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Aging Medicine

Series Editors: Robert J. Pignolo · Mary A. Forciea · Jerry C. Johnson

Michael L. Malone
Elizabeth A. Capezuti
Robert M. Palmer Editors

Acute Care
for Elders
A Model for Interdisciplinary Care
Aging Medicine
Robert J. Pignolo, MD, PhD; Mary A. Forciea, MD;
Jerry C. Johnson, MD, Series Editors

For further volumes:

Michael L. Malone • Elizabeth A. Capezuti
Robert M. Palmer

Acute Care for Elders

A Model for Interdisciplinary Care
Michael L. Malone, MD Elizabeth A. Capezuti, PhD, RN, FAAN
Aurora Senior Services & Aurora Visiting William Randolph Hearst Foundation
Nurse Association of Wisconsin Chair in Gerontology
Aurora Sinai Medical Center Hunter College of the City University
Aurora Health Care of New York
University of Wisconsin School of Medicine Hunter-Bellevue School of Nursing
and Public Health New York, NY, USA
Milwaukee, WI, USA

Robert M. Palmer, MD, MPH

Glennan Center for Geriatrics and
John Franklin Chair and Professor
of Internal Medicine
Eastern Virginia Medical School
Norfolk, VA, USA

ISBN 978-1-4939-1024-3 ISBN 978-1-4939-1025-0 (eBook)

DOI 10.1007/978-1-4939-1025-0
Springer New York Heidelberg Dordrecht London

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Foreword: The Story of ACE

Acute Care for Elders (ACE): A Model for Interdisciplinary Care tells how to
improve the effectiveness, and efficiency, and outcomes of care for acutely ill elders
with the ACE model. I will tell the story behind ACE, the story of how Bob Palmer,
Denise Kresevic, and I invented ACE.
I tell the story behind ACE not only to inform your understanding of ACE, how-
ever but I explain the story to illustrate what I have learned might help you in your
path to discover, implement, and disseminate ways to improve care for patients,
especially the most vulnerable. I highlight six themes of learning from this story:
1. Context is key—the context is both you and your environment.
2. Prepare your mind.
3. Seek a culture of support and respect.
4. Be curious, be rigorous, persist.
5. Be open to serendipity.
6. Build sustainability.

In the fall of 1989, a woman called and introduced herself, “My name is Donna
Regenstreif. I am the Senior Program Officer at the John A. Hartford Foundation in
New York, and I would like to come talk with you. One of our trustees came out of
the hospital much worse than he was when he went in. This experience resonated
with our trustees and they are concerned about what happens to older people in the
hospital—they call it ‘hospitalitis.’ We wonder, Can you help us?”
I was 37, an academic general internist in my fourth year as an Assistant Professor
at Case Western Reserve University School of Medicine and University Hospitals of
Cleveland. My family and I had settled in Cleveland, where I grew up, and we loved
it. My wife was a dermatology resident, we liked writing together, and our 4-year
old son, John, was thriving in his second year in “Betty’s School,” a Montessori
preschool founded by a remarkable teacher, Betty Hissong. I liked my work. My
Division Chief and Department Chair were supportive. I had my first grant to
develop and test an intervention to prevent bleeding during anticoagulant therapy in

vi Foreword: The Story of ACE

older people. The President of the hospital had allocated funds for me to develop a
program that would build knowledge to improve clinical care. Life was good and
I was open to every good opportunity. The context of my work, with my interests,
made the invention of ACE possible.
When Donna Regenstreif spoke about “hospitalitis,” she captured my attention.
I loved hospitals. My earliest memory was of being wheeled in a crib through the
sub-basement of University Hospitals on my way to the operating room. As an
intern, resident, and chief resident at UCSF, I loved caring for my patients in every
part of the hospital. Also, I knew that bad things happened in hospitals unintention-
ally and often we didn’t know why. Sometimes it was a drug side-effect like
anticoagulant-related bleeding or a fall or a surgical misadventure or an error, but
often it was not. Older people in particular sometimes came to the hospital walking
and talking before their acute illness, and they left bedridden and confused, even
when the acute illness itself was treated appropriately and resolved.
I wanted to make things better. I saw as a resident and attending physician on
wards and in ICUs that we often fail to do every time with every patient what we
know needs to be done. This was certainly the case with anticoagulant therapy,
which rarely caused bleeding when managed well and often caused bleeding when
the INR wasn’t controlled after a patient left the hospital or changed diet or was
prescribed an antibiotic, or when a NSAID was prescribed without remembering its
prohemorrhagic effect, or when a patient fell. I had chosen to train in clinical epide-
miology and patient-based research rather than laboratory investigation in nephrol-
ogy because I wanted to improve our approaches to diagnosis, prognosis, and
treatment in clinical medicine. And with my experience in practice and research in
academic hospitals, I knew I could make things happen in a hospital. And I knew
that doctors and nurses could transform how healthcare systems worked. In the
1840s, Ignaz Semmelweiss reduced maternal mortality on the First Obstetrical
Clinic at Vienna General Hospital from 18 to 2 % by convincing doctors and medi-
cal students to wash their hands before assisting in delivery. In the 1850s, Florence
Nightingale was credited with reducing mortality rates from 42 to 2 % in British
army hospitals in the Crimean War. In 1916, EA Codman established the principle
that the results of surgery could and should be determined systematically and
reported to the public. Fifty years ago, Sidney Katz developed the index of indepen-
dence in activities of daily living (ADL) and applied it in studies to improve to care
for people with chronic disease. When I was deciding between research training in
nephrology (which then meant doing membrane biology) and clinical epidemiol-
ogy, I chose the latter because it was the basic tool for answering clinical questions
about how to take better care of patients.
In inventing Acute Care for Elders, three things enriched my clinical and research
experience. First, I worked in an interdisciplinary team with wonderful colleagues
in Geriatrics (Bob Palmer, MD, MPH) and Geriatric Nursing (Denise Kresevic, RN,
GCNS). Together we developed and wove together the ideas and practices that cre-
ated ACE.
Second, I knew the literature well enough to know what was known, what was
not, and what needed to be done. For example, Larry Rubenstein and his colleagues
Foreword: The Story of ACE vii

had developed inpatient Geriatric Evaluation and Management (GEM) and showed
that it reduced mortality and nursing home stays in veterans aged 65 years or older
who stabilized after 1 week in the hospital. GEM was used in only 4 % of hospital-
ized elders, however. We believed that all hospitalized elders were at risk for pre-
ventable functional decline, that the cascade of deleterious effects of hospitalization
often began on admission, and that an approach was needed to improve care and
outcomes for all older patients from admission. In other pioneering work, Harvey
Cohen and his team had studied state-of-the-art geriatric consultation to improve
care and outcomes for hospitalized elders. In a randomized trial, they showed the
limits of consultation when they found no effect of geriatric consultation on out-
comes. They suggested, and we agreed, that advice alone was inadequate to improve
care and that direct control of care to assure provision of preventive or restorative
services might be necessary.
Third, the social sciences informed my thinking. I had read Erving Goffman’s
concept of the total institution in his book Asylums, and this concept stayed in the
back of my mind through medical training. A total institution is a residence that
dictates the behavior of a group of people with a specific purpose, such as healing,
education, reformation or protection of society. He described asylums, orphanages,
nursing homes, prisons, and boarding schools as total institutions. The methods
total institutions use to control behaviors often have unintended consequences that
thwart the ultimate stated goal. Although Goffman did not classify acute hospitals
as total institutions, they struck me as having many features of total institutions
insofar as the methods used to control behaviors and events, which may not be con-
trollable, often have unintended consequences that thwart the ultimate stated goal.
For example, in caring for frail elders, we wish to avoid falls and related injuries
and, therefore, we may prescribe bedrest and restraints, yet these interventions may
themselves increase the risk for debility and injury. Thus, efforts to achieve the main
goal, such as returning an older person safely to her home after an acute illness,
might be informed by redesigning hospital policies and procedures that may have
unintended adverse effects.
With our son in Montessori preschool, I was learning from Betty, the founder and
lead teacher, about Maria Montessori’s approach to education. Three of her insights
especially struck me: children want to learn, a physical and social environment pre-
pared for learning promotes learning, and the teacher’s role is to prepare and main-
tain the environment. These principles are directly applicable to hospital care,
I thought. Patients want to get better and return home, not go to a nursing home or
die. An environment prepared for getting better and regaining mobility will help
patients get home. Doctors and nurses can and should prepare and manage the hos-
pital environment, not treat the disease alone. Giving the right antibiotic to a frail
older person with pneumonia will not help them get home nearly as much as giving
the right antibiotic and making sure they maintain their nutrition, strength, and
mobility and don’t become delirious or depressed.
My mind was prepared for thinking about the adverse outcomes of hospitalization,
and I was curious to learn how we might reduce their frequency. Thus, when I spent a
Saturday writing a draft of a proposal to the Hartford Foundation, I built on my
viii Foreword: The Story of ACE

Fig. 1 Conceptual model for Functional Older Person

the development of the
“Dysfunctional Syndrome.”
From a grant submitted to the
John A. Hartford Foundation, Acute Illness
Inc. (The Dysfunctional Possible Impairment
Syndrome: Characterization
and Prevention. Grant
#88277-3G) Hospitalization
Hostile Environment

Depressed Mood Physical

Negative Expectations Impairment

Dysfunctional Older Person

clinical experience and the insights of Goffman and Montessori, to suggest that
hospitalization-as-usual can lead to what I called “The Dysfunctional Syndrome”:
hospitalization could promote the transition of a functional older person to one who
was “dysfunctional” in the sense of being unable to perform the Activity of Daily
Living (ADL) she could perform before the acute illness. Figure 1 from the original
proposal illustrates the process leading to the Dysfunctional Syndrome. A func-
tional older person develops an acute illness, such as pneumonia, and may lose
ability to perform one or more ADL before hospitalization. In the hospital, this
person finds a hostile and depersonalizing environment: the person is stripped and
covered in a gown that is chilly and immodest, her clothes are taken away, her
glasses and hearing aid may be misplaced, and she is put in a bed that may require
gymnastics to get up to the bathroom or a chair. Like a casino, there may be no clock
or other orienting information. If the patient is able to get out of bed to go to the
bathroom or walk, she may be tethered to the bed by catheters to administer oxygen,
fluids, and medicines and to drain the bladder, and when she breaks free of the bed,
she may find a ward that limits her independence. The toilet is so low that she can’t
rise without help, the polished linoleum floors may appear slippery to someone with
cataracts, the hall is so cluttered with carts and paraphernalia that she can neither
navigate the hallway nor use the handrail on the wall to assist her walking. Sleep
deprivation may result from noise and light streaming into her room, and from
middle-of-the-night wakening for 1 a.m. vital signs and at 5 a.m. for morning medi-
cines. Her physicians may have ordered bedrest, which rapidly leads to deconditioning
Foreword: The Story of ACE ix

and loss of muscle and postural tone. The patient may starve not only because her
appetite is diminished but also because she misses meals for tests and procedures off
the ward and the usual social cues for eating are lost. Medicines may be adminis-
tered in doses that are too high for a frail older person and some medicines, such as
sedative-hypnotics, may be ordered for convenience even when they can have unin-
tended adverse effects. Procedures are undertaken that may leave the patient immo-
bilized or volume depleted. The net effect during hospitalization can be a depressed
mood, negative expectations that death or nursing home placement is likely, and
physical impairment, which together prevent recovery of ability to perform ADL
and may further compromise their independent performance. Many elders have lost
their bounce, and the hospital may accentuate this loss of resilience.
We proposed the Unit for Acute Care of Elderly (ACE) as the site to deliver what
we then called the “Prehab Program for Patient-Centered Care,” which was designed
to prevent the unintended consequences of hospitalization (see Fig. 2). The value of
a unit rather than a dispersed approach lies in the fact that it is easier to shape the
culture and practice of a single unit than a whole hospital. Moreover, a unit provides
the opportunity for monitoring and sustaining an intervention that might otherwise
dissipate over time.
In this original model (Fig. 2), a prepared environment would promote patients
in their quest to retain or regain independence in ADL. We chose hospital beds that
could go low enough for patients to get out of bed and that had soft night lights to
make nighttime arousal less frightening and to help people get to the bathroom.
Toilet seats were elevated. Floors were carpeted to eliminate the glare and to make
walking more inviting. Clutter was removed from halls and wallcovering was
selected to make it easier for a patient to find her own room. Interdisciplinary col-
laborative care, multidimensional assessment, and nonpharmacologic prescription
constituted patient-centered care that focused doctors and nurses on working
together, along with social workers and physical and occupational therapists to
advance each patient towards independence and returning home if possible. Each
patient underwent geriatric assessment to identify barriers to independence for
which specific interventions were prescribed. Care routines were changed so that
nurses could drive things for which doctors were conventionally responsible and
tended to forget, like removing urinary catheters, assuring nutrition (e.g., with
snacks and food available around the clock), eliminating restraints, and promoting
mobility. A room for activities and socializing was provided in the ACE Unit, and
patients were encouraged to dress and use the room for activities and meals. Night
routines were changed to reduce ambient light and noise, to eliminate unnecessary
waking at night, and to promote sleep with soft music, warm milk, and gentle mas-
sage rather than sedative-hypnotic drugs. Medical review entailed geriatric consul-
tation, discussion of recommendations with housestaff caring for the patient, and
daily follow up. Planning to go home began the day of admission with identification
of the patient’s informal support network and elucidation of possible barriers to
returning home to live independently. Each day, the team of the patient’s doctor,
nurse, and social worker worked with the patient and family to assess and prepare
the actions that would help the patient go home and stay there. We encouraged a
focus on planning to go home, with congruent language, rather than a focus on
x Foreword: The Story of ACE

Functional Older Person

Acute Illness
Possible Impairment


Depressed Mood ACE Unit

Negative Expectations Unit for Acute Care of Elderly

Prehab Program for Patient-Centered Care

Prepared Environment
Interdisciplinary Collaborative Care
Multidimensional Assessment and Nonpharmacologic
Medical Review
Home Planning/Informal Network
Transitional Care

Improved Mood Reduced Decreased Iatrogenic

Positive Expectations Impairment Risk Factors

Functional Older Person

Fig. 2 Conceptual model for the beneficial effects of the unit for the acute care of elderly (ACE)
and its Prehab Program for Patient-Centered Care. From a grant submitted to the John A. Hartford
Foundation, Inc. (The Dysfunctional Syndrome: Characterization and Prevention. Grant

discharge planning. Discharge planning connotes the patient is leaving as a “dis-

charge,” the final step in the hospital’s excretory function, which is critical to the
hospital’s “throughput.” With a focus on “discharge,” the actions that will be neces-
sary for a patient to leave the hospital are often not considered until the medical
team decides the patient should leave, and this last minute planning often extends
hospitalization and misses opportunities to prepare the home for the patient.
Moreover, considering a person to be a “discharge” further depersonalizes the
patient, raising the question of how a patient compares to other discharges, which
are generally malodorous and purulent. As the last part of ACE, we suggested that
formal transitional care of medical and other services in the home would help the
Foreword: The Story of ACE xi

patient reenter the home and stay there. (Transitional care was not incorporated in
the initial ACE interventions because of insufficient resources.)
With this conceptual framework, and with the ambition that more acutely ill elders
would go home from the hospital and do well there, University Hospitals of Cleveland
developed the first ACE Unit and the John A. Hartford Foundation funded the grant
to determine the effects of ACE. This work had two effects. First it demonstrated the
effectiveness of ACE in improving functional outcomes and increasing the propor-
tion of patients discharged home as opposed to a nursing home. Second, the initial
studies of ACE provided the foundation for its dissemination and for further develop-
ment and application of the concept in ACE Tracker, in Mobile ACE, and in other
innovations in acute care for elders, such as “e-Geriatrician model”.
I highlight six themes of learning in the story of ACE.
1. Context is key. The context of your work—you, your environment, and the rela-
tionships between you and your environment—shapes its possibilities. The
opportunity to develop ACE arouse because the senior program officer of a foun-
dation interested in the problem identified me based on what she learned from
others, and because the President of my hospital was interested in innovation and
had the resources to support it. I brought to this opportunity relevant clinical
experience, a passion for the topic, and ideas from other disciplines. My clinical
and academic environment provided colleagues with complementary interests
and abilities, and together we could do what none of us could do alone.
2. Prepare your mind. I sought clinical experience that gave me the practical knowl-
edge for understanding hospitals and changing how they worked, and I obtained
first-rate training in the science of evaluating diagnosis, prognosis, and therapy.
Although I did not prepare my mind to develop or test ACE specifically, and I did
not start my career asking, What do I need to know and be able to do to develop
new ways to improve outcomes for older people in the hospital?, I knew that I
wanted to be prepared to improve care and to demonstrate what worked and what
didn’t. Thus, I was grounded in the practical and scientific knowledge that
informed the development and implementation of ACE and allowed me to test it.
3. Seek a culture of support and respect. Work is easier and more fun in a culture
that supports one and respects one’s values and interests. I was fortunate that
University Hospitals of Cleveland and Case Western Reserve University pro-
vided such a culture, one with the mix of respect and support I needed at that
time in my career.
4. Be curious, be rigorous, persist. In my view, curiosity, with compassion and
competence, drives everything good in medicine. Curiosity leads one to seek to
understand each patient, her circumstances and predicament, and this under-
standing leads to both diagnosis and empathy. Similarly, curiosity drives one to
ask questions like, Why do bad things happen to people in the hospital even
though we have remarkable resources? How can we make health care better?
How can we make improvements that are sustainable and lasting? Getting
answers to these questions that will stand the test of time requires rigor and per-
sistence. No field demonstrates the combination of curiosity, rigor, and persis-
tence in answering such complex questions better than geriatrics, which has
xii Foreword: The Story of ACE

developed and evaluated interventions such as geriatric assessment, consultation,

falls prevention, and transitions management. In the case of ACE, curiosity drove
its invention and rigor and persistence allowed my colleagues, me, and others to
learn its effects in different settings.
5. Be open to serendipity. Serendipity creates opportunities to look at old problems
in new ways. For me, in thinking about functional decline of elders in the
hospital, the understanding and ideas that came together to create ACE came
from reading in sociology, learning about Montessori education in my son’s
school, my clinical experiences, and listening to the experiences of others.
6. Build sustainability and disseminate what is important. When we undertake an
intervention, it is prudent to ask from the beginning, How will we sustain what
works?, just as we ask from the beginning of hospitalization, Where will this
patient go and how will she do there? In my initial work with ACE, my col-
leagues and I did not ask at the beginning about the sustainability of the team at
the core of the intervention and how new members would succeed the original
members. Similarly, we did not think early on about how to disseminate ACE
might have accelerated its uptake by other hospitals. Early attention to sustain-
ability and dissemination could have accelerated the uptake of ACE and the
spread of its benefits.
The invention of ACE and the further development and application of its core
concepts have transformed the care of hospitalized elders across the country.
Moreover, the invention and subsequent development, as described in Acute Care
for Elders—A Model for Interdisciplinary Care, illustrate how geriatricians, nurses,
and other acute care clinicians demonstrate that our creativity, learning, and work
have good effects for our patients.

Department of Medicine C. Seth Landefeld

University of Alabama at Birmingham
Birmingham, AL, USA
Preface: “Waking Us Up- to Better Care”

“I flew across the Atlantic Ocean seventy times” said my patient when he intro-
duced himself to me. His name was Will. I met him in our clinic office. He wore a
suit and was accompanied by his wonderful wife and his patient son. His son had
heard the same line dozens of times. I knew this patient was going to be special. He
was strong at age 90; he wanted me to know he was special. He went on to tell me
that he had been the CEO of a mining company and that he had several patents for
drilling pieces. I could only imagine what he had done in his career. Now, he was
frail. He wanted me to know him as a person. I enjoyed the clinic visits and each
time I heard the same story. I smiled and glanced at his son, who gave me an under-
standing wink.
Will was admitted to the hospital on a Sunday, late afternoon. He had pain to his
right hand from cellulitis that had become complicated. His pain was expressed as
delirium. His wife was upset; his son was away on business. Will’s confusion led to
agitation. His wife and the hospital nurses tried to calm him. This didn’t work. His
“on- call” physician ordered haloperidol. This did not work. The dosage was
repeated and Will slept … until Friday.
I saw my patient on Monday morning. He was not arousable. His wife and son
were at his bedside. I explained the circumstances: delirium in a frail, oldest old
man who had baseline dementia, and kidney disease. I described the situation to
them, then treated my patient’s cellulitis, and managed his pain. I was distraught.
I thought, “How could this have happened?” How could our best efforts to help this
man have led to a cascade of complications? I re-examined my patient daily and
kept his wife and son abreast of his progress.
As my patient slept, I pressed for a better way forward. I spoke with our hospital
librarian to ask for a literature search of models of hospital care which would
address the needs of vulnerable older patients. I prayed for Will and for the wisdom
to be able to find a better/safer method of caring for older persons who were
acutely ill.
As I walked down the hallway towards my patient, a resident physician came out
of an adjoining unit. The unit had been ‘moth-balled’ to accommodate resident
physician on-call rooms. I caught the doors and went into the unused nursing unit.

xiv Preface: “Waking Us Up- to Better Care”

I looked around and thought, “what if we used this area to take care of older, acutely
ill patients like Will”. I snooped around and began to see more than what was in front
of me. I saw an answer to frustration in usual care. I saw an Acute Care for Elders unit,
which could address our challenges in providing excellent care.
We took really good care of Will and paid meticulous attention to his needs. Will
woke up several days later and needed lots more help to transfer out of bed. His wife
was at his side daily and helped get him settled back at an assisted living center
(down the hallway from their apartment).
I told Will’s story to my geriatrics partners, to my nursing colleagues, our hospi-
tal chief executive officer, and to the Wisconsin Freemasons (a fraternal organiza-
tion that had given financial support to our geriatric programs). We started on a
compelling journey towards improving care for folks like Will. We initially thought
that the Acute Care for Elders unit would be the answer to the problem addressing
the needs of vulnerable, acutely ill older persons. In fact, Acute Care for Elders was
simply the beginning of a long journey towards improvement.
My colleagues, Drs. Elizabeth A. Capezuti and Robert M. Palmer, and I present
in this book, our best description of a better/safer way forward. We are pleased to
serve older individuals (like Will) and their caregivers with a holistic, person-cen-
tered approach towards helping their recovery.
Thanks to all of our colleagues who have contributed to improving care for
acutely ill older persons.
My patient, Will, may have slept from Sunday to Friday, but he woke us up to
pursue this journey to better health, and to a better healthcare system.

Milwaukee, WI, USA Michael L. Malone


1 An Introduction to the Acute Care for Elders ...................................... 1

Michael L. Malone, Ji Won Yoo, and James S. Goodwin
2 The Team Approach to Interdisciplinary Care .................................... 9
Maryjo Cleveland, Carolyn Holder, Ariba Khan,
and Aileen Jencius
3 Patient and Hospital Factors That Lead to Adverse
Outcomes in Hospitalized Elders........................................................... 21
Edgar Pierluissi, Deborah C. Francis, and Kenneth E. Covinsky
4 An Overview of Hospital-Based Models of Care.................................. 49
Elizabeth A. Capezuti and Marie Boltz
5 The Acute Care for Elders Unit ............................................................. 69
Robert M. Palmer and Denise M. Kresevic
6 How to Develop, Start, and Sustain an Acute
Care for Elders Unit ............................................................................... 97
Ellen S. Danto-Nocton, Carolyn Holder, Rebecca Ramsden,
Jonny Macias Tejada, Anita Steliga, and Karen Padua
7 How to Disseminate the ACE Model of Care Beyond One Unit ......... 117
Roger Y. Wong, Marsha Vollbrecht, and Patti Pagel
8 How to Use the ACE Unit to Improve Hospital Safety
and Quality for Older Patients: From ACE Units
to Elder-Friendly Hospitals .................................................................... 131
Samir K. Sinha, Sandra Liliana Oakes, Selma Chaudhry,
and Theodore T. Suh
9 ACE Unit Business Model ...................................................................... 157
Kyle Allen, Peter DeGolia, Susan Hazelett, and Diane Powell

xvi Contents

10 Models of Care to Transition from Hospital to Home ......................... 175

Ella Harvey Bowman, Kellie L. Flood, and Alicia I. Arbaje
11 What Is the Role of Hospitalists in the Acute
Care for Elders? ...................................................................................... 203
Heidi L. Wald and Melissa L.P. Mattison
12 How to Improve Care for Seniors
in the Emergency Department ............................................................... 217
Soryal Soryal, Marie Boltz, Scott Wilber, and Michael L. Malone
13 How to Improve Care for Older Patients in the Intensive
Care Unit.................................................................................................. 233
Leanne Boehm, E. Wesley Ely, and Lorraine Mion
14 The Future of Acute Care for Elders..................................................... 245
Kanwardeep Singh and Michael L. Malone

Index ................................................................................................................. 251


Kyle Allen, DO, AGSF Department of Lifelong Health and Aging Related
Services, Riverside Health System, Newport News, VA, USA
Alicia I. Arbaje, MD, MPH Division of Geriatric Medicine and Gerontology,
Johns Hopkins University School of Medicine, Center Tower, Baltimore, MD, USA
Leanne Boehm, MSN, RN, ACNS-BC School of Nursing, Vanderbilt University,
Spring Hill, TN, USA
Marie Boltz, PhD, RN New York University College of Nursing, New York, NY,
Ella Harvey Bowman, MD, PhD Division of General Internal Medicine &
Geriatrics, Department of Medicine, Indiana University School of Medicine, Sidney
& Lois Eskenazi Hospital, Indianapolis, IN, USA
Elizabeth A. Capezuti, PhD, RN, FAAN School of Nursing, Hunter College,
New York, NY, USA
Selma Chaudhry Department of Medicine, Mount Sinai and the University Health
Network Hospitals, Toronto, ON, Canada
Maryjo Cleveland, MD Post Acute and Senior Services, Summa Health System,
Akron, OH, USA
Kenneth E. Covinsky, MD, MPH UCSF Division of Geriatrics, San Francisco,
Ellen S. Danto-Nocton, MD Center for Senior Health and Longevity, ACE Unit
and Senior Services, Aurora Sinai Medical Center, Milwaukee, WI, USA
Peter DeGolia, MD Department of Family Medicine, University Hospitals Case
Medical Center, Cleveland, OH, USA

xviii Contributors

E. Wesley Ely, MD, MPH Pulmonary and Critical Care Medicine, Geriatric
Research Education Clinical Center (GRECC) of the VA Tennessee Valley
Healthcare System, Vanderbilt University Medical Center, Nashville, TN, USA
Kellie L. Flood, MD Division of Gerontology, Geriatrics, and Palliative Care,
University of Alabama at Birmingham, Birmingham, AL, USA
Deborah C. Francis, RN, MSN, GCNS-BC Kaiser Permanente Medical Center,
South Sacramento, CA, USA
James S. Goodwin, MD Sealy Center on Aging, University of Texas Medical
Branch, Galveston, TX, USA
Susan Hazelett, BSN, MS Seniors Institute, Summa Health System, Akron, OH,
Carolyn Holder, MSN, RN, GCNS-BC Department of Transitional Care and
Utilization Management Administration, Summa Health System, Akron City
Hospital, Akron, OH, USA
Aileen Jencius, MLIS Post Acute and Senior Services, Summa Health System,
Akron, OH, USA
Ariba Khan, MD Department of Geriatrics, Aurora Health Care, Milwaukee,
Center for Senior Health and Longevity, Milwaukee, WI, USA
Denise M. Kresevic, RN, PhD Louis Stokes Cleveland VAMC, University Case
Medical Center, Cleveland, OH, USA
C. Seth Landefeld, MD Department of Medicine, University of Alabama at
Birmingham, Birmingham, AL, USA
Michael L. Malone, MD University of Wisconsin School of Medicine & Public
Health, Madison, WI, USA
Aurora Senior Services & Aurora Visiting Nurse Association of Wisconsin,
Aurora Health Care, Milwaukee, WI, USA
Aurora Sinai Medical Center, Aurora Health Care, Milwaukee, WI, USA
Melissa L.P. Mattison, MD Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA, USA
Lorraine Mion, PhD, RN, FAAN Independence Foundation Professor of Nursing,
Vanderbilt University, School of Nursing, Nashville, TN, USA
Sandra Liliana Oakes, CMD, AAFP, AGSF Geriatrics and Palliative Care,
Wellmed Medical Management, San Antonio, TX, USA
Christus Santa Rosa Medical Center, Family and Community Medicine, University
of Texas Health Sciences Center, San Antonio, San Antonio, TX, USA
Geriatrics Research Education and Clinical Center (GRECC), University of Texas
Health Sciences Center, San Antonio, San Antonio, TX, USA
Contributors xix

Karen Padua, DO Center for Senior Health and Longevity, Aurora Sinai Medical
Center, Milwaukee, WI, USA
Patti Pagel, MSN, RN, GCNS-BC Department of Clinical Innovations, Wheaton
Franciscan Healthcare, Brookfield, WI, USA
Robert M. Palmer, MD, MPH Eastern Virginia Medical School, Norfolk,
Edgar Pierluissi, MD Department of Medicine, San Francisco General Hospital,
Potrero Avenue, San Francisco, CA, USA
Diane Powell, BS/ACC Department of Financial Analysis, Summa Health System,
Akron, OH, USA
Rebecca Ramsden, RN, MN, NP, GNCC Acute Care for Elders Unit, Mount
Sinai Hospital, Toronto, ON, Canada
Kanwardeep Singh, MD University of Wisconsin School of Medicine & Public
Health, Madison, WI, USA
Center for Senior Health & Longevity, Aurora Sinai Medical Center, Milwaukee,
Samir K. Sinha, MD, DPhil, FRCPC Department of Medicine, Mount Sinai and
the University Health Network Hospitals, Toronto, ON, Canada
Soryal Soryal, MD University of Wisconsin School of Medicine and Public
Health, Madison, WI, USA
Aurora West Allis Medical Center, West Allis, WI, USA
Village of Manor Park Nursing Home, Milwaukee, WI, USA
Anita Steliga, GNP Aurora St. Luke’s Medical Center, Milwaukee, WI, USA
Theodore T. Suh, MD, PhD, MHS Division of Geriatric and Palliative Medicine,
Department of Internal Medicine, University of Michigan Health System, Ann
Arbor, MI, USA
Jonny Macias Tejada, MD Aurora St. Luke’s Medical Center, Milwaukee,
Marsha Vollbrecht, MS, CSW, NHA Aurora Health Care, Milwaukee,
Heidi L. Wald, MD, MSPH Division of Health Care Policy Research, Department
of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
Scott Wilber, MD Northeast Ohio Medical University, Rootstown, OH, USA
Emergency Medicine Research Center, Summa Akron City Hospital, Akron,
xx Contributors

Roger Y. Wong, MD, FRCPC Postgraduate Medical Education, Faculty of

Medicine, University of British Columbia, Vancouver, BC, Canada
Division of Geriatric Medicine, Department of Medicine, University of British
Columbia, Vancouver, BC, Canada
Ji Won Yoo, MD University of Wisconsin School of Medicine & Public Health,
Madison, WI, USA
Center for Senior Health & Longevity, Aurora Sinai Medical Center, Milwaukee,
About the Editors

Michael L. Malone, MD is Clinical Adjunct Professor of Medicine at the University

of Wisconsin School of Medicine and Public Health, the Medical Director of Aurora
Senior Services and the Aurora Visiting Nurse Association of Wisconsin. He also
serves as the Director of the Geriatrics Fellowship Program at Aurora Health Care.
He is the Chairman of the Public Policy Committee for the American Geriatrics
Society and Section Editor-Models of Geriatric Care, Quality Improvement and
Program Dissemination for the “Journal of the American Geriatrics Society”.
Dr. Malone has devoted his career to improve the care of vulnerable older per-
sons in American hospitals. He led the development of the first Acute Care for
Elders unit in Wisconsin. He and his colleagues have developed innovative strate-
gies to disseminate geriatrics models of care including the ACE Tracker software to
identify vulnerable hospitalized elders, and the e-Geriatrician telemedicine program
to bring geriatrics expertise to rural hospitals with no geriatrician on staff. Dr.
Malone has developed innovative teaching tools including: ACE pocket cards, an
ACE NICHE app for Android phones, and the Geriatrics Fellows’ Most Difficult
Case conference. He joined Elizabeth A. Capezuti, Paul Katz, and Mathy Mezey as
editor of The Encyclopedia of Elder Care - The Comprehensive Resource on
Geriatric and Social Care, third edition, Springer Publishing Company.

xxii About the Editors

Elizabeth A. Capezuti, PhD, RN, FAAN is the William Randolph Hearst Chair in
Gerontology and Professor at Hunter College of the City University of New York
(CUNY). From 2003 through 2013 she was the Director of NICHE (Nurses
Improving Care of Health System Elders), a program of New York University
College of Nursing. NICHE provides the principles and tools to stimulate a change
in the culture of healthcare facilities to achieve patient-centered care for older
adults. Dr. Capezuti is known for her work in improving the care of older adults by
interventions and models that positively influence healthcare provider’s knowledge
and work environment. Dr. Capezuti has published extensively in the areas of fall
prevention, restraint and side rail elimination, APN (advanced practice nurse) facili-
tated models, and geriatric nursing work environment. Dr. Capezuti is the 2001
recipient of the Otsuka/American Geriatrics Society Outstanding Scientific
Achievement for Clinical Investigation Award and in 2013 received the American
Academy of Nursing Nurse Leader in Aging Award.
About the Editors xxiii

Robert M. Palmer, MD, MPH is Director of the Glennan Center for Geriatrics and
Gerontology at Eastern Virginia Medical School, where he is also Professor of
Medicine. Dr. Palmer attended medical school at the University of Michigan and
completed residency training in Internal Medicine at the Los Angeles County-
University of Southern California Medical Center. He obtained a Master in Public
Health degree at the University of California, Los Angeles, where he later com-
pleted a fellowship in Geriatric Medicine.
Dr. Palmer has attained international attention for his research focused on
improving the functional outcomes of hospitalization, patient safety and quality of
care. Dr. Palmer was Principal Investigator of a grant from the John A. Hartford
Foundation that established the effectiveness of a medical unit for acute care of
elders (ACE Unit).
He is the author of numerous publications including research articles, geriatric
textbooks, book chapters, and scientific reviews; and is Associate Editor of the
Journal of the American Geriatrics Society.
Chapter 1
An Introduction to the Acute Care for Elders

Michael L. Malone, Ji Won Yoo, and James S. Goodwin

Abstract This book will highlight a model of care which is clinician led and data
driven. The ACE model focuses on improving the health, function, and quality of
life of older patients. We hope that this book will provide a resource for health pro-
fessionals to take a systems approach to improving care.

