A Massachusetts-based health system is reporting positive results from an initiative designed to improve care for geriatric patients and increase the use of advance care planning.

Baystate Health’s Acute Care for Elders (ACE) model of care is a designated unit that includes staff trained on mobility, rationalizing, medication, early discharge planning, and early recognition and treatment of dementia, according to Maura J. Brennan, MD, division chief for geriatrics and palliative care with Baystate Health.

The ACE model of care first emerged in the 1990s.1 As defined by the author of one study, an ACE unit “includes principles of a prepared environment that encourages safe patient self-care, a set of clinical guidelines for bedside care by nurses and other health professionals to prevent patient disability and restore self-care lost by the acute illness, and planning for transitions of care and medical care. By applying a structured process, an interdisciplinary team completes a geriatric assessment, follows clinical guidelines, and initiates plans for care transitions in concert with the patient and family.”2

ACE is a medical acute care unit. There are not different levels of service; beds and services are billed as acute care. End-of-life beds on the unit are not hospice beds; rather, they are used for patients who are expected to die before discharge who were previously scattered over the hospital.

The Baystate Health ACE program began when Brennan was conducting grand rounds and reviewed a paper on the success of such programs. The vice chair of medicine asked why Baystate was not running such a program if they were so successful.

Brennan received enthusiastic support from the hospital’s quality department, which recruited and trained a team. Quality improvement staff also provided “basic quality 101 training” to Brennan’s entire division, she says.

“Everyone from the secretarial staff up to me learned what a run chart and a PDSA cycle are,” Brennan says. “We began a pilot on a medical unit where we used typical ACE criteria on about eight patients. A member of our group was from decision support and finance. He became very enthusiastic about participating in meaningful change rather than just crunching numbers somewhere.”

Initial funding for the program included some modest support from a Health Resources & Services Administration grant, philanthropy, the hospital, and the medical practices group. (Today, the program largely is baked into operations.)

Over 18 months, the hospital studied length of stay, costs, use of restraints, falls, and other criteria, showing enough improvement to win the hospital president’s annual safety award. That led to enough support that the pilot project was expanded to become a full ACE unit, despite budgetary restraints. The unit includes 34 beds, with additional space dedicated to patients at the end of life.

One of the biggest challenges is to keep patients mobile, Brennan says. The staff tried walking patients regularly, but Brennan found the staff members were too busy with their primary duties to regularly mobilize patients. Volunteers helped walk patients until leaders became concerned that home care and post-acute rehab services were affected by patients not moving around enough while in the hospital.

“That prompted a hospitalwide interest in improving mobilization. That allowed us to get approval for patient mobility technicians,” Brennan explains. “We’re now tracking and recording distances in ways that we hadn’t before. It seems like mobility shouldn’t be so challenging but it was one of the toughest nuts to crack.” Part of the impetus for improving mobility hospitalwide was that Baystate is an accountable care organization and shares the risk of post-acute costs. That makes it easier to address issues that affect more than one silo in the hospital, Brennan explains.

After the first year, ACE unit patients’ length of stay was almost one full day shorter than other patients, and there were measurable gains in patient safety. Complication and delirium rates decreased by 30% to 50%, and falls were reduced by 50%.

Use of restraints was virtually eliminated, and 17% more patients returned home rather than discharging to another facility. More than 500 medication changes resulted from the ACE team’s recommendations. Approximately 60 nurses and 50 physicians were trained in the ACE program.3 The ACE unit also leads other departments in patient satisfaction scores.

A team approach is necessary to see good results from the ACE unit, Brennan says. However, one should not assume everyone’s idea of teamwork is the same.

“We talk about teamwork a lot in healthcare but I think it’s not always seen the same way as we see it in geriatrics. You might have a physician who thinks teamwork is the doctor making the calls and everyone else doing as he says,” Brennan says. “Truly grasping teamwork and building processes in which everyone is equally valued and can see their successes is important.”

Hospital quality leaders interested in establishing an ACE unit should remember that it requires a genuine interdisciplinary approach. Care is provided in a less hierarchical way, with a focus on the need to treat basic geriatric and palliative care needs while also addressing medical concerns. “It’s a classic quality improvement win because it is an example of eliminating the quality waste,” Brennan says. “If you get rid of the unnecessary drugs, eliminate falls and restraints, you’re improving the care of the patient, and you’re also going to save money. You can do better by doing the right thing, which was surprising to a number of people who thought this was going to be more expensive.”

REFERENCES

  1. Palmer RM, Landefeld CS, Kresevic D, Kowal J. A medical unit for the acute care of the elderly. J Am Geriatr Soc 1994;42:545-552.
  2. Palmer RM. The acute care for elders unit model of care. Geriatrics (Basel) 2018;3. pii: E59. doi: 10.3390/geriatrics3030059.
  3. Baystate Health. Acute Care for Elders (ACE) unit & program. Available at: http://bit.ly/2lwmbT2. Accessed Nov. 5, 2019.