September/October 2013

ACE Units Improve Complex Patient Management

By Kellie L. Flood, MD, and Kyle R. Allen, DO, AGSF
Today’s Geriatric Medicine
Vol. 6 No. 5 P. 28

Older adults disproportionately represent the majority of health care consumers,1 a fact threating the financial stability of both the Centers for Medicare & Medicaid Services (CMS) and the United States. Consider that in 2007, individuals aged 65 and older accounted for only 13% of the total US population but also for 43% of hospital days.2

If this “silver tsunami” were simply a matter of hospitals adapting to an increase in the number of hospitalized patients, then the solution would be straightforward: build more hospital rooms. However, it is not purely a numbers challenge.

This patient population is physiologically and functionally more heterogeneous than younger adults, with a higher prevalence of comorbidity and complexity. Sixty-two percent of older adults are experiencing multimorbidity (two or more chronic conditions), and this population consumes 96% of the Medicare budget.3

In addition to comorbid conditions, many elders experience geriatric syndromes such as cognitive impairment and functional decline, often compounded by a lack of social or financial support. Therefore, the next few decades present not only a numbers challenge for hospitals but also a patient population complexity challenge.

Hospitals can be hazardous environments for older adults. Common adverse outcomes in hospitalized elders include functional decline, delirium, undernutrition, polypharmacy, and other iatrogenic events.4-8 In a 2010 Office of Inspector General report, an estimated one in seven Medicare patients experiences an adverse event during a hospitalization, resulting in 134,000 adverse events every month. Twenty-seven percent of the older adults who experience an adverse event in the hospital subsequently cascade to having multiple related adverse events. These cascade events were some of the most severe and included episodes contributing to patient deaths.9

In 2001, the Institute of Medicine report “Crossing the Quality Chasm” highlighted the fact that our current health care system is not equipped to consistently deliver evidence-based medicine to elders with complex multiple chronic conditions.10 Hospitals must adapt their care delivery models to include geriatric assessments and individualized care plans for older adults while simultaneously containing cost.

More recently, studies have demonstrated that well-coordinated, person-centered care for older adults can be accomplished through interdisciplinary team models that ensure the care plan aligns with a patient’s functional, cognitive, and psychosocial status and goals.11-14 One such model that achieves these goals is an Acute Care for Elders (ACE) unit.

What Is an ACE Unit?
Over the last two decades, ACE units have been developed in hospitals nationwide. The distinguishing feature of ACE units is the use of an interdisciplinary team model as opposed to a multidisciplinary model in which providers from all disciplines deliver care but practice predominantly independently or in silos. An interdisciplinary team model integrates disciplines to collaboratively develop the patient-centered care plan.

The ACE unit model of care consists of the proactive identification and management of geriatric syndromes, frequent (often Monday through Friday) interdisciplinary team rounds that focus on patient-centered vs. disease-centered care, care transition planning from the day of admission, communication of team recommendations to the appropriate caregiver (ie, physician, nurse, family, patient), and often environmental modifications that promote safe mobility, cognitive stimulation, and an overall less institutional and more homelike atmosphere.

ACE unit teams typically consist of a geriatrician, a nurse coordinator, staff nurses, rehabilitation therapists, pharmacists, dietitians, and social workers/care managers. ACE unit design modifications may include the use of color contrasting for low vision; handrails in bathrooms, patient rooms, and hallways; furniture designed to ease transfers; and a congregate room as a destination for group activities (eg, music or art therapy sessions).

While all five components of the ACE model are important, the interdisciplinary team is the key to providing best practice geriatric care and ongoing staff training. Previous research evaluating outcomes for older adults admitted to ACE vs. usual care has shown improved processes of care, prescribing practices, physical functioning, restraint rates, and patient and provider satisfaction as well as reduced nursing home placement, length of stay, costs, and readmissions.11,12,15

Lessons Learned in Developing an ACE Unit
ACE units benefit both patients and hospitals in the delivery of higher-valued care. An increasingly common question then is how does my hospital start an ACE unit?

Each hospital has its own unique culture, leadership structure, and processes for new program development. One implementation strategy, described by ACE unit founders as the “ABCs of ACE unit implementation,” outlines the following stepwise approach for program development16:

• agreement on the need by key stakeholders;

• build the program through interdisciplinary leadership support;

• commence the new program with ongoing monitoring;

• document every phase of program implementation;

• evaluate all processes and outcomes; and

• feedback to key stakeholders for ongoing support and direction.

Each step has prescribed elements for planning, implementation, and measurement. Additionally, an ACE unit is a laboratory for continuous quality improvement initiatives that align ACE with the hospital’s patient safety mission.

