Model of care improves outcomes, ADLs for elderly

Results: Lower costs, shorter LOS, more discharges

When older, frail patients are hospitalized at Akron City Hospital in Akron, OH, they're likely to be placed on a home-like unit with carpeted floors, a common area with a parlor and a stocked kitchen their families can use, better lighting, and furniture designed so older people can easily get in and out of it.

The 34-bed unit is called an Acute Care for Elders (ACE) unit, and it's designed to provide patient-centered care for older patients in an environment that helps them return more quickly to their homes.

The ACE initiative, which provides care by a team specializing in geriatric issues, has resulted in shorter lengths of stay, lower costs, fewer readmissions, and other positive outcomes for elderly patients at the 550-bed teaching hospital, which is part of Summa Health Systems in Akron, OH.

The ACE model is a multi-component intervention that improves outcomes for older patients hospitalized with an acute medical illness, says Carolyn Holder, MSN, RN, geriatrics coordinator of post-acute senior services for Summa Health Systems in Akron, OH.

"Older adults often experience a loss of function and independence during hospitalization for an acute illness. Loss of function is associated with negative outcomes for the patient, including prolonged hospital stay, need for nursing home placement, and death. The ACE model was designed to prevent functional decline and maximize independence," Holder says.

The ACE unit was developed in the 1990s by clinicians and researchers at University Hospitals of Cleveland, and demonstrated a positive impact on patients, who were more functional and less often discharged to long-term care, she says.

"In 1994, Summa Health System conducted a randomized trial of the ACE intervention over a three-year period and concluded that ACE makes a difference in preventing functional decline of hospitalized adults," Holder says.

During the study, the team found that the elder patients improved in mobility and other functions from the time of admission to discharge, no matter what illness caused the hospitalization. There was a decrease in discharges to long-term care facilities among patients in the ACE program and an increase in patient satisfaction.

There was significantly less use of restraints on the ACE unit. "Because of changes in the process of care, there were fewer patients who were ordered bed rest, fewer on high-risk medication, and significantly less use of restraints," Holder says.

Depression was recognized and treated more often. All of the factors contributed to an overall reduction in expenses for patients in the pilot project. "ACE is designed to prevent older adults from declining physically and functionally. It not only made a difference in their function, it was more cost-effective and decreased length of stay. The results were positive for the hospital as well as the patients and their family members," she adds.

Patient-centered care

The interventions were so successful that in addition to admitting patients at highest risk to the dedicated ACE unit, the hospital has adopted the ACE interventions for elderly patients in the stroke, heart failure, pulmonary, orthopedic, and psychiatric units.

"This model is the way that care should be delivered to elders as well as other chronically ill patients in every hospital unit. When the team sits down and puts their heads together, they can accomplish so much for people who are so complicated and so at risk," Holder says.

At Akron City Hospital, patients ages 70 and older who are at most risk for functional decline are admitted to the ACE unit. "We screen patients who are at high risk for losing function, such as people who had problems with mobility before they came in, those without social support, or who have depression or memory problems. We look for cues that say a patient needs more support," Holder says.

The team meets five days a week for one hour and brainstorms on how to improve the plan of care for patients identified as at high risk for decline. The plan they develop is shared with the primary care physician and the rest of the staff.

The unit provides patient-centered care by an interdisciplinary team led by a clinical nurse specialist. The team includes a geriatrician, physical therapist, occupational therapist, dietitian, social worker, a pharmacist who specializes in geriatric medications, spiritual support, and the patient's nurse. The geriatrician consults with the team informally and is available for a formal consultation if the primary care physician requests it.

All members of the ACE team are trained in geriatrics. "We have the level of expertise so that the most challenging are referred to us," Holder reports.

The team works with the patient's primary care physician to develop treatment plans based on best practices of care for the elderly.

The traditional hospital environment and the process of care are designed for clinical efficiency by the providers and often do not take into account the needs beyond the acute illness, Holder points out.

For instance, Holder describes a scenario, in which an 80-year-old woman who lives alone develops simple pneumonia and comes to the emergency department, where an IV is started. She may be confused because of the illness and not eating for a few days and may try to get up to go to the bathroom. As a result, a catheter is inserted, and the woman is restrained and possibly given medication to control her behavior. She is admitted to the medical unit with an order for bed rest, which is maintained for several days, leading to immobility, weakness, and functional decline.

In this scenario, the patient was living independently when she was admitted. At discharge, she needs assistance with activities of daily living and walking and requires placement in a skilled nursing facility.

"Many older patients never regain preadmission functional status despite hospitalization. In fact, hospital care may contribute to adverse outcomes in older persons," Holder says.

The ACE model includes a multidimensional assessment, which is a holistic evaluation of the patient, looking at the medical assessment and history. It includes a functional assessment, including activities of daily living, such as dressing and toileting, instrumental activities of daily living, including cooking and managing finances, cognitive and depression screening, that patient's support system, and discharge planning information.

By having a geriatrician on the staff, the team can suggest revisions of the plan of care to the primary care physician by pointing out the latest evidence-based care recommended for treating the elderly.

"The physicians love it, and so do the patients and their families. The team provides extra support for the patient. We don't just look at the acute illness. We look at the comorbidities and help the physician and family address other issues, such as end-of-life issues, if it is appropriate," she says.

The team starts working on discharge planning as soon as the patient is admitted. "When we talk about discharge planning, it's not just the immediate discharge. It's the big picture. If patients need to go to a rehab or skilled facility, we look at what the plan should include beyond the rehab stay," Holder says.

The plan may include referrals to a community agency, such as the area Agency on Aging, to provide long-term assistance with self-care and care management. "We look beyond the episode of illness that brought the patient to the hospital. We look at how we can keep patients healthy and functional after discharge," Holder says.

The team recognizes early on what the patient will need after discharge. If it's home health care, the team arranges for a home evaluation to look at safety issues, medication, and nutrition.

"The holistic assessment often uncovers unrecognized problems, such as cognitive issues, depression, and nutritional issues, which the primary care physician may not be aware exist. In addition, families often are challenged in managing problems such as self-care issues and impaired cognition. The ACE unit provides interventions to support both the family and the physician in maximizing the patient's independence," Holder says.

The team often holds patient and family conferences to develop a comprehensive plan.

The ACE interdisciplinary team process involves each member of the team contributing his or her expertise as well as all disciplines learning from each other. For instance, in the ACE model, it may be the dietitian who recognizes the symptoms of depression as she talks with the patient and brings them to the attention of the team.

The team carefully scrutinizes the medications the patients are taking to make sure the medication and dosages are appropriate for older people and makes recommendations to the primary care physician for changes.

Depression often is overlooked in the elderly, Holder points out. The ACE unit staff and team provide further assessment of patients with symptoms of depressions and make recommendations for follow-up.

Holder supervises the advanced practice nurses working for Summa Health System covering several other units with the ACE model in other hospitals in the Summa system. "We're spreading the model. About 85 other hospital systems across the nation have come to us to learn how to do this," she says.

(For more information, contact Carolyn Holder, MSN, RN, e-mail: