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Acute Care for Elders (ACE) Units: Geriatric Care as a Team Sport. Kellie L. Flood, MD Assistant Professor Division of Gerontology, Geriatrics, and Palliative Care UAB School of Medicine. Objectives. Advocate to stakeholders the need for interdisciplinary team programs for care coordination

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acute care for elders ace units geriatric care as a team sport

Acute Care for Elders (ACE) Units: Geriatric Care as a Team Sport

Kellie L. Flood, MD

Assistant Professor

Division of Gerontology, Geriatrics, and Palliative Care

UAB School of Medicine

objectives
Objectives

Advocate to stakeholders the need for interdisciplinary team programs for care coordination

Define the components of an Acute Care for Elders (ACE) Unit as an example of an interdisciplinary team model of care

List outcomes from clinical trials evaluating ACE Units

Access available tools for geriatric interdisciplinary team training

slide4

Silver Tsunami is Coming!!

http://www.agingstats.gov/agingstatsdotnet/main_site/default.aspx

multimorbidity
Multimorbidity

Boult et al, The Permanente Journal Winter 2008;12:50-4; Boyd et al, Guided Care for Multimorbid Older Adults, Gerontol, 2007

.

62% of older Americans are experiencing multimorbidity

Older adults experiencing multimorbidity consume 96% of the Medicare budget

geriatric syndromes
Geriatric Syndromes
  • Dementia
  • Delirium
  • Depression
  • Gait and balance abnormalities/Falls
  • Frailty/Functional Decline
  • Malnutrition
  • Pressure ulcers
  • Polypharmacy
  • Incontinence
  • Caregiver Stress

Geriatric Syndromes = Increased Risk for Adverse Outcomes

Kresevic et al, Ger Nursing, 1998

hospitalized older adults
Hospitalized Older Adults
  • Patients aged 65 and over account for ~ 49% of hospital days
  • Geriatric syndromes often go unrecognized during a hospitalization

Counsell et al, JAGS, 2000; Palmer et al, Clin Geriatr Med, 1994; Palmer et al, Clin in Geriatr Med, 1998; Lyons, Landefeld, Ann of Long-Term Care, 2001

frail part of the tsunami is hitting hospitals
Frail part of the Tsunami is hitting hospitals

~35% have Cognitive Impairment on admission (65% unrecognized)

Dementia: ~25% older inpatients

Delirium:

10-15% on admission

10-40% in-hospital (new onset)

Up to 60% of hip surgery patients

Up to 80% of mechanically ventilated patients

Naylor et al, AJN, 2005; Counsell et al, JAGS, 2000; Palmer et al, Clin in Geriatr Med, 1998; Lyons, Landefeld, Ann of Long-Term Care, 2001; www.cdc.gov/nchs/agingact.htm

frail part of the tsunami is hitting hospitals1
Frail part of the Tsunami ishitting hospitals

Depression:

Minor depressive symptoms: 23%

Depression + dementia: 22-54%

23-62% are under-nourished

25-35% are more dependent in their ADLs at discharge

Up to 50% receive potentially inappropriate medications

Higher 30-day re-admission rates

Naylor et al, AJN, 2005; Counsell et al, JAGS, 2000; Palmer et al, Clin in Geriatr Med, 1998; Lyons, Landefeld, Ann of Long-Term Care, 2001; www.cdc.gov/nchs/agingact.htm

30 day readmission rates
30-Day Readmission Rates

2004 data: Unplanned rehospitalization cost Medicare $17.4 billion, making this a target for cost reduction

Jencks et al, NEJM 2009;360:1418-1428

a case ms jones
A Case: Ms. Jones
  • 78 yo AA Female living in an Assisted Living Facility
  • Multimorbidity: Hypertension, Hyperlipidemia, Congestive Heart Failure, Type II Diabetes, Renal Insufficiency, Spinal Stenosis that causes severe pain (she is not a surgical candidate)
  • Geriatric Syndromes: Frailty, Mild Cognitive Impairment, Depression, Polypharmacy
  • Limited Health Literacy: 8th grade education from rural Alabama
ms jones example of poorly coordinated hospital care
Ms. Jones: Example of Poorly Coordinated Hospital Care
  • Ms. Jones is hospitalized for pain and altered mental status
  • Admitted to a general medicine floor to a doctor who has never met her before
    • A traditional, multidisciplinary model of care
  • Day 1 she is diagnosed with a UTI
    • Antibiotics are started
ms jones example of poorly coordinated hospital care1
Ms. Jones: Example of Poorly Coordinated Hospital Care
  • During her first 48 hrs of admission Ms. Jones is observed to be intermittently agitated and moaning
    • Receives repeated doses of benzodiazepine for agitation
  • Day 2 she suffers a fall while trying to get to the bathroom
    • She is restrained
  • Day 4 she has completed her course of antibiotics for her UTI
    • She remains confused and is still occasionally moaning as if she is in pain
    • Later that day she is discharged back to her Assisted Living Facility
quality timeline
Quality Timeline