Keywords Geriatrics • Acute Care for Elders • ACE unit • Geriatric model of care
• Patient-centered care


ACE Acute Care for Elders

M.L. Malone, M.D. (*)

University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
Aurora Senior Services & Aurora Visiting Nurse Association of Wisconsin,
Aurora Health Care, 1020 N. 12th Street, Milwaukee, WI 53233, USA
Aurora Sinai Medical Center, Aurora Health Care, Milwaukee, WI, USA
e-mail: michael.malone@aurora.org
J.W. Yoo, M.D.
University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
Center for Senior Health & Longevity, Aurora Sinai Medical Center, Milwaukee, WI, USA
J.S. Goodwin, M.D.
Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 1
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_1,
© Springer Science+Business Media New York 2014
2 M.L. Malone et al.


The Chief Executive Officer of Doctors Hospital of Manteca, 75 miles east of San
Francisco, reached out to a small group of geriatrics leaders to learn more about a
model of care called Acute Care for Elders. The CEO and his leadership team
described their 75-bed hospital, which serves a community of 67,000 in an agricul-
tural area of central California. The hospital is a part of a large health care system,
with more than 50 hospitals in seven states. The hospital leader expressed a com-
mitment to excellent care of older persons in their community. He also noted pres-
sure to improve the quality of care, very quickly since they were going to begin to
serve a large Medicare Advantage Plan and hence the leadership wanted to improve
the quality and safety of their care. The hospital leadership team had already
implemented strategies to improve provider communication with older patients.
The hospital nursing staff also rounded daily, to review the care of older patients
who were receiving treatment for pneumonia or for heart failure. Their three initial
questions were: “Can Acute Care for Elders help this hospital to care for older
patients?” “How do we get this model into place, with finite resources?” and “Can
we eventually disseminate the Acute Care for Elders model to all of the hospitals in
our health system?”

The Acute Care for Elders (ACE) Unit

Acute Care for Elders is a geriatrics model of care designed to provide:

• A prepared environment to promote mobility and orientation
• Patient-centered care with nursing initiated protocols for independent self-care,
sleep hygiene, mood, and cognition
• Comprehensive plans for returning home, facilitated by social service interven-
tion early in the course of care to mobilize the family and other community
• A review of the medical care to promote optimal prescribing for older patients [1].
Chapter 6 of this book will describe basic strategies for hospitals to plan, start,
and sustain an ACE unit. Further, Chap. 5 will describe the evidence to support this
intervention. We will describe the details of a systematic assessment of older
patients who receive care on an ACE unit, and the main interventions of the model.
We will define the equipment which will benefit older patients on an ACE unit, and
thus the basic equipment which should be available on any medical–surgical unit in
an acute care hospital. We will comment on the special populations of older patients
who will benefit from the ACE approach.
There are several unique challenges that hospitals will face in the future, which
will continue to make the ACE unit model relevant. The Center for Medicare and
Medicaid Services will implement payment reductions for hospital care of older
1 An Introduction to the Acute Care for Elders 3

patients as a part of the Affordable Care Act. This will force hospitals to carefully
review their practices to sustain a high quality of care while remaining efficient and
effective in their care. The Acute Care for Elders model can help hospitals to achieve
these goals. Chapter 9 will outline a business plan for ACE and will note how the
model improves the quality of care and the safety for older patients.
Acute Care for Elders can be started at any acute care hospital. There are key
strategies to implement an ACE unit that include: defining the characteristics of
older patients who already receive care at the hospital, defining the hospital’s per-
formance on key quality indicators in the care of older patients, building consensus
among professionals and administrative leaders of the need to improve the care,
defining the business plan for the project, building philanthropic support for the
project, and charging an advisory team to develop the model. This process will be
described in further detail in Chap. 6.
Acute Care for Elders is a model that can improve the quality of care and the
safety for older adults. We initially felt that opening the first ACE unit in Wisconsin
was a solution to the quality and safety needs of our rapidly growing older popula-
tion. In fact, opening the ACE unit was the beginning of a long process of continu-
ous improvement. Once we studied the care processes carefully, we realized the
scope of the problems that older adults faced during their hospitalization. The ACE
model gave us the forum to recognize the problems, improve the areas which needed
to be addressed, and monitor the outcomes. Providing excellent care for acutely ill
older patients is challenging. The ACE program is an efficient, clinician-led, and
data-driven model of care that focuses on health, function, and the quality of life of
older patients. This book will outline how teams can sustain the ACE unit and how
they can reach out to other areas of the hospital (e.g., the emergency department—
Chap. 12, and the intensive care unit—Chap. 13) to improve care.
ACE can be disseminated to other units within the same hospital and to other
hospitals within a health system. The challenge is to sustain excellence on the origi-
nal ACE unit, while extending to the other areas of the hospital where older persons
also receive their care. Chapter 7 will describe strategies to disseminate the ACE
unit model. We feel this systems-based approach will be relevant to hospitals and
hospital systems in America and in Canada.

The Challenges That Hospitals Face in Providing

Care for Older Persons in America

While older persons make up about 13 % of the population, they account for 36 %
of admissions to American hospitals. Older patients account for almost 50 % of
hospital expenditures for adults. As the Baby Boomer population ages, hospitals
will provide care for an older clientele. Approximately 41.4 million older persons
(age 65 or older) live in America. Moreover, the percent of older persons in this
country is projected to increase over time to 16.1 % in 2020, 19.3 % in 2030, and
20.0 % in 2040 [2].
4 M.L. Malone et al.

During a hospitalization, older persons may be at particular risk for secondary

complications. Compared to young and middle-aged adults, they face an increased
risk of functional impairment, the risk of immobility and falls, and a risk of delir-
ium. Older persons are additionally more likely to experience adverse drug reac-
tions, depression, threats to optimal communication, and errors as they transition
from one setting to the next. Any one of these risks may precipitate a cascade of
additional complications, the culmination of which could result in additional post-
hospital care and eventually long-term institutionalization. Chapter 3 will outline
these common hazards and challenges of hospital care.
During the last 10 years, the Center for Medicare and Medicaid Service has
reported hospital quality outcomes for Medicare beneficiaries on their website
(www.Medicare.gov). This public accountability to their communities has fostered
competition among hospitals to improve outcomes. Two chapters address this by
demonstrating how transitions practices (Chap. 10) are integrated into the ACE unit
and how geriatricians and hospitalists (Chap. 11) play a key role within the ACE
model to improve key outcomes.
Another major challenge in the care of acutely ill older patients is that the aver-
age hospital stay is short and thus results in many older inpatients being discharged
with health needs that require medical and skilled nursing intervention. Older inpa-
tients more commonly receive care under Medicare’s observation status. There is
less time to assess the patient and monitor their response to the initial treatment
plan. Chapter 4 will describe key interventions to attend to an older patient early in
the course of their illness. Likewise, we will highlight strategies to enhance the care
in the emergency department (Chap. 12) and in the intensive care unit (Chap. 13).
In short, this book will provide resources to providers who work in all the areas of
the acute care setting where older persons receive care.
Older patients are likely to receive care provided by a hospitalist, who probably
did not have a prior relationship with the patient or their family. Although care pro-
vided by hospitalists has been viewed by some as diminishing the continuity of care
for older patients; the outcomes for specific quality measures have improved.
Chapter 11 outlines approaches for hospitalists to incorporate in their care of older
patients. Additionally, we will describe how a hospitalist can actively participate
within an interdisciplinary team caring for an older patient on an ACE unit.
It can be difficult to assess an older patient’s baseline function and the trajectory
of their functional status during an acute hospitalization. Those older patients who
need assistance with managing their own care are at particular risk for further loss
of independence during their acute illness. Chapter 3 features a discussion of the
vulnerabilities of older adults for functional decline and the unique opportunity of
an ACE unit to address these susceptibilities.
The electronic health record can be viewed by health care professionals as both
a facilitator and barrier to their work. Systems-based strategies to enhance patient
care usually include efforts to improve documentation of care, but hospital leaders
do not want to add additional burden to providers. Chapter 7 will describe how
health systems can use the electronic health record to create simple checklists to
1 An Introduction to the Acute Care for Elders 5

identify the unique needs of older patients on an ACE unit that will streamline
efforts to address their needs.
There are several challenges to the care of older persons that did not exist when
the initial Acute Care for Elders unit was developed in 1995. Although many have
been noted already, three aspects deserve additional comment. First, Medicare has
linked quality performance to the hospital’s reimbursement. This book will high-
light how an ACE unit can be leveraged as a continuous quality improvement pro-
gram. Secondly, in the last few years, CMS has placed emphasis on avoiding
re-hospitalization. This book will illustrate how ACE improves transitions from
hospital to home. Lastly, many hospitals are caring for more older persons through
their involvement in Medicare Advantage Plans or in Accountable Care
Organizations. Chapter 4 will describe how to integrate models of care into a port-
folio of approaches to serve the needs of a diverse group of older individuals.

Interdisciplinary Team-Based Care

An interdisciplinary team is an essential component to ACE. The assessment of an

older patient who has an acute illness requires input from a team of professionals
including the nurse’s aide, nurses, social workers, rehabilitation experts, dieticians,
and pharmacists. The assessment must be provided in a timely manner and must be
integrated into a plan of care for individual. The focus on function provides an
emphasis which is complementary to the patient’s diagnosis. Coordinating the care,
based on the input from multiple team members, is a key feature of the ACE unit.
Chapter 2 describes key components and behaviors of mature teams. We further
outline communication strategies of teams. Also, we describe methods to build pro-
fessional relationships to improve team work.

The Current Status of Hospital Care for Older

Persons in Canada

This book is meant for readers both in the United States and Canada. Approximately
four million older persons reside in Canada [3]. The aging population in Canada has
increased, accounting for 9.7 % of the total population in 1982 and 14.9 % of the
total population in 2012. The proportion of older population varies by provinces and
territories: 3.2 % of Nunavut, 14.6 % of Ontario, and 17.2 % of Nova Scotia popula-
tion is aged 65 and older. The hospitalization rate of Canadian older persons is 210
per 1,000 [4], lower than the American rate [5]. The Canadian government public
funding pays for approximately 70 % of the total health costs of older Canadians
[4]. Nearly half of health care expenditures for older persons in Ontario, for exam-
ple, were devoted to the care of older individuals [6]. The top 10 % of older Ontarians
6 M.L. Malone et al.

account for 60 % of annual spending on health of older persons. Those older per-
sons with complex needs drive the majority of health costs, particularly in the acute
care setting. In short, older persons who are frail and those with multiple chronic
conditions account for a higher percentage of health care expenditures in Canada
and in America. Chapter 10 will highlight ACE strategies designed to coordinate
older persons’ care across settings and to focus on the persons’ function during their
acute illness.

The Dissemination of ACE

Acute Care for Elders has not been fully disseminated in the United States or in
Canada. There are over 5,500 acute care hospitals in America and between 100 and
200 of them have ACE units. There are several barriers to the dissemination of the
ACE model of care. The business plan for an ACE unit requires an up-front invest-
ment by the hospital. The hospital administration may be hesitant to make such an
investment. If the ACE program has a focus that is limited to the care of older per-
sons only on that unit, the concepts will not be practiced beyond that setting. The
emphasis on the external environment and the building of an ACE unit may distract
the planning team from efforts to change the process of care of older patients. There
also is a lack of geriatricians in North America, leading to challenges of developing
a program for older patients in hospitals where there is no geriatrician on staff.
Finally, the hospital administration may be focused on programs which emphasize
all hospitalized patients, without extra attention to those older persons with multiple
chronic conditions. Chapter 7 will describe how hospitals can disseminate the ACE
model beyond one unit. We will highlight strategies to bring ACE to scale within a
health system.
In summary this book will highlight a model of care which is clinician led and
data driven. The ACE model focuses on improving the health, function, and quality
of life of older patients. We hope that this book will provide a resource for health
professionals to take a systems approach to improving care.
The Chief Executive Officer of Doctors Hospital of Manteca reviewed the evi-
dence of the Acute Care for Elders unit and commissioned a group to plan to imple-
ment the model of care, as soon as possible. The hospital was planning to renovate
an 18-bed nursing unit, so the timing of the project was ideal. A local geriatrician
was contracted to serve as the medical director for the ACE unit two mornings per
week. The geriatrician started to measure simple outcomes of the current care for
older patients, and worked towards a consensus on a specific goal. The hospital
information technology team was integrated into the planning for the program, to
provide support for the project and to develop reports in the electronic health record
that could identify vulnerable older patients throughout all of the hospitals of their
health system.
1 An Introduction to the Acute Care for Elders 7


1. Landefeld CS, Palmer RM, Kresevic D, et al. A randomized trial of care in a hospital medical
unit especially designed to improve the functional outcomes of acutely ill older patients.
N Engl J Med. 1995;332:1338–44.
2. Administration on Aging. A profile of older Americans: 2012. Washington, DC: Department of
Health and Human Services; 2013. www.aoa.gov/aging_statistics/profile/2012docs/2012profile.
pdf. Accessed 24 July 2013.
3. Population by sex and age group. Table 051-0001. Canadian socioeconomic database from
Statistics Canada. www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo10a-eng.htm.
Accessed 8 Aug 2013.
4. Canadian Institute for Health Information. Health care in Canada, 2011: a focus on seniors and
aging. Ottawa, ON: Canadian Institute for Health Information; 2011, p. 29. https://secure.cihi.
ca/free_products/HCIC_2011_seniors_report_en.pdf. Accessed 8 Aug 2013.
5. Hall MJ, De Frances CJ, Williams SN, Golonsinsky A, Schwartzman A. National Hospital
Discharge Survey: 2007 summary. Natl Health Stat Report. 2010;26:1–20, 24.
6. Sinha S. Living longer, living well. Report submitted to the Minister of Health and long-term
care and the minister responsible for seniors on recommendations to Inform a Senior Strategy
for Ontario. 2012. Accessed 27 Sep 2013
Chapter 2
The Team Approach to Interdisciplinary Care

Maryjo Cleveland, Carolyn Holder, Ariba Khan, and Aileen Jencius

Abstract The medical complexity of the older adult continues to increase as people
are living longer and accumulating more disease burden. No longer can any person,
acting solo, have all of the required knowledge and expertise to manage patients. An
interdisciplinary team is a group of individuals who bring their own special knowl-
edge and skills to contribute to creating a cohesive care plan for a patient and family.
These teams require hospital commitment to assemble and maintain over time. The
teams themselves require nurturing and education, not only in disease or care man-
agement, but in team development. Done well, the team approach to health care will
benefit the patient, the family, the hospital, and the team members themselves.
While cost should be considered, much research suggests that the teams pay for
themselves in cost savings. Other measureable outcomes are described.

Keywords Interdisciplinary team • Patient care teams • Models of care • Advanced

practice nurse • Communication • Acute Care for Elders • Outcomes assessment •
Process assessment

M. Cleveland, M.D. (*) • A. Jencius, M.L.I.S.

Post Acute and Senior Services, Summa Health System,
75 Arch Street, Ste. G-1, Akron, OH 44304, USA
e-mail: clevelam@summahealth.org; jenciusa@summahealth.org
C. Holder, M.S.N., R.N., G.C.N.S-B.C.
Department of Transitional Care and Utilization Management Administration,
Summa Health System, Akron City Hospital, 525 East Market Street,
Akron, OH 44309-2090, USA
e-mail: holderc@summahealth.org
A. Khan, M.D.
Department of Geriatrics, Aurora Health Care, Milwaukee, WI USA
Center for Senior Health and Longevity, 1020 N 12th Street, Suite 301,
Milwaukee, WI 53233, USA
e-mail: ariba.khan@aurora.org

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 9
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_2,
© Springer Science+Business Media New York 2014
10 M. Cleveland et al.


ACE Acute Care for Elders

APN Advanced practice nurse

The Team Approach to Interdisciplinary Care


Americans are living longer and accumulating more health care burden. Complexity
of care, number of providers and medications taken per patient continue to rise.
Models of care have undergone a virtual revolution to meet the needs of the increas-
ingly complicated patient. Most of these new models focus on the use of health care
teams. However, a barrier to the widespread implementation of health care teams is
the difficulty in measuring important outcomes of team-based care.
The literature on the benefits of health care teams is limited, but does indicate
positive outcomes in the areas of processes, team strength, disease influence, and
performance. The use of interdisciplinary teams has a long and inconsistent history.
The components of successful health care teams however, have remained standard.
As described in this chapter, these components include behaviors, process, profes-
sional relationships, and communication styles that teams incorporate over time.
In addition, this chapter explores the role of the nurse, which is critical to the suc-
cess and stability of health care teams. The difficulty in quantifying outcomes with
a team model is described. A strategy for implementation of teams with a focus on
evidence-based outcomes measurement is included as well.

A Brief History of Health Care Teams

The history of health care teams is well documented. Health care teams existed in
India before 1900 and in Great Britain since the early twentieth century [1]. As is
usually the case in innovation, a nurse was an early pioneer in this method of care
in this country. Dorothy Rogers RN authored a paper in 1932 extolling the virtues
of teams in hospitals, quoting Kipling for emphasis:
It ain’t the individual, nor the army as a whole,
But the everlasing effort of every bloomin’ soul. [2]

During World War II and into the 1940s health care teams continued to be uti-
lized to provide efficient and collaborative care. The literature does not describe
these military teams as interdisciplinary by the definition used today, but more as a
triage model [1]. At this same time, the rise of medical specialists and the perceived
2 The Team Approach to Interdisciplinary Care 11

demise of the general practitioner contributed to the development of health care

teams in hospitals as well as primary care in rural areas. These teams usually con-
sisted of a physician, social worker, and a public health nurse [3].
The Great Society and the War on Poverty in the 1960s was the impetus for the
formation of widespread neighborhood clinics that utilized interdisciplinary teams
to provide comprehensive care. Federal funding in the 1970s formed the Office of
Interdisciplinary Programs which provided for education programs to train clini-
cians in this approach to care. However, this funding dwindled in the 1980s [1]. Of
special significance to geriatric medicine and with influence enduring today was the
creation by the Veterans Administration of specific training programs in interdisci-
plinary teams for geriatrics in the mid-1970s. These teams included many disci-
plines beyond the typical physician, nurse, and social worker [4].
Geriatric medicine, with the support of professional associations such as the
American Geriatrics Society and funding sources such as the John A. Hartford
Foundation, has continued to support and refine the use of trained interdisciplinary
teams since the 1990s. As this training has progressed a true interdisciplinary team
model has emerged that is transferable to any branch of medicine.

Interdisciplinary Team Process and Behaviors

The mark of a well-functioning interdisciplinary team is that it becomes more than

individual disciplines and members; the whole is greater than the sum of its parts
[5]. This is achieved with the implementation of standard characteristics of the
interdisciplinary team as described below. These characteristics of specific pro-
cesses, behaviors, relationships, and communication styles are critical to all suc-
cessful teams.
To begin, a bit of semantic clarification is necessary. It’s important to distinguish
interdisciplinary from multidisciplinary. Multidisciplinary is defined as care pro-
vided by disciplines such as nurses, physicians, social workers, case managers,
pharmacists, physical, occupational, and speech therapists. Each discipline brings
their individual expertise to the management of the patient but function separately.
Each discipline develops a plan of care for the patient but does not collaborate on a
common comprehensive plan of care [6].
In contrast, interdisciplinary teams practice true collaboration. Team members
form a common assessment and plan of care. Discipline boundaries expand and
may overlap. This synergy extends the scope of the team’s expertise in managing
complex patients. The strength of interdisciplinary teamwork is the process of
ongoing communication, a shared sense of responsibility, and a desire to work
towards a common goal. Interdisciplinary care supports a patient-centered focus
that provides expertise in consultation or in direct patient care [7]. A mature team
that communicates well improves patient experience, prevents complications, and
enhances smooth transitions. The components of the interdisciplinary team as
described above create the culture for such a collaboration to exist in successful,
strong and stable teams.
12 M. Cleveland et al.

The evidence in the literature and our corroborating experience identifies specific
characteristics of this team culture as follows: leadership, shared vision/common
goals, appropriate skill mix, mutual respect of skill mix, adaptability, and commu-
nication skills [8–10]. The implementation of these characteristics into teams fol-
lows as well as a review of the nurse’s role in interdisciplinary teams.
Geriatric interdisciplinary teams are located in a variety of settings, such as acute
care, outpatient or long-term care. The team leadership varies with the setting. As
an example, the physician might lead the team in a geriatric assessment center and
a nurse might lead the team in the long-term care setting. Regardless, strong leader-
ship is essential for optimal functioning of the team. Effective skills of a strong team
leader include facilitating the discussion during team meetings, summarizing com-
plex discussion and diplomatically addressing conflicts. In addition, the successful
leader practices effective time management and ensures the establishment and fol-
low through on next steps in the care plan.
Shared vision and common goals are essential in geriatrics, as in all disciplines
for quality patient care. As an example, the interdisciplinary team on the Acute Care
for Elders (ACE) unit has a singular vision for effective patient management.
Broadly stated, this includes the common goal of preventing functional decline and
maximizing independence for hospitalized elders. This goal guides the develop-
ment of plans of care. Achieving this goal is never a solitary endeavor. Due to the
complex needs and multi-morbidities of older patients, it is not feasible for an indi-
vidual discipline to have the depth of knowledge for comprehensive care [11]. The
accumulated interdisciplinary expertise of the team is essential to achieve the com-
mon goals. The ability of a team to maintain this singular vision is directly related
to the skill mix and ability to respect each member’s contribution.
Geriatric interdisciplinary teams comprise individuals from multiple disciplines.
The core group of individuals usually includes a physician, advanced practice nurse
(APN) (Clinical Nurse Specialist or Nurse Practitioner), staff nurse, social work,
dietitian, physical therapist, and pharmacist (see Table 2.1). Additional team mem-
bers may include medical residents, interns, home care nurse, and other community-
based providers. Each member brings a unique perspective to a common assessment
and collaborates on the development and implementation on a plan of care.
The focus of the team in geriatrics is on patients who may have multiple comor-
bidities, functional issues, and complex interacting problems [14]. The team has an
appropriate skill mix among its members to meet these varied needs. As such, they
share responsibility for the effectiveness and outcomes of care. The true strength of
interdisciplinary teamwork is ongoing communication, trust in each other’s compe-
tency and expertise, a perspective of equality within the team, and the desire to work
towards shared goals.
Interdisciplinary teamwork requires special interpersonal skills and personal
commitment of each member for the team to function effectively. The cornerstone
of the interdisciplinary team process of care appears to be twofold: it relies on an
efficient pattern of communication among multiple disciplines and a philosophy of
patient-centered care among multiple disciplines that provides expertise in consul-
tation or direct care [7]. Crucial to this foundation of stable teams is the willingness
2 The Team Approach to Interdisciplinary Care 13

Table 2.1 Team roles

ACE team members Roles/responsibilities
Geriatrician Comprehensive evaluation of medical issues including medications
Advanced practice Organizes and participates in interdisciplinary rounds
nurse (APN) Provide education to nursing and all interdisciplinary staff on geriatric
Perform assessments on complex cases
Registered nurse Bedside assessment of patient’s physical, cognitive and emotional
status, communication with attending physician, assurance of
patient safety
Case manager/social Coordinate discharge plan
worker Facilitate referrals/transitions of care
Physical therapy Evaluate and treat patients for mobility problems, need for devices
needed at home. Prevent functional decline
Provide opinion on best discharge level of care
Educate family members on transfers, devices, etc.
Occupational therapy Evaluate and treat patients for self-care skills
Provide opinion on best discharge level of care
Educate patient and family on home safety issues/modifications
Dietician Evaluate for causes of weight gain or loss
Provide recommendations for improving oral intake
Educate patient/family about nutritional requirements/specific diets
Pharmacy Assess for drug/drug or drug/disease interactions
Assess for polypharmacy
Assess for high risk, “Beers Criteria” potentially inappropriate
medications and recommend alternatives
Assess for inappropriate doses of medications based on kidney
Pastoral care Minister to the spiritual needs of patients and families

to help other disciplines as needed. This willingness to adapt is identified by team

members as a key component of a “good team” [8].
A pattern of efficient communication in teams is a learned skill set. A strong
leader and proficient team members educate one another in a common communica-
tion style. Honing these skills over time results in crucial team processes, such as
effective relationship-building, information exchange, emotional support, and
shared decision-making. Members need to be comfortable in “speaking up,” and by
doing so improve team performance [12]. The size of the team also affects success-
ful communication. Research indicates that the larger the team, the less two-way
communication results [8]. The comfort to engage in this type of interdisciplinary
discourse is critical for comprehensive case discussion. In addition, the ability of all
team members to respond appropriately to empathic opportunities, as well as to
offer and receive constructive feedback contributes to a supportive environment.
Skilled communication is also essential for interactions with non-clinicians.
Successful team members utilize age, gender, and culturally appropriate language in
discussions with patients, families, and caregivers. These competent team members
utilize communication to gauge limitations of understanding, facilitate the determina-
tion of goals of care, and educate as necessary on medical issues in such situations.
14 M. Cleveland et al.

The Role of the APN

For the geriatric interdisciplinary team, there are key disciplines that facilitate team
development and provide ongoing leadership. These individuals may be the geriatri-
cian and the geriatric APN such as the Clinical Nurse Specialist or the Nurse
Practitioner. As an example, the geriatrician provides medical leadership and
guidance in geriatric care. The geriatrician also serves as a liaison with attending
physicians and as a role model for nurse–physician collaboration. The APN assumes
responsibility for developing and improving the quality of geriatric nursing practice
through provision of direct patient care, consultation, education, and research. The
APN works collaboratively with the geriatrician in the facilitation of interdisciplinary
team development and in the day-to- day functioning of the team. The facilitation
done by the APN includes providing consistency in time and location of the inter-
disciplinary rounds, inviting/coordinating team members, coordinating documenta-
tion, communication, and follow-up [7]. In other terms, the APN is the “quarterback”
of the interdisciplinary team (Chap. 5).
The APN’s role is depicted in the ACE interdisciplinary model (Fig. 2.1). The
model depicts the APN’s role as a team member and as the outer circle of the wheel
focusing and supporting all of the disciplines within the circle on the needs of the
patient. The APN provides ongoing communication and serves as a liaison to physi-
cians, the interdisciplinary team, nursing staff, patients, and families. The APN

Fig. 2.1 ACE interdisciplinary model

2 The Team Approach to Interdisciplinary Care 15

Table 2.2 Factors impact Internal factors External factors

on care
Time commitment Changes in care delivery model
Involvement of all disciplines Cost-containment strategies
Staff turnover Staffing
Feeling valued Changes in administration
Conflict management Cohorting issues
Communication Computer order entry
Accountability Changes in documentation

coordinates/facilitates the rounding process. This includes guiding and focusing the
team members on the development of an interdisciplinary plan of care. This plan
encompasses the geriatric syndromes, functional issues, and future planning to sup-
port patient autonomy and goals of care. These may include advanced directives and
encouraging patient self-management of medication lists and medical history.
The ACE interdisciplinary team process focuses on improved transitions of care
beyond the discharge plan with realistic goals for the patient. The APN facilitates
and ensures that all interdisciplinary team members are involved in the rounding
process and contribute to the plan of care. Timely follow-up is crucial. The APN
interfaces with team members on plan implementation and addresses any issues or
barriers. For complex cases, the ACE team may identify a need for meeting with the
patient/family/caregiver [7]. The APN facilitates this process.
The development of a well-functioning interdisciplinary team requires a signifi-
cant degree of administrative and individual commitment. The APN facilitates the
collaboration of team members in addressing patient/caregiver issues. In addition,
the APN provides opportunities for academic detailing or direct application of
evidenced-based practice.
In spite of the positive outcomes from interdisciplinary teamwork, interdisciplin-
ary teams are fragile. Vigilance is required to barriers that may impair or destroy the
team. Factors, both internal and external, may impact the team (Table 2.2). The
APN is key in early identification of the barriers as well as facilitating solutions.
Barrier examples include low attendance and participation at team meetings.
Possibly low attendance is due to workload, member choice, or perceived function-
ing of the team. Staff participation, or lack thereof, might be related to conflict or
lack of comfort with issue or other team members. Often health care providers tend
to choose avoidance [13] Low participation during team meetings might be caused
by a few members who dominate the discussion leaving shy members reluctant to
speak up. The ability to speak freely in meetings is directly related to team perfor-
mance [13]. The role of the APN in these situations is to investigate the cause and
facilitate solutions.
The APN facilitates solutions to these issues through several methods. The APN
explores these situations privately with each discipline or individuals to identify
sensitive issues. Alternatively, the APN might involve the team identifying prob-
lems and work as a group to find solutions. Additional strategies used by the APN
for improved performance include behavior modeling and direct education.
16 M. Cleveland et al.

The APN mentors new members to the team and its process. The APN also
guides the team to recognized great ideas or solutions with praise. Process chal-
lenges for interdisciplinary teams include accountability and ongoing communica-
tion. The APN works to ensure that all members are actively involved in follow
through on the plan of care. Ongoing communication is crucial for individuals who
are not core members. As an example, a patient’s physician may not be an active
participant in the formal team rounds but definitely needs ongoing communication
and collaboration with the interdisciplinary team. A responsibility of the APN as the
team leader is the identification of a team member to follow-up on issues/plan with
the physician. The APN also circles back to make sure that the communication has
External factors also pose threats to sustaining stable interdisciplinary teams.
Health care is changing rapidly. Health care systems are changing processes of care
to meet the challenges of maintaining quality care and keeping costs low. These
modifications bring challenges such as changes in staffing and roles. The APN as
the team leader evaluates the impact of the change and recalibrates team process. As
an example, a number of positions are eliminated due to budget cuts in disciplines
such as pharmacists and physician therapy. The first interdisciplinary team meeting
after this reduction is attended only by the APN and the staff nurse. The APN’s
strategy to address this requires follow-up with administration on the impact on the
team. The APN is responsible for gaining recommitment by the administration to
ensure continued participation of all disciplines on the team. Changes in administra-
tion pose its own challenge to team stability. The APN is then responsible to educate
the new administration on the interdisciplinary model to ensure buy-in [13].
Patient assignment to nursing units is another external factor that impacts team
performance. Examples include cohorting patients by disease focus or adding hos-
pice/palliative care to a unit. The APN’s role is critical to address such change and
assist with team adaptation.
Information technology order entry and changes in documentation also impact
the interdisciplinary process. The APN directs the team in examining how informa-
tion technology changes impact the team model and their communication.

Professional Relationships

Formal team building efforts have shown to improve teamwork [14]. Education
specific to how to work within a team varies by discipline. Working in an interdisci-
plinary environment can be a culture change, especially for new graduates.
Individual adjustment is necessary, as the evaluation of the team carries more weight
than the individual. In contrast, members are vulnerable as they come under scru-
tiny of colleagues. The development of professional relationships is a process that
must develop in order for the team culture to mature.
Relationship building in teams occurs over time. It’s important for members to
learn the style of team members, their roles, and responsibilities. Communication
2 The Team Approach to Interdisciplinary Care 17

by leaders of expectations must be clear. The ideal environment is one in which

team members are comfortable in providing feedback to one another. A well-
developed team supports its members through difficult situations. However, in order
for teams to thrive support from the organizational leadership is essential. For maxi-
mum team performance and stability, it’s crucial that the organization supports
innovation and empowers members to effect change [14].

Team Benefit in Health Care

Although the use of high performance teams has long been the standard in industry,
this is not true in health care. As in industry, health care relies on a solid evidence base
to implement change. The introduction of new system wide processes and models of
care must have positive measureable outcomes for support by administration. This is
the dilemma with the use of interdisciplinary teams. Quantifying their benefit is com-
plicated due to the number of variables involved in complex patient care. Outcomes
research is limited, but does provide evidence that measureable benefit does occur
with the implementation of teams. These outcomes, described below, include mor-
bidity, readmission rates, disease management, clinical performance, and cost.
Using the airline industry as an example, it’s relatively easy to connect the dots
between a team process change such as a new boarding method and a desired out-
come, e.g., on time departure. An example of change in team process that is largely
modeled after industry is the use of a structured surgical checklist. Bliss et al.
reported a prospective cohort study in which a surgical team attended sessions to
review basic team training as well as to orient to the use of a comprehensive surgical
checklist [15]. Subsequently, 73 cases with the checklist use were compared to 246
cases without checklist use. Demographics, comorbidities, and procedure types
were similar between the groups. Thirty day morbidity was reduced from 15.9 % in
cases with team training only to 8.2 % in cases with team training and checklist use.
Implementation of the checklist was inexpensive and yet resulted in improved com-
munication, reduced team tension, and increase efficiency, all of which are beneficial
outcomes in the value-based health care environment [15].
An example related to team strength is evident in the congestive heart failure
literature. Thirty day readmissions to acute care related to congestive heart failure
diagnoses continue to be high, over 25 % in most health systems [16]. In the last few
years a variety of approaches have been used to reduce readmission rates. The com-
monality of these approaches is the implementation of interdisciplinary teams.
Team members include the following: primary care physicians, cardiologists,
nurses, dietitians, behavioral health specialists, pharmacists, care managers, and
exercise therapists. Program content includes pre-discharge planning, communica-
tion pathways, evidence-based prescribing, and pharmacologic strategies and pro-
motion of self-care. Stewart reports “Any review of the literature and how CHF
management programs achieve improved health outcomes in predominately old and
fragile individuals, reveals the importance of teamwork, not only in applying a
18 M. Cleveland et al.

Table 2.3 Stakeholder

Patient Reduced length of stay
Increased function on discharge
Improved education regarding specific disease processed
Increased reliability in care processes
Better hospital experience
Family Improved education regarding specific disease
Reduced caregiver burden on discharge
Team Increased standardization of process
Increased communication
Increased satisfaction of team process
Hospital/health system Reduced 30-day readmissions
Reduced length of stay
Reduced cost/case

multidisciplinary approach but in working with affected patients and their families.”
[17] Programs that effectively employ excellent team-based care have been success-
ful in driving down readmission rates and reducing length of stay [18].
The literature also reports the influence of disease-specific teams in the hospital
management of diabetes. Hsia and Draznin report that inpatient diabetes manage-
ment teams that follow the patient through transitions of care from ICU to a medical
floor and then home improve diabetes care during the hospital. These teams are also
successful in reducing length of stay and increasing the patient’s ability to under-
stand and manage their illness to improvement in long-term outpatient control [19].
Schmutz recently published a review of articles focused on the relationship of
team process and clinical performance. Twenty eight studies were reported on at
least one “significant relationship between team processes or an intervention and
performance.” [10, p. 529] The individual studies employed widely variant process
behaviors as well as measured outcomes. This study concluded that both team train-
ing and process result in increase performance [10].
Extrapolating from these and other studies, it is clear that many stakeholders
benefit from the team concept. Table 2.3 summarizes specific benefits and benefi-
ciaries of team care:
The literature reports very few team interventions that quantify the relationship
of team care with cost savings or increase. Flood et al. designed a retrospective
cohort study to examine the cost of an interdisciplinary ACE team compared to a
multidisciplinary usual care unit. The ACE team introduced geriatrician led daily
team rounds. The rounds focused on geriatric syndromes, early discharge planning
and communication with the medical unit hospitalists. The ACE unit reduced the
total variable direct cost per patient by $300.00. In addition, all-cause readmission
rates were reduced to 7.9 % from 12.8 % for usual care [18].
Questions remain regarding the cost/benefit balance of teams in general. It is
clear that some teams provide cost-effective interventions. However, continued
research on the benefits of teams remains significant as health care evolves towards
more value-based metrics. Areas to critically examine include the following: specific
constellation, location, and volume of team members.
2 The Team Approach to Interdisciplinary Care 19

In summary, research and practice supports the integration of interdisciplinary

teams in the care of the geriatric population. Successful teams utilize standard
behaviors, process, communication styles, nurse guidance, and evidence-based out-
come measurement. The implementation of the Accountable Care Act and its
increased emphasis on metrics and comprehensive care underlies the importance of
both utilizing interdisciplinary teams in the quality care of seniors and the ability to
quantify the team’s effectiveness.


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3. Silver G. Beyond general practice: the health team. Yale J Biol Med. 1958;31:29–39.
4. Warshaw G, Bragg E, Shaull R. Geriatric medicine training and practice in the united states
at the beginning of the 21st century. The Association of Directors of Geriatric Education
Programs; 2002.
5. Waite MS, Harker JO, Messerman LI. Interdisciplinary team training and diversity: problems,
concepts and strategies. CME J Geriatr Med. 1994;15:65–82.
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care. In: Carstensen LL, Edelstein BA, Dornbrand L, editors. The practical handbook of clini-
cal gerontology. Thousand Oaks: Sage; 1996. p. 423–49.
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8. Nanacarro S, Booth A, Arris S, Smith T, Enderby P, Roots A. Ten principles of good interdis-
ciplinary team work. Hum Resour Health. 2013;11(19):1–11.
9. Salas E, Sims D, Burke C. Is there a “big five” in teamwork? Small Group Res. 2005;36(5):
10. Schmutz J, Manser T. Do team processes really have an effect on clinical performance: a sys-
tematic literature review? Br J Anaesth. 2013;110(3):529–44.
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Patient-centered care for older adults with multiple chronic conditions: a stepwise approach
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12. Kolbe M, Burtscher MJ, Wacker J, Grande B, Nohynkova R, Manser T, Spahn DR, Grote
G. Speaking up is related to better team performance in simulated anesthesia inductions: an
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Greenwood Publishing Group; 2000.
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complex needs: American Geriatrics Society position statement. J Am Geriatr Soc. 2006;54(5):
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SJ. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll
Surg. 2012;215(6):766–76.
16. Stone J, Hoffman GJ. Medicare hospital readmissions: issues, policy options and PPACA.
Congressional research service 7-5700. 2010.
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for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981–7.
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future? J Diabetes Sci Technol. 2011;5(6):1596–601.
Chapter 3
Patient and Hospital Factors That Lead
to Adverse Outcomes in Hospitalized Elders

Edgar Pierluissi, Deborah C. Francis, and Kenneth E. Covinsky

Abstract Hospitalization is a sentinel event in the life of an older person. Despite

appropriate treatment for the reason for admission to the hospital, older adults suffer
high rates of hospitalization-associated disability (HAD) and other complications
such as delirium, falls, and pressure ulcers with long-term consequences. HAD car-
ries a poor prognosis for further disability, nursing home placement, and increased
mortality and confers significant costs to patients, families, and society. Patients at
risk for HAD can be identified and hospital processes of care that contribute to HAD
are well known. The Acute Care for Elders (ACE) model of care addresses both
patient and hospital-level risk factors and has demonstrated its effectiveness in
reducing HAD, improving patient satisfaction, while reducing costs compared to
usual care. The ACE model of care achieves the triple aim of improving care,
improving patient satisfaction, and reducing costs.

Keywords Functional decline • Hospitalization-associated disability • Low mobility

• Delirium • Falls • Pressure ulcers • Inappropriate prescribing • Iatrogenesis

E. Pierluissi, M.D. (*)

Department of Medicine, San Francisco General Hospital,
1001 Potrero Avenue, Room 5H17, San Francisco, CA 94110, USA
e-mail: epierluissi@medsfgh.ucsf.edu
D.C. Francis, R.N., M.S.N., G.C.N.S.-B.C.
Kaiser Permanente Medical Center, 6600 Bruceville Road,
South Sacramento, CA 95823, USA
e-mail: deborah.c.francis@kp.org
K.E. Covinsky, M.D., M.P.H.
UCSF Division of Geriatrics, 4150 Clement Street, #181G,
San Francisco, CA 94121, USA
e-mail: ken.covinsky@ucsf.edu

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 21
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_3,
© Springer Science+Business Media New York 2014
22 E. Pierluissi et al.


ACE Acute Care for Elders

ADE Adverse drug event
ADL Activity of daily living
AHRQ Agency for Healthcare Research and Quality
EPESE Established Populations for Epidemiologic Studies of the Elderly
HAD Hospitalization-associated disability
HARP Hospital admission risk profile
HAPU Hospital-acquired pressure ulcer
IADL Instrumental activity of daily living
LSA Life-Space Assessment
PEP Precipitating Events Project
PIM Potentially inappropriate Medication
RCT Randomized controlled trial
RN Registered nurse
SNF Skilled nursing facility
PRODIGE PROgettoDImissioni in GEriatria Study
STRATIFY St. Thomas Risk Assessment Tool in Falling Elderly
STOPP Screening Tool of Older Persons’ potentially inappropriate


Hospitalization is a significant event in the life of an older adult. Its significance lies
not only in the threat hospitalization poses for future health and function, but also in
the untapped opportunity it presents to assess and address both acute and chronic
medical conditions. In addition to treating the acute illness, the hospital team should
assess a patient’s living situation for safety and the match between function and the
environment, community and social supports, appropriateness of medication pre-
scribing, goals of care, and screen for cognitive impairment and depressive symp-
toms [1]. During the hospital stay, early planning for home discharge, preservation
of function through exercise, and avoidance of adverse events such as falls, pressure
ulcers, and medication errors is essential. At discharge, plans for managing the tran-
sition home, communication with the primary provider regarding the hospital course
and medication changes, and patient and caregiver education about home-based
disease management should occur. While significant declines in hospital length of
stay over the last 20 years have added challenges to address multiple domains of
care, these activities represent the important opportunity to improve outcomes for
older adults.
When examined, however, US hospitals fail to meet these basic standards.
Instead, acute illness and hospitalization present significant threats to a patient’s
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 23

functional independence and survival [2]. These threats occur even with appropriate
therapy directed at the reason for admission and pose a terrible burden on patients,
families and caregivers, and society. The idea that hospitalization can be hazard-
ous was first described by Schimmel [3] in his 1964 Annals of Internal Medicine
article, “The Hazards of Hospitalization.” This work described adverse events that
occurred in over 1,000 hospitalized patients. In 1993, Morton Creditor [4]
expanded this concept to include a more prevalent problem, hospitalization-asso-
ciated functional decline, in his article “Hazards of hospitalization of the elderly.”
Much work has subsequently described in detail the magnitude of the risk older
adult’s face in the hospital. This body of work forms the rationale for the need to
reengineer hospital care to reduce disability in our hospitalized elders and is the
basis of the answer to the question, “Why is it important to consider the ACE
model of care?”
Hospitalization markedly increases the risk for subsequent functional decline
and death. For example, approximately 1/3 of older adults surviving an acute hospi-
talization on a medicine service die in the year after discharge [5]. This compares to
a 1-year death rate of 4.5 % for Americans 65 or older in 2010 [6]. Hospitalization
also markedly increases the risk for future functional decline. Overall, about 1/3 of
hospitalized older adults will experience a decline from baseline function at hospital
discharge [7]. This decline continues after hospital discharge with over 20 % devel-
oping a new disability in the year following hospital discharge. This compares with
an estimated 8 % of older adults living in the community who will develop a new
disability in an activity of daily living [8] in a year.
In addition to functional decline, older adults are vulnerable to other complica-
tions with serious consequences. These include delirium and cognitive impairment,
falls, skin breakdown and pressure ulcers, urinary and bowel dysfunction, and mal-
nutrition. These complications have significance in and of themselves; however,
many have a bidirectional association with functional decline.
The risks to older adults take on even greater significance both for patients,
health care systems, and policymakers, when the aging population and high rate of
hospitalization among older adults are taken into account. Older adults make up
13 % of the US population, but account for 36 % of hospital admissions and 44 %
of hospital charges [9]. In 2008, people over 65 years old accounted for over 14
million hospital discharges, and this number is expected to grow [10]. While rates
of hospitalization for older adults are declining, the overall number of hospital
discharges of older adults is expected to rise due to the aging of the “baby-boom”
generation. This will pose a significant challenge and opportunity for the US
In this chapter, we will describe why older adults are vulnerable to adverse out-
comes associated with hospitalization. These outcomes are particularly amenable to
the ACE model of care. We will focus on functional decline since preventing func-
tional decline is the central focus of ACE care. Patients consistently cite functional
independence as an important goal of care. Functional decline is an important pre-
dictor of nursing home placement and mortality in the year after hospital discharge.
24 E. Pierluissi et al.

We will also discuss other complications, common in older adults, such as delirium
and cognitive impairment, falls, pressure ulcers, and urinary dysfunction, all of
which increase the risk of functional decline. In this chapter we will:
1. Describe the prevalence and incidence of hospitalization-associated disability
(HAD)/functional decline
2. Describe the long-term outcomes of HAD including sustained disability, nursing
home placement, and death and health-system costs
3. Describe the prevalence, risk factors, and implications of common problems of
older patients during an acute illness
4. Describe the patient-level risk factors associated with HAD and indices that uti-
lize these risk factors to identify elders at highest risk of HAD
5. Describe hospital-level factors associated with HAD
6. Describe the unique opportunity of an ACE unit to address the vulnerabilities of
older patients

Prevalence and Incidence of HAD/Functional Decline

Many studies of HAD measure function using the Katz Index of Activities of Daily
Living (ADLs) [11]. First described by Sidney Katz in 1963, the ADLs were shown
to be a useful guide to the course of chronic illness and as a tool for studying the
aging process. The ADLs used in most studies are bathing, dressing, transferring,
toileting, and eating, while some include walking. A patient is considered depen-
dent in an ADL if he or she cannot accomplish the activity or requires the assistance
of another person to accomplish the activity. An elder who needs help with an ADL
will require the assistance of a caregiver, or will require long-term care.
Functional decline in hospitalized older adults has been recognized as an impor-
tant problem for over 30 years. In 1982, in a cross-sectional study of 279 hospital-
ized patients aged 70 years or older, Warshaw and colleagues [12] demonstrated
that more than half needed help with an ADL. This study also found high rates of
delirium (50 %), restraint use (20 %), and sensory impairment (33 %). Hirsch et al.
[13] conducted one of the first prospective studies of functional disability associated
with hospitalization in 1987. Of patients functionally independent 2 weeks prior to
admission, by day two of hospitalization, 81 % were dependent in at least four of
seven functional domains (mobility, transferring, toileting, feeding, grooming, con-
tinence, and mental state) assessed. Continence and feeding were the least likely to
have declined during hospitalization.
Larger studies, conducted in the 1990s, also showed significant rates of func-
tional decline. These studies examined functional decline from baseline (2 weeks
prior to admission as assessed at the time of admission) to hospital discharge. The
hospital admission risk profile (HARP) investigators demonstrated that 31 % of
1,279 hospitalized older adults declined in ADL function from baseline to hospital
discharge [14]. In the largest study conducted of functional state in hospitalized
older adults, approximately one-third of 2,279 hospitalized patients developed new
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 25

Fig. 3.1 Changes in ADLs from baseline to hospital admission and discharge among patients 70
years and older admitted to a medicine service (With permission from J Amer Ger Soc)

or additional disability (loss of at least one of five ADLs-bathing, dressing, eating,

transferring from a bed to a chair, and using the toilet) compared to 2 weeks prior to
admission [15]. (Please see Fig. 3.1.) Of note, almost half were independent in all
ADLs 2 weeks prior to admission. Among those with declining function, approxi-
mately half declined in ADL function while in the hospital and the other half declined
entirely before hospitalization and were discharged with disability because they did
not recover function during the hospitalization. Thus, HAD reflects both new dis-
ability and failure to recover from disability that occurs before admission. A recent
study (PRODIGE) demonstrated that among 1,048 hospitalized patients, approxi-
mately 30 % suffered new disability from baseline to hospital discharge [16].
In sum, over three decades of research has documented consistently high rates of
functional decline associated with hospitalization, often despite appropriate man-
agement of the reason for hospital admission. This syndrome, also known as func-
tional decline or deconditioning, was named “hospitalization-associated disability”
(HAD) in a recent review of the topic [2].
The importance of HAD can be seen in studies of functional decline among
community-dwelling elders. The Precipitating Events Project (PEP) investigators
followed 754 persons aged 70 years and older who were not disabled to examine
risk factors for new onset disability. They found that half of new onset disability in
community-dwelling elders was attributable to hospitalization [17].
A similar finding was observed using the University of Alabama at Birmingham
(UAB) Study of Aging Life-Space Assessment (LSA) [18]. The LSA is a validated
tool that measures mobility by accounting for the frequency and ease with which a
26 E. Pierluissi et al.

person moves to increasing distances ranging from their bedroom to beyond their
community. The scale ranges from 0 to 120. In a study of 167 patients hospitalized
on a medicine service, the mean score was 64 prior to admission (someone who
needs no assistance to go into the neighborhood daily and to town 1–3 times a week)
and dropped 10 points after discharge (needs a cane to go into town less than once
a week). Patients admitted to a medicine service, in contrast to those admitted to a
surgical service, often failed to recover baseline mobility. This suggests that dis-
ability associated with hospitalization has long-term consequences and is of particu-
lar concern for patients admitted on a medicine service.
A dose–response relationship between the number of hospitalizations and subse-
quent disability was demonstrated in 595 non-ADL disabled, community-dwelling,
older women in the Women’s Health and Aging Study. Over 18 months, women
with more hospitalizations suffered greater incidence of disability even after adjust-
ing for age, self-reported health, depression, baseline function, comorbidities, and
cognitive impairment [19].
Thus, research over the last 30 years suggests the following:
1. HAD occurs frequently among older adults and the incidence has not changed
2. Disability following hospitalization reflects the failure to recover from disability
that happened before the admission, as well as new disability occurring after
3. HAD accounts for half of all new onset disability and significant life-space
mobility restrictions among older adults.
4. Recurrent hospitalizations increase the risk for incident disability.

Outcomes of HAD

HAD is a feared hazard of hospitalization for good reasons. Having a new disability
at hospital discharge is a risk factor for many deleterious outcomes including sus-
tained disability, nursing home placement, and mortality. In addition, the costs asso-
ciated with HAD are significant for both patients and their families and for society.

Long-Term and Sustained Disability

Of patients who developed HAD in the HARP study, 41 % suffered further disabil-
ity in the 3 months after discharge and only 10 % improved. The remainder had
persistent disability at 3 months. This poor prognosis was also seen in the largest
study of HAD [7], where only a third of those with HAD recovered their baseline
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 27

function in the year after hospital discharge. (Please see Fig. 3.3.) Even more strik-
ing, 41 % died in the year after discharge. Recovery of function in the first month
after discharge partially blunts the effect of HAD and highlights the importance of
exercise both during and after hospital discharge. On the other hand, patients not
recovering function in the first month after discharge face a particularly grim prog-
nosis, and care should include assessing capacity, helping patients and families dis-
cuss goals of care, and facilitating arrangements for durable powers of attorney for
finances and healthcare.

Nursing Home Placement

Nationally, three-quarters of all new nursing home placements are precipitated by

hospitalization, approximately 16 % of hospitalized Medicare beneficiaries over 65
years are discharged directly to a skilled nursing facility (SNF), and 6 % remain in
long-term care 6 months after hospital discharge [20]. In a study of 1,265 community-
dwelling, hospitalized older adults, the HARP investigators identified advanced
age, living alone, baseline disability, and HAD as significant risk factors for SNF
placement. Of these, HAD was the strongest predictor of new SNF placement [21].


Many studies have demonstrated the poor prognosis of hospitalized older adults in
the year after discharge. As seen in Fig. 3.2, those with HAD at discharge had not
only worse functional outcomes 1 year later, they also were at much greater risk of
death compared to those without HAD. Walter and colleagues developed and vali-
dated a prognostic index for mortality in the year after hospital discharge [5]. This
index assigns points (see Table 3.1) for patient factors present at hospital discharge.
Not surprisingly, disability at discharge was found to be an important factor, with
dependency in all ADLs noted to be the second best indicator of death after cancer.
One year mortality for patients with 1–4 points, 2–3 points, 4–6 points, and 7 or
more points was 4 %, 19 %, 34 %, and 64 %, respectively.
This prognostic index can be used to assist patients and clinicians in making
decisions about future care, including screening, and to raise critical issues such
as arranging for durable powers of attorney for finances and healthcare. Other use-
ful prognostic indexes have been developed for hospitalized older adults. The
website www.eprognosis.org is a helpful repository of published geriatric prog-
nostic indices where clinicians can obtain evidence-based estimates of patient
28 E. Pierluissi et al.

Fig. 3.2 Course of self-care activities of daily living (ADL) outcomes and survival after hospital-
ization footnotes: discharged at baseline function: N = 1,480. Discharged with new or additional
disability in self-care ADL: N = 799 (with permission from J Amer Ger Soc)

Table 3.1 Walter prognostic Walter prognostic index

index for estimating 1 year
Factor Points
prognosis in patients 70
and older Male gender 1
ADL dependencies at discharge
In 1–4 2
In all 5
Congestive heart failure 2
Solitary 3
Metastatic 8
Creatinine >3.0 2
3.0–3.4 1
<3.0 2


The cost for patients who develop HAD compared to those who do not, has not been
evaluated. However, community-based studies that assess the costs associated with
development of disability shed light on the economic costs of HAD. In the
Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 29

of community-dwelling elders, decline in mobility and ADL function over a 1-year

period is associated with increasing Medicare Part A mean expenditures costs.
Compared to those who maintain independence in mobility and ADLs, expenditures
are twice as high for those who transition to dependence in mobility, and almost 10
times as high for those who transition to dependence in mobility and one or more
ADLs [22]. In a cohort of 843 community-dwelling older adults, the 20 % of per-
sons who were dependent in ADLs at baseline or became dependent over 2 years
accounted for 46 % of hospital, outpatient, home healthcare, and nursing home
Medicare-reimbursed expenditures. Expenditures over a 2-year period for these
groups were $10,000 more than those who maintained independence [23].
These costs do not take into consideration the financial, physical, and emotional
burden of caregiving on patients and families. The costs of custodial care needed by
individuals with HAD are not typically reimbursed by insurers, but are considered
out of pocket expenses that can quickly deplete savings. This is in addition to the
significant physical and emotional cost of caring for an older loved one who is
becoming increasingly more dependent. For families caring for older adults at a dis-
tance, these costs are amplified. Thus, HAD significantly increases health care
expenditures and family caregiver burden and provide additional rationales to develop
effective interventions, such as those pioneered by ACE units, to counter HAD.
The evidence is clear that HAD carries a poor prognosis for further disability,
institutionalization, and increased mortality. In addition, the tremendous costs to
patients, families, and society associated with HAD are significantly greater than
for patients without HAD. Given the large numbers of older adults hospitalized each
year, and high rates of HAD, efforts to prevent it are urgently needed and can have
an important impact on government-funded health care services. The ACE model of
care has strong evidence suggesting it can reduce HAD. In addition, systematic
reviews of the costs associated with ACE demonstrate cost savings of approxi-
mately $300/patient served, while reducing HAD and other adverse outcomes.

Patient-Level Risk Factors and Predictive Indexes for HAD

Identifying patients at risk for HAD is the first step in preventing it. As a general
observation, older adults are more vulnerable to poorer health care outcomes due to
the effects of age-related physiological changes, multiple chronic diseases, polyphar-
macy, and psychosocial stressors. Prognostic indices to identify patients at risk for
HAD have been developed over the last 20 years (see Table 3.2). Inouye developed
and validated a predictive index for functional decline from baseline to hospital admis-
sion [24]. Pre-existing functional and cognitive impairment, as well as social isolation
and the presence of pressure ulcers increased the risk for disability at discharge.
Sager developed and validated the HARP using three identifiable risk factors on
admission—older age, lower admission abbreviated (range 0–21) Mini-Mental
State Exam scores, and lower preadmission instrumental ADLs (IADLs) function
(two or more dependencies out of seven). This index was predictive of disability on
hospital discharge, compared to 2 weeks prior to admission [14].

Table 3.2 Studies examining prognosis of hospitalization-associated disability

Prognostic No. of Participant age, Total points (risk %, ROC area
stratification source participants mean (SD), yearsa Outcome Risk factors Points validation sample) (validation sample)
Mehta et al. [25] 1,638 79 (7) Need for assistance Age, years: 0–1 (9) 0.78
≥1 ADL at 80–89 1 2–3 (31)
dischargeb ≥90 2 4–5 (44)
Needed assistance in ≥3 2 ≥6 (75)
IADLs 2 weeks before
Mobility 2 weeks before
• Unable to run a short 1
distance (but able to walk
up stairs or uphill)
• Unable to walk uphill or 2
up stairs
No. of ADLs for which
assistance was needed at
2–3 1
4–5 3
Metastatic cancer or stroke 2
Severe cognitive impairmentd 1
Albumin ≤3.0 g/dL 2
E. Pierluissi et al.

Inouye et al. [24] 330 78.1 (6.0) New need for Pressure ulcer 1 0 (6) 0.77f
assistance in ≥1 Poor cognitive function on 1 1–2 (29)
ADL between admissione
admission and Needed assistance with ≥1 1 3–4 (83)
discharge ADL 2 weeks before
Low social activity before 1
Sager et al. [76] 827 80 (6.1) New need for Age, years: 0–1 (19) 0.65
assistance in ≥1 75–84 1 2–3 (31)
ADL between 2 ≥85 2 4–5 (55)
weeks before
admission and Poor cognitive functiong 1
discharge Needed assistance in ≥3 2
IADLs 2 weeks before
Reproduced with permission of ref. [2]: Covinsky KE, Pierluissi E: Hospitalization Associated Disability: “She Was Probably Able to Ambulate, but I’m Not Sure.”
JAMA 306:1782–1793, 2011
ADL activities of daily living, IADL instrumental activities of daily living, ROC receiver operating characteristic
All participants were older than 70 years of age
Patients in this study needed no assistance in any ADL 2 weeks prior to admission
IADLs included using the telephone, accessing transportation, shopping, preparing meals, doing housework, taking medicines, and handling money
Patient and Hospital Factors That Lead to Adverse Outcomes…

Severe cognitive impairment was defined as a diagnosis of dementia or five or more errors in inability to perform on the Short Portable Mental Status Questionnaire
Poor cognitive function as defined as a score of less than 20 on the Mini-Mental State Examination
Calculated from data in Inouye et al. [24]
Poor cognitive function: score <15 on abbreviated 20-item Mini-Mental State Examination that excluded naming, repetition, 3-stage command, reading, writing, and
32 E. Pierluissi et al.

Fig. 3.3 Relationship between Mehta index prognostic index point scores and new onset disability
and death (with permission from J Amer Ger Soc)

Mehta and colleagues demonstrated that a combination of factors reflecting

baseline function, severity of the acute illness as reflected in new ADL disability on
admission, and co-existing conditions was found to accurately predict risk for new
disability at discharge in patients who did not report ADL disability 2 weeks prior
to admission [25]. The Mehta Index not only predicted new disability, it also accu-
rately predicted disability severity (Fig. 3.3).
These three indices, using easy to gather data, available at admission, can accu-
rately identify patients at high risk for HAD. All three indices include measures of
prior level of disability and cognitive functioning and highlight the importance of
obtaining this information on admission. While the indices are potentially very use-
ful in targeting patients for aggressive efforts to prevent decline, they are rarely used
to guide care. One reason may be that cognitive impairment is rarely assessed on
hospital admission. In a study of the quality of hospital care for the so-called
geriatric conditions, assessment of cognitive impairment was documented in only
5 % of cases [26]. Since individuals with cognitive impairment are admitted to the
hospital at higher rates than those without cognitive impairment and suffer high
rates of adverse events, including delirium, falls, pressure ulcers, and urinary incon-
tinence, it is particularly important that cognitive impairment is recognized on
admission and care plans implemented to prevent disability and adverse events [27].
ACE units routinely assess preadmission physical and cognitive functioning and use
this information to create care plans.
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 33

Preillness determinants of functional reserve (vulnerability and capacity to recover)

Age Geriatric syndromes
Poor mobility (falls, incontinence)
Cognitive function Social functioning
ADLs and IADLs Depression

Severity of acute illness

Hospitalization factors
Environment Enforced dependence
Risks for Restricted mobility Polypharmacy
disability Undernutrition Little encouragement of independence

Posthospitalization factors
Community supports
Quality of discharge

Acute illness onset Hospitalization Discharge

Functional level
New New New
Recovery Recovery Recovery
Loss of disabilitya disabilitya disabilitya

Fig. 3.4 Factors contributing to the development of hospitalization-associated (with permission

from JAMA). aIndicates that a new disability can occur at various points in the timeline between
acute illness onset and hospital discharge

Together, these indices suggest that pre-illness determinants of functional reserve

(vulnerability to decline and the capacity to recover from decline) and the severity
of illness are important in determining the risk for HAD (Fig. 3.4). What these indi-
ces do not consider is the important role of hospital-level factors in driving the
development of HAD. These factors are considered next.

Hospital-Level Risk Factors for HAD

Patient-level risk indices can predict functional decline, but do not consider impor-
tant hospital- or organizational-level structure and processes of care that affect
quality and can contribute to high rates of HAD and other iatrogenic complica-
tions of hospitalization. The dysfunctional model was developed by the creators of
the ACE model of care to describe the central role of hospital-level factors in caus-
ing HAD. (Please see Fig. 3.5.) Hospital-level factors we consider are low mobility,
iatrogenesis, inappropriate prescribing, and important structural and process

Low Mobility

A prominent hospital process of care associated with HAD is low mobility. Through
the careful work of Brown and others, the prevalence of low mobility and its asso-
ciation with HAD has been convincingly demonstrated. Using the primary nurse’s
rating of mobility in the preceding 24 h among 498 hospitalized older adults,
34 E. Pierluissi et al.

Fig. 3.5 Model for Functional Older Person

dysfunction in hospitalized
older adults

Acute Illness

Hostile Environment
Bedrest and Immobility
Iatrogenic Illness
Poor Nutrition

Physical Depressed
Impairment Mood

Dysfunctional Older Person

mobility was defined as low (average mobility level of bedrest or bed to chair for the
entire hospitalization), intermediate (average mobility of ambulation one or two
times with total assistance), and high (average mobility of ambulation two or more
times with partial or no assistance). Even after adjusting for ADLs, demographics,
severity of illness, comorbidity, and intensive care unit/coronary care unit stay, low
and intermediate mobility was strongly associated with HAD when compared to
patients with high mobility. In addition, low mobility was strongly associated with
new institutionalization and death [28]. This work was repeated and the findings
confirmed in 525 older adults in Israel where the magnitude of low mobility was
demonstrated using wireless accelerometers. In 45 patients previously able to ambu-
late without assistance, 83 % of the hospital stay was spent lying in bed and the
median time spent standing or walking was 43 min [29].
Brown and colleagues offered a conceptual framework (Fig. 3.6) to understand
the multiple barriers to mobility during hospitalization [30]. They and others [31]
have found evidence from patient interviews to support this framework.
A major mechanism by which low mobility or bedrest could cause disability is
through reduced strength. This was demonstrated in a study in 12 healthy volunteers
(mean age 67 years) of the effect of 10 days bedrest on muscle mass, knee extension
strength, and muscle protein synthesis, which declined by 6 %, 15 %, and 30 %,
respectively [32]. The loss of 15 % in knee extension strength with 10 days of
bedrest is significant when compared to the loss of approximately 3–4 % of knee
extension strength that community-dwelling older adults experience each year [33].
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 35

Patient-related factors Treatment-related factors

Illness Severity Requires bed rest
Co-morbid conditions Physician activity orders
(depression, dementia, diabetes) Medications
Symptoms Hospital devices
(pain, weakness) (catheters, restraints, IVs, oxygen)

Low Mobility During Hospitalization

Institution-related factors Attitude-related factors

Nursing to patient-ratio Attitudes toward mobility
Availability of assistance (patient, nurse, physician)
Availability of mobility equipment Expectations of hospital stay
(patient, nurse, physician)
Concerns about falling

Fig. 3.6 Conceptual model for barriers to mobility in the hospital

In addition, this study probably underestimated the degree of strength loss that
occurs in the hospital, since the subjects were not ill, and did not have inflammatory
factors present. Even in patients without HAD at discharge, the loss of strength from
bedrest can significantly increase the risk for future disability. Other mechanisms
such as impaired balance or coordination have not been as carefully evaluated.
Pain is an additional contributor to low mobility. Approximately one-third of
patients interviewed identified this as a barrier to mobility [30]. Pain is known to be
under-reported by older adults and is frequently undertreated in this population
[34]. An interdisciplinary analgesic program, similar to those employed in ACE
programs, reduced pain and improved walk times in older adults after hip fracture
repair and knee arthroplasty [35]. Yet, unlike best practice on ACE units, few hos-
pitals utilize pain protocols appropriate for vulnerable older patients.
A systematic review of interdisciplinary interventions to increase mobility dem-
onstrated improved function at hospital discharge. Exercise programs alone have
had marginal effectiveness. However, exercise—mainly, walking—when used with
a multicomponent intervention, including attention to pain management, such as
that utilized by the ACE model of care, has resulted in improved function at dis-
charge and fewer discharges to nursing home, at lower costs [36].
36 E. Pierluissi et al.


Iatrogenesis or adverse events are another hospital-related risk factor for

HAD. Iatrogenesis is defined as an unintended patient injury or harm that is not a
consequence of the illness but is secondary to a health care intervention. Historically,
adverse events have included adverse drug events (ADEs), hospital-acquired infec-
tions, and complications of diagnostic and therapeutic interventions. Creditor
expanded this concept to include geriatric syndromes such as HAD, delirium, falls,
and pressure ulcers. This concept was further expanded to include the effects of
inadequate pain management and the attitudes and beliefs of otherwise well-
meaning, but age-biased providers and clinicians [37]. In this section we will con-
sider delirium, urinary incontinence, pressure ulcers, and falls. It is important to
note that the relationships between these complications and HAD are complex with
these iatrogenic events both contributing to and resulting from HAD.
Older adults suffer a disproportionate burden of adverse events in the hospital
[38]. The landmark study of adverse events, the Harvard Medical Practice Study,
found that geriatric patients suffered twice as many diagnostic complications, twice
as many medication reactions, four times as many therapeutic mishaps, and nine
times as many falls as compared to younger patients [39]. The Office of the Inspector
General estimated that in 2008, approximately 13.5 % of hospitalized Medicare
beneficiaries suffered an adverse event that resulted in a prolonged hospital stay
(62 %), permanent harm (5 %), required life-sustaining interventions (23 %), or
resulted in death (10 %). These adverse events were related to (1) medications
(31 %), and included excessive bleeding, delirium, hypoglycemia, and acute renal
injury; (2) patient care-related events (28 %) such as volume overload, aspiration,
deep venous thrombosis, stage III pressure ulcer, and fall with injury; (3) surgery or
other procedures (26 %) that caused bleeding, hypotension, iatrogenic pneumotho-
rax, ileus, urinary retention and urinary catheter-associated trauma; and (4) infec-
tions (15 %) such as urinary tract, vascular catheter-associated, respiratory, and
surgical site infections [40]. In addition to HAD, delirium, incontinence, falls, and
pressure ulcers can be seen as the result of an interaction between patient-level risk
factors and hospital-level risk factors.


