networks to manage patients’ mental state. Risk of hospitalisation and death correlated with patients’ medical state. The results from the prospective cohort study of community dwelling older adults in Ireland are available at http://www.biomedcentral.com/1471-2318/15/92.
In Australia, over 500 community-dwelling older adults have been screened using the RISC and the CARI completed as part of a formalised CGA. Inter-rater reliability in a sample of 50 patients was assessed by a nurse and a doctor. The instrument was found to have good reliability across all domains, especially for risk of death and institutionalisation. Following receipt of a grant from the Fremantle Hospital Medical Research Foundation, the Australian cohort is now undergoing 12 month analysis for the three key outcomes of hospitalisation, institutionalisation and death.
In Spain 374 community-dwelling older adults living in Barcelona and receiving home care have been screened using the RISC. They are currently being followed to identify whether those with higher RISC scores, have increased rates of adverse outcomes. Results showed that 48.4% had mental problems, 93.6% had problems with activities of daily living, and 80% medical/physical problems. With regards to the caregiver network, 20.6% of caregivers were burdened and 24.1% had problems or couldn’t handle the situation. Overall there were 19.3% who had a high risk of developing adverse outcomes in the next year, with 8.6% at high risk of institutionalisation, 13.4% at high risk of hospitalisation and 7.2% at high risk of death33. There were 14 statistically significant associations between high risk of adverse outcomes and other morbidity measures such as worse Clinical Risk Groups (CRG) classification, being a complex or advanced chronic patient, having COPD, dementia and a high score on the Barthel Index. Also problems with the ability of the caregiver network to cope, were associated with higher risk of adverse outcomes. Provisional eight month follow-up data of the incidence of death and nursing home admission shows an almost four times higher risk of both adverse outcomes high risk groups as characterised by the RISC.
In Portugal, 4499 community-dwelling older adults have been screened using the RISC and are currently being followed. The sample consisted of 1854 (41.2%) males and 2645 (58.8%) females with a mean age of 76.3 years (standard deviation =+/-7.3, range=65-103 years). Only 734 patients (16.7%) were living alone. In total, 1616 (35.9%) of the patients were scored as having mental health concerns using the RISC, compared with 2043 (45.4%) with ADL concerns and 3222 (78.3%) with medical concerns. Of patients with mental health concerns on the RISC, less than half (48.5%) had a caregiver network that was perceived to be able to manage the situation. Evaluating the risk of adverse outcomes showed that 16.3% of the sample was perceived to be at risk of institutionalisation, 32.8% at risk of hospitalisation and 23.1% at risk of death.
CARTS has multi-source funding, directly from the HSE (Irish health department) and indirectly through the Centre for Gerontology and Rehabilitation, see http://www.ucc.ie/en/cgr/. The Australian site received funded from the Fremantle Hospital Medical Research Foundation and the Spanish and Portugeuse sites have since applied for local govermental funding.
Dissemination and Research Activity
The results of the CARTS programme were presented at the Irish Gerontological Society meetings 2012-14 and the IAGG-ER meeting April 2015. Further results will be presented at the Gerontological Society of America conference (November 2015). Papers validating the CARTS tools, using the CARTS programme in three countries and integrating management strategies using a Delphi consensus are now being prepared for publication.
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O’Caoimh R, Healy E, O Connell E, Gao Y, Molloy D.W. The Community Assessment of Risk Tool, (CART): Investigation of Inter-Rater Reliability for a New Instrument measuring risk of Adverse Outcomes in Community Dwelling Older Adults. Irish Journal of Medical Science 2012,181 S(7) p227.
O’Caoimh R, Gao Y, Healy E, O’Connell E, Gabrielle O’Keeffe G, Molloy DW. Screening for Markers of Frailty and Percieved Risk of Adverse Outcomes Using The Community Assessment of Risk Tool. Irish Journal of Medical Science 2013 182 S(6) p230.
Sweeney C, Molloy DW, O’Caoimh R, Bond R, Hynes H, McGlade C, Shorten G. European Innovation Partnership on Active and Healthy Ageing: Ireland and the COLLAGE experience. Irish Journal of Medical Science 2013, 182 S(6) p278-279.
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O’Caoimh R, FitzGerald C, Cronin U, Svendrovski A, Gao Y, Healy E, O’Connell E, O’Keeffe G, O’Herlihy E, Nicola Cornally N, Leahy-Warren P, Clarnette R, Molloy DW. Which Part of the Risk Instrument for Screening in the Community (RISC) Predicts Adverse Outcomes? Irish Ageing Studies Review 2015 6 (1) p296.
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Leahy-Warren P, O’Caoimh R, Fitzgerald C, Cochrane A, Svendrovski A, Cronin U, O’Herlihy E, Cornally N, FitzGerald C, Gao Y, Healy E, O’Connell E, O’Keeffe G, Coveney S, McGlynn J, Clarnette R, Molloy DW. Components of the Risk Instrument for Screening in the Community (RISC) that predict Public Health Nurse perception of risk. Journal of Frailty & Aging 2015, 2015;4(3):149-154. Journal of Frailty & Aging 2015, doi.org/10.14283/jfa.2015.56.
O’Caoimh R, FitzGerald C, Cronin U, Svendrovski A, Gao Y, Healy E, O’Connell E, O’Keeffe G, O’Herlihy E, Weathers E, Cornally N, Leahy-Warren P, Orfila F, Paúl C, Clarnette R, Molloy DW. Which part of a short, global risk assessment, the Risk Instrument for Screening in the Community (RISC), predicts adverse healthcare outcomes? Journal of Aging Research 2015, Article ID 256414, 7 pages, doi:10.1155/2015/256414.
O’Caoimh R, Cornally N, Weathers E O’Sullivan R, Fitzgerald C, Orfila F, Clarnette R, Paúl C, Molloy DW. Risk prediction in the community: A systematic review of case- finding instruments that predict adverse healthcare outcomes in community-dwelling older adults. Maturitas September 2015, 82; (1):3–21. Maturitas 2015, DOI 10.1016/j.maturitas.2015.03.009.
O’Caoimh R, Sweeney C, Hynes H, McGlade C, Cornally N, Daly E et al. COLLaboration on AGEing-COLLAGE: Ireland’s three star reference site for the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). European Geriatric Medicine 2015 DOI: 10.1159/000433432.
Weathers E, O’Caoimh R, Paúl C, Clarnette R, Orfila F, O’Sullivan R, Daly BD, Cornally N, Molloy DW. The Community Assessment of Risk Screening and Treatment Strategies (CARTS) programme: An Update. ICT4Ageing Well 2015 Lisbon, Portugal 20-22 May 2015.
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Orfila F, Cegri F, Canela M, Ensenyat P, Cos X, Peligros X, Molloy DW. Proyecto CARTS, estudio piloto de una herramienta de riesgo de fragilidad y declive funcional en la personas mayores en Atención Primaria. 4a Jornada del Pla de Salut de Catalunya 2011-2015. Sitges, 28 noviembre 2014.
Paúl C, Teixeira L, Azevedo MJ, Alves S, Duarte M, O’Caoimh R, Molloy DW. Perceived risk of mental health problems in primary care. (Submitted 2015).
Leahy-Warren P, Weathers E, Lupari M, Campbell S, Clarnette R, Orfila F, Fitzgerald C, Paúl C, O'Herlihy E, Cornally N, O'Caoimh R, Day MR, Mulcahy H, Molloy DW. Risk Instrument for Screening Older People in the Community (RISC): Cross Cultural Perspectives. International Journal of Research in Nursing, 2015, DOI: 10.3844/ijrnsp.2015.