2008

1999

2001: ACOVE Quality Indicators Published

2006: National Quality Forum releases “Never Events”

2003: Joint Commission’s initial National Patient Safety Goals

2008: CMS limits payments for “Hospital Acquired Conditions”

2001

acove quality indicators
ACOVE Quality Indicators

Assesses care of vulnerable elders by evaluating processes of care

Hospital Care QIs for vulnerable elders

Admission evaluation of cognition and function

Discharge planning initiated within 48 hrs

Medication reconciliation

Transfer of records across settings

Decision-making capacity assessed prior to informed consent

Evaluation for causes of delirium

Avoidance of potentially inappropriate medications

Shekelle et al, Ann Intern Med 2001;135:647-67

2009 national patient safety goals for hospital care
2009 National Patient Safety Goals for Hospital Care

Improve the accuracy of patient identification

Improve the effectiveness of communication among caregivers

Improve the safety of usingmedications

Reduce the risk of health care-associated infections

Accurately and completely reconcile medications across the continuum of care

Reduce the risk of patient harm resulting from falls

Encourage patients’ active involvement in their own care as a patient safety strategy

Identify safety risks inherent in its patient population

Improve recognition and response to changes in patient’s condition

www.jointcommission.org

fy 2009 cms hospital acquired conditions never events
FY 2009 CMS Hospital Acquired Conditions/Never Events

Foreign object left in surgical patient

Air embolism

Incompatible blood transfusion

Stage 3 or 4 pressure ulcers

Catheter-associated UTIs

Vascular catheter-associated infection

Mediastinitis after coronary artery bypass grafting

Injurious Falls

Surgical site infections following certain elective procedures

Extreme blood sugar derangement

Deep venous thrombosis/Pulmonary embolism following knee and hip replacements

www.cms.hhs.gov

slide21
Reimbursement is linked to quality mandates

Hospital financial health is dependent on patient-centered, coordinated care

disaster preparedness
Disaster Preparedness
  • Physicians
    • ~7,100 geriatricians and declining
    • ~1,600 geriatric psychiatrists
    • Only 0.5% of medical school faculty are geriatric specialists
    • < 10% of medical schools have a required geriatrics course

IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

disaster preparedness1
Disaster Preparedness
  • Registered Nurses
    • < 1% of 2.2 million practicing RNs are ANCC certified in geriatrics
    • Only 1/3 of BSN programs have a required geriatrics course
    • Associate degree programs - unknown
  • Advanced Practice Registered Nurses
    • About 2.6% of APRNs certified in geriatrics

IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

disaster preparedness2
Disaster Preparedness
  • Social Workers
    • Today, only 4% specialize in geriatrics (about 1/3 of the estimated need)
    • 40% of schools lack faculty in aging
    • Only 20% of BSW programs and 29% of MSW programs have any coursework in aging

IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

disaster preparedness3
Disaster Preparedness
  • Pharmacists
    • Less than 1% certified in geriatrics
    • 0 residency programs in geriatric pharmacy (out of 351)
  • Dieticians
    • 22% of undergraduate dietetics and nutrition programs offer courses in aging

IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

crossing the quality chasm a new health system for the 21 st century
Crossing the Quality Chasm: A New Health System for the 21st Century

IOM Crossing the Quality Chasm Brief Report, March 2001

is there a need for interdisciplinary coordinated care yes
Is there a need for interdisciplinary coordinated care? YES!!!

Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51

  • Crossing the Quality Chasm: A New Health System for the 21st Century
    • Health care teams play a central role
  • Multimorbidity + Geriatric Syndromes requires coordinated care from multiple disciplines
  • National Patient Safety Goals/Never Events require interdisciplinary approach to achieve
  • Cost containment imperatives/Limitations to reimbursement
    • Increase use of non-physician providers
  • Demand for quality requires interdisciplinary teams
  • Patients deserve it
intersection of quality and finances momentum
Intersection of Quality and Finances = Momentum

Slide by Michael D. Wang, MD, UC Irvine

key features of models that enhance care coordination
Key Features of Models that Enhance Care Coordination

Systematically assess patients’ functional, cognitive, and psychosocial status as well as expectations and wishes