Delirium is associated with increased hospital length of stay, admission to an SNF,

functional decline or HAD, future cognitive impairment, and mortality. Delirium is
present in 25 % of patients over 70 admitted to a medicine service and develops in
another 20–29 % during the course of the hospitalization [41]. In a seminal study by
Inouye and colleagues, incident delirium in hospitalized older adults was associated
with patient-level factors of cognitive impairment, severity of illness, visual impair-
ment, and elevated BUN/Cr ratio, and hospital-level factors of restraints or indwell-
ing urinary catheter use, decline in albumin to less than three, adding more than
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 37

three new medications, and iatrogenesis (including ED stay >12 h, volume overload,
urinary tract infection following instrumentation, transfusion reaction, pressure
ulcer, and unintentional injury) [42]. Additional hospital-level risk factors for delirium
include low mobility, multiple room changes, lack of proper day–night orientation
cues such as large clocks or windows, not providing eyeglasses or hearing aids,
inadequate pain management, urinary retention and fecal impaction, sleep disruption,
and inappropriate prescribing such as using diphenhydramine or a benzodiazepine
as a sleeping aid. These are all factors that hospitals have control over and can elimi-
nate or significantly reduce. The effectiveness of eliminating these risk factors was
demonstrated in a matched controlled trial (RCT), which reduced incident delirium
by 33 % in the intervention group [43]. Eliminating these harmful hospital practices
and replacing them with evidence-based practices that promote patient function and
recovery is the basis of the ACE model of care. For example, cognitive deficits are
assessed for upon admission and routinely thereafter, and interventions to prevent
delirium are promptly implemented. Such practice is a key feature of the ACE
model of care and has been shown to result in significantly less delirium than usual
care [44].

Urinary Incontinence

New urinary incontinence occurs in approximately one of six hospitalized older

adults and is another iatrogenic event with both patient- and hospital-level risk fac-
tors [45]. Patient factors include older age, high body mass index, cognitive deficits,
and functional impairment. Hospital factors include low mobility, the use of
restraints, and the use of diapers or urinary catheters. The use of an indwelling blad-
der catheter without a specific medical indication is particularly pernicious, as it is
associated with greater risk of death and longer hospital stay [46]. Many of the same
factors (low mobility, use of restraints, and urinary catheters) that precipitate delir-
ium can also precipitate urinary incontinence. In fact, many of the so-called geriat-
ric syndromes (delirium, incontinence, pressure ulcers, and falls) that occur in the
hospital and in the community have similar risk factors [47]. In addition, the geriat-
ric syndromes are associated with each other. For example, delirium is associated
with falls and incontinence is associated with both pressure ulcers and falls. This
highlights the importance of identifying and addressing underlying risk factors for
geriatric syndromes since, once one occurs, there may be a cascading effect for oth-
ers to occur, a phenomenon known as cascade iatrogenesis.

Pressure Ulcers

Hospital-acquired pressure ulcers (HAPU) represent a common, costly, and poten-

tially preventable condition. As of October 1, 2008, the Center for Medicare and
Medicaid Services (CMS) no longer reimburses hospitals for the ancillary cost of
care of a facility-acquired pressure ulcer. The case is paid as though the secondary
38 E. Pierluissi et al.

diagnosis is not present. Nonetheless, in 2006 and 2007, approximately 4.5 % of

hospitalized Medicare hospitalized beneficiaries developed a pressure ulcer at a cost
of $2.41 billion in excess health care costs [48]. The development of pressure ulcers
can interfere with functional recovery, may be complicated by pain and infection,
contributes to higher inhospital mortality, longer hospital lengths of stay, and higher
30-day hospital readmission rates. In addition to incontinence, additional risk fac-
tors for pressure ulcers include older age, undernutrition, cognitive and functional
impairment, and low mobility. Many tools are commonly used to identify patients
at risk for developing a pressure ulcer (i.e., Braden, Norton, and Waterlow scales).
These scales all have moderate sensitivity (46–89 %) and lower specificity (22–
68 %) with low positive predictive values (5–7 %) [49]. Effective strategies to pre-
vent HAPU include the use of pressure redistribution support surfaces on beds,
chairs, gurneys and operating tables, rigorous turning and repositioning interven-
tions, and attention to continence and nutrition [50]. While repositioning is a main-
stay in pressure ulcer prevention efforts, data to support specific turning regimens
for patients with impaired mobility is lacking. Urinary and fecal incontinence must
be prevented or appropriate management strategies implemented (good hygiene,
protective barrier products, and containment devices) to reduce HAPU occurrence.
For patients with nutritional deficits, dietary consultation and supplements may be
beneficial. ACE units have been shown to have fewer pressure ulcers than usual care
units in part due to the interdisciplinary team approach and proactively assessing for
risk and intervening to prevent skin breakdown [44].


Falls with injuries in the hospital are another common adverse event for which CMS
no longer reimburses hospitals. In a study of falls in US hospitals from 2006 to
2008, the falls rate was 3.6 per 1,000 patient days with a slight decline in falls noted
over the study period. Of the over 315,000 falls reported, 26 % suffered an injury,
the vast majority of which (86 %) were minor (requiring application of a dressing,
ice or topical medication, limb elevation, or wound cleaning). Approximately 10 %
of injurious falls were considered moderate (requiring sutures, steri-strips, skin
glue, or splints), 4 % were considered major (requiring surgery, casting, traction, or
a neurological consult), and 0.2 % resulted in death [51]. The most common risk
scales used to identify patients at risk for falling in the hospital (Morse, STRATIFY,
Hendrich) have sensitivities ranging from 63 to 80 % and specificities ranging from
64 to 67 % [52]. The risk factors embedded in these risk scales include prior history
of falls, functional impairment, use of a walking aid or assistive device, cognitive
impairment or dementia, impaired mobility or low activity level, high risk medica-
tions, and balance abnormality [53]. Less known are risk factors for falls with injury.
In one study, of 784 patients who fell in a hospital, 228 (29 %) sustained an injury.
Risk for factors for suffering an injury were Caucasian race and having received
certain medications; an SSRI, an opiate, two antipsychotics, or a diuretic antihyper-
tensive [54]. Patients who fall in the hospital have longer lengths of stay and higher
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 39

charges associated with their hospitalization [55]. The evidence that the rate of falls
in the hospital can be reduced is the strongest for risk assessment and targeted inter-
vention including exercise, patient and family education, mediation review, envi-
ronmental review, medical examination, and eyesight correction [56]. Many of
these activities are embedded in the daily work of ACE units and a systematic
review demonstrated fewer falls in acute geriatric care units, such as ACE, com-
pared to usual care [44]. This highlights three lessons: (1) restricting mobility to
prevent falls is rarely appropriate, (2) efforts to prevent and recover from functional
decline are not associated with increased risk of falls, a common misconception,
and (3) the work of preventing and recovering from HAD requires careful interdis-
ciplinary assessment and planning.

Inappropriate Prescribing

Inappropriate prescribing is: (1) the use of a medication when not indicated, such as
treating mild or moderate hypertension in the hospital; (2) using a medication when
a non-pharmacological alternative can work just as well, such as using an opiate for
pain when local heat is just as effective, or a benzodiazepine for sleep when reducing
light and noise at night is equally effective; (3) using a medication for an indication
when a safer alternative is available, such as using a nonsteroidal anti-inflammatory
for pain when acetaminophen works just as well; (4) using a medication for an indi-
cation and not taking into account drug interactions or reduced creatinine clearance
with age; and (5) not monitoring the safety of the medication (such as not checking
the creatinine after an angiotensin-converting enzyme inhibitor is started). It is a
common underlying culprit for many geriatric syndromes including delirium,
incontinence and falls, and the cause of other serious ADEs in older adults. The link
between inappropriate prescribing and adverse events has been shown most con-
vincingly in the outpatient setting. In a study of 600 patients over 65 years of age
admitted to the hospital, the principal cause of the admission was an ADE in 6 % of
cases and an ADE significantly contributed to the admission in 20 % of cases. Of
these ADEs, half were considered avoidable. After adjusting for age, sex, comorbid-
ity, chronic cognitive impairment, baseline ADL function, and number of medica-
tions, the likelihood of an ADE increased by 85 % with each instance of inappropriate
prescribing (as defined by the Screening Tool of Older Persons’ potentially inap-
propriate Prescriptions—STOPP—criteria) [57]. The most commonly prescribed
potentially inappropriate medications (PIMs) are shown in Table 3.3. The effective-
ness of using the STOPP criteria to reduce inappropriate prescribing has been dem-
onstrated in a recent RCT [58].
In the hospital, less is known about the link between inappropriate prescribing
and ADEs in older adults. Serious ADEs occurred in 5 % of Medicare beneficiaries
while hospitalized [40]. In a study of inappropriate prescribing among hospitalized
adults using the Beer’s criteria, 28 % of patients received a PIM. However, only 9 %
of the ADEs were attributed to a PIM and prescription of a PIM was not associated
40 E. Pierluissi et al.

Table 3.3 Commonly prescribed potentially inappropriate medications according to STOPP

Most commonly prescribed potentially inappropriate medications according to the STOPP
criteria in order of prevalence
STOPP criteria
Proton pump inhibitor for uncomplicated peptic ulcer disease at full therapeutic dosage for
>8 weeks
Aspirin with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive
arterial events
Benzodiazepines in patients with ≥1 fall in past 3 months
Duplicate drug class prescriptions
Long-term (>1 month), long-acting benzodiazepines or benzodiazepines with long-acting
Loop diuretic as first-line monotherapy for hypertension
Long-term use of nonsteroidal anti-inflammatory drugs (>3 months) for relief of mild joint pain
in osteoarthritis
Long-term use of opiates in those with recurrent falls (≥1 fall in past 3 months)
Neuroleptic drugs in those with recurrent falls (≥1 fall in past 3 months)

with an ADE [59]. Further work is needed using more sensitive measures of
inappropriate prescribing such as the STOPP criteria. Since hospitalized older
adults have higher rates of ADEs largely secondary to the higher number of medica-
tions they receive, efforts to reduce inappropriate prescribing and polypharmacy in
older hospitalized adults will likely result in lower ADEs.
The use of clinical pharmacists has been shown to reduce ADEs in hospitalized
patients on medical wards and in the intensive care unit [60]. In an RCT of hospital-
ized patients 80 years and older, the addition of a clinical pharmacist’s medication
review reduced combined ED visits and hospitalizations in the year after discharge.
Attention to prescribing in the hospital, especially in the setting of an interdisciplin-
ary team staffed with a clinical pharmacist, can reduce ADEs in older adults. The
interdisciplinary team approach with the inclusion of a pharmacist in the care of
older adults is the hallmark of ACE units. This can serve to remove potential barriers
to recovery and maintenance of functional independence.


Central to improving the processes of patient care practices that contribute to HAD
and other complications is attention to organizational issues that address both the
structure and processes of care. At the core of these structural issues is management
of staff and staffing levels, policy and procedures, nursing staffing, workflow design,
and competency in geriatrics. The groundbreaking Agency for Healthcare Research
and Quality (AHRQ) report, Keeping Patients Safe: Transforming the Work
Environment of Nurses, demonstrated that nurse staffing and workflow design
clearly impact errors and patient safety outcomes [61]. A number of cross-sectional
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 41

and longitudinal studies have demonstrated an association between higher nurse

staffing levels and lower hospitalization-associated mortality [62]. The most meth-
odologically sound of these investigated the risk of death with exposure to shifts
that were staffed 8 h or more below targets, based on the number of patients and
their severity of illness. For each shift staffed at 8 h or more below target, the risk of
death increased 2 %. Approximately one-third of patients stayed in units that had
three or more shifts with below-target staffing and consequently were exposed to a
6 % increased risk of death [63].
Besides adequate staffing, ensuring nursing competence is critical, given the
strong evidence that it inversely affects patient care and outcomes [64]. Hospitals
that have adopted and adhere to evidence-based geriatric best practice have posi-
tively influenced patient care [65]. In a study of the quality of care for hospitalized
older adults, adherence to standards for general medical care were higher than for
geriatric-prevalent conditions such as pressure ulcers, cognitive impairment, and
delirium [26]. Yet, patients who received higher quality of care for geriatric-
prevalent conditions died less often in the year after discharge compared to those
who received lower quality of care for these conditions [66]. For this reason, nurs-
ing leadership and enhanced geriatrics training of nurses are central components of
ACE units, and fully integrating nursing expertise into management plans are key to
improving these hospital processes.
In addition, hospital infrastructure and information technology has the potential
to significantly improve our ability to promote safe patient care by enhancing com-
munication and providing decision support. For example, computerized prompts or
order sets to use a non-pharmacologic sleep protocol has been shown to promote
sleep while decreasing the use of higher risk sleeping medication among hospital-
ized patients [67]. A nurse-driven protocol to remove unnecessary indwelling cath-
eters reduced the risk of catheter-associated urinary tract infections [68] and a
nurse-driven progressive mobilization protocol was shown to decrease HAD and
length of stay in hospitalized older adults [69]. Information technology has been
used to extend ACE concepts to hospitals without geriatricians [70]. Thus, attention
to organizational issues, including the use of information technology, can improve
care for hospitalized older adults.

Factors Associated with Recovery and Mortality

After Hospital Discharge

Just as pre-illness reserve, the severity of illness and disability on admission, and
capacity for recovery are important in predicting which patients will develop HAD,
these same factors are important in predicting recovery after HAD. Barnes and col-
leagues demonstrated this recently; in patients without any ADL disability at base-
line who developed ADL disability at hospital discharge, age, gender, baseline
IADL function, cognitive impairment at admission, reason for admission, creati-
nine, and degree of disability at discharge all were associated with recovery in the
42 E. Pierluissi et al.

year after hospital discharge [71]. This study did not include depressive symptoms
as a potential predictor of recovery; however, multiple studies have demonstrated
the importance of depression and depressive symptoms in recovering function after
hospitalization. Depressive symptoms on admission are predictive of disability after
discharge [72], and patients who consistently report more depressive symptoms
after discharge are at especially high risk for disability and death [73]. The capacity
to recover is also related to other factors such as positive views of aging and pov-
erty. In a cohort of community-dwelling elders, half of whom had HAD, positive
age stereotypes were associated with functional recovery and poverty with worsen-
ing disability [74]. Similar to our ability to identify patients at risk for HAD on
hospital admission, so too, at hospital discharge, tools exist to identify patients at
greater risk for disability after discharge. This information can inform discussions
with patients and family members about prognosis, help to elicit patient goals of
care, and guide the development of patient-centered care plans.

How ACE Can Help

The ACE model of care incorporates features that address both patient- and hospital
or organizational-level factors associated with HAD and other iatrogenic complica-
tions that disproportionately affect the older patient [75]. The developers of the
ACE model of care called this the Prehabilitation Program. (Please see Fig. 3.7.)
The ACE Unit is staffed with a health care team that is trained in evidence-based
geriatric care and best practice protocols. The team consists of a nurse leader with
advanced training in geriatrics, nursing staff, geriatrician, social worker, pharmacist,
nutritionist, and rehabilitation therapist who perform initial patient assessments and
meet daily to develop patient-centered, function-focused, care plans for each patient.
The team elicits the patient’s goals of care, screens for and identifies risk, and imple-
ments evidence-based practice protocols, often nurse driven, to promote functional
recovery and prevent complications, while treating the presenting medical condi-
tion. Unlike usual hospital care, the registered nurse (RN) on ACE unit’s screens for
cognitive and functional deficits and other risk factors upon admission and proac-
tively implements best-practice protocols to prevent HAD, delirium, pressure ulcers,
falls, and other complications. In a truly interdisciplinary model such as on ACE
units, the RN is able to independently order progressive mobilization and discon-
tinue indwelling urinary catheters based on hospital policy. By focusing on function
and promoting mobility the care model reduces many of the risk factors associated
with poor outcomes in hospitalized older adults such as HAD, delirium, falls, and
pressure ulcers. The interdisciplinary team, a centerpiece of the ACE model of care,
ensures that the multifactorial nature of functional decline is met with a multicom-
ponent plan to prevent it. By addressing these factors, ACE models of care can
reduce adverse events, improve prescribing, and prevent HAD. This, in turn, results
in fewer discharges to nursing home, higher patient satisfaction, at reduced costs.
These results are consistent with the Institute for Healthcare Improvement’s Triple
Aim and warrant broad uptake of the ACE model of care in hospitals.
3 Patient and Hospital Factors That Lead to Adverse Outcomes… 43

Functional Older Person

Acute Illness

Hospitalization (ACE UNIT)

Prehabilitation Program
Hospitalization Prepared Environment
Hostile Environment Interdisciplinary Care
Depersonalization Multidimensional Assessment,
Bedrest Nonpharmacologic
Medicines Home Planning
Procedures Medical Review
Negative Expectations Positive Expectations

Physical Depressed Reduced Improved Decreased

Impairment Mood Impairment Mood Iatrogenesis

Dysfunctional Older Person Functional Older Person

Fig. 3.7 Conceptual model for how ACE can prevent hospitalization-associated disability


Older adults hospitalized with an acute illness suffer high rates of HAD. The risk for
HAD can be seen as an interaction between pre-illness reserve (e.g., vulnerability
for decline and capacity for recovery), severity of illness, and hospital-level factors
such as the structure and processes of care. Hospital factors such as adoption of an
interdisciplinary approach and best-practice protocols to promote mobility and
patient safety can speed recovery. After hospitalization, both patient factors and
community resources will affect functional recovery. Systems of care that are con-
cerned with reducing the burden of disability must address pre-illness function,
hospital-based preservation and recovery of function, and post-discharge mainte-
nance and continued recovery of function. The ACE model of care is a well-studied
intervention that can prevent HAD and other serious iatrogenic events. As a hospital-
based intervention, it has a place in systems of care that are concerned with preserv-
ing function and quality of life among older adults.
44 E. Pierluissi et al.


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Chapter 4
An Overview of Hospital-Based
Models of Care

Elizabeth A. Capezuti and Marie Boltz

Abstract The science of geriatric health care has evolved tremendously during the
last 30 years including the development of several geriatric models of care across all
healthcare settings. This chapter provides an overview of the various geriatric hos-
pital models of care, including their objectives, unique strategies, and outcomes,
including costs. Each geriatric care model may differ in its approach to prevent
complications and address hospital factors that can contribute to complications,
yet all embrace a common set of general objectives that reflect the care domains of
CGA: physical health, functional status, psychological health, and socio-
environmental parameters. These include patient–family-centric care, evidence-
based geriatric screening, prevention and treatment, function-focused care, and
discharge planning (or transitional care).
Institutional approaches utilized by geriatric models of care address workforce
issues as well as how the evidence-based geriatric care processes are embedded
within the organizational structure of the hospital or health system. Specific models
of care described include the consultative service or mobile ACE unit, NICHE, and
HELP as well as evolving specialty models of care.

Keywords Acute care • Geriatrics • Outcomes • Implementation • Sustainability •

Teaching • Geriatrics • Care models • Interdisciplinary • Patient/family centered

E.A. Capezuti, Ph.D., R.N., F.A.A.N. (*)

School of Nursing, Hunter College, 425 E. 25 th Street,
New York, NY 10010, USA
e-mail: c773@hunter.cuny.edu
M. Boltz, Ph.D., R.N.
New York University College of Nursing,
New York, NY 10013, USA
e-mail: marie.boltz@nyu.edu

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 49
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_4,
© Springer Science+Business Media New York 2014
50 E.A. Capezuti and M. Boltz


ACE Acute Care for Elders

AGS American Geriatrics Society
CGA Comprehensive geriatric assessment
GIAP Geriatric Institutional Assessment Profile
GPCA Geriatric Patient Care Associate
GRN Geriatric Resource Nurse
GRN Geriatric registered nurse
GSA Gerontological Association of America
HELP Hospital Elder Life Program
NICHE Nurses Improving Care for Healthsystem Elders
NYU New York University
OT Occupational therapy
PT Physical therapy
QA Quality assurance

Overview of Models


The comprehensive geriatric assessment (CGA) programs developed in the 1970s

were the first hospital-based models in the United States to address the unique needs
of older inpatients [1]. These CGA programs include ACE units [2, 3] or geriatric
consultation services that are currently referred to as the ACE consult or mobile
ACE team. According to Rubenstein [4], the major purposes of CGA are “to
improve diagnostic accuracy, optimize medical treatment, improve medical out-
comes (including functional status and quality of life), optimize living location,
minimize unnecessary service use, and arrange long-term case management.” CGA
programs accomplish these objectives by screening older patients at high risk for
geriatric-specific problems, evaluating for modifiable risk factors, and providing
evidence-based interventions consistent with the patient’s treatment goals.
The science of geriatric health care has evolved tremendously during the last 30
years including the development of several geriatric models of care across all health-
care settings. These are the result of the increasing proportion of the adult hospital
population over the age of 65 and the vulnerability of older inpatients to experience
the complications described in Chaps. 5 and 8. Adverse outcomes are due to pro-
vider practices and organizational policies that do not take these vulnerabilities into
consideration. Thus, the overall goals of these geriatric models of care within the
hospital target the (1) prevention of complications that occur more commonly in
older adults and (2) address hospital factors that contribute to complications [5].
4 An Overview of Hospital-Based Models of Care 51

Table 4.1 Geriatric care model clinical objectives, strategies, intervention examples, and model
Objective Strategies Intervention examplesa
Patient–family-centric Focused advance directive discussion
care Family meetings
Evidence-based Target risk factors for Screening tools
geriatric screening, complications Standardized, valid, and reliable risk
prevention, and assessment tools
treatment Prevent health problems University fall precautions
common during Pain relief
hospitalization Promote continence
Early detection of geriatric Admission OT/PT screening
syndromes such as delirium Assessment of skin integrity,
and other common geriatric hydrations, nutrition, mood,
syndromes self-care
Admission and ongoing assessment
of cognition
Comprehensive medication Assessment of medications
and treatment review Minimization of high risk meds
Function-focused care Admission OT/PT assessments and
ongoing evaluation/treatment
Standardized and individualized
attention to mobility, ADL, and
ROM exercises
Discharge Community provider liaison
planning— Home environment assessment and
transitional care) modification
Social worker involvement
Adapted from: Appendix S1. Description of Reported ACE Components in each Trial from Fox
et al. (2013)

This chapter provides an overview of the various geriatric hospital models of

care, including their objectives, unique strategies, and outcomes, including cost.
A full description of the ACE unit is found in Chaps. 5 through 9; however, this
chapter includes how the ACE and other models have been adapted to specialty

Geriatric Care Model Clinical Objectives

Each geriatric care model may differ in their approach to prevent complications and
address hospital factors that can contribute to complications, yet all embrace a com-
mon set of general objectives that reflect the care domains of CGA: physical health,
functional status, psychological health, and socio-environmental parameters [2].
These objectives are derived from several systematic and other reviews of geriatric
models of care [5–8]. Table 4.1 provides the intervention examples of strategies
employed to meet these objectives that have been reported in the literature.
52 E.A. Capezuti and M. Boltz

Patient–Family-Centric Care. The central underlying concept of quality geriatric

care is informed patient choice. Some complications of hospitalizations can be
attributed to over or under treatment, whether it is diagnostic tests, procedures, or
medications. All geriatric models emphasize a comprehensive, holistic approach to
the older person’s health that incorporates psychosocial aspects of the older patient’s
life. Educating the patient and family regarding the prognosis and treatment choices
facilities informed discussion among the patient, family, and healthcare providers
so that the older person’s preferences are respected and followed. The treatment
goals then guide choices, ranging from decisions about activity level and medica-
tions to more complex issues including aggressive treatments (e.g., intensive care
treatment), advance directives, and discharge destination.
This proactive approach is meant to prevent difficult decisions regarding life-
sustaining treatment during times of health crisis. These decisions, best pondered
while the older persons’ condition is stable, are often influenced by quality of life
considerations balanced by the potential length of life. This is also extremely help-
ful for family members acting in the best interests of patients who can no longer
participate in decision-making. Treatment choices are then more likely to be con-
cordant with the patient’s explicit preferences so that palliative care can be initiated
sooner and unnecessary life-sustaining treatments employed during the last days of
life can be prevented. Geriatric care models support efforts to provide care that is
consistent with patients’ preferences [9]. For this reason, many geriatric models
work collaboratively or in conjunction with palliative care programs [10]. The
Center to Advance Palliative Care supports the implementation of hospital palliative
care teams that integrate their services with other geriatric models of care [11, 12].
Evidence-based geriatric screening, prevention, and treatment. Geriatric models
provide the strategies to ensure optimal physical health, based on the patient’s treat-
ment goals and preferences [13]. These involve several components.
Target risk factors for complications. Given the high proportion of certain compli-
cations or geriatric syndromes among hospitalized older adults, all geriatric models
include early identification of these problems as well as risk factor reduction.
Targeting risk factors requires standardized assessment tools known to be valid and
reliable for older adults in the hospital setting [14–16].
Prevent health problems common during hospitalization. Risk assessment will
identify what syndromes and conditions individuals would be most susceptible and
then employ the preventive measure such as using a pressure relief mattress for an
older person that scores high on pressure ulcer assessment scale. Another approach
is to proactively prevent problems commonly occurring in older inpatients such as
dehydration, nutritional problems, and cognitive decline [14].
Early detection of geriatric syndromes such as delirium and other common geriat-
ric syndromes. Despite the best effort to evaluate and reduce risk, some health prob-
lems will develop or, geriatric programs are not consulted until the occurrence of
these problems. Early recognition, however, can help reduce the extent and duration
of the geriatric syndrome such as delirium [14] or functional decline [17–20].
4 An Overview of Hospital-Based Models of Care 53

Evaluate the complex, multimorbidities with comprehensive medication and

treatment review. Early initiation and frequent review of minimization of high risk
medications or treatments is associated with reduced complications [21]. Often that
review includes a pharmacist that works as part of the team [22]
Function-Focused Care. Maintaining maximum independence and autonomy
despite the multimorbidities and age-related organ decline are major determinates
of an older persons quality of life. Although prevention of health problems is a com-
ponent of evidence-based geriatric care, the focus on functional health from the
older persons’ perspective [23] and that functional decline is the most common
adverse outcomes of hospitalization [24] justifies the emphasis on function-focused
care. These include early rehabilitation and restorative care practices to prevent
functional decline [17, 18, 20, 25] by nurses [26, 27] and from consults to occupa-
tional and physical therapists [19].
Discharge planning (or transitional care). Despite early rehabilitation efforts, many
older patients will require rehabilitation or skilled nursing services following hospi-
talization. Nearly 25 % of older hospital patients are discharged to another institu-
tion such as a rehabilitation hospital or nursing home and more than 10 % are
discharged to home with skilled home care services [28]. Older adults are more
likely to experience problems associated with discharge planning that can lead to
delays in discharge and greater use of emergency service use and hospital readmis-
sion [5]. Hospital readmission for older patients frequently is attributed to medical
errors in medication continuity [29, 30], diagnostic work-up, or test follow-up [31].
Such poor outcomes are due to a lack of coordination among healthcare providers
that can result in unresolved medical issues [32] and deficient preparation of patients
and their caregivers to implement discharge instructions [33]. There are wide varia-
tions among providers in discharge planning effectiveness with providers citing
their own lack of knowledge and experience when not making appropriate home
care referrals [34]. Thus, a critical component of quality geriatric care is anticipat-
ing the post-hospital care environment and the care transition following hospital
discharge [35]. There are numerous transition models developed in the last 20 years
and many geriatric care programs either incorporate their implementation within
their program or interact in a close, collaborative way [36].

Institutional Approaches

The complications most frequently encountered among older patients are often due
to system-level problems [5]. Institutional approaches utilized by geriatric models
of care address workforce issues as well as how the evidence-based geriatric care
processes are embedded within the organizational structure of the hospital or health
system. Table 4.2 provides examples of institutional approaches to incorporate
geriatric care objectives.
54 E.A. Capezuti and M. Boltz

Table 4.2 Institutional approaches to incorporate geriatric care objectives, examples, and model
Institutional approaches Examplesa
Employ geriatric Geriatricians, geriatric advanced practice nurses, gero-psychiatrist,
specialists gero-psychiatric nurse
Support interdisciplinary Teams usually include physician (preferably geriatrician), advanced
practice practice nurse (preferably geriatric specialist), and social
worker. Other members include hospitalist, gero-psychiatrist,
gero-psychiatric nurse, registered nurse, patient care assistant
(nurses’ aide), occupational and physical therapists,
pharmacists, nutritionists, psychologist, volunteer (especially
HELP program)
Educate healthcare Geriatrics (ACE)
providers in core Hospitalists (CHAMP Curriculum for the Hospitalized Aging
geriatric principles Medical Patient Program)b
Geriatric Resource Nurse (NICHE)
Geriatric Patient Care Associate (NICHE)
Incorporate geriatric care Include a shared vision for geriatric care within the institution’s
principles within the mission (NICHE)
organization Incorporate evidence-based geriatric clinical protocols
Evaluate quality outcomes grouped by age and include outcomes
more common among older adults
Support senior-friendly Patient room: Clocks, calendars, elevated toilet seats, floor lighting,
physical environment night lights
Hallway/unit: Communal dining room, handrails in corridors,
non-slip flooring, padded hallway seats, visually contrasting
floors, and wall coverings
Adapted from: Appendix S1. Description of Reported ACE Components in each Trial from Fox
et al. (2013)
Developed at University of Chicago: http://champ.bsd.uchicago.edu/index.html

Employ geriatric specialists. The specialized knowledge of clinicians with specific

geriatric training such as geriatricians, geriatric psychiatrists, geriatric advanced
practice nurses, pharmacists, and others (some disciplines only provide continuing
education without recognized specialty expertise) are considered necessary to facil-
itate integration of geriatric care principles [15, 22, 37, 38].
Support interdisciplinary practice. Geriatric syndromes are not just medical prob-
lems but represent a complex compilation of health, functional, psychological, and
social issues [5]. Thus, their resolution depends on input from several disciplines
such as medicine, nursing, pharmacy, social work, physical, and occupational ther-
apy. All geriatric care models include interdisciplinary teams that can address the
multifaceted aspects of older adult health and related social issues.
Educate healthcare providers in core geriatric principles. Most healthcare provid-
ers have not received integration of geriatric care principles in their basic educa-
tional programs. The inadequate educational preparation of healthcare providers to
recognize age-specific factors can increase risk of complications and usage of inap-
propriate treatments. All geriatric care models require a coordinator or clinician
4 An Overview of Hospital-Based Models of Care 55

with advanced geriatric education; however, the successful usage of any model
depends on direct care staff with the core competencies to deliver safe and
evidence-based care to older patients. Thus, the coordinator or other geriatric clini-
cian’s role often includes teaching of other staff through presentations, interdisci-
plinary rounds, journal clubs, conferences, and other internal institutional
educational venues [39].
Incorporate geriatric care principles within the organization. Implementation of
geriatric care models often include institutionalizing these practices such as incor-
porating these tools in the medical record as well as hospital policies, procedures,
and protocols. Advances in geriatric science, similar to other research-based
approaches, are not consistently employed in hospital practice. Problems with poly-
pharmacy, inappropriate medications (e.g., overuse of psychoactive drugs), inade-
quate detection of delirium, depression, and pain are some of the many hospital
factors that can contribute to poor outcomes. Thus, geriatric models promote the use
of standardized evidence-based protocols, preferably embedded with the electronic
medical record [40].
Support senior-friendly physical environment. A prepared environment is meant to
reduce physical obstacles for transferring and ambulating, promote orientations and
socialization [7]. Physical modifications to the typical hospital setting include
enhanced lighting, furniture (chairs and bed) that adjusts height to facilitate mobility,
carpeted flooring, clocks, and calendars as well as a communal dining space [3, 7].

Specific Geriatric Models of Care

Several types of geriatric models are currently employed in hospitals throughout the
United States and Canada. CGA not only uncovers actual or potential health prob-
lems but also employs the considerable advances in geriatric healthcare science over
the last 30 years in treating or preventing these conditions. By employing the geri-
atric care objectives and institutional practices to support those objectives, each
model also strives to deliver quality care for older adults thus result in better health
outcomes in a cost-effective manner by minimizing length of stay and reducing
hospital readmissions.
Although each model may employ different methods to intervene, each address
both common health problems and related organizational, including workforce,
issues. The geriatric model may target specific geriatric syndromes such as delirium
or functional decline; however, by doing so they will also address related geriatric
syndromes. This is because the interrelationship of complications common in older
inpatients and their shared risk factors often result in a reduction of the other geriat-
ric syndromes. Some models may be initially utilized as unit-based intervention but
in practice most models eventually are employed as a hospital-wide approach. The
ACE unit is reviewed in depth in other chapters.
56 E.A. Capezuti and M. Boltz

The Consultative Service or Mobile ACE Unit

Geriatric or ACE Consultation Service provides a geriatrician, a gero-psychiatrist, a

geriatric advanced practice nurse, or an interdisciplinary team of geriatric special-
ists and other healthcare providers to conduct a comprehensive assessment to evalu-
ate a specific geriatric syndrome (delirium) or a complicated discharge or treatment
decision. In the 15 years hospitalist involvement has become more prevalent and
some hospitalists play an active role in geriatric models of care (see Chap. 11). For
this reason, the traditional consultative service has changed to actively incorporate
hospitalists. For example, in one large community teaching hospital a proactive and
preventive geriatric consultation model in which the geriatrician rounded during the
hospitalists daily clinical meetings to identity older inpatient with significant prob-
lems in cognition and physical function. The geriatric team (geriatrician and nurse
practitioner) provided complementary instead of duplicative clinical care that
resulted in lower length of stay and associated hospital costs [41].
Another approach is to provide a mobile ACE service for the elderly (MACE)
that provides inpatient care for patients enrolled in a geriatrics patient-centered
medical home. Since these patients are often dispersed throughout the hospital, this
mobile interdisciplinary team (geriatrician-hospitalists, socials workers, and clini-
cal nurse specialists) provided the primary hospital care for these patients with the
goals of preventing complications and promoting a smooth transition. The latter
was achieved by incorporating a transitional care model within the service so that
the nurse coordinator also acted as the transition “coach” for patient or caregiver
education. When compared to usual care, this type of service is associated with
reduced length of stay and lower hospital costs [42] as well as lower rates of adverse
events and better patient satisfaction [43].