In addition to these systematic steps in program development, we have found several lessons learned that may be helpful whether converting an existing unit into an ACE model or starting de novo:

• Don’t reinvent the wheel. Nurses Improving Care for Healthsystem Elders (NICHE) is a national nursing organization that has been guiding hospitals in the development of inpatient geriatric programs for more than 20 years. NICHE provides evidence-based resources to develop and measure systemwide geriatric care initiatives, including ACE units. Resources include tools to assess institutional readiness for change and training needs as well as assistance in building the business case for ACE. Implementing NICHE programs and ACE units together can be synergistic in helping to “reengineer” a hospital and accelerate the transformative changes needed for a growing elder population.

Both Riverside Health System in Virginia and the University of Alabama at Birmingham (UAB) Hospital have used this approach. We have found that developing a consulting relationship with an existing ACE unit and/or conducting a site visit results in time saved and serves as an aid in garnering leadership support. The NICHE website (www.nicheprogram.org) lists all hospitals implementing a formal NICHE program, many of which include ACE units. In addition, Aurora Health Care in Wisconsin, a system with well-established ACE programs in 15 hospitals, hosts an annual ACE conference in November at which ACE teams from around the nation meet to share best practices.

• Assess your hospital’s needs regarding complex patient population management and align your initiative to these objectives. The Joint Commission, the CMS, and other payers are increasingly focusing on quality measures for accreditation and reimbursement. Several hospital-acquired conditions as well as unplanned 30-day readmissions can be impacted by evidence-based geriatric care. Each hospital will have a priority list of needs to be addressed, and ACE principles can positively impact many of them.

• Build the financial case. While the quality outcomes from ACE units are well established, the financial case for establishing an ACE unit must be presented to hospital leaders. Several ACE unit studies have demonstrated positive financial outcomes associated with the ACE model of care.17,18 For example, a 2013 study from the UAB ACE unit demonstrated significantly reduced mean variable direct cost/case as well as reduced 30-day readmissions (7.9% vs. 12.8%, P = 0.02) for elder patients admitted to ACE vs. usual care.15

Using published results and NICHE resources as well as working with hospital quality and financial officers will help project the return on investment of a new ACE unit.

• Form a development team consisting of hospital leaders. Because an ACE unit requires interdisciplinary collaboration, successful development of this new model requires support from the leaders of every key discipline as well as hospital administrators. As an example, prior to launching the UAB ACE unit in 2008, a development team was formed and included the department directors for nursing, rehabilitation services, pharmacy, nutrition, volunteer services, and care management; physicians from geriatrics and palliative medicine along with hospitalists; and key hospital administrative leaders (vice president, chief nursing officer, quality officer, finance officer). In addition, the team included representatives from the development office, health information management system, and hospital data management. Once an ACE unit is launched, key members of the development team must continue to serve as the ACE unit steering committee.

As with all clinical programs and the ever-changing health care environment, an ACE unit will require ongoing adaptations to meet the needs of a growing number of complex patients and hospital goals.

• Take time to explain to staff members the purposes behind starting an ACE unit. Transformative learning recognizes that emotional changes often are involved in effecting change in providers’ practices and decision making. For providers from all disciplines to alter their practice styles from a disease-focused multidisciplinary approach to a patient-centered interdisciplinary model requires providers to want to change.

The primary reason providers want to change the way they deliver care is to understand why it is important. For example, prior to the launch of the UAB ACE unit, providers from all disciplines who would be working on the new unit attended mandatory ACE workshops. The curriculum focused on the ACE model and improved outcomes, interdisciplinary team functioning (including role play of a team meeting), and hands-on geriatric sensitivity training.

Sustaining an ACE Unit
As with any clinical program, it is vital to continually measure all activities to demonstrate impact and provide justification for ongoing support. Outcomes to highlight are those aligning with the previously identified institutional priorities. There are multiple domains in which ACE may demonstrate beneficial impact, including the following:

• new staff expertise as demonstrated by pre- and posttraining tests or performance of new skills;

• new geriatric care processes, such as standardized assessment of cognitive or functional status;

• clinical outcomes, such as reduced rates of hospital-acquired infections; and

• financial goals, such as reduced resource utilization or length of stay.

We found having the expertise of data management personnel on the development team to be helpful in planning our program monitoring.

Final Thoughts
In conclusion, the ACE unit interdisciplinary model of care has been shown to improve outcomes for hospitalized elders while reducing costs for hospitals. Because this model of care is low tech and high touch, development also is low cost but requires thoughtful planning and interdisciplinary leadership support.

— Kellie L. Flood, MD, is an associate professor in the division of gerontology, geriatrics, and palliative care at the University of Alabama at Birmingham. She also is the medical director of the Acute Care for Elders unit and serves as the geriatric quality officer for UAB Hospital.

— Kyle R. Allen, DO, AGSF, is vice president of clinical integration, medical director for geriatric medicine, and a lifelong health and senior physician research fellow for the Center of Excellence for Aging and Lifelong Health at Riverside Health System in Newport News and Williamsburg, Virginia.

References
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10. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

11. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care for elders (ACE) in a community hospital. J Am Geriatr Soc. 2000;48(12):1572-1581.

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