Target most vulnerable patients

Coordinate care across settings

Utilize interdisciplinary teams that meet patient in setting of care

what characteristics do winning teams have
What characteristics do winning teams have?
  • Clear leadership
  • Definite aim
  • Common enemy
  • Trust each other
  • Communication
  • Heterogeneity of members
  • Established rules
  • Plan to deal with barriers/change
  • Mutual respect
  • Flexibility/adaptability
  • Self-selected
  • Understanding of roles
  • Optimal team size
  • Able to cooperate
  • Measure performance
  • Self/team reflection
types of teams in healthcare
Types of Teams in Healthcare

GITT Curriculum: Teams and Teamwork

  • Unidisciplinary:
    • Group of people all from the same discipline working together
  • Multidisciplinary:
    • Group of people from different disciplines who develop a treatment plan independently
  • Interdisciplinary:
    • Group of people from different disciplines assess and plan care in a collaborative manner
slide33

Acute Care for Elders (ACE) Unit are a proven interdisciplinary team model of coordinated care in the hospital setting and a site for training

slide34
Slide by SUMMA Health Care

Traditional Acute Care Model

LOS

Cost

Functional Older Person

Acute Illness

Possible Impairment

Hospitalization

Hostile Environment

Depersonalization

Bed Rest

Starvation

Medicines

Procedures

Institutionalization

Depressed Mood

Negative Expectations

Physical

Impairment

ACE

Acute Care for Elders

Dysfunctional Older Person

SUMMA Health System

slide35
Slide by SUMMA Health Care

Model of Coordinated Care in the Hospital: Acute Care for Elders (ACE) Unit

Functional Older Person

Depressed Mood

Negative Expectations

Acute Illness, Possible Impairment

Hospitalization: ACE Unit

Prehab Program:

Prepared environment

Patient-centered, interdisciplinary care

Multi-dimensional assessment and non-pharmacologic prescription

Home planning/informal network

Daily medical review

Decreased Iatrogenic

Risk Factors

Improved Mood

Positive Expectations

Reduced Impairment

ACE

Acute Care for Elders

Functional Older Person

SUMMA Health System

who are members of ace unit interdisciplinary teams
Who are members of ACE Unit Interdisciplinary Teams?
  • Geriatrician/Gerontological Advanced Practice Nurse
  • Nurses
  • Rehabilitation Services
  • Pharmacists
  • Dietician
  • Social Work/Care Manager
  • Pastoral Care/Psychologist
  • Complimentary therapists (art, pet, music)
  • Volunteers
  • Home Care representative
  • Palliative care/Hospice representative
  • Other
  • ??? Patient’s physician
how does it work
How does it work?

Frequent (daily) team meetings/rounds

Clearly defined structure and goals for the rounds

Requires training

Method of communicating team recommendations

Will patient’s physicians attend the rounds?

Many units use informal communication sheets

Ongoing geriatric and team functioning training

Frequent feedback and revision to processes

UAB Highlands ACE Unit Daily Interdisciplinary Team Meeting

slide38

UAB HIGHLANDS ACE ROUNDS NURSE REPORT FORM

Room #:__________ Name:_____________________ Age:_____________

Lives in: House Apt Assisted Living Facility Nursing Home Other

Lives with: __________________________________________

goals of an ace unit
Goals of an ACE Unit

Prevent, identify, and manage geriatric syndromes

Elicit and respect patient/family preferences regarding goals of care

Maintain functional status and return patients to home

Prevent medication errors or adverse drug events

Coordinate in-hospital and transitional care from the day of admission

Training site for geriatric education for all health care disciplines

Research “laboratory” for piloting geriatric team care interventions

Increase philanthropy/grant support for hospital

Other

ace unit interdisciplinary team care coordination
ACE Unit Interdisciplinary Team Care Coordination

Mobility

Intervention

Analgesic or Laxative Prescribed

PT/OT Consulted

Medication Error Corrected

Adapted from Flood, et al. Am J GeriatrPharmacother 2009;7:151-58; Carroll, Solipuram, Li, Flood. Gerontological Society of America Annual Scientific Meeting Poster Presentation, Dallas, TX, November 2006

.

change in patients ability to perform adls from admission to discharge p 009
Landefeld et al, N Engl J Med 1995;332:1338-44

ACE Units: Randomized Controlled Trials

Change in patients’ ability to perform ADLs from admission to discharge (p.009)