The NICHE Program

Nurses Improving Care for Healthsystem Elders is a program at New York University
College of Nursing that supports member sites to integrate evidence-based geriatric
care. It works as a professional membership organization for health facilities to col-
laborate with other member sites. Members pay an initiation and annual member-
ship as well as demonstrate via an annual self-evaluation of active geriatric
programming [16]. NICHE designation demonstrates a hospital’s organizational
commitment and continued progress in improving quality, enhancing the patient
and family experience, and supporting the hospital’s efforts to serve their communi-
ties. A web portal [44] to a comprehensive learning management site provides the
educational, clinical, and operational resources to assist hospital’s systemic capac-
ity to effectively embed NICHE principles including the implementation of both the
GRN (Geriatric Resource Nurse) and the ACE models.
4 An Overview of Hospital-Based Models of Care 57

Table 4.3 Examples of NICHE clinical resourcesa,b

Geriatric Resource Nurse (GRN) Core Curriculum is designed to train nurses in best practices
for older hospitalized adults
Introduction to Gerontology Curriculum is meant for all disciplines as a way to develop
geriatric-sensitive care across all hospital departments
Geriatric Patient Care Associate (GPCA) Core Curriculum consists of active learning modules
for the patient care associate
Nursing Care of the Older Adult with Cancer provides the nurse clinician with practical
information regarding the special considerations in caring for older adults with cancer, in all
practice settings
Critical Care Nursing of Older Adults provides education for the nurse clinician working with
older adults in critical care, step-down units, and trauma and emergency departments
NICHE Webinars address clinical topics, management approaches, regulatory issues, and
General Discussion Forums assist NICHE site interact with others involved in the NICHE
designation process, other NICHE sites, and NICHE experts
Education Briefs are concise in-services that focus on clinical care issues and trends pertinent to
the bedside nurses’ ability to provide evidence-based care
The NICHE Need to Know series provides concise information on a variety of topics such as
functional and delirium prevention for consumers
Adapted from Capezuti (2013)

Goals of NICHE Program

The vision of NICHE is that all older adults will be given sensitive and exemplary
health care. The mission is to support member sites to enact system-level change
that targets the unique needs of older adults and embeds evidence-based geriatric
knowledge into practice [45]. Thus, the guiding principles of the NICHE program
are: evidence-based geriatric knowledge, patient–family-centered care, healthy and
productive practice environment, and multidimensional metrics of quality [46].

Key NICHE Components

The core components of NICHE are guiding principles, leadership, organizational

structures, the physical environment, patient- and family-centric approaches, aging
sensitive practices, geriatric staff competence, and interdisciplinary resources and
processes [16, 47]. These components are meant as a unified system-wide approach
to quality geriatric care. The NICHE program at NYU, guided by members’ input,
provides a comprehensive array of clinical/educational and organizational resources
(see Tables 4.3 and 4.4).
In terms of clinician competence, the GRN is considered foundational to NICHE
The GRN is a staff nurse that completes an intensive continuing education pro-
gram and is mentored by a NICHE Coordinator or other clinician (preferably a
58 E.A. Capezuti and M. Boltz

Table 4.4 NICHE organizational resources

Leadership Training Program is a 38 h, self-paced, web-based, blended-learning training
program, held over 6-week period to guide NICHE implementation.
The NICHE Planning and Implementation Guide provides the most current content for full
implementation of NICHE in an acute care setting
Clinical Improvement Models are series of modules providing an overview of system-level
adoption of clinical best practices including a Restraint Reduction Program, Pressure Ulcer
Prevention Program, and Reducing the Risk of Fall-Related Injuries
NICHE Organizational Strategies are a series of toolkits designed to assist sites in securing
financial and organizational support for the NICHE program such as a hospital-level
certification campaign and a Patient Family Advisory Councils.
The Cost Savings Estimate Model enables hospitals to measure the financial outcomes of NICHE
within their hospitals and units
Crosswalk: Joint Commission Standards and NICHE Resources describes how NICHE resources
comply with the Joint Commission Standards in care of the older adult hospital patient
NICHE Benchmarking Service provides valid and reliable measures of staff knowledge, unit level
outcomes, program status, and improvement gains
NICHE Hospitals Reports identify the initiatives and their positive outcomes from NICHE
designated hospitals in their care of older adult patients
NICHE Solutions Series are innovative ideas from NICHE hospitals based on the application of
best practices
Media Kit & Marketing Resources include a variety of marketing and outreach materials
available to NICHE hospitals to help communicate their commitment to improving care for
older adults and their families and promote their NICHE designation in their community
NICHE Conferences is an annual meeting of interdisciplinary healthcare professionals to share
current quality initiatives and innovative practices related to the care of older adults
Speaker’s Bureau provides sites with access to geriatric specialists and other experts for
speaking engagements
Adapted from Capezuti (2013)

geriatric advanced care nurse [48]) to be a unit-based clinical resource leader to

other nurses and to work collaboratively with other disciplines to promote evidence-
based geriatric care. The GRN is thus an active member of the NICHE clinical team,
working together on patient rounds and through bedside teaching as well as promot-
ing positive change through geriatric interest groups, hospital committees, and geri-
atric initiatives in their facility.


NICHE Outcomes

NICHE has provided a benchmarking service since 1997 so that member sites can
assess their strengths and weaknesses as they initiate the NICHE implementation
process and to evaluate progress over time [46]. The primary measure, the NICHE
Geriatric Institutional Assessment Profile (GIAP) is a valid and reliable instrument to
4 An Overview of Hospital-Based Models of Care 59

evaluate staff perceptions of the work environment, institutional structure, and other
measures of organizational alignment compared with other NICHE sites [46, 49–52].
Single study evaluations using the GIAP as well as other measures have reported
positive outcomes associated with NICHE implementation including incontinence
and sleep as well as clinical outcomes such as reduced physical restraint use,
delirium, nosocomial incontinence [53], urinary tract infections, mobility loss [53],
pressure ulcers, and fall-related injuries. These improvements also have been linked
to reported decreased length of stay and reduced costs of care [46].
One of the four NICHE guiding principles is a productive practice environment.
Three studies that have evaluated the work environment prior and following
NICHE implementation have demonstrated improvements in work environment,
knowledge of care of older adults, and care processes. The most important finding
was that nurses perceived the quality of care provided to older adults was better
[46, 54, 55]. Since NICHE is a program that is tailored to each institution’s indi-
vidual culture and resources, study designs employing randomization have not
been feasible to conduct.

NICHE Sustainability

NICHE began in 1992 with eight pilot sites; it continued to grow slowly to 157 sites
in 2006. A major grant from Atlantic Philanthropies foundation for a business plan to
expand the operational capacity of NICHE to reach more healthcare facilities resulted
in an increase to nearly 500 active member sites that pay fees that support the web-
based portal to the many NICHE resources in a streamlined and efficient way [45].
NICHE has achieved these financial goals for sustainability by generating diver-
sified revenue sources to sustain NICHE program operations while: Developing
NICHE-specific resources that target geriatric-specific staff development, clinical
practice guidelines, organizational strategies, and program evaluation; Creating the
platforms (website and virtual platforms for knowledge management) for individual
and site development; Expanding the NICHE benchmarking service; and Supporting
the research that generates evidence-based practices [45]. For sites, NICHE is more
than a warehouse of resources but rather a guided process that supports the plan-
ning, implementation, and evaluation of geriatric best practices. The focus on
strengthening the role of nurses within the interdisciplinary team and the institu-
tions leadership resonates with nurse administrators who recognize the critical need
for better geriatric care.

Hospital Elder Life Program

The Hospital Elder Life Program (HELP) is a patient care program that is designed
to prevent delirium among hospitalized older patients [56, 57]. HELP was pioneered
with initial efficacy studies at Yale Haven Hospital [3, 14], and its effectiveness has
been established in national dissemination research.
60 E.A. Capezuti and M. Boltz

Table 4.5 HELP interventions for specific risk factors

Risk factors Intervention
Cognitive impairment Orientation board
Orienting communication
Cognitive stimulation activities
Vision hearing impairment Visual aids and adaptive equipment
Hearing amplifiers
Ear wax disimpaction
Immobilization Early mobilization and active range of motion
Minimizing immobilizing equipment
Psychoactive medication use Nonpharmacologic approaches to sleep/anxiety
Restricted use of sleeping medications
Dehydration and nutritional problems Early recognition and volume repletion
Meal assistance
Sleep deprivation Noise reduction strategies
Sleep enhancement

Goals of HELP

The core HELP intervention focuses on delirium; however the model is designed to
be a comprehensive model of care for hospitalized older adults [5]. HELP supports
integration of principles of geriatric care into standard care throughout the hospital.
The goals are: (1) to promote physical and cognitive function; (2) to maximize inde-
pendence at discharge; (3) to facilitate transitions; and (4) to prevent unplanned
readmissions [5].

HELP Components

Protocols. A central component of the model is the interdisciplinary protocols car-

ried out by trained staff and volunteers. All older adults aged 70 and above are
screened and older adults at risk for functional decline are identified. Interventions
are assigned from a menu based on the individual’s risk factors for common geriat-
ric syndromes (see Table 4.5) [3–5].
Staff and volunteers The Elder Life Specialist Nurse is a master’s prepared nurse
who performs daily assessments of patients, conducts nursing interventions includ-
ing medication reviews, and collaborates with the interdisciplinary team. This posi-
tion is also responsible for educating staff, serving as a liaison with the hospital
community, and assisting with discharge planning and transitions. A Volunteer
Coordinator screens patients for inclusion in HELP and develops a plan for indi-
vidualized interventions. This role also recruits, trains, assigns, and supervises vol-
unteers, and provides them with ongoing education, support, and communication.
4 An Overview of Hospital-Based Models of Care 61

Volunteers play a key role implementing the protocols. The HELP volunteer training
program consists of 16 h of didactic and small group training followed by 16 h of
one-on-one training on the unit. Daily staff communication, quarterly educational/
support session, monthly newsletter, and incentive awards are recommended to sup-
port volunteer retention. A Program Director is responsible for overseeing the pro-
gram, conducting quality assurance, developing and monitoring the budget, and
communicating activities and outcomes to the hospital community and community
at large. HELP sites may combine or modify these roles, and often include a geri-
atrician who provides consultation to the team and education to physicians [3–5].
Interdisciplinary expertise. The HELP team draws on the expertise of multiple cli-
nicians during interdisciplinary rounds including the geriatric nurse practitioner,
nutritionist, pharmacist, rehabilitation therapists, social workers, and chaplains.
These experts may participate in staff and volunteer training also. The degree and
type of interdisciplinary involvement varies in HELP programs; their input when
available is considered a factor contributing to the program’s strength and effective-
ness [3–5].
Other program interventions include education of staff often provided by a geriatric
nurse practitioner, linkages with community providers, and post-discharge tele-
phone follow-up [5].
Quality assurance (QA) activity is considered key to success. Inouye recommends
that a working group monitor program implementation, adherence, and outcomes
[5, 6]. In addition to daily review to ensure adherence to interventions, HELP
resources include staff performance checks and competency-based volunteer and
staff performance assessments (recommended to be conducted quarterly and twice
yearly, respectively). A survey of patient and family satisfaction is another facet of
QA activity [3, 5].

Implementation of HELP

The HELP model can be incorporated into a hospital’s existing framework; a dedi-
cated unit is not necessary [3, 5]. Tools to support implementation are available on
the HELP website [2]; they include start-up guides, a training/education manual,
and tools to help sites develop the business case. Key hospital attributes identified
as enabling HELP implementation include senior management support, including
commitment of the nurse leader [58]. Support has been found to be motivated by
senior managers’ concern for care, satisfaction, and cost-effectiveness, as well as
their personal experiences with geriatrics or their hospital’s strategic plan to become
known for excellence in elder care [7]. Other factors that support implementation
include effective clinical leadership, consistent reporting of outcomes, and aligning
HELP with existing programs (e.g., transitional care) [6, 59–61].
62 E.A. Capezuti and M. Boltz

Inouye and colleagues demonstrated that high adherence was associated with
lower delirium rates [62]. Accordingly, effective treatment fidelity measures (meth-
ods to monitor protocol implementation, and staff and volunteer competence) sup-
port program implementation [5, 7].

HELP Outcomes

The HELP program began as a research model that demonstrated in a controlled

clinical trial a reduction in the incidence of delirium, overall delirium days, and delir-
ium episodes [3–5]. HELP has largely been implemented on medical units. However
a modified HELP intervention in Taiwan effectively reduced older surgical patients’
functional decline and delirium rates by hospital discharge [63]. Additionally, HELP
has demonstrated cost saving, including those related to avoiding “sitter” costs [64].
Leslie and colleagues [65] estimated savings of about $9,500 per patient per year for
avoided long-term nursing home placements. Rubin and colleagues [66], reported an
annual cost savings of $2,031,440 related to delirium prevention.
In addition to improved functional and delirium outcomes, other reported bene-
fits to the hospital include perceptions of increased nursing education and retention,
patient and family satisfaction with care, visibility for geriatrics, and overall quality
of care [60, 67–69]. Hospitals also report improved public relations and formal
recognition [6].

Sustaining HELP

Qualitative study with HELP programs, the majority of which were in operation
longer than 2 years, identified factors associated with sustainability [17]. A critical
factor is the ability to interact meaningfully with decision-makers, and provide data
that demonstrates the positive patient and financial outcomes of the program.
Another important characteristic of sustainable programs is the ability to garner
support from influential staff at all levels, in all disciplines. Thus communicating
the goals and successes of the program in a manner that shows alignment with staff
values and agendas supports sustainability. Finally, supporting multiple champi-
ons, or leaders, in the HELP program will support sustainability when there is staff
Over 200 hospitals have implemented HELP, with growing international interest
[11, 70]. Dissemination and sustainability is supported through an annual HELP
conference and Symposia, the work of Special Interest Groups at the American
Geriatrics Society (AGS) and Gerontological Association of America (GSA), and
HELP Working Groups for Palliative care, Emergency Department, Intensive Care
Unit, and Nursing Homes. Additionally, HELP Centers for Excellence (8 across the
United States and Canada) host site visits and provide mentoring [4].
4 An Overview of Hospital-Based Models of Care 63

Geriatric Models with Specialty Populations

Geriatric care models were first developed to target the needs of older medical
patients. Over the years the success of these models has been expanded to other
services or units caring for older patients or has added services to meet the special-
ized needs of frail older inpatients such as described in Chaps. 12 (Emergency
Department) and 13 (Intensive Care Unit). Some have replicated the core compo-
nents of a model for older patients with specific condition such as stroke, heart
failure, and acute pulmonary illnesses [71, 72].
For older oncology patients, some have established oncology-specific ACE units
[73] while others have integrated geriatric assessment within oncology practices
[74]. For older surgical patients, there are positive outcomes associated with co-
management (with geriatric team or ACE unit) services to reduce complications
post-hip fracture surgery [75, 76]. Others have modified a model such as HELP for
postsurgical patients and have reported reduction of functional decline and delirium
rates compared to others receiving usual care [63].
Geriatric models have also become integrated within other categories of services.
Some have expanded a model to include innovative services such as a delirium
room [77], a geriatric emergency department [78], or a sub-intensive unit for criti-
cally ill older adults [79]. There has been a great deal of collaboration with pallia-
tive care since many of these programs have evolved from geriatric departments. In
addition to screening potential patients to receive palliative care, some geriatrics
teams are part of a combined geriatrics and palliative care consultation program
[80] or co-manage in a specific geriatric palliative care unit.

A Portfolio Approach to Model Integration

Multiple geriatric models are also employed in some hospitals. NICHE is often
paired with ACE and HELP programs or part of a larger geriatric consultation ser-
vice or department. The geriatric advanced practice nurse may serve as coordinator
of these multiple models. In an effort to reduce the potential duplicative activities
involved with implementing multiple models, the Medicare Innovations
Collaborative utilizes a portfolio or service line approach to model integration [81].
With a focus on improving inpatient hospital and transitional care, they brought
together a collaborative of six health systems that received both peer-to-peer guid-
ance and advice from model innovators through a central technical assistance pro-
gram. These system implemented two or more models simultaneously while
customizing their healthcare organizations’ local circumstances. The models
included ACE, NICHE and HELP as well as the Care Transitions Intervention, the
palliative care consultation and the Hospital at Home® models. The Medicare
Innovations Collaborative has demonstrated that this approach is feasible and their
findings suggest the potential for expansion across the care continuum [76].
64 E.A. Capezuti and M. Boltz


Although all geriatric care models have reported positive outcomes, the vast majority
of hospitals in the United States have not implemented even a single model. Each
model was developed with government and/or foundation financial support. Since
there is no direct reimbursement for the major components of these models (inter-
disciplinary rounds, nurse coordinator, specialized, volunteers, etc.) administrators
seek funding from grants or donors [5]. They are more likely to support model
implementation if they believe it aligns with the hospitals strategic plan (e.g., excel-
lence in senior care), the institution’s mission, community needs, consumer satis-
faction, and cost savings [5, 20, 82, 83]. However, for many hospitals and health
systems, financial and administrative barriers deter the implementation of geriatric
models. Changes in the current Medicare policies that focus on organizational rede-
sign and outcomes across health settings will improve the likelihood of geriatric
care model implementation. Demonstrating how ACE and the other geriatric mod-
els of these models enhance the hospital experience of the older patient will ensure
future survival [8, 84].


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Chapter 5
The Acute Care for Elders Unit

Robert M. Palmer and Denise M. Kresevic

Abstract Older patients often experience a loss of independent physical functioning

during the course of an acute illness requiring hospitalization. This functional
decline is often associated with adverse health outcomes for these patients. Acute
Care for Elders (ACE) units were designed as a cost-efficient model of care to
reduce the risks of functional decline and to enhance the patient’s physical function-
ing. The ACE Unit program includes a modification of the physical and therapeutic
environments, an expanded role for bedside (relationship-based) nurses including
bedside guidelines for patient care, interdisciplinary collaboration, and team-based
planning for patient discharge to home. Three randomized clinical trials of the ACE
unit demonstrate favorable outcomes of improved physical functioning of elderly
patients, reduced hospital length of stay, fewer transitions to nursing facilities,
higher patient and provider satisfaction with care, and reduced costs of hospitaliza-
tion, compared to usual care. The ACE Unit program would likely improve quality
of care and safety of all medically ill elderly patients.

Keywords Hospitalization • Functional decline • Elderly • Interdisciplinary team •

Patient safety

R.M. Palmer, M.D., M.P.H. (*)

Eastern Virginia Medical School, 825 Fairfax Ave. Suite 201, Norfolk,
VA 23507-1912, USA
e-mail: palmerrm@evms.edu
D.M. Kresevic, R.N., Ph.D.
Louis Stokes Cleveland VAMC, University Case Medical Center,
10701 East Boulevard, Cleveland, OH 44106, USA
e-mail: Denise.Kresevic@va.gov

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 69
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_5,
© Springer Science+Business Media New York 2014
70 R.M. Palmer and D.M. Kresevic

Acute Care for Elders: Background and Conceptual Model

Older patients often experience a loss of independent physical functioning during

the course of an acute illness requiring hospitalization. This functional decline is
often associated with adverse health outcomes for these patients, including func-
tional disability, prolonged hospital length of stay, hospital-acquired conditions,
postacute care in skilled or long-term care nursing facilities, home care, and greater
costs of medical care. Acute care geriatric units were created to help prevent the
“hazards of hospitalization” [1] through modified physical and therapeutic environ-
ments that foster independent patient functioning, expanded roles for bedside
(relationship-based) nurses, multidisciplinary collaborations, and improved dis-
charge planning [2].

Acute Care for Elders: University Hospitals of Cleveland

Building on these early studies, a new model of care, Acute Care for Elders (ACE),
was implemented at University Hospitals of Cleveland and a conceptual model of
functional decline, the “Dysfunctional Syndrome” (Fig. 5.1) explained how ele-
ments of hospitalization interacted with patient vulnerabilities to result in

Functional Older Person

Acute Illness
Possible Impairment

Hostile Environment

Depressed Mood Physical

Negative Impairment

Fig. 5.1 The dysfunctional

syndrome. Modified from Dysfunctional Older Person
reference [3]
5 The Acute Care for Elders Unit 71

Table 5.1 Philosophical models of care for hospitalized older adults [4]
Biomedical Biopsychosocial
Disease focus Focus on function: physical, cognitive, and social
Limited focus on environmental issues Considerable focus on the hospital environment
for function
Physician directed decision-making Care directed by team with expertise in geriatrics
Focus on acute illness Focus on acute and chronic illnesses including
post-hospital care needs

functional decline [3]. The conceptual model informed implementation of a

multifaceted intervention designed to prevent or reduce the degree of functional
decline, with the goal of preventing the patient’s loss of ability to perform activities
of daily living (ADL). The intervention was initially conceived as a “Prehab” pro-
gram for patient-centered care, but is now generally recognized as the ACE pro-
gram. The intervention integrated principles underlying continuous quality
improvement and comprehensive geriatric assessment. The ACE intervention was
conceptualized as a systematic approach to reengineering of care for older hospital-
ized patients (Table 5.1). The ACE intervention shifted the general approach to
patient care with a model that supplements the biomedical model with the biopsy-
chosocial model, attempts to ensure congruence between the patient’s needs and the
physical environment, moves from strictly disease-oriented to function-focused
care, shifts from physician-only to team-directed care, and adopts patient/family-
centric approaches to care [4].
To enable rigorous evaluation of the ACE model of care, a medical-surgical
nursing unit was selected that allowed the research team to initiate environmental
modifications and interdisciplinary collaboration with control over the environment
and processes of care provided to elderly patients. Fifteen beds on a 29-bed unit
were identified for the purposes of testing the intervention. The unit would also
serve as a “clinical research laboratory” for testing the effectiveness and accept-
ability of each component of the ACE intervention. The most successful and cost-
effective components could then be disseminated to the remainder of the hospitals
units, gradually modifying the process of care for all older patients [2]. The ACE
unit underwent environmental modifications and some modest changes in nurse
staffing on the unit. A clinical nurse specialist (CNS) was recruited to the unit to
provide direct care of geriatric patients, consultation to nursing staff, and coordina-
tion of the processes of patient care and education. An interdisciplinary team was
organized to include the CNS, geriatrician as medical director, primary physician,
and the existing primary (bedside) nurses, social worker, physical and occupational
therapists, and home care coordinator (Fig. 5.2). The nursing staff was trained by
the CNS in bedside care of elderly patients and practice protocols were created to
guide patient care.
72 R.M. Palmer and D.M. Kresevic

Clinical Nurse

Geriatrics Social
Medical Worker





Physical and/or
Dietitian Occupational

Fig. 5.2 The ACE Team. From reference [5], with permission

The ACE Intervention: University Hospitals of Cleveland

A conceptual framework for the prevention of the dysfunctional syndrome inspired

the ACE program’s focus to help patients maintain or achieve independence in basic
ADL through the combined effects of four key elements: especially designed physi-
cal environment, patient-centered care, planning for discharge (to home), and review
of medical care (Table 5.2) [2, 6].

Prepared Environment

The physical environment of the ACE unit was designed to prevent functional dis-
ability and to maximize patient independence. The specific modifications built on
the experience of environmental experts in the design of long-term care facilities
and acute care and subacute care units. The design of the unit served to allay the
disorienting and depersonalizing effects of an unfamiliar (hostile) environment of
the hospital. The hallway corridor and patient rooms had waxed floors that were
replaced with geometric carpeting to decrease noise, enhance distance perception,
and encourage ambulation. Clocks and calendars were prominently placed in each
5 The Acute Care for Elders Unit 73

Table 5.2 Key elements and illustrative features of the ACE intervention program [6]
Prepared Carpeting, handrails, uncluttered hallways
environment Large clocks and calendars
Elevated toilet seats and door levers
Patient-centered Daily assessment by nurses of physical, cognitive, and psychosocial
care function
Protocols to improve self-care, continence, nutrition, mobility, sleep, skin
care, mood, cognition (implemented by the primary nurse and based on
the daily assessment)
Daily rounds by the multidisciplinary team, led by the medical and nursing
directors with the primary nurse, social worker, nutritionist, physical
therapist, and visiting-nurse liaison.
Planning for Early, ongoing emphasis on the goal of returning home
discharge Assessment of plans and needs for discharge by a nurse at the time of
Early involvement of a social worker and home healthcare nurse, if
Medical care Daily review by the medical director of medicines and planned procedures
review Protocols to minimize the adverse effects of selected procedures (e.g.,
urinary catheterization) and medications (e.g., sedative–hypnotic
From reference [6], with permission

room. Carpeting patterns and wall coverings with visual contrasts were chosen to
aid patient orientation and way-finding. Space for personal items from home was
created, special beds with floor lighting were added, additional lighting behind each
patient’s bed was installed, cubical curtains were added, and visually appealing
paint and wallpapered colors were selected. Grab bars were installed in bathrooms,
levered door handles replaced doorknobs, toilet seats were elevated, and handrails
were installed along walls in the hallway corridors. A large common space (activity
room) was created to encourage patient dining outside of rooms, socializing with
family and other patients, and light exercise [2]. Furniture on the ACE unit included
low height beds with automatic night lights, bed alarm exits, and low pressure mat-
tresses. Chairs of various heights and recliners and rocking chairs met the unique
needs of the patients.

Patient-Centered Care

Patient-centered care requires every health professional to place priority on meeting

the needs of the individual patient. On the ACE unit transforming multidisciplinary
to interdisciplinary team-based care requires acknowledgment of the expertise and
credibility of each health professional and a commitment of individual team mem-
bers to each team member’s recommendations. On the ACE unit this was achieved
through small work groups in which the medical director and CNS met with
74 R.M. Palmer and D.M. Kresevic

members of the team and validated their recommendations for optimal and
cost-efficient patient care.
The initial comprehensive assessment is performed by the bedside nurse in col-
laboration with the attending physician. Participation of family members and
patients is valued in the process of interdisciplinary patient-centered care.
Information from the initial assessment is reviewed by the interdisciplinary team at
team meetings following the patient’s admission and is reviewed by the team daily.
The CNS reviews each patient in the morning and provides bedside consultation and
role-modeling for the staff nurses. The daily team rounds assure communication
and coordination of care (“therapeutic consistency”) among all teams and serve to
efficiently assure optimal use of team members’ time. For example, if a patient was
thought to be unlikely to benefit from physical therapy, the team can recommend to
the physician that the order for “PT consult” could be discontinued; or the team
could recommend a PT consult early in hospitalization if it might enable a patient to
recover more quickly and return home.

The Functional Assessment

Dependence in one or more ADL is likely to be present at admission or to develop

during an older patient’s hospitalization for a medical illness. The nurses and inter-
disciplinary team perform daily multidimensional assessment of the patient’s physi-
cal, cognitive, and psychosocial functioning. The multidimensional assessment is
the basis for individualized “prescriptions” designed to maintain or restore the
patient’s independent physical functioning. Protocols are implemented by the nurses
to improve patient self-care, continence, nutrition, mobility, sleep, skin care, mood,
and cognition (Table 5.3). A comprehensive functional assessment identifies physi-
cal and cognitive impairments could lead to improved clinical and health outcomes
of hospitalization: prolonged patient survival, reduced medical care costs, reduced
use of acute hospitals and nursing homes, and improved mood and cognition.
Comprehensive functional assessment is performed by an interdisciplinary team,
usually beginning with the patient’s relationship-based nurse. The use of standard-
ized screening instruments for ADL and Instrumental Activities of Daily Living
(IADL) may simplify the process of assessment and allow for detection of mild
degrees of functional impairment. Most importantly, repeated reassessment of the
patient by nurses throughout the day improves detection of functional impairments
at a time when an intervention might be most effective. For example, nurses have an
excellent opportunity to observe the fluctuation in level of attention that is charac-
teristic of patients with delirium. Likewise, they are likely to first observe changes
in the patient’s level of independence in performing basic ADL. Physical therapy
and bedside exercises to maintain joint flexibility and muscle strength and to pre-
vent pressure sores is ideally started on the first hospital day to prevent the hazards
of bed rest. Physical activity is not limited unless there are explicit contraindica-
tions. The patient can be taught by nurses or therapists to perform bedside
5 The Acute Care for Elders Unit 75

Table 5.3 Acute Care of the Elderly (ACE) protocols

Start Stop
Mobility Preventive
Purpose is to return patient’s • Out of bed for meals unless
mobility or prevent functional contraindicated
decline during hospitalization.
Mobility goals: • Avoid bedrest
– Maintain safety • Ambulate TID in hallway unless
– Pt/family aware of safety needs • Shoes to be worn or activities
(transfer, ambulation, etc.)
– Maintain/restore independent • Assess falls risk-see falls plan of care
– Skin integrity maintained • Teach patient/family: active ROM
– No signs of postural hypotension • Teach Patient: safe ambulation
– No signs of infection • Check postural blood pressure,
HOB up every shift
– All the above individualize • Teach patient/family: antipostural
hypotensive exercises
Preventive criteria: Restorative
Pt ambulatory
Restorative criteria: • Range of Motion, Passive, TID
Pt nonambulatory • Shoes to be worn for activities
(transfer, ambulation, etc.)
• Assess falls risk-see falls plan of care
• Assess for adaptive equipment
• Discharge Planning consult home
care/SW, Discharge anticipated:
___/__ __/ __ __
• RN to recommend PT consult
ADL Preventive
Purpose is to maintain and • Provide ADL supplies as needed
encourage patients to be (grooming, toothbrush, dentures, sensory
independent in ADL. aids, shoes)
ADL goals: • Encourage family to bring in ADL
– Maintain safety • Teach patient: Rationale for self-care
– Self-care maintained/restored Restorative
– No signs of infection • Assist with set up for meals
and/or feeding
– Adequate nutrition • Encourage self AM care
and provide assistance as needed
– Continence maintained/restored • Mouth care, assist TID
– All the above individualized • Assist with individualized toileting
Preventive criteria: Pt independent • Assess need for home ADL assist
in bathing, dressing, toileting,
76 R.M. Palmer and D.M. Kresevic

Table 5.3 (continued)

Start Stop
Restorative criteria: Pt needs • Review recommendations of PT and OT
Nutrition Preventive
Purpose is to maintain adequate • Identify patient’s food preferences
caloric and fluid intake and to
prevent dehydration and weight
loss during stay.
• Maintain ideal weight and electrolyte
Nutrition goals: • Maintain adequate nutritional and fluid
– Maintain weight Restorative
– Maintain fluid/electrolyte • Monitor weight
– Provide 1,000 cal/day • I&O
– Provide 1,000 cc of fluid/day • Oral assessment (dentures, pain, dry
mouth, lesions, infection/plaque)
including swallow assessment
– Maintain skin integrity • Assess for constipation
– Pt/Family knowledgeable about • Consider interdisciplinary meeting to
caloric needs, dietary restrictions discuss alternative nutrition (tube feeding,
– All the above individualized • Validate NPO status with MD if >24 h
Preventive criteria: Patient is • Assess for IVF if NPO >8 h
consuming >50 % of ordered
diet (>1,000 cc, >1,000 cal)
Restorative criteria: Pt is • Consider liberalizing diet if appropriate
consuming <50 % of ordered • Snacks: dietary and family to supply
diet (<1,000 cc, <1,000 cal) • Dietary consult and calorie counts
Continence Preventative
Purpose is to maintain continence, • Encourage patient to maintain normal
independent toileting, and voiding schedule (Q 2–4 h)
prevent UTI.
ADL goals: • Teach Patient: Risk factors for
incontinence during hospitalization (IV
fluids, diuretics, narcotics, Foley catheter)
– Maintain/restore continence • Teach patient: Kegel exercises
– Pt/Family knowledgeable about Restorative
risk factors for UTI
– Pt/Family knowledgeable about • Order adaptive equipment as needed
all the above prevention for UTI (urinal, bedpan, BS commode w/out
(toileting schedules, Kegel wheels, elevated toilet seat)
– All the above individualize • Bladder, Encourage: assist with
individualized toileting schedule and
provide assistance as needed; record
results even if no void
5 The Acute Care for Elders Unit 77

Table 5.3 (continued)

Start Stop
Preventive and restorative criteria: • Use UTI bundle (stat lock, discuss
Voiding appropriately, able to removal of Foley catheter daily)
remain dry • Assess for UTI
• Ensure adequate hydration of >1,000 cc
• Encourage non-caffeinated beverages
• Teach patient: Kegel exercises
• Assess for urinary retention (bladder
Cognitive Preventative
Purpose is to promptly identify • Review meds to validate appropriate med
those patients at risk for acute and dose (narcotics, antianxiety,
confusion or those presently antipsychotic; avoid med with
confused. anticholinergic side effects)
Cognitive goals: • Assess cognitive function using
Confusion Assessment Method (able to
take info in, process it and act
accordingly, no symptoms of inability to
concentrate, fluctuating alertness,
disorganized thinking, perceptual
disturbances or hypo/hyperkinetic
– Maintain safety • Assure availability of sensory devices
(glasses, hearing aids) and validate
working order
– Decrease anxiety Restorative
– Maintain/restore independent • Review meds to validate appropriate med
ADL and dose—narcotics, antianxiety,
antipsychotic, sleeping medication; avoid
med with anticholinergic side effects
– Maintain/restore normal wake • Assess for causes confusion (infection,
and sleep cycles dehydration, electrolyte imbalance,
hypoxia, pain) and consult with
healthcare team to treat underlying
– All the above individualize • Avoid restraints
Preventive criteria: No confusion • Foster orientation-frequently reassure and
reorient patient, calendar/clocks,
caregiver identification, communicate
clearly, explain all activities, consistent
Restorative criteria: baseline mental • Noise reduction
status cognition improving • Provide meaningful daytime activities
• Facilitate sleep schedule
• Complete family teaching re:
etiology, management and discharge
78 R.M. Palmer and D.M. Kresevic

range-of-motion exercises and low intensity resistive exercises. As patients

convalesce from acute illnesses, they spend increasing lengths of time in the activity
room where they may exercise, or socialize with other patients and their family
members. The patient’s medical history, physical examination, laboratory evalua-
tion, and goals of care are all critical components of the assessment of malnutrition.
A history of weight loss is an important and sensitive antecedent of malnutrition and
is predictive of post-hospitalization mortality. Prevalent malnutrition at admission is
suspected in patients with recent unintentional weight loss, generalized weakness,
muscle atrophy, a low serum albumin, a low serum cholesterol, or unexplained nor-
mocytic anemia. Diagnostic evaluation of these patients may reveal evidence of
underlying chronic diseases (e.g., COPD, CHF, cancer), dysphagia, dementia, or
depression. Therapeutic interventions often include high calorie and high protein
diets, including nutritional supplements or snacks and less commonly enteral or
parenteral alimentation. Social visits and meals with family members can be helpful
in restoring the patient’s appetite. Individualized fluid and caloric requirements are
prescribed and monitored daily to prevent under nutrition during hospitalization.

Psychosocial Assessments

Anxiety, fear, and distress are common symptoms during hospitalization and may
be exacerbated by negative expectations of hospital outcomes harbored by the
patients or their family members. Symptoms of depression may interfere with
recovery of physical functioning. Thus, the psychosocial needs of patients and their
families are addressed by physicians and the bedside nurses. Family and patient
conferences may serve to allay fear and clarify confusing aspects of the patient’s
personal needs during and after hospitalization. The patient’s physical pain can be
relieved with adequate doses of analgesics and other comfort measures such as posi-
tioning, relaxation, and music. Patient fear can be alleviated through continuity of
nursing care, correction of sensory deficits, and reality orientation; increasing social
visits from family members; and a quiet environment that promotes periods of
relaxation and sleep at night. The patient’s perceptions of the hospital experience
and their personal values should be explored. Advance directives and the patient’s
wishes for treatment should be discussed early in the hospitalization with the patient
and when appropriate with family members, the durable attorney for health care, or
guardian, and updated as needed throughout the hospital stay.

Interdisciplinary Team Rounds

In designing the ACE Unit rounds special effort was taken to spend most of the team
meeting time discussing more challenging patients who were thought to most ben-
efit from multidisciplinary input (Table 5.4) [4]. Typically, an experienced
5 The Acute Care for Elders Unit 79

Table 5.4 Interdisciplinary team rounds: process and roles-new patient presentation
Physician or bedside nurse • Admitting diagnosis or problem: key findings
introduction of patient • Relevant past medical history
• Treatment plans
• Anticipated length-of-stay and postacute site of care
Bedside nurse report • Baseline and current functional status: ADL, mobility,
mood/affect, cognition, living situation, social support,
nutritional status
• Assessment and Nursing Care plans: preventative/restorative
Care coordinator/social • Resources (caregiving, finances, options)
worker • Disposition (transitions) options
Clinical pharmacist • Medication appropriateness
• Plans for monitoring of high-risk medications
Physical therapist • Mobility assessment
• Transfer and gait assessment and recommendations
Occupational therapist • ADL devices/aids
• Physical functioning
Dietitian • Baseline nutritional status
• Dietary recommendations
Summary: interdisciplinary • Estimated functional trajectory
team • Estimated LOS
• Quality of care and safety review
• Plans for care transitions
Daily meetings: 30 min: goal is review of up to ten patients including all new admissions: 5 min
for new and 1–2 min for follow-up patients. Team Participants: Core team: Bedside Nurse,
Geriatric Resource Nurse/Clinical Nurse Specialist, Care manager (RN/Social Worker), consultant
geriatrician, attending physician, clinical pharmacist; Extended team: physical therapist, occupa-
tion therapist, dietitian, speech therapist, as available

interdisciplinary team can review ten patients in 30–40 min. Family/patient meetings
(conferences) are held as required to review challenging issues such as a review of
the patient’s goals of care. Patient-centered care and the review of patient function-
ing complement the process of planning for care transitions.
The role of the CNS is critical to the daily operation of the ACE intervention. The
CNS assumes responsibility for developing and improving the quality of geriatric
nursing practice, provision of direct patient care, consultation, education, and
research. The CNS works collaboratively with the geriatrician medical director in the
facilitation of interdisciplinary team development and in the daily functioning of the
team. The CNS secures space, invites team members to participate, coordinates doc-
umentation and communication of the teams’ assessment, and serves as the overall
“quarterback” of the interdisciplinary team [5]. Follow-up presentations last 1–2 min.
Medical discussion focuses on any changes in diagnoses, treatment, prognosis or
disposition, and length of stay that have occurred. Nurses review any changes in the
patient’s nurse-initiated guidelines (ADL status, skin care, nutrition, mood, and cog-
nition). Nurses also report any adverse events such as falls, pressure sores, or use of
physical restraints, or psychotropic drug administration. The nurse and care coordi-
nator or social worker update the team on the patient’s social support, plans for a
80 R.M. Palmer and D.M. Kresevic

family conference, and discharge plans and plans for home care. The physical and
occupational therapists review the indications for changes in mobility and transfer
protocols. Patients are expected to ambulate and/or stand at least three times daily
and to participate in group exercises or individual exercises at the bedside. Patients
are taught to perform active or passive range-of-motion exercises, weight bearing
exercises, and low intensity resistive and aerobic exercises as tolerated. Independent
patient mobility is promoted by avoiding physical and chemical restraints, dispens-
ing assistive devices and encouraging coughing and deep breathing exercises to
maintain airway patency. Patients who are dependent in mobility and transferring are
seen by a physical or occupational therapist (or discussed at team rounds) in consul-
tation. Assistive aids and bedside appliances, such as lifts, are employed as needed.
Graded exercises, ranging from passive to active range-of-motion exercises are
offered on the ACE Unit or patients are sent to the OT or PT departments.


Indwelling urinary catheters are avoided whenever possible and adequate hydration
is maintained to provide a normal stimulus to voiding; patients receive verbal prompt-
ing or initial assistance in tilting when necessary; and a pre-planned toileting sched-
ule is decided for each patient. For example, patients who are independent in their
ambulation are encouraged to drink adequate fluids and to stay out of bed. For patients
who need assistance with toileting or are incontinent, episodes of incontinence are
assessed and documented and discussed with the team. Interventions that can be con-
ducted by the team or the nurse include maintenance of adequate non-caffeine hydra-
tion, a prompting and toileting schedule; and an assessment of factors contributing to
incontinence: for example, impaired mobility, frequent urination, diuretic administra-
tion, retention/overflow, incontinence, and urinary urgency. Other available options
are the dispensing of assistive devices and commodes, or urinals as needed, use of
short-term physical therapy, and a revised toileting schedule based on toileting pat-
terns. For example, patients with urinary urgency and frequency are offered a toilet-
ing schedule every 2 h, with habit training to extend that interval to every 4 h as
feasible. Intermittent catheterization is preferred over the placement of an indwelling
catheter except in cases of bladder outlet obstruction, patient comfort, or need for a
24 h urine collection. Bladder scanners are used to assess post-void residual volumes
in an attempt to decrease use of urinary catheters. Women with stress incontinence or
urinary dribbling are instructed in Kegel exercises. Patients with urinary tract infec-
tions are instructed in perineal care, adequate hydration, and routine voiding.


The patients are requested to perform oral care before meals, to use a soft tooth-
brush and mouthwash, and to cleanse dentures before meals. They are also encour-
aged to get out of bed and sit up for meals and to socialize at mealtimes with their
5 The Acute Care for Elders Unit 81

families. Nutritious snacks are made available to patients 24 h a day. The nutritional
goals are reassessed daily and are discussed with the dietitian technician and dieti-
tian. Patients who are dependent in feeding or nutrition are reviewed at team rounds.
Explicit guidelines are established for the following situations: when patients are
nothing by mouth (NPO) for less than 24 h, when patients are NPO for greater than
24 h, and when patients require enteral alimentation. For example, patients who are
NPO for less than 24 h are given intravenous hydration with a peripheral intrave-
nous line. If they remain NPO for more than 48 h, however, temporary peripheral
hyperalimentation (e.g., intralipids) or nasogastric tube feeding will be considered
and nutritional support consulted. Placement of feeding tubes, including nasoen-
teric tubes, are carefully evaluated as consistent with the patient’s short- and long-
term goals.

Skin Care/Wound

Upon admission patients are assessed for skin integrity and the risk of skin break-
down using standardized scales. Interventions for high-risk patients include recom-
mending a high fluid intake (to prevent dehydration), utilizing a pressure release
mattress, applying moisture barrier lotion, providing passive range-of-motion exer-
cises, changing patient position every 2 h, applying heel and elbow pads, and keep-
ing the perineum dry. If patients have pressure ulcers (sores) the stage of the wound
(I–IV) is determined, and graded levels of treatment are initiated per protocol.
Identified wounds are photographed. The enterstomal skin care nurse is consulted
for complex wounds.


Every patient is assessed for symptoms of depression within 24 h of admission. For

example, they or their families are asked if there is a history of depression or treat-
ment of depression and patients are asked about their general mood (with a single
question such as, “Are you sad, depressed, or blue?”). Patients with depressive
symptoms receive further evaluation by the interdisciplinary team at team rounds.
Patients may also be asked to select questions derived from standardized depression
scales. Patients with depressive symptoms, or a history of depression, are reviewed
by the team for remediable causes (e.g., medication side effects). Patients are
encouraged to participate in social activities on the ACE Unit and to participate in
exercises or physical therapy as medically indicated. Where depressive symptoms
are precluding patient improvement, psychiatric nurse consultation or a psychiatry
consult is recommended by the team.
82 R.M. Palmer and D.M. Kresevic

Delirium/Acute Confusion

To detect delirium, each patient is assessed daily for acute change in mental status,
including inattention and fluctuating mental status. Changes in mental status are
explained to the family and reported to other nurses and team members. All patients
are checked for orientation and recall of recent events in the hospital. For example,
patients are asked at admission when they came in to the hospital, and who brought
them here. Each day, they are asked about events that occurred the day before. For
example, the patients are asked about how things went yesterday, and the nurse
determines whether they have good recall of those events. A communication board
is posted in each room that displays pain ratings and goals of care. Patients are also
observed for level of attention, i.e., their ability to attend to a task or maintain con-
centration. Any abnormalities in attention, speech, or language are noted and dis-
cussed with other nurses and team members. Sensory impairments are screened for
and addressed. For example, if patients have hearing impairments, they may benefit
from the use of a headphone and amplifier, or placement of their hearing aids. Visual
impairment is corrected with magnifying glasses and page covers or with corrective
lenses and perhaps additional light in the room or reduction of glare. Delirious
patients will be assessed for possible reversible factors. In particular, nurses are
attentive to the use of psychotropic agents by patients and the presence or absence
of fever or changes in vital signs. Reality orientation techniques are augmented
when patients are delirious. Communications with the delirious patients are simpli-
fied: simple repetitive words are used in conversation, gestures are used, and daily
care and routines are made consistent. Family members are asked to spend more
time with the patient. A delirium tool kit is used to provide meaningful items for
distraction including books and puzzles.

Planning for Discharge (Home Planning)

Planning for the patient’s discharge to home begins on the day of admission. The
process of planning for home is integrated into the daily care of the patient. The
interdisciplinary team focuses on the patient’s plans to go home. A functional tra-
jectory (care path) is used by the interdisciplinary team to identify the patient’s
current functional status, baseline functional status, and social supports prior to the
acute illness that required hospitalization, and the projected functional status the
patient would need to achieve before going home by the time of expected discharge
(Fig. 5.3). Clinical guidelines and other patient-centered interventions are imple-
mented as required to achieve the anticipated outcomes of the hospitalization. For
example, physical and occupational therapy, dietitian consultation, and medication
review are undertaken for patients with complex medical problems (Table 5.5).
Barriers to achieving the trajectory are reviewed daily and addressed by the interdis-
ciplinary team. The team also addresses the home care requirements for the
5 The Acute Care for Elders Unit 83

Baseline function sets

goals for discharge

Baseline Function Admission Functional

• ADL Assessment
• IADL (Nurse/Physician)
Patient-Centric Care • ADL
• Mobility • ADL Home
• Mobility
• Cognition • Cognition
• Clinical stability
• Affect • Mobility Physical therapy
• Supports
• Living situation • Affect Occupational therapy
• Supports • Nutrition Medication review
Nutritional support
Care coordination

Alternate site

Fig. 5.3 The functional trajectory. From reference [7], with permission

individual patient beginning well before discharge from hospital. The team depends
on patient self-reports of baseline and current physical functioning The validity of
patient self-reports of independence at baseline ADL was later validated, and the
functional trajectory was found to predict nursing home placement [8–10].
Limitations in funding and resources prohibited the ACE team from continuing the
transition of care component of the intervention once the patient was discharged
from the unit.

Medical Care Review

The geriatrician–medical director provides medical leadership and guidance to the

team in geriatric care. The geriatrician educates and mentors interdisciplinary team
members, as well as the bedside nurses and support staff and assures high quality
geriatric care. The medical director serves as a liaison with attending physicians and
as role model for nurse–physician collaboration. The geriatrician reviews ACE unit
patients, for changes in functional status, and contributes to the plan of care. The
medical director served as a consultant to the interdisciplinary team when advice
was needed about appropriate medical care of the patient, including issues related to
patient values and goals of care. Once the ACE Unit was fully developed the medi-
cal director committed 15–20 % of his/her time to the ACE Unit while the CNS was
full time.
Medical care review includes guidelines for the prescribing of oral doses of psy-
choactive medications, grounded in evidence-based literature reviews. They are
shared with the medical attending physicians and learners. Diagnostic and thera-
peutic procedures are reviewed in respect to patient safety, consistency with goals
of patient care, and established clinical practice. Other guidelines were developed
in concert with medical and other health professionals for the use of physical
restraints and alternatives, and the prevention of malnutrition and dehydration.
84 R.M. Palmer and D.M. Kresevic

Table 5.5 The functional trajectory: operational process

Determine patient’s baseline • Able to perform basic ADL without assistance: bathe,
functional status prior to acute dress, transfer from bed to chair, toilet?
illness, using as reference point • Able to perform IADL without assistance: pay bills,
two weeks prior to admission handle medications?
function • Mobility: able to walk without assistance? Use of cane,
walker or wheelchair?
• Identify living situation: at home, alone or with other,
assisted living, board and care, skilled nursing facility,
long-term care nursing home?
• Identify social supports: primary caregiver, spouse,
children, other relatives, friends or associates,
Compare baseline to current • Complete functional assessment by nurse/physician
functional status • Current performance (capacity) of basic ADL
• Cognitive function: dementia, delirium?
• Assess nutritional status: malnourished, dehydrated?
• Assess affect: anxious, depressed?
• Assess mobility: observe gait, upper and lower
extremity range of motion and strength
• Estimate hospital length of stay using (DRG diagnosis
can be a guide)
• Meet with interdisciplinary team to review functional
assessment, diagnoses, anticipated length of stay,
advanced care plans, goals of care, and anticipated
discharge site
Daily rounds
Patient-centered interventions: • Identify the individual patient-centered approaches and
health professional services needed for the patient in
order to achieve the anticipated length of stay and
discharge site: includes team members
• Review trajectory daily by updating the functional
status: identify any barriers to achieving anticipated
length of stay and the anticipated date of discharge of
the patient, and modify therapies in order to achieve
length of stay and discharge goals
The patient's baseline level of • Reassess performance of basic ADL: this patient able
physical functioning predicts the to bathe, dress, and transfer independently?
discharge level of functioning • Check mobility: is patient able to walk independently?
Are assistive devices needed?
• Assess clinical stability: does the patient have new
symptoms of delirium, fever, hypotension, or
hypertension? Is it safe to discharge patient to home?
• Discharge to home or alternate site based on the
patient's functional status, available home supports,
need for rehabilitation, or placement in long-term or
acute care setting
5 The Acute Care for Elders Unit 85

Specific protocols were implemented for pressure ulcer treatment, nutritional support,
and medication guidelines. A manual of the medical care guidelines is maintained
on the ACE unit in a readily accessible area. Protocols to minimize the adverse
effects of selective procedures such as urinary catheterization were developed in
collaboration with other health professionals. Patients are assessed at the time of
admission for potential risk of falling using standard guidelines for falls/risk assess-
ment. Patients at risk for falls are assigned to a room near the nurse’s station when-
ever possible, and their ambulation, toileting schedule, and need for assistive
devices are reviewed.
Patients with a high risk of falling, including a history of recent falls, are assessed
for increased safety needs such as bed exit alarms and are referred for physical
therapy and range-of-motion exercises. Ambulation is supervised, and patients are
instructed in falls prevention (e.g., using hand rails in the hallway corridor, super-
vised toileting). Cognitively impaired patients are supervised directly for all ADLs.
Family participation is encouraged, such as asking them to sit with cognitively
impaired patients. Hypotension is treated with extra fluids, exercise for decondition-
ing, elastic stockings, and the use of rocking chairs. Fluid balance and sodium
intake are reviewed. Environmental interventions may include placing the patient’s
bed in the low position; keeping the call light, water, and accessories within patient
reach; using dim light at night; placing furniture in non-obtrusive positions; raising
bed rails at night; checking carpet, floors, and lights for repairs; raising height of
toilet seats; checking tips and heights of canes and walkers; and turning on intercom
from patient room to nursing station.

Lessons and Challenges

A randomized controlled trial of 651 acutely ill medical patients aged 70 years or
older was conducted to compare functional outcomes in patients admitted to the
ACE unit compared to patients admitted to usual care nursing units. The research
findings are described further later in this chapter. In brief, patients assigned to the
intervention group had significantly better physical functioning and fewer patients
were discharged to long-term care institutions. A nonsignificant reduction in length
of stay was seen in the intervention group but no differences in mortality or read-
mission rates were found. The initial study showed that the principles of compre-
hensive geriatric assessment and continuous quality improvement can be
incorporated into a system of care that improves aspects of hospital care of older
patients. However, the study showed that the short-term benefits of ACE may be
difficult to sustain following the patient’s discharge from hospital. The benefits of
ACE in the hospital may be lost unless similar quality improvement models of care
are transported to other clinical settings, notably outpatient, subacute, and long-
term care [4, 10]. We also learned that maintenance of the ACE model of care
requires an ongoing commitment from healthcare professionals and administrators.
New staff members require training in the principles of ACE and need to be incor-
porated into the team. The ACE principles are transformational. Success requires a
86 R.M. Palmer and D.M. Kresevic

change in the culture of patient care and the training of healthcare professionals. We
found that the first 6 months of the program were most challenging. It took substan-
tial effort on the part of the CNS to convince nursing staff that the ACE protocols
would make care of frail patients easier if they could prevent functional decline and
hospital complications such as pressure ulcers and delirium. Attending physicians
were initially skeptical about the role they would play on the ACE unit and the pos-
sible loss of autonomy for patient care to the medical director. Meetings with opin-
ion leaders and stakeholders were helpful initially in assuaging physicians concerns.
In time the attending physicians welcomed input from the nurses and team mem-
bers. Nurses on the ACE unit gradually acknowledged the improved care of patients
and several became champions of the “ACE approach” [11]. Nurses needed to learn
to be assertive and confident in making recommendations for bedside care of
patients. The interdisciplinary team was helpful in reinforcing their recommenda-
tions, thereby contributing to the continuous improvement of quality care. Overall,
many of the ACE protocols for care including falls prevention and skin care were
subsequently adopted within the institution as they demonstrated age-specific com-
petencies and met regulatory standards for such organizations as the Joint
Commission and Accreditation of Health Care Organizations (JCAHO). Some of
the components of the ACE program were controversial. Carpeted floors in patient
rooms and hallway corridors consisted of square pieces that could be replaced.
Although carpets dampened noise and probably contributed to a more homelike set-
ting of the ACE unit, and were considered easier to sanitize than highly waxed
linoleum floors, the carpets tended to absorb odors such as antibiotics that leaked
onto the floor and made transportation with gurneys more difficult. The activity
room was used less frequently than anticipated especially for patient exercise. On
the other hand, the environmental modifications and clinical protocols were subse-
quently disseminated to hospital units in a new bed tower. Although a goal of dis-
charge planning was improved efficiency and decreased length of patient stay,
financial incentives in those days to do this were not visible to the healthcare sys-
tem. In this study, the ACE intervention appeared to produce short-term benefits on
health outcomes. However, questions remained about the appropriate targeting of
patients for this intervention, the feasibility of implementing units in community
hospitals, the costs of starting an ACE Unit, and the long-term benefits with respect
to the independent functioning of these patients. Also, the first study had limitations
in its methodology such as follow-up of discharged patients being limited to 90
days, satisfaction of patient care on the unit not being evaluated, medication appro-
priateness not being measured, length of stay not being statistically decreased, indi-
vidual processes (protocols) not being quantified, and hospital readmissions and
healthcare costs not being reduced in the cohort receiving the ACE intervention. As
the ACE intervention requires modification of the nursing unit in older hospitals,
replication of the unit was hampered by perceived costs without clear financial ben-
efits to the hospital. Two more randomized clinical trials of the ACE unit, with
larger sample sizes and additional outcome measures, were conducted in order to
address these issues and to firmly establish the feasibility and effectiveness of the
ACE model of care.
5 The Acute Care for Elders Unit 87

Acute Care for Elders: Akron City Hospital

A second randomized clinical trial of the Prehab (ACE) intervention was conducted
in 1,531 community-dwelling patients, aged 70 years or older, admitted for an acute
medical illness at Akron City Hospital, in the Summa Health System [12]. The
intervention compared usual care on medical-surgical units with quality of care and
health outcomes on a 34-bed unit that was renovated to provide the prepared envi-
ronment of ACE, including a room for physical therapy and a parlor or activity
room for dining and visiting with family. The ACE intervention was closely aligned
with the program developed at the University Hospitals of Cleveland. The Akron
City Hospital ACE unit was designed to provide the same physical and caregiving
environment as seen in the original ACE unit. Once again, the nursing unit was
retro-fitted to provide a prepared environment designed to enhance patient indepen-
dent functioning and safety. Fidelity to the original ACE intervention was achieved
by having three of the Cleveland investigators serving as consultants to Akron City
Hospital. The “dose of ACE” was documented as activation of nursing protocols
related to the intervention, and measurement of appropriate drug prescribing in the
control and intervention groups. In addition, satisfaction with care was measured
among patients, caregivers, physicians, and nurses. In brief, the ACE program
improved the processes of care (nursing care plans, physical therapy consultations,
reduced use of physical restraints) and patient and provider satisfaction without
increasing hospital length of stay or costs. The composite outcome of ADL decline
from baseline or nursing home placement was less frequent in the intervention
group at discharge and during the year following hospitalization [12].

Acute Care for Elders: Second Clinical Trial

at University Hospitals of Cleveland

Another ACE Unit randomized controlled trial was conducted at University

Hospitals of Cleveland. A total of 1,632 patients were randomized to the usual-care
control group or to the ACE intervention group. As with the first two clinical trials,
the four key elements of the program were a specially designed hospital environ-
ment, patient-centered care designed to promote independent patient functioning,
early discharge planning with the goal of returning the patient home, and regular
review of medical care to optimize patient functioning and safety. The larger sample
size was chosen in order to better assess the effect of ACE on hospital length of stay
and costs of care. The earlier study had not shown statistically significant benefits
of ACE on either length of stay or costs related to environmental modifications and
additional staffing [6, 13]. By the time of the this clinical trial some “contamina-
tion” of the ACE intervention had occurred on usual care and other hospital units,
as they had adopted some of the protocols used on the ACE unit. About 1 year after
the clinical trial had begun, the usual-care units were relocated to a new bed tower
88 R.M. Palmer and D.M. Kresevic

that included several physical renovations similar to the ACE unit, such as private
spaces to support family and team meetings as well as carpeted hallways in some
rooms. Several of the ACE protocols, such as skin care assessment and alternatives
to physical restraint, were implemented throughout the hospital before the end of
the study. Consequently, the key differences between ACE and usual care groups in
this study were the separate inpatient unit for older patients and the team-based
approach to care [14]. In brief, the trial found no effect on patient functioning but
hospital length of stay and cost were significantly lower in the group receiving the
ACE intervention [14].

Results of the Acute Care for Elders Program

in Three Clinical Trials

The first randomized clinical trial at University hospitals of Cleveland resulted in

improved patient functioning and a greater likelihood of patients being discharged
to home, without increasing costs [6]. Patients enrolled in the trial were a mean age
of 80 years, 41 % black and 2/3rd female. The intervention group (n = 327) was
similar to the usual care group (n = 324) in their baseline performance of ADL,
IADL, chief reason for admission, coexisting conditions, Charlson comorbidity
score, mental status score, and depression score. As with the other clinical trials
clinical data were obtained through interviews with patients or caregivers, or
through chart review. Among 603 patients discharged alive from the hospital, basic
ADL function, measured as independence in bathing, dressing, toileting, transfer-
ring from bed to chair, and eating, was better at discharge than on admission in 34 %
of patients receiving ACE compared with 24 % of patients receiving usual care.
ADL function was unchanged in 50 % and 54 % of patients, respectively, and was
worse in 16 % of patients receiving ACE compared with 21 % of patients receiving
usual care (p < 0.01). Fewer patients receiving ACE were discharged for the first
time to institutional long-term care settings (p < 0.02). Mean measured hospital
costs and length of stay were 12 % and 17 % lower, respectively, for patients receiv-
ing ACE, although these differences were not statistically significant. Inhospital and
subsequent mortality rates, hospital readmission rates, and mean ADL scores at 90
days were no different between the patient groups receiving ACE or usual care.
Patients also reported somewhat better ability to walk by the time of hospital dis-
charge. Analysis of plausible subgroups of patients revealed clinically important
trends favoring ACE. The mean length of hospital stay was 1 day shorter for patients
assigned to the ACE unit but the median length of stay was similar.
Hospitalization cost on the ACE unit was not greater than usual care. Factored in
the analysis were the costs of the intervention, including renovation of the unit and
additional health professional staffing. Although doing so slightly increased the
daily cost of caring for patients on the ACE unit, the total cost to the hospital for
patients on the ACE unit was somewhat lower because the average length of stay
was shorter on the ACE unit [6, 10, 13]. A detailed cost analysis examined whether
5 The Acute Care for Elders Unit 89

the ACE unit increases hospital costs [13]. As the ACE unit needed renovation,
there was an initial cost associated with removal of a wall, creation of an activity
room, decoration of the unit, and modification of patient rooms and hallway corri-
dors as described earlier in the chapter. The cost analysis took into account salary
support provided by an extramural grant to the personnel responsible for developing
and implementing the ACE unit program. It also accounted for additional salary
support provided to personnel above and beyond usual staffing of an acute medical-
surgical unit. The per diem cost estimate for the intervention team was considered
an overestimate as all patients and not just the ACE patients could benefit from the
renovations and change in processes of patient care. In the analysis, mean and daily
hospital costs, taking into consideration the additional costs related to personnel and
unit renovation, were slightly higher for ACE compared to usual care patients.
However, the average cost per admission on the ACE unit was slightly lower, most
likely because of a shorter length of stay on the ACE unit. This data left unclear,
though, whether costs of care are lower for patients admitted to ACE compared to
usual care [13]. An additional clinical trial would resolve this issue.
The clinical trial at Akron City Hospital randomly assigned 767 patients to the
ACE intervention and 764 patients to usual care on other medical-surgical units.
The primary outcome measure included ADL function at hospital discharge com-
pared with baseline, and a performance-based measure of mobility. Patients in each
group of the study were similar in their baseline characteristics, baseline ADL and
instrumental ADL. At enrollment the patients had a mean age of 80 years, 60 %
were women, and 11 % were black. Compared with the first study sample, the
Akron sample had more white and fewer black patients and was healthier, reflected
by a lower APACHE II score and hospital mortality rate. Due to administrative
errors in patient assignment following randomization, 79 of the 1,531 study patients
were not admitted to the unit to which they were randomly assigned. Nonetheless,
these patients were included in the intention-to-treat analysis. The crossover of ran-
domized patients might have had a small effect on the study results as suggested by
slight differences in statistical significance when intention-to-treat analysis was
compared to per protocol analysis [12]. For two-thirds of all study patients, the
attending physician on the unit was the patient’s physician in the outpatient setting
as well and most patients in both groups did not receive care by residents. In con-
trast to the first study, mobility was assessed at patient discharge using a performance-
based measure. More process measures were quantified with use of nine nursing
care plans aimed at preventing disability, time from admission to initiation of dis-
charge planning, social work consultation, orders for bed rest, physical therapy con-
sult, use of urinary catheters, and application of physical restraints. Also, physician
orders and pharmacy records were reviewed for the prescription of 18 potentially
inappropriate medications in older patients. Physician recognition of depression
was identified in a subgroup of patients scoring positive on a depression screen.
Follow-up data on ADL function and mobility were gathered in interviews at
discharge and one, 3, 6, and 12 months after discharge. Patient satisfaction with
hospitalization was assessed 1 month after discharge and caregiver satisfaction
was assessed in patient surrogates at discharge. As in the first study, cost of the
90 R.M. Palmer and D.M. Kresevic

additional personnel and unit renovations were added to the costs of care for
intervention patients. Patients in the intervention group were slightly older but oth-
erwise similar to the usual care group in sociodemographic characteristics, func-
tional status, chief reasons for admission, and most coexisting conditions. This
study found a trend towards better functional status at hospital discharge compared
with baseline in patients receiving the ACE intervention. A composite outcome of
ADL decline from baseline or nursing home placement was less frequent in the
intervention group at discharge (p = 0.027) and during the year following hospital-
ization (p = 0.022). However, in the intention-to-treat analysis, change from baseline
to discharge in the number of independent ADL did not differ significantly between
the two study groups. No significant differences were observed, between the two
groups, in the change from admission to discharge in the mean number of
independent ADL at discharge. Among patients who underwent performance-based
mobility evaluation at discharge, scores were better in intervention than usual care
patients. In per protocol analysis, ADL decline from baseline to discharge was less
frequent for intervention patients compared to usual care (p = 0.05). Differences
between groups for ADL decline from baseline to discharge through 12 months
follow-up favored the intervention group. No differences were observed between
groups in hospital length of stay, hospital costs, proportion of patients receiving
home healthcare visits within 1 month of discharge, or proportion of patients read-
mitted within 1 month of discharge. Nursing home residence was similar between
groups during the year following hospitalization. Process of care measures was bet-
ter for ACE unit patients. Nursing care plans to promote independent function were
more often implemented in the intervention group, discharge planning was docu-
mented earlier, and social work was consulted more frequently and earlier in the
hospital stay. Days at bed rest were lower and physical therapy consults more fre-
quent among the ACE patients. Fewer physical restraints were used and fewer inter-
vention patients were prescribed high-risk medications during the first 24 h
following admission. Satisfaction with care was higher for the intervention group
than the usual care group among the patients, caregivers, physicians, and nurses.
Physicians were more likely to recognize depression by the ACE intervention. As
with the first trial neither mortality nor readmission rates differed between interven-
tion and control groups [12].
The third clinical trial and second at University Hospitals of Cleveland extended
the findings of the first trial with a larger sample size in order to ascertain the effect
of the ACE intervention on hospital costs (left unclear after the first study) and
length of hospital stay (not statistically lower in the first trial). Publication of the
results of the trial was delayed and the data was used primarily for observational
analyses. The research grant included a pilot study of a care transition intervention
conducted by a home care nurse (unpublished). A total of 1,632 patients were
enrolled, 858 randomized to the ACE unit, and 774 to the usual-care control. The
patients had a mean age of 80.6 years, 67 % were female, and 40 % were black. No
significant differences were observed between ACE intervention and usual care
groups in their baseline clinical and demographic characteristics. The intervention
was similar to the first study. There were small differences in the selection of
5 The Acute Care for Elders Unit 91

cognitive and depression measures. The study results showed no differences in

functional status measured by independent performance of basic ADL from hospital
admission to discharge between ACE intervention and usual-care groups. Likewise,
no differences were observed in mobility or performance of instrumental ADL
between the two groups. In-hospital mortality, discharge to home, and 3 months
hospital readmission rates were similar between the groups. As the analysis occurred
years after the clinical trial was completed, the online consumer price index and
inflation calculator was used to obtain conversion rates for each year of the study;
and these were used to convert actual costs from the year of discharge to equivalent
costs in 2011. Length of stay was significantly reduced in the ACE intervention
group (p = 0.004) compared to usual care group. Costs were significantly lower in
the ACE group compared to the usual care group (p < 0.001) for a cost savings of
nearly $1,000 per patient [14]. Length of stay and cost were highly correlated with
each other. The reason for the lack of benefit of ACE on ADL at discharge among
patients in the ACE group is unclear. One possibility is that the fidelity of the inter-
vention declined over time. During the time of this clinical trial, the ACE unit moved
to a new bed tower and there were changes in medical directorship of the ACE unit.
Overall, the study suggests that benefits of the ACE unit are related to greater
efficiency of inpatient care that reduces costs without adversely affecting other
important health outcomes. Combined with the earlier studies, the clinical trials
show a consistent pattern in which the ACE model is associated with shorter hospi-
tal length-of-stay and, consequently, lower costs [14].