Significantly fewer patients on ACE Unit were discharged to a nursing home compared to usual care (14% vs 22%; p.01)

ace in a community hospital
ACE in a Community Hospital

1531 community-dwelling patients age ≥ 70 admitted for acute medical illness

Randomized to ACE vs Usual Care

Demonstrated improved processes of care

Reduced use of restraints

Fewer high risk meds

Earlier and more frequent involvement of physical therapy and social work

Improved patient and provider satisfaction

Counsell et al, JAGS 2000; 48:1572-1581

ace units reduce mortality
ACE Units Reduce Mortality

254 patients age > 75 meeting a targeting criteria for frailty

Randomized to ACE Unit vs Usual Care

Saltvedt et al, JAGS, 2002;50:792-798

health care utilization and ace
Health Care Utilization and ACE

Retrospective, case-control study

Academic urban hospital

680 ACE vs 680 non-ACE patients age ≥ 65

Matched for age, ethnicity, comorbidity, and DRG (CHF, pneumonia, UTI)

ACE patients:

Shorter mean LOS (4.9 ± 4.3 vs 5.9 ± 4.5 , p=0.01)

9.7 % reduced mean costs ($13,586 vs $15,040)

11% reduced readmission rate after controlling for age, race, comorbidity, and pre-admission rate

Jayadevappa et al, Value in Health, 2006;9:186-192

interdisciplinary team care in hospitalized older adults
Interdisciplinary Team Care in Hospitalized Older Adults

Reduced mortality

Improved functional performance

More likely to be living at home after discharge

Reduced use of restraints

Reduced use of inappropriate medications

Reduced delirium

Reduced length of stay

Reduced health care utilization costs

Improved patient and provider satisfaction

Baztan et al, BMJ ONLINE FIRST, 2009

ms jones example of well coordinated hospital care
Ms. Jones: Example of Well Coordinated Hospital Care
  • Ms. Jones is hospitalized for pain and altered mental status and diagnosed with a UTI
  • Admitted to ward utilizing an interdisciplinary team model of care
  • Patient initially placed in a low bed for periodic agitation
  • Symptom/care management discussed in daily team meeting
    • Team members included nurse, PT, OT, SW, RD, Pharm D, Psychologist, Chaplain, and Volunteers
ms jones example of well coordinated hospital care1
Ms. Jones: Example of Well Coordinated Hospital Care

Patient receives aggressive pain management and analgesics are scheduled and timed with physical therapy

Patient experiences early mobilization and physical therapy is consulted on day 1

Agitation resolves with pain control and treating UTI; patient never restrained

Volunteer services provide socialization during mealtime when daughter is at work

Patient is discharged back to Assisted Living Facility with ongoing physical therapy arranged

geriatric and interdisciplinary team training
Geriatric and Interdisciplinary Team Training
  • Geriatric Interdisciplinary Team Training (GITT) Curriculum:
    • www.gittprogram.org
    • www.americangeriatrics.org
  • Nurses Improving Care for Health System Elders (NICHE)
    • www.nicheprogram.org
  • Harford Institute for Geriatric Nursing: Try This Series
    • www.hartfordign.org/Resources/Try_This_Series
gitt curriculum
GITT Curriculum
  • Team and Team Work
  • Team Member Roles and Responsibilities
  • Team Communication and Conflict Resolution
  • Care Planning Process
  • Multiculturalism
  • Ethics and Teams

UAB Highlands ACE Unit Interdisciplinary Team

http://www.americangeriatrics.org/education/gitt/gitt.shtml

geriatric team training outcomes knowledge
Geriatric Team TrainingOutcomes: Knowledge

UAB Highlands ACE Unit Workshop Pre- and Post-Test Total and Selected Question Knowledge Scores

p<.001

p<.001

p<.001

p=.0028

geriatric team training outcomes attitudes
Geriatric Team TrainingOutcomes: Attitudes

UAB Highlands ACE Unit Workshop Pre- and Post-Scores on Attitudes Toward Health Care Teams Scale

p<.001

p=.0007

p=0.06

p=.0002

ace unit feedback from team members
ACE Unit: Feedback from Team Members
  • UAB Highlands ACE Unit:
    • “I feel like I learn more information this way than just the chart. It also helps me know which patients would benefit most from my care.”
    • “Get a lot more info about the patients from different disciplines.”
    • “Patients’ needs are better met.”
  • UTMB ACE Unit:
    • “ACE made my job as an OT easier because nurses and PCTs understand the goals to maintain function.”
    • “ACE helps bring everyone else up.”
take home messages
Take Home Messages
  • Impending “Silver Tsunami” DEMANDS care coordination in all settings
    • Complexity
    • Quality
    • Financial Sustainability
  • Patient safety/quality movement and reduced reimbursements create momentum for developing interdisciplinary team models of care
  • The ACE Unit model of interdisciplinary team coordination improves outcomes
  • Interdisciplinary team models of care can be viable sites for geriatric team training/professional development
  • Curriculum exists to assist with development and implementation of geriatric interdisciplinary teams
  • Much work is still left to be done!!!
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