Effectiveness of Acute Geriatric Units

The initial ACE unit model evolved from the work of other investigators with a
focused interest in environments of care, interdisciplinary teams, patient safety, and
comprehensive discharge planning [2]. The physical environment of the ACE Unit
was inspired by experiences of gerontologists in long-term care facilities, subacute
units, and inpatient geriatric assessment units. However, the randomized clinical
trials that demonstrate the effectiveness of the ACE unit are limited to the three
studies described in this chapter. There are, though, numerous publications of inter-
ventions or models of care that strive to improve acute geriatric care either on speci-
fied nursing units or through hospital consultation. Systematic reviews of acute
geriatric unit care have combined data from studies conducted with individuals in
the acute and subacute illness phases, with results that may have limited validity for
individuals who are only in the acute phase of an illness. By combining studies of
acute and subacute care, meta-analysis of acute geriatric care was made infeasible.
Recently, though, a systematic review and meta-analysis was performed that com-
pared acute geriatric unit care, in which all or part of the ACE model components
were introduced in the acute phase of illness or injury, with usual care [15]. This
review found that acute geriatric unit care was associated with less functional
decline at discharge from baseline (2-week prehospital admission) status, less delir-
ium, shorter hospital length of stay, fewer discharges to a nursing home, lower costs,
92 R.M. Palmer and D.M. Kresevic

and more discharges to home. The findings appear applicable to the care of acutely
ill and injured older adults on medical, surgical, and medical-surgical units. The
review did not find evidence that acute care units reduce patient mortality or 30-day
hospital readmissions. However, the ACE units were not originally designed to
reduce mortality or to make provisions for postacute care.
The first ACE program was implemented on a medical-surgical unit in order to
conduct the clinical trial. The investigators assumed that the most successful and
cost-effective interventions would be adopted by other nursing units in the hospital.
To some extent this occurred at the University Hospitals of Cleveland. The underly-
ing concept was that ACE principles—a safe environment, patient-centered care
provided by an interdisciplinary team with expertise in geriatric care principles,
early discharge planning, and medical care review—constitute optimal care for all
hospitalized adult patients, and are not limited to a single unit. In support of this
concept, ACE programs have been disseminated to other hospital units although not
evaluated in randomized controlled trials. The original ACE unit remains at
University Hospitals Case Medical Center to this day and a second surgical ACE
unit has been added. “ACE” education of nurses has been expanded to all units and
consultation by the geriatrician and geriatric CNS is hospital-wide. The potential
for dissemination of ACE programs is underscored by recent publications that sup-
port the effectiveness of ACE unit replications and mobile ACE consult teams in
other hospital settings [16, 17].

Who Benefits From Acute Care of Elders Model of Care?

The ACE model of care was originally designed to help prevent functional decline,
a loss of independence in the performance of ADL, or to restore independence in
patients who had declined prior to admission. Although the environmental modifi-
cations of the ACE unit would benefit all adult patients, the protocols and interdis-
ciplinary team rounds were targeted at patients who were likely to be responsive to
the intervention. As a practical matter, the investigators were not able to determine
the functional status of patients prior to their enrollment in the study. Information
about baseline functional status was not obtained until patients were randomly
assigned to study group. An a priori assumption was that long-term care nursing
home patients would be less responsive to the intervention as they most likely had
chronic disability that would not reverse during hospitalization. Another assump-
tion was that patients admitted from other hospital units and transferred from out-
side hospital would be less responsive to the intervention. Consequently, patients
residing in long-term care facilities, intra-hospital and inter-hospital transfers were
considered ineligible for enrollment in the clinical trial although they were often
admitted to the ACE unit. Accurate identification of nursing home status was not
easily achieved in the emergency department and 8 % of the randomized patients
came from long-term care facilities. We were not able to identify a subgroup of
patients who were most likely to benefit from admission to the ACE Unit. When
different subgroups of patients were analyzed, trends towards benefits were seen in
5 The Acute Care for Elders Unit 93

patients younger or older than 80 years, dependent or not dependent in baseline

ADL function, and with high or low disease severity. In short, all patients seemed to
benefit from ACE care [6]. Long-term care residents were too few in number for
subgroup analysis. A hallmark of the ACE intervention is its efficiency in identify-
ing and meeting the needs of hospitalized patients. Resources can be targeted to
patients as prioritized by the team. The intervention on the unit is inexpensive once
established, as demonstrated in the third clinical trial where an established interdis-
ciplinary team under the leadership of the CNS and medical director provided unit-
based care at a lower cost per patient to the hospital [14]. Over the past two decades,
rates of hospitalization have declined for all age groups, but older patients still have
the highest rates and the longest lengths of hospital stay. In most urban community
and teaching hospitals patients admitted from the community remain at high risk for
functional decline and would be expected to benefit from ACE program irrespective
of their primary diagnosis or comorbidities. In summary, given the low cost of the
intervention, the ability to attain quality standards, and the realization that all acutely
ill patients admitted from home are at potential risk for functional decline, it is
likely that most elderly patients would benefit from admission to an ACE unit.

Lesson Learned: Function Does Matter

Three large cohorts from the randomized trials of ACE enabled secondary analyses
that demonstrate the value of measuring functional status of medically ill older
patients. The functional status measures used in the research [6] provided new
insights into the relationship between functional and demographic factors measures
and the vulnerabilities of older patients. Studies revealed the importance of depres-
sive symptoms as a predictor of incident ADL decline [18] and subsequent mortal-
ity [19]. Loss of independence was shown to be one of six independent predictors
of 1-year mortality among patients aged 70 years and older in a prognostic index
[20]. Cognitive screening predicted magnitude of functional recovery from admis-
sion to 3 months after discharge in hospitalized elders [21]. Self-reported unsteadi-
ness at the time of admission was predictive of ADL decline in the hospital [22].
A clinical index to stratify hospitalized older patients according to risk for new-
onset disability was created as an important tool to identify high-risk patients who
might benefit from early interventions during hospitalization [23]. Of relevance to
quality of care measures, a tool was created to enable prediction of recovery, depen-
dence, or death in elders who become disabled during hospitalization [24].

Special Considerations

The ACE unit targets patients at risk for functional decline during hospitalization.
However, the ACE program is adaptable to the needs of patients who require pro-
longed hospitalization, are approaching end-of-life, who are admitted from skilled
94 R.M. Palmer and D.M. Kresevic

nursing facilities, and who have complex biopsychosocial needs. The ACE
principles, including the physical environment of the ACE unit that promotes inde-
pendent functioning and personalizes patient care, patient-centered care conducted
by an interdisciplinary team, early discharge planning with intent to discharge
patient to lowest level of dependency, and medical care review with its focus on
appropriateness and safety of patient care, all have potential to improve quality and
health outcomes for patients with these special considerations. The case is made for
combining models of care (e.g., ACE with care transitions or palliative care consul-
tation) that strive to improve quality and financial metrics to meet the needs of
patients with special risks and vulnerabilities [25]. ACE is the most evidence-based
intervention for improving the care of hospitalized seniors. The next step in its pro-
gression is dissemination of ACE principles across all hospital units caring for older
patients and transitioning care plans to postacute sites.


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2. Palmer RM, Landefeld CS, Kresevic D, Kowal J. A medical unit for acute care of the elderly.
J Am Geriatr Soc. 1994;42:545–52.
3. Palmer RM, Counsell S, Landefeld CS. Clinical intervention trials: the ACE Unit. Clin Geriatr
Med. 1998;14:831–49.
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CS. Improving functional outcomes in hospitalized elders: lessons learned from an acute care
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a hospital medical unit especially designed to improve the functional outcomes of acutely ill
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Acute emergencies and critical care of the geriatric patient. New York: Marcel Dekker, Inc;
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8. Fortinsky RH, Covinsky KE, Palmer RM, Landefeld CS. Effects of functional status changes
before and during hospitalization on nursing home admission of older adults. J Gerontol A
Biol Sci Med Sci. 1999;54A:M521–6.
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for optimizing health outcomes. Dis Manage Health Outcomes. 2003;11:507–17.
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aspects of caring for the chronically ill. New York: Springer; 1993.
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LM, Allen KR, Covinsky KE, Landefeld CS. Effects of a multicomponent intervention on
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trolled trial of acute care for elders (ACE) in a community hospital. J Am Geriatr Soc.
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13. Covinsky KE, King JT, Quinn L, Siddique R, Palmer RM, Kresevic D, Fortinsky RH, Kowal
J, Landefeld CS. Do acute care for elders units increase costs? A cost analysis using the hos-
pital perspective. J Am Geriatr Soc. 1997;45:729–34.
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CS. Acute care for elders units produced shorter hospital lengths of stays at lower costs while
maintaining patients’ functional status. Health Aff. 2012;31:1227–36.
15. Fox MT, Persaud M, Maimets I, O’Brien K, Brooks D, Tregunno D. Effectiveness of acute
geriatric unit care for elders components: a systematic review and meta-analysis. J Am Geriatr
Soc. 2012;60:2237–45.
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for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173:981–7.
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(MACE) service. JAMA Intern Med. 2013;173:990–6.
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depressive symptoms to health outcomes in acutely ill hospitalized elders. Ann Intern Med.
19. Covinsky KE, Kahana E, Chin MH, Palmer RM, RH F, Landefeld CS. Depressive symptoms
and three year mortality in older hospitalized medical patients. Ann Intern Med. 1999;130:
20. Walter LC, Brand RJ, Counsell SR, Palmer RM, Landefeld CS, Fortinsky RH, Covinsky
KE. Development and validation of a prognostic index for 1-year mortality in older adults after
hospitalization. JAMA. 2001;285:2987–94.
21. Sands LP, Yaffe K, Covinsky K, Chren MM, Counsell S, Palmer R, Fortinsky R, Landefeld
CS. Cognitive screening predicts magnitude of functional recovery from admission to three
months after discharge in hospitalized elders. J Gerontol A Biol Sci Med Sci. 2003;58:
22. Lindenberger EC, Landefeld CS, Sands LP, Counsell SR, Fortinsky RH, Palmer RM, Kresevic
DM, Covinsky KE. Unsteadiness reported by older hospitalized patients predicts functional
decline. J Am Geriatr Soc. 2003;51:621–6.
23. Mehta KM, Pierluissi E, Boscardin J, Kirby KA, Walter LC, Chren MM, Palmer RM, Counsell
SR, Landefeld CS. A clinical index to stratify hospitalized older patients according to risk for
new-onset disability. J Am Geriatr Soc. 2011;59:1206–16.
24. Barnes DE, Mehta KM, Boscardin WJ, Fortinsky RH, Palmer RM, Kirby KA, Landefeld
CS. Prediction of recovery, dependence or death in elders who become disabled during hospi-
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care in the acute care setting. Health Aff. 2009;28:113–25.
Chapter 6
How to Develop, Start, and Sustain
an Acute Care for Elders Unit

Ellen S. Danto-Nocton, Carolyn Holder, Rebecca Ramsden,

Jonny Macias Tejada, Anita Steliga, and Karen Padua

Abstract The Acute Care for Elders, or ACE, unit is an evidence-based model of care
focused on improving the management of acutely ill hospitalized older adults. The
process of establishing an ACE unit as a new hospital program begins with develop-
ment of a vision. Hospital administrators must understand and appreciate the demo-
graphics of the aging population as well as their unique needs and the potential
complications they may suffer as a result of a hospitalization. Next, leaders in geriatrics
must bring together an interdisciplinary team that should follow a systematic “ABC”
approach to ACE unit implementation. Data collection is another important step, both
in identifying and establishing the need for an ACE unit and following unit outcome
measures as a means of showcasing the value-added to patients, staff, and the broader
hospital system. Strong leadership to support ACE and potentially expand its reach

E.S. Danto-Nocton, M.D.(*)

Center for Senior Health and Longevity, ACE Unit and Senior Services, Aurora Sinai
Medical Center, 1020 North 12th Street, Suite 301, Milwaukee, WI 53233, USA
e-mail: ellen.danto-nocton@aurora.org
C. Holder, M.S.N., R.N., G.C.N.S.-B.C.
Department of Transitional Care and Utilization Management Administration, Summa Health
System, Akron City Hospital, 525 East Market Street, Akron, OH 44304-1619, USA
e-mail: holderc@summahealth.org
R. Ramsden, R.N., M.N., N.P., G.N.C.C.
Acute Care for Elders Unit, Mount Sinai Hospital, 600 University Avenue,
Toronto, ON, Canada M5g 1x5
e-mail: RRamsden@mtsinai.on.ca
J. Macias Tejada, M.D. • A. Steliga, G.N.P.
Aurora St. Luke’s Medical Center, H6367, 2900 West Oklahoma Avenue,
Milwaukee, WI 53213, USA
e-mail: jonny.maciastejada@aurora.org; anita.steliga@aurora.org
K. Padua, D.O.
Center for Senior Health and Longevity, Aurora Sinai Medical Center, 1020 North 12th
Street, Suite 301, Milwaukee, WI 53233, USA
e-mail: karen.padua@aurora.org

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 97
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_6,
© Springer Science+Business Media New York 2014
98 E.S. Danto-Nocton et al.

beyond a single unit is essential in sustaining and growing the ACE program. Finally,
education of patients, families, and the hospital staff, including nurses, physicians, and
other members of the interdisciplinary team, is also essential for continued success.

Keywords ACE unit • Outcomes • Implementation • Sustainability • Teaching

Developing the Vision for an ACE Unit

The US population is aging. By the year 2030, it is projected that just over 20 % of
the population will be aged 65 years and older [1]. Adults aged 65 and older cur-
rently account for about 43 % of inpatient hospital days [2]. Although older adults
constitute only about 15 % of the population in the United States, they are respon-
sible for more than 50 % of hospital expenditures [3]. Therefore, this particular pop-
ulation plays an important role in the business of hospitals and acute care settings.
On average, older adults have four chronic illnesses, which can lead to frequent hos-
pitalizations that may then initiate a sequence of events that leads to functional decline,
institutionalization, and death [4]. It is well known that current health care systems are
geared toward procedurally based acute care services, and there is a wealth of data
showing that this approach is inadequate to address the needs of hospitalized older
adults [5]. A multidisciplinary team approach using gerontologic expertise in specially
designed units has been shown to be an effective way to improve the care of older adults
in the hospital setting [5]. As the population continues to age, finding a more cost-
effective way to manage older adults who require hospitalization becomes more and
more important. Acute Care for Elders, or ACE, was specifically designed to address the
needs of acutely ill elders from the moment of admission to the hospital [6]. A review of
the literature reveals that ACE is a model of care that can help improve the processes and
quality of care delivered to these acutely ill hospitalized older adults.
Creating an ACE unit in a hospital can be seen as a first step toward improving the
method by which all disciplines “touch” the older adult. Care on an ACE unit is deliv-
ered by members of a carefully trained interdisciplinary team, all of whom have been
educated about the special needs of an older adult population. As staff members move
on and off the unit, caring for patients elsewhere in the hospital, their experience on ACE
will help to spread the ACE concepts regarding the importance of focusing on function
as well as the patients’ acute medical problems. Over time, the ACE unit can also
become the site in which new geriatric programs may be developed. In this manner, one
ACE unit can help to improve the care of older adults throughout a hospital system.

The ABCs of ACE Unit Implementation

Once the team has agreed upon a shared vision, then implementation of the ACE
unit can begin. The Continuous Quality Improvement (CQI) methodology used for
ACE unit implementation is captured in the conceptual model’s components: Agree,
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 99

Fig. 6.1 Stages for

implementing an ACE unit
(With permission from
Counsell SR, Holder CM,
Liebenauer LL, Allen KR,
Palmer RM, Kresevic DM,
Landefeld CS. The ACE
Acute Care for Elders
Manual Meeting the
Challenge of Providing
Quality and Cost-Effective
Hospital Care to Older
Adults. Akron (Ohio):
Summa Health System,

Build, Commence, Document, Evaluate, and Feedback. These are also referred to as
the ABCs of ACE [7] (Fig. 6.1).
A Agree—This step involves identifying key stakeholders and reaching agreement
that the ACE unit is necessary and committing to improve the care of elderly patients.
B Build—This step involves creation of the interdisciplinary team, development of
ACE protocols, and planning and development of the ACE unit itself.
C Commence—This step involves engaging the interdisciplinary team in daily team
rounds and implementing the ACE protocols.
D Document—This step involves documentation of the implementation process to
identify any inefficient or ineffective processes.
E Evaluate—This step involves analysis of administrative and/or Medicare data to
evaluate outcomes of the ACE unit.
F Feedback—This step involves providing evaluative information to health system
administration and medical staff leadership to gain ongoing support of the ACE unit.
G Grow—This step involves expansion of various aspects of the program to other
patient care areas.


The first step in implementing an ACE unit is to get everyone to AGREE that having
an ACE unit is a good idea. Although this is the most challenging step in the imple-
mentation process, it is also the most important because it has the potential to greatly
ease the successful completion of subsequent steps. The following are suggested
sequential steps to obtain the AGREE.
100 E.S. Danto-Nocton et al.

Fig. 6.2 Key stakeholders (With permission from Counsell SR, Holder CM, Liebenauer LL, Allen
KR, Palmer RM, Kresevic DM, Landefeld CS. The ACE Acute Care for Elders Manual Meeting
the Challenge of Providing Quality and Cost-Effective Hospital Care to Older Adults. Akron
(Ohio): Summa Health System, 1998.)

Identify Key Stakeholders

Key stakeholders include colleagues in geriatrics, chairs, and “opinion leaders” of

the Departments of Medicine and Family Practice, nursing administration, and
senior management (Fig. 6.2). Support of these “key stakeholders” is essential to
the implementation of an ACE unit in a community hospital. A “bottom-up”
approach starting with colleagues in geriatrics, including attending physicians,
nurses, social workers, and therapists, is likely to be the most effective. Other health
care professionals already interested in the care of older adults are likely to be the
easiest sell. It is critical that a shared vision be developed at this level before
approaching leaders of the medical staff, nursing administration, and senior
Chairpersons and “opinion leaders” of the Departments of Medicine and Family
Practice are the next group to rally to the cause, along with appropriate representa-
tives of nursing administration (e.g., medical unit manager and Director of Medical/
Surgical Nursing). Finally, upon having an improved understanding of the major
issues surrounding the implementation of an ACE unit by both the medical staff and
nursing administration through this “bottom up” strategy, one can approach with
confidence the hospital CEO and senior management. ACE is also congruent with
emerging managed care and accountable care organizations, providing another
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 101

driving force for ACE implementation. Gaining enthusiastic support of these “key
stakeholders” up front for the implementation of an ACE unit and the Prehab
Program is instrumental in getting over many subsequent hurdles during the BUILD
and COMMENCE phases.

Win Support of Key Stakeholders

Winning the support of key stakeholders will take time, but the investment is neces-
sary. Approach the key stakeholders formally and informally on a one-on-one or
small group basis to develop support. Items to convey include the ACE mission, the
need for ACE, the goals of ACE and the interventions by which these goals are met,
benefits to the patient, provider and health system, the need for commitment of
hospital resources, and costs. It is also important to demonstrate how the ACE
model is consistent with the health system’s mission.


The second step in implementing an ACE unit is BUILD. This part of the process
starts with planning the core components. This involves identifying a geriatrician
and geriatrics advanced practice nurse (APN). Both of these roles are essential.
When selecting the geriatrician medical director, it is best to choose someone who
has training as an internist or family physician who is fellowship trained and Board
Certified in Geriatric Medicine. This physician should have an established clinical
reputation and be trusted by the medical staff as someone who is a champion for the
older patient and interdisciplinary care and one who is skilled in program develop-
ment and education. Responsibilities of the geriatrician include reviewing new
admissions and follow-up of patients with changes in functional status, assisting the
Geriatrics APN in facilitating interdisciplinary team rounds, recording interdisci-
plinary team suggestions, acting as a liaison with attending physicians, educating
and mentoring interdisciplinary team members, nursing, and support staff in geriat-
ric care, advocating and providing a role model for increased nurse–physician
collaboration and representing the ACE unit to medical staff and administration.
The APN assumes responsibility for developing and advancing the quality of
geriatric nursing practice through specialized direct patient care, consultation, edu-
cation, and research. Ideally, the APN should be an APN with certification in geri-
atrics, who has an established clinical reputation and is trusted by nursing staff and
nursing administration. This person should be a champion for the older patient and
interdisciplinary care and have skills in program development and education. The
APN’s responsibilities include development and implementation of nurse-initiated
care plans/protocols, education of ACE unit nursing staff and organizing and direct-
ing daily interdisciplinary team rounds. Patient care responsibilities include review-
ing functional status and interventions prescribed, performing in-depth functional
102 E.S. Danto-Nocton et al.

assessments, screening for depression and cognitive problems, counseling and

teaching patients and their families, conducting patient/family conferences, and
coordinating transitional care. The APN also serves as a communicator and liaison
to the medical staff and administration as well as a case manager.
The next step is for the team to designate a general medical unit in which to build
the ACE unit. Convenience and ease of renovation are factors to consider. The unit
should be able to accommodate the projected number of patients, have a common
room for an activity/kitchen area, therapy room, and a conference room accessible
for interdisciplinary team rounds. The team should consider delirium and dementia
patients when reviewing potential units for safe monitoring of exits or ease of appli-
cation of a wandering alarm system. Issues to be addressed include moving/chang-
ing walls, appropriate carpeting, lighting, electrical costs, and adaptive equipment.
In order to develop the ACE unit processes, an ACE unit multidisciplinary self-
directed workgroup must be established. This workgroup will become the core ACE
interdisciplinary team. The workgroup/team is made up of actual caregivers from
the designated ACE unit. The Medical Director and Geriatrics APN will serve as
co-chairs and the rest of the group will be comprised of a social worker/discharge
planner, physical therapist, occupational therapist, pharmacist, dietitian, unit RN
and LPN representatives, assistive personnel representative, the Nursing Unit
Manager, 2–3 primary care physicians (Internal Medicine and Family Practice) and
other disciplines, such as a clinical psychologist or Geropsych APN. This work-
group should meet 1 h per week during the development phase to develop the team
(changing multidisciplinary to interdisciplinary), a mission statement and goals,
ACE unit renovation plans and a budget proposal, admission orders, team commu-
nication sheet, a standard nursing assessment, and care plans.
This workgroup must then develop standardized physician orders (a paper or
electronic guide to order-writing that supports patient function for physicians and
staff) and nursing assessment and care plans (nurse-initiated guidelines addressing
key areas of function/psychosocial well-being necessary for maintaining indepen-
dence). They will also need to determine how the ACE team suggestions are com-
municated to the primary care physician and nursing staff.
Next the team must train ACE unit clinical and support staff and determine the
educational content that all staff require to care for elders. All staff working on the
ACE unit, including all ACE interdisciplinary team members, nurses, and aides,
should participate in the education. The initial education can be completed in an
8-h educational day. Education should begin with an overview of care of the geriat-
ric patient, including a review of normal aging changes, basic geriatric assessment,
and a review of high risk medications and suggested alternatives. Then the focused
ACE education should include an overview of the ACE model, the goal of the ACE
unit to prevent the dysfunctional syndrome, ACE protocols addressing geriatric
syndromes, and a case study demonstrating ACE patient presentation and the team
rounds process.
Ongoing education should be provided to maintain staff knowledge and skill.
Some of this can be done informally at daily interdisciplinary rounds as members of
the team teach each other about their challenging patients. In addition, more formal
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 103

Table 6.1 New ACE model education

• Introduction to the ACE • Geriatric syndromes/protocols (mobility, self-care deficit,
model of care and nutrition, cognitive impairment (i.e., delirium/dementia),
dysfunctional syndrome depression, constipation, incontinence)
• ACE unit philosophy • High risk medications
and goals • Case study
• Normal aging changes
• ACE process
• Discharge planning

Table 6.2 High risk patients

• Age 70 or greater • Use of high risk medications
• Impairments of two or more ADLs/IADLs • Lives alone/limited social support
• Presence of geriatric syndromes • Frequent readmissions
(delirium, dementia, depression, falls, • Suspected abuse or neglect
incontinence, poor nutrition, polypharmacy)

education is accomplished through brief education sessions on the unit, through

lectures and Nursing Grand Rounds on complex patient issues, such as managing
delirium. Web-based offerings such as through the Hartford Institute for Geriatric
Nursing provide easy access to education on an individual basis (http://hartfordign.
For education of staff who are new to the ACE team, at Summa Health System,
a curriculum was created based on the content identified in the original ACE educa-
tion table (see Table 6.1). The curriculum is offered monthly to all new staff hired,
with an additional clinical competency component. The ACE competencies include
demonstrations of assessment skills, development of the plan of care, and presenta-
tion to the ACE team.


Now is the time to COMMENCE with the implementation of the ACE unit’s Prehab
Program. This should start with the establishment of admission criteria. The Summa
ACE unit targeted patients aged 70 or greater coming from home or the community.
It is also important to select those who will be presented at daily team rounds. These
include patients aged 85 or older, and those who have baseline ADL/IADL impair-
ment, a geriatric syndrome (especially delirium, mild/moderate neurocognitive
impairment, depression, incontinence, falls, or polypharmacy) or poor social sup-
ports, as well as those who live alone. Patients identified by staff or family as high
risk should also be included (see Table 6.2).
Rounds should occur the same time each day. During rounds, patients are pre-
sented by the primary nurse. New patient presentations should be comprehensive
104 E.S. Danto-Nocton et al.

yet succinct, covering the reason for admission, the attending physician (and pri-
mary care physician if different), baseline and current medical and functional status,
the presence of any common geriatric problems (e.g., depressive symptoms, hearing
impairment), and the social situation. Follow-up patient presentations focus on
goals for the stay, new problems, functional status, psychosocial issues, implemen-
tation of team suggestions, and any barriers to the discharge plan. Barriers may
include, but are not limited to, internal acute care processes such as delays in test-
ing, therapy evaluations, payor-related delays with pre-certifications, conflict over
the goals of care, patient/family decision-making, lack of social supports or finan-
cial support for optimal post-hospital level of care, or more complex issues related
to cognitive issues (e.g., delirium or dementia with question of competency).
Responsibility for implementation of suggestions and plans to address barriers is
divided among team members. The nurse assigned to a particular patient is respon-
sible for communicating suggestions to the attending physician. The Geriatrics
APN will also frequently personally assist in making the connection with the attend-
ing physician. In addition, the Geriatrics APN is available to help implement more
work-intensive or complex suggestions, as well as to assist with physicians less
attentive to team suggestions.
It is important throughout the implementation process to maintain the support of
the medical staff. Gain their input and feedback continually. Be sure to emphasize
that the team is here to complement and support the physician in caring for his/her
complex elderly patients. The team suggestions are aimed at functional and psycho-
social issues to help bring the functional care up to speed with the medical care. It
is essential to remember that the primary physician remains the attending. There is
no required geriatrician consultation, no orders are written without attending
approval, team suggestions are not a part of the medical record, and ACE interven-
tions add no additional charge to the patients. The patients need to know what is
different about the unit and its philosophy ON ADMISSION. One of the ways to
accomplish this is through development of a patient/family brochure. A video
explaining the goals of the unit as well as the concept of “use it or lose it” may also
be helpful.
In summary, each of the disciplines brings its expertise to the ACE Interdisciplinary
Team Rounds and participates by contributing suggestions and feedback from its
own specialty. BUT as the team grows and develops—all disciplines learn from
each other. The ACE Interdisciplinary Team members work together, sharing the
goal of providing comprehensive care for the elderly while preventing loss of


From the beginning, it is a good idea to set in place a few methods to DOCUMENT
implementation of the Prehab Program, ensuring that the pieces set up during
COMMENCE are actually taking place. Documentation provides assurance of
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 105

Table 6.3 Benefits of the ACE unit model

Benefits for patients Benefits for the health system
• Improved functional status • Improved quality and coordination of care
• Decreased iatrogenic illness • Decreased nursing staff turnover
• Decreased restraint use • Decreased length of stay
Benefits for providers • Patient and family satisfaction
• Knowledge and skills • Geriatric education and research
in geriatric care opportunities
• Satisfaction with interdisciplinary
collaboration and geriatric care

implementation, identification of strengths and weaknesses, and a mechanism of

accountability for tasks of interdisciplinary team members. Using simple docu-
mentation of the various pieces of the Prehab Program should allow both daily
tracking and more formal quarterly or yearly evaluation. Since the APN works with
all of the ACE patients, he/she serves as the ideal point person for most documenta-
tion and tracking. The following items should be used to track Implementation of
the Prehab Program: the use of admission orders, completion of the nursing assess-
ment, use of the ACE nursing care plans, and participation in ACE interdisciplinary
team rounds.


In order to demonstrate the benefits of the ACE unit, the team must EVALUATE the
benefits to the patients, providers, and health care system. Sources of evaluative
information include hospital administrative databases, process of care documenta-
tion, anecdotal reports, and a diary of health system changes. Tracking of benefits
to patients and providers should begin immediately upon ACE unit implementation,
although the full evaluation should not be conducted until after year one.


FEEDBACK to key stakeholders, through utilization of DOCUMENT and

EVALUATE data, will help ensure long-term support. As with any new program,
hospital administrators and clinicians are likely to demand a comprehensive evalu-
ation of the effectiveness of the program in accomplishing its goals. Remember that
the ACE unit is initially presented (see AGREE) as a win/win/win situation. When
evaluating and providing feedback, focus on the benefits experienced by patients,
providers, and the health system (Table 6.3).
106 E.S. Danto-Nocton et al.


Once the value of ACE has been demonstrated the team may be asked to expand the
program to other areas of the hospital. ACE has broad applicability to patients of all
ages admitted to various acute nursing units. This broad applicability derives from
the fact that ACE provides an efficient means by which an interdisciplinary team can
deliver more comprehensive care not only to older adults, but to patients of all ages.

Getting Baseline and Follow-Up Outcomes to Show

the Quality Improvement With an ACE Unit

When establishing an ACE unit, as with any new program, it is important to first
demonstrate that there is a need for a new model of care. Therefore, it would be
important to first gather demographic data for the population the hospital serves.
Given the aging baby boomer generation, it should be fairly easy for most hospitals
to demonstrate that there is a need to emphasize care of the older patient. Other use-
ful baseline data would include the current average length of stay and average cost
of care.
Once the ACE unit is implemented, it is then essential to track the positive out-
comes previously demonstrated by others who have studied the ACE model of care.
Data and outcomes for ACE patients should be compared either to patients previ-
ously admitted to the same unit prior to the initiation of the ACE model of care or
to patients admitted to other units receiving usual care. Once again, it would be
important to collect demographic data to track the age of the patients. It might also
be useful to track diagnoses and the attending physicians who are admitting to the
unit (to be aware of the physicians/medical staff the unit is serving).
The literature has demonstrated that the ACE model of care is associated with
many positive outcomes and improvements in processes of care. For example, most
studies of the ACE unit have demonstrated a decrease in length of stay [6, 8–14] and
cost of care [9, 12–15]. In order to demonstrate the value of the ACE unit to the
hospital administration, it would be essential to track length of stay and cost of care
for patients on a new ACE unit. This should be data that the hospital is already col-
lecting and should be fairly easy to obtain. In addition, previous ACE studies have
often shown a decrease in readmission rates [11, 12, 15]. This would be another
important indicator to follow for patients served by a new ACE unit. Collection of
these economic and quality indicators should help to demonstrate the potential cost
savings to the health care system created by the implementation of the ACE unit.
Saving health care dollars is clearly important to the future viability of the health
care system and potentially to accountable care organizations as US health care
continues to evolve over time.
One of the original goals of the ACE unit was to improve the functional status of
older adults admitted to the hospital with an acute medical problem. This was
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 107

demonstrated in the original randomized controlled trial in a university hospital

setting [6]. The second randomized controlled trial showed less of an impact on
functioning [16] and the third randomized controlled trial found no effect on the
patients’ function [13]. While this data is a little harder to collect, it would still be
important to track the functional status of patients upon admission and upon dis-
charge. Some studies also have looked at functional status 2 weeks before the index
hospitalization for comparison. Functional status can be tracked using the Katz
Index of Independence in Activities of Daily Living [17]. Malone, et al., have cre-
ated a tool called the Acute Care for Elders (ACE) Tracker that can help to track
such data if it is entered into an electronic health record (see Table 6.4) [18]. This
tool can also be used to help track other important indicators of quality of care, such
as incidence of delirium and use of Beers’ List [19–22], potentially inappropriate,
medications. The ACE Tracker can also help follow use of physical therapy and occu-
pational therapy consultations, which may help to preserve or improve the patients’
functional status. Finally, the use of restraints can also be incorporated in the ACE
Tracker to follow on a real-time basis. In addition to its utility in following changes in
processes of care over time, the ACE Tracker can also be used on a daily basis during
interdisciplinary rounds to get a quick snapshot of each patient’s current status.
Another recent study has demonstrated the effectiveness of the ACE unit model
in maintaining hospital quality indicators [23]. This study tracked the ACE unit’s
incidence of falls, unit-acquired pressure ulcers, and restraint use, and the ACE unit
met the hospital’s goals for all of these. In addition, rates of Foley catheter use and
catheter-associated urinary tract infections (CAUTIs) should also be tracked.
Once the patient is ready to leave the ACE unit, it is important to be able to cap-
ture his/her discharge destination. The original ACE study and the Akron replica-
tion study were both able to demonstrate a decrease in new discharges to nursing
homes [6, 16]. A recent meta-analysis also found that care on an ACE unit led to
fewer discharges to nursing homes and more discharges to home [24]. Again, this
would be important data to track and follow over time. If possible, determining if
the nursing home placement is used for long-term care versus short-term subacute
rehabilitation might also be helpful.
One of the key components of the ACE model is patient-centered care. Along
with all the other data that is tracked, it is also critical to assess patient satisfaction.
This can be done with brief surveys developed by the hospital itself or tracked
through the Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey, Press Ganey, or other patient satisfaction survey. It is also
important to assess the satisfaction of the medical staff since they are also the ACE
unit’s customers. Several studies have shown that care on the ACE unit is associated
with improved patient, nursing, and physician satisfaction [11, 12, 16, 25].
Following the data is a rigorous way of looking at outcomes for a new ACE unit.
However, there are also some less regimented ways to look at and demonstrate the
success of an ACE unit for a hospital system. Often case studies can be used to
demonstrate improved processes of care [26]. It is helpful to demonstrate that the
expertise of professionals on the ACE unit is sought after by others in different parts
of the hospital to expand their knowledge and the ability to care for older adults.
Table 6.4 Example of printout from ACE tracker summarizing risk factors for patients aged of 65 or older on a hospital unit
Patient Length History of Number HX of Bed Press Wound Braden Social Advanced
room/bed Age of stay dementia CAM of meds Beers Morse falls rest P/T O/T RES ADL Cath ulcer care scale Albumin services directives
Patient A 76 2 N N 13 N 60 Y N Y Y N 8 Y Y Y 17 ND Y N
Patient B 74 1 Y N 7 N 50 Y Y N N N 6 Y Y Y 9 2.9 N Y
Patient C 78 12 Y Y 10 Y 50 Y N Y Y N 7 N N Y 14 3.9 Y Y
Patient D 72 1 N N 5 N 50 N N N N N 12 N N N 15 ND N N
Patient E 91 6 Y N 8 N 60a N N Y Y N 6a N N N 14 ND Y N
Patient F 78 1 N N 7 N 70 Y Y N N N 6 Y N N 16 ND N N
Patient G 75 1 N N 0 N 45 N N Y Y N 12 N N N 14 4.3 N N
Patient H 93 1 Y N 12 N 65 Y N Y Y N 6 N N N 15 ND Y Y
Patient I 91 1 Y N 1 N 95 Y N Y Y N 7 N N N 12 3.5 N Y
Patient J 74 5 N N 20 N 45 Y N Y Y N 7 Y Y Y 12a ND Y Y
Patient K 72 6 N Y 14 N 20 N N Y Y N 8 N N N 17 3.2 Y Y
Patient L 83 3 N Y 12 N 80a Y Y Y Y N 8 Y N N 12 2.3 N Y
Patient 5 3 11 1 8 3 9 9 0 5 3 4 6 7
With permission from Malone ML, Vollbrecht M, Stephenson J, Burke L, Pagel P, Goodwin JS. Acute Care for Elders (ACE) tracker and e-geriatrician: methods to dis-
seminate ACE concepts to hospitals with no geriatricians on staff. J Am Geriatr Soc. 2010; 58(1): 161–7, John Wiley & Sons
Report date: 02/27/08
Report time: 17:17
History of dementia = Cognition as defined by nursing admission assessment of history of dementia or Alzheimer’s disease
CAM = Confusion assessment method [10] as performed by nursing staff on admission and repeated daily on high risk patients
Meds = Number of total prescribed medications given to the patient on a scheduled basis
Beers = Administration of potentially inappropriate medications for use in older adults within the prior 48 h [9]
Morse = Morse falls risk from calculated on admission and daily by nursing staff. A score >45 indicates an increased risk of in hospital falls [11]
Hx of Falls = Any history of falls prior to hospitalization as recorded on nursing admission assessment
Bed Rest = Bed rest as determined by daily nursing database describing the patients activity level
PT = Physical therapy consultation ordered
OT = Occupational therapy consult ordered
RES = Current use of a physical restraint device as recorded on nursing daily assessment
ADL = activity of daily living score for bathing, dressing, transferring, walking, using the toilet and eating. 0 score for requiring total assistance; 1 score for requiring some
assistance; 2 score for independent. These data from nursing admission assessment are repeated every other day
Cath = Urinary catheter in place as noted on nursing daily assessment
Press Ulcer = Pressure ulcer as noted on nursing daily assessment
Wound Care = Wound care consultation ordered
Braden Scale = Calculated Braden Scale: 15–18 at risk, 13–14 at moderate risk, 10–12 at high risk, and 9 or below at very high risk [12]. These data are from nursing daily
Albumin = The most recent serum albumin value with an asterisk noting a value of 3.5 mg/dL or lower
Social Services = Any documentation of a social services assessment
Advanced Directive = Any documentation of the presence of the patient’s advanced directives
Y = Yes
N = No
ND = Not drawn
This score is less favorable than the admission score
110 E.S. Danto-Nocton et al.

The second ACE study in Akron, Ohio demonstrated decreased nursing staff turnover
with implementation of the ACE model of care [16]. This can be a source of cost
savings to the hospital and can be tracked over time. Finally, since the ACE unit can
be a way of improving a hospital’s public image, keeping track of media events
covering the ACE unit might also prove helpful.

How to Sustain the ACE Unit Model in a Time of Economic

Challenges and Professional Turnover

As is true for other hospital programs, ACE units can be threatened during difficult
economic times. It is, therefore, important to have an enthusiastic advocate or
“champion” in senior leadership who can help keep the successes of the ACE team
visible. Keeping “key stakeholders” abreast of demonstrated outcomes of the ACE
unit on an ongoing basis is essential. Having the support of the Quality Management
department is also essential as they can assist with tracking important quality mea-
sures that will help demonstrate the importance of the ACE unit in improving the
care of the growing older adult population. The immediate ACE unit leadership
must continually publicize and “beat the drum,” re-enforcing the benefits of ACE to
all levels of hospital staff, including physicians, nurses, administration, and support
services. It is important to know upon what current issues the hospital is concentrat-
ing, such as length of stay versus readmissions versus patient satisfaction, and focus
most on those issues.
Health care organizations change; thus, it is important for ACE units to be able
to adapt during difficult times. Having a vision going forward is also essential. The
immediate ACE unit leadership needs to be enthusiastic and be ready to state where
they are headed in the future. Once the initial ACE unit demonstrates its successes,
the ACE model of care can be promoted and expanded to other units of a hospital.
Both Summa Health System in Akron, Ohio, and Aurora Healthcare in Southeastern
Wisconsin have demonstrated this. In Summa Health System, after they published a
study demonstrating the success of their original ACE unit [16], they successfully
expanded the ACE model to a stroke unit [11], improving the care of a specialized
population of older adults, and then built a second ACE unit at Summa Barberton
Citizens Hospital. At Aurora Healthcare, one hospital in the system started an ACE
unit in 2000. After several years, the model was moved from a general medical unit
to a cardiac step down unit in the same hospital, creating the ACE of Hearts unit.
The ACE model over the years has grown so that now there are multiple ACE units
in multiple different hospitals within the Aurora Healthcare system. In one of these
hospitals, a tertiary care hospital, a roving ACE consult team was developed, creat-
ing an ACE without walls model.
In addition to the promotion of the ACE unit itself, the ACE team can also
become instrumental in building additional geriatric programs to further improve
the care of hospitalized older adults. For example, in one Aurora Healthcare hospi-
tal, because of their success in managing older adults with challenging medical
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 111

problems, the ACE team was enlisted to help the hospital create a sitter reduction
program in an effort to decrease the cost of managing confused and agitated inpa-
tients. Likewise, this same team is now starting a Hospital Elder Life Program
(HELP), which utilizes specially trained volunteers to work with senior patients in
the hospital to prevent delirium and functional decline [27, 28].
The ACE unit may also become the site within the hospital where new geriatric
initiatives can be trialed. At Summa Health System, for example, a delirium initia-
tive was implemented first on the ACE unit and then spread throughout the hospital
[29]. This initiative included a delirium screen and assessment, a care plan for pre-
vention and a physician order set. The pilot for this initiative showed positive out-
comes, including reduction in average length of stay for patients with delirium, as
well as a decrease in ICU transfers and 30-day readmissions. As the ACE team
continues to demonstrate its successes such as this, its leadership must be sure to
keep the ACE program active and visible. This strategy will build support among
peers and managers that will help to create opportunities to further disseminate the
ACE principles via new quality improvement projects.

Describe the Role of Medical and Nursing Education

in Starting and Sustaining an ACE Unit

In an effort to minimize staff turnover, promote staff satisfaction and minimize

costs, it is essential to develop a comprehensive and sustainable education plan that
meets the needs of medical, nursing, and allied health staff. The principles that
guide geriatric models of care, such as the ACE unit, have been shown to improve
patient safety, influence cost-effectiveness, improve transitions of care and chronic
disease management, positively influence inter-professional collaboration, maintain
a focus on patient preferences, goals, and wishes [30] as well as maintain or improve
patient functioning [13]. In order to acquire such outcomes, hospitals implementing
this model of care need their health care practitioners to be educated in the unique
and complex needs of the older patient population.
The ACE unit model of care addresses the aforementioned principles through the
integration of a physical environment that fosters functional independence, employs
dedicated unit-based staff with expertise in aging, an inter-professional team-based
approach, a focus on patient- and family-centered care, and early, comprehensive
discharge planning [31]. Although the design and delivery of ACE units may vary
across organizations, the underlying concepts and principles remain the same—hos-
pitalized older adults have a unique set of needs that can be anticipated and met to
prevent functional decline [26]. To achieve such outcomes, geriatric knowledge,
and skill of unit clinicians is instrumental. The concept seems simple—provide staff
that work on the unit with basic knowledge and skill training to care for older
patients in a way that aligns with best practice standards. The complexity, however,
arises in how to implement such an objective in a dynamic, financially constrained,
and ever-changing health care environment.
112 E.S. Danto-Nocton et al.

Although health care organizations are becoming aware of the aging demographic
and the impact this will have on their health care system, there continues to be a
void in the amount of geriatric knowledge that exists among hospital clinicians. As
a result, leaders of the ACE unit must “sell” the importance of geriatric-specific
education to organizational leaders to ensure the financial support necessary to
implement a comprehensive and sustainable curriculum for staff. Without doubt,
the assessment and management of this patient population requires an informed
gerontological approach by all members of the health care team in order to mini-
mize adverse events and hospital-associated decompensation and to maximize posi-
tive outcomes. Specifically, patients on an ACE unit require clinicians to have a
sound understanding of the complex functional, physiological, cognitive, psychoso-
cial, behavioral, and financial factors that are often unique to older adults [26].
Health care systems putting the financial and human resource support up front to
ensure sufficient education of staff will have a positive long-term impact and return
on investment. Without education, the positive, cost-effective outcomes of ACE
units would be difficult to attain.
Despite the commonality of geriatric education necessary for physicians and
nurses working on ACE units, leaders looking to develop a unit need to engage in
an analysis of the staff culture and make-up, organizational leadership and financial
support, and existing geriatric resources to determine the most appropriate means of
developing and delivering geriatric education. Such an evaluation will aim to sup-
port the buy-in of staff, determine the format of the educational program, and the
ability to support staff in an ongoing fashion [27]. Separate analyses of the nursing
and physician groups must occur, given their unique roles within the organization
and the unit.
For physicians, the American Geriatrics Society Education Committee has iden-
tified three core components of geriatric education for medical internists [32]. These
include attitude (i.e., appreciation of the importance of maintaining and promoting
function and quality of life, valuing the social and psychosocial influences on health
and well-being, respect, and autonomy), knowledge (i.e., normal age-related
changes, atypical presentations, iatrogenic complications, understanding of the
need for a multifaceted approach given multiple causes often exist for a single issue,
and awareness of community resources), and skill (i.e., comprehensive history and
examination in the areas of gait/balance, cognition and sensory assessment, and the
ability to safely and appropriately prescribe medications). These components should
be incorporated into the education plan of physicians who work on or rotate through
the ACE unit. How this education and its content are delivered should be the respon-
sibility of the Geriatric Medicine experts aligned with the unit and/or participating
in the development of the unit. For many, the Medical Director of the ACE unit is a
key member of this plan.
As is true for medical professionals, the care provided by nurses plays a signifi-
cant role in the outcomes of hospitalized patients. Nurses who work on ACE units
have demonstrated the highest level of competency in geriatric nursing, resulting in
patient comfort and dignity, prevention of hospital-acquired functional decline,
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 113

and a successful return of the patient back to his/her community dwelling [33].
To promote such positive outcomes, nurses need to acquire knowledge, skill, and
competence in gerontological nursing. Similar to medical staff, nurses need to have
a general understanding of the unique physical, cognitive, psychosocial, and behav-
ioral factors of older adults. The focus of the nursing educational curriculum should
be on the various geriatric-specific issues common to older hospitalized patients
[23, 27]. NICHE (Nurses Improving Care of Healthsystem Elders) [34] is a compre-
hensive resource available to hospitals on a membership basis. At a reasonable
annual fee, hospitals acquire access to a comprehensive repertoire of resources,
including 14 core educational modules that are an excellent basis for educating
ACE unit nursing staff. These modules include:
• Why geriatric nursing?
• Age-related changes in health
• Depression, delirium, and dementia
• Falls
• Family caregiving
• Function
• Health care decision-making
• Medications
• Nutrition, hydration, and oral health
• Pain
• Pressure ulcers and skin tears
• Restraints
• Sleep
• Urinary incontinence
These online modules should be used in conjunction with face-to-face education
that utilizes various learning modalities. Providing staff with a predetermined time-
line for completion of online modules and attendance at a mandatory education day
promotes a comprehensive learning and skill development experience.
In putting together a multifaceted plan for education, various factors must be
taken into consideration. These include but are not limited to:
• Who will be responsible for the development of the educational plan?
• Have you received financial support to pay for staff time?
• What will be the duration of the educational sessions?
• Will staff be backfilled to attend formal education sessions?
• Will staff be compensated for long education sessions, if they are planned?
• Are interdisciplinary sessions possible?
• How many iterations of the educational sessions are needed to capture the major-
ity of staff?
• What teaching modalities will be used (i.e., role play, case studies, didactic,
online modules, standardized patients, bedside teaching and mentoring)?
114 E.S. Danto-Nocton et al.

• Are there geriatric experts within the organization (or externally) that can con-
tribute to the presentation of content?
• Have staff worked together or is this a newly forming team?
• How can team building and inter-professional collaboration be integrated into
the educational content?
• What geriatric-related issues and practice standards are highest priority for early
• Is there an opportunity for staff to build the unit’s vision, mission, and values
statements to foster team collaboration?
• What opportunities exist for ongoing teaching and learning? Who will facilitate
• Can unit “champions” be developed to support integration and sustainability of
policies and practices?
• How will learning needs of staff be determined on an ongoing basis for knowl-
edge and skill sustainability?
Furthermore, to promote ongoing education and self-learning, staff and educa-
tors should be aware and access some of the various online geriatric resources avail-
able free of cost. Some of these include the John A. Hartford Foundation, the Portal
of Geriatric Online Education (POGOe), American Association of Colleges of
Nursing (AACN), American Geriatrics Society, and ConsultGeriRN.
Education of staff, most notably of nursing and medical team members, is essen-
tial in the development and sustainability of an ACE unit and the promotion of posi-
tive outcomes. When developing an educational curriculum, it is important to
consider the culture of the unit and its learners, the baseline knowledge of the staff
and the means by which the initial education will occur and how it will be sustained.
Without clinical competence and a geriatric-lens for providing care, the positive
outcomes that ACE units provide will be limited.


The Acute Care for Elders (ACE) model was conceived as a way of improving hos-
pital care for acutely ill older adults. Although the original study was completed in
the mid-1990s, recent studies have shown its continued value, despite the fact that
health care has changed significantly over time. In order to start an ACE unit as a
new program in a hospital, it is essential to “sell” the vision to senior leadership and
hospital administration. They must see ACE as a method of addressing the needs of
an ever-aging population. Using the ABCs, an ACE unit can be built and sustained.
Once implemented, as the program grows, it is essential to follow important mea-
sures of care, such as length of stay, cost, readmission rates, and quality indicators,
6 How to Develop, Start, and Sustain an Acute Care for Elders Unit 115

such as catheter-associated urinary tract infections (CAUTI), pressure ulcers, and

falls, to demonstrate the improvement in care and the value of ACE to the hospital.
Sustaining the unit will take time and effort and the work of leaders who will help
to expand the program beyond the walls of the original ACE unit to the rest of the
hospital. Ongoing teaching of all staff, including all members of the interdisciplin-
ary team, will also help to maintain and grow the ACE program.


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Chapter 7
How to Disseminate the ACE Model
of Care Beyond One Unit

Roger Y. Wong, Marsha Vollbrecht, and Patti Pagel

Abstract Acute Care for Elders (ACE) programs can be effective in the
management of frail older adults during hospitalization, and there is great interest in
disseminating the ACE model of care beyond a single unit setting. This chapter
provides an overview of the processes and outcomes on disseminating the ACE
model beyond one unit. Specifically the chapter outlines the resources needed
(equipment and staffing) and the innovations that support the dissemination (ACE
Tracker tool; ACE cards; e-Geriatrician; ACE advisory teams; communication

Keywords Dissemination • Process • Outcome • Equipment • Staffing • ACE

tracker • ACE cards • e-Geriatrician • ACE advisory team • Communication

R.Y. Wong, M.D., F.R.C.P.C.

Postgraduate Medical Education, Faculty of Medicine, University of British Columbia,
7153-2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9
Division of Geriatric Medicine, Department of Medicine, University of British Columbia,
7153-2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9
e-mail: roger.wong@ubc.ca
M. Vollbrecht, M.S., C.S.W., N.H.A. (*)
Aurora Health Care, 1020 North 12th Street, Milwaukee, WI 53233, USA
e-mail: marsha.vollbrecht@aurora.org
P. Pagel, M.S.N., R.N., G.C.N.S.-B.C.
Department of Clinical Innovations, Wheaton Franciscan Healthcare,
19475 West North Avenue, Brookfield, WI 53045, USA
e-mail: patti.pagel@wfhc.org

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 117
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_7,
© Springer Science+Business Media New York 2014
118 R.Y. Wong et al.

Chapter Overview

Acute Care for Elders (ACE) units have existed for some time since the first report
in the literature [1]and the ACE principles of patient-centered care, frequent medi-
cal review, prepared elder-friendly environment, early rehabilitation, and enhanced
discharge planning have long been endorsed as important principles in many com-
prehensive geriatric programs. ACE units can be especially effective in the manage-
ment of vulnerable older adults, as evidenced in a recent systematic reviews and
meta-analyses [2, 3]. While ACE units have been implemented in many jurisdic-
tions across North America, there remains great interest in disseminating the ACE
model of care beyond a single unit setting. Widespread knowledge translation of
this proven effective model of care is necessary at a system and institutional level so
that ACE can become the preferred and sustainable way of delivering health care to
older adults in the acute care setting.

Relevance to Acute Hospital Care of Seniors

The population of Americans 65 years or older is expected to climb during the next
25 years to about 72 million. By 2030, older adults will account for approximately
20 % of the US population. Every day in America, an estimated 10,000 people are
turning 65 and will continue to do so for the next 20 years. In 2030, one of every five
Americans will be an older adult [4]
The average American 70-year-old has three chronic diseases and takes more
than five prescription medications. Hospital care for older adults in the United
States cost three to five times more than those persons under 65. Most of the US
healthcare costs are spent on older adults. Hospitalized older adults have longer
length of stays than their younger counterparts and are more likely to lose function,
suffer complications, and adverse events during a hospital stay. They are also more
likely to be readmitted within 30 days of discharge [5]. Thirty-five percent of older
hospitalized adults have some form of cognitive impairment which places them at
risk for longer length of stays and delirium. One third to one half of older hospital-
ized patients experience an iatrogenic event [5]. Thirty-five percent of hospitalized
older adults experience an adverse drug event (ADE). Nearly one half of these are
preventable [5].
Recognizing subtle changes in the hospital older adults requires an educated staff
to intervene in their care. Less than 1 % of the 2.2 million registered nurses in
America are certified in gerontological nursing. Only half of Bachelorette prepared
nurses programs require geriatric course content [5].
ACE programs provide a framework to train healthcare workers in the care of
older adults and can reduce length of stay, new delirium onset, functional decline,
and overall healthcare costs.
7 How to Disseminate the ACE Model of Care Beyond One Unit 119

Evidence Supporting the Need for Improving

Process and Outcomes of Hospital Care

As stated above, older adults at higher risk for functional decline, complications due
to iatrogenic events (hence with patient safety implications), and readmission.
According to the Center for Medicare and Medicaid Services (CMS), one in five
older adults is re-admitted to the hospital within 30 days. These adverse events have
also been associated with higher costs, mortality rates, and institutionalization.
Preventing these adverse events has become a priority for service providers, as well
as government payers. The ACE model of care is a pre-habilitation (interventions to
prevent functional decline, rather than rehabilitate after loss of function), function-
focused approach that is designed to address these concerns [6].

Assessing the Needs of Older Patients in a Hospital

and Health System

Older patients may receive care in a variety of nursing units at both large and small
hospitals. It is important to assess the needs of older patients in order to employ
proper interventions in a focused approach, as described in the ACE model of care.
One way to do this on large scale, for a hospital or health system, is to leverage the
electronic health record. Clinical staff and physicians enter data into the patient’s
electronic health record multiple times each day. One strategy to address the needs
of vulnerable elders is to harvest the medical record information and display it for
clinicians in a manner that helps them to address the patient’s needs. A tool called
ACE Tracker is a good example of this, and will be described in this chapter.
Many hospitals are part of larger, integrated health systems. It is a challenge to
make sure the environments are “senior friendly,” especially in older buildings that
were not designed for an aging population. This chapter describes some models of
care and electronic tools that can help. The environment of care is a key component
of the ACE model which can have implications beyond the ACE unit.
Table 7.1 shows a list of equipment/tools that would be standard for a unit with
an ACE model of care.
Another important consideration is the staffing composition in ACE programs.
There are many effective staffing models, and all of them involve some combina-
tions of inter-professional staff. For instance, at the Vancouver General Hospital, a
leading ACE program in Canada, the following staffing complement was deployed
to manage a 22-bed ACE program (Table 7.2).
Once the ACE staffing is identified, it is imperative to nurture the ACE team,
such as through continuous professional development. This will also help to deliver
best practices in ACE programs within the context of the hospital environment at
large. Many of the ACE program-specific care processes are developed based on the
needs of patients (for instance, delirium protocol, use of least physical restraint
policy, etc.).
120 R.Y. Wong et al.

Table 7.1 Standard Equipment

equipment, tools, and • Wall Clock and Calendar (large numbers and print)
supplies for a unit with an
• Wander Guard alarm
ACE model of care
• Handrails in hallways
• Gait belt
• Shower bench with handheld shower head
• Low beds
• Bed/chair alarm
• Wheel-lock recliner
• Chairs with arms and elevated seats
Strategic tools
• Geriatric Depression Scale
• Confusion Assessment Method (CAM) to assess for
• Education packet for staff, such as ACE Cards
(described in this chapter)
• Power pudding (prune recipe for constipation)
• Recreational supplies
• Voice amplifier
• Adaptive utensils and cups (for arthritic hands, etc.)
• Dry erase boards to post-staff names
• Goals and reminders for family to bring in adaptive
equipment (hearing aids, walkers, etc.)

Table 7.2 An example Medical Manager or Medical Director: 0.2 full-time-equivalent

of the staffing composition (FTE) Geriatrician.
of an acute care Patient Service Manager: 0.3 FTE.
for elders unit
Patient Care Coordinator: 1.0 FTE.
Clinical Nurse Specialist: 0.3 FTE.
Registered Nurses:
4.0 FTE days (1:5.5),
3.0 FTE nights (1:7.3).
Licensed Practical Nurses: 1.0 FTE.
Patient Care Aide: 2.0 FTE.
Physical Therapist: 1.0 FTE.
Occupational Therapist: 1.0 FTE.
Rehabilitation Assistant: 0.5 FTE.
Social Worker: 0.5 FTE.
Dietician: 0.7 FTE.
Pharmacist: rotational.
Spiritual Care Staff: rotational.
Care Management Leader: 1.0 FTE.
Transitional Service Officer: rotational.
7 How to Disseminate the ACE Model of Care Beyond One Unit 121

Interventions Designed to Improve Quality,

Safety, and Outcomes of Hospitalization

Randomized controlled trials have demonstrated ACE interventions are associated

with improvements in quality of care, patient safety, and outcomes of hospitalization
[2, 3]. ACE programs are effective in reducing iatrogenic events such as falls, skin
breakdown, and delirium. Patients admitted to ACE programs have favorable short-
term, intermediate-term, and long-term outcomes compared to usual care. For
instance, ACE programs promote post-hospitalization discharge to the patient’s orig-
inal residence [3, 7], ACE programs can reduce functional decline in patients, and
the longitudinal trajectory of patients discharged from ACE programs have also been
studied [8]. ACE programs are associated with reductions in hospital length of stay,
without increasing mortality, although the data on readmission rate is inconclusive.

Vision of ACE in Improving Care for Seniors in the Hospital

Older adults receive care in all aspects of the healthcare system, not just on desig-
nated ACE units. Older adults have care provided in emergency rooms, surgery
centers, and outpatient clinics. The 2012 keynote speaker at the Institute of
Healthcare Improvement (IHI) conference, Maureen Bisigano, stated that health
care is going through changes we have never seen before [9]. Healthcare systems
will face fierce financial pressures going from a fee for service model to value-based
care. To move forward, healthcare systems will need to listen to their patients.
Rather than asking “what’s the matter with you” we need to be asking “what matters
to you” [9]. Quality focuses, innovative models of care, and a patient-centered
approach will be driving forces to improving the speed of spreading best practice.
ACE principles of care fit the definition of quality, patient-centered care, and inno-
vation by utilizing an education format within the interdisciplinary team approach
to improving care for our older adult patients. In short, hospital teams will need to
take research-based models, such as the ACE unit, and deploy these models as qual-
ity improvement strategies.

Models to Bring Acute Care for Elders to an Entire Hospital

Aurora Health Care in Wisconsin is a large, not-for-profit, health system that has
widely disseminated the ACE model of care through multiple strategies. The Aurora
system provides hospital care to approximately 30,000 seniors per year within their
15 hospitals in Eastern Wisconsin. They have a small number of geriatricians (about
ten) all within the metro Milwaukee area. They started with one ACE Unit in one
hospital, led by Dr. Ellen Danto-Nocton and her colleague Dr. Michael Malone.
122 R.Y. Wong et al.

There was a desire to disseminate the ACE program to other units and other hospitals
in the system, but the non-urban hospital sites did not have geriatricians on staff.
They currently have more than 40 ACE programs through use of multiple quality
improvement strategies described below [10].
1. ACE Tracker Tool
The ACE Tracker Tool (Table 7.3) was developed by Dr. Michael Malone and
members of the senior service team, along with information technology pro-
grammers. It is a one-page report that displays risk factors for geriatric syn-
dromes and poor outcomes for older patients. It includes Beer’s list medications,
risk of falls, restraints, urinary catheters, risk of pressure ulcers, and multiple
other markers. The report is programmed to pull data from various parts of the
electronic health record. It is updated each day at midnight, thus displaying
“real-time” data. This report is available for every older patient on every unit of
every hospital. Senior Service leaders teach teams how to access and use the
tool. This assists clinicians to provide interventions that improve outcomes. This
electronic tool is easy to access and use, which helped to widely disseminate the
ACE program. Also, this has been a key tool to bring the ACE model of care to
medical/surgical units, as a “virtual ACE” program. These units have younger
patients as well, but the ACE Tracker helps to provide the ACE model of care to
all the older patients, without having to build special units at high cost. It has
been a key tool for broad dissemination of ACE principles to over 40 units.
2. ACE Cards
ACE Cards are pocket size laminated, education cards that address various geri-
atric syndromes. They provide brief descriptions, risk factors, assessment meth-
ods, and interventions to consider. These are distributed to all the ACE teams,
and are available online within the system’s internal web site for clinicians. They
function as “decision support” for clinicians as they assess and care for senior
patients on their units. This is also an education tool for the interdisciplinary
ACE team members, and they reinforce the principles of the original ACE inter-
ventions. The cards serve as reminders to the professional staff of the principles
of geriatrics as they care for patients throughout the hospital.
3. e-Geriatrician
The e-Geriatrician program was developed to address the fact that most of the
rural/non-urban hospitals have no geriatricians on staff. This program links a
geriatrician located in the metro area with teams at non-urban sites through: (1)
use of a teleconference call, (2) access to the remote site’s electronic health
record, and (3) the ACE Tracker tool. The geriatrician assigned to the outlying
site develops a relationship with the team. He or she initially visits the site, helps
to educate the team and various physician groups. They get to know the culture
of the team and site. Each site holds interdisciplinary team rounds daily, Monday
through Friday. The geriatrician then joins the team at the remote site virtually
(through the technology tools described) twice per week. This provides the team
with geriatrician guidance and input for older patients. This also provides “just
in time” learning for the team members, as the geriatrician addresses geriatric
Table 7.3 Example of printout from ACE tracker summarizing risk factor for patients aged 65 years or older on a hospital unit
Patient Length History of No. of Hx of Bed Press Wound Braden Social Adv.
room/bed Age of stay dementia CAM meds Beers Morse falls rest P/T O/T RES ADL Cath ulcer care Scale Albumin services directives
Patient A 76 2 N N 13 N 60 Y N Y Y N 8 Y Y Y 17 ND Y N
Patient B 74 1 Y N 7 N 50 Y Y N N N 6 Y Y Y 9 2.9 N Y
Patient C 78 12 Y Y 10 Y 50 Y N Y Y N 7 N N Y 14 3.9 Y Y
Patient D 72 1 N N 5 N 50 N N N N N 12 N N N 15 ND N N
Patient E 91 6 Y N 8 N 60a N N Y Y N 6a N N N 14 ND Y N
Patient F 78 1 N N 7 N 70 Y Y N N N 6 Y N N 16 ND N N
Patient G 75 1 N N 0 N 45 N N Y Y N 12 N N N 14 4.3 N N
Patient H 93 1 Y N 12 N 65 Y N Y Y N 6 N N N 15 ND Y Y
Patient I 91 1 Y N 1 N 95 Y N Y Y N 7 N N N 12 3.5 N Y
Patient J 74 5 N N 20 N 45 Y N Y Y N 7 Y Y Y 12a ND Y Y
Patient K 72 6 N Y 14 N 20 N N Y Y N 8 N N N 17 3.2 Y Y
Patient L 83 3 N Y 12 N 80a Y Y Y Y N 8 Y N N 12 2.3 N Y
Patient 5 3 11 1 8 3 9 9 0 5 3 4 6 7
Reproduced with permission from Malone et al. [10], John Wiley & Sons, Inc.
History of Dementia = Cognition as defined by nursing admission assessment of history of dementia or Alzheimer’s disease, CAM = Confusion Assessment Method,
Meds = Number of total prescribed medications given to the patient on a scheduled basis, Beers = “Beers” high risk medications, Morse = Morse fall score, Hx of Falls = Any
history of falls prior to hospitalization as recorded on nursing admission assessment, Bed Rest = Bed rest as determined by daily nursing database describing the patient’s
activity level, P/T = Physical therapy consultation ordered, O/T = Occupational therapy consultation ordered, Res = Restraints, ADL = Activity of daily living, Cath = Urinary
catheter in place as noted on nursing daily assessment, Press Ulcer = Pressure ulcer noted on nursing daily assessment, Wound Care = Wound care consultation ordered,
Braden Scale = Calculated Braden Scale, Social Services = Any documentation of a social service assessment, Advance Directives = Any documentation of the presence of
the patient’s advance directives, Y = Yes, N = No, ND = Not drawn
This score is less favorable than the admission score
124 R.Y. Wong et al.

syndromes, risk factors, assessments, and recommended interventions. The

recommendations go back to the attending physician to address, as the geriatri-
cian does not write orders for remote site patients. The e-Geriatrician program
helps to widely disseminate the ACE model of care to sites that have no geriatri-
cians on staff.
4. ACE Advisory Teams
Senior Service leaders at Aurora work with the individual sites to develop an
“ACE Advisory Team.” This team includes representatives from each discipline
(nursing, social work, pharmacy, dietary, therapy, etc.), as well as the nursing
leader and physician champion if available. Mature teams also include long-term
care partners in their communities and some have patient representatives. The
role of this team is to monitor the program, identify needs for education—both
topics (delirium, frailty, etc.) and groups (physicians, new nurses, etc.), to iden-
tify barriers, opportunities for improvement and expansion. The leaders can
work to remove barriers. The geriatrician and senior service leaders can provide
education. This team also reviews the data provided by the system senior service
leader support person. The data provides information on their site’s performance
for selected ACE Tracker elements, as well as other parameters such as readmis-
sion rate, rate of new nursing home placement, and rate of home care referrals.
This helps them identify opportunities for improvement. They often develop a
quality improvement (Plan, Do, Study, Act) strategy to address the problem
areas at their site. The system support person can also connect them with con-
tacts at other sites that may have addressed the same issue or developed a “best
practice.” Teams that include long-term care partners have worked to improve
transitions of care between their facilities.
5. Emerging Trends in ACE
The ACE model of care has also been modified for a variety of healthcare set-
tings. For instance, there are ACE-style units for patients with dementia [11],
acute stroke [12] orthopedic problems [13], and cancer [14]. The ACE model has
also been adapted for geriatric consultation programs. Last but not least, the
ACE model is the foundation of elder-friendly hospitals. In order to transform
the acute care environment to an elder-friendly hospital, ACE programs are well
positioned to initiate and test changes, with the goal of implementing multiple
improvements over time. ACE programs become the “in vivo laboratories” to
develop small-scaled, evidence-based patient care practices that can improve
clinical care. These would in turn ensure relevance to the hospital, and possible
extension and replication in other distributed sites and hospital units.

Models to Bring ACE to Rural Hospitals with No Geriatrician

There are not enough geriatricians to care for our growing older adult population.
According to the American Geriatrics Society (AGS), nearly 90 % of geriatricians
practice in urban settings. AGS reports that in the United States, we have less than
1 geriatrician per 10,000 older adults practicing in rural settings [15].
7 How to Disseminate the ACE Model of Care Beyond One Unit 125

One model of care to bring geriatricians to rural areas is the e-Geriatrician model.
This model focus is to educate the interdisciplinary team to identify geriatric syn-
dromes while providing real-time education to the interdisciplinary team, as
described above. The Difficult Case Conference is another method utilized to
engage care providers in rural areas. Utilizing the Wisconsin Star Method devel-
oped by Doctor Timothy Howell [16] (the geriatrician with the interdisciplinary
team discusses an older patient who has complex problems, via telephone commu-
nication). The WI Star Method provides a bio-psycho-social framework to review
the case. Summary teaching points are outlined by the geriatrician at the end of the
sessions. Community partners in the rural setting are encouraged to participate in
the discussion.

Effective Communication of the Importance of ACE

to Hospital Leadership and/or Community

It is important to put in place effective communication strategies to highlight the key

messages in care of older patients to the hospital leadership and community at large.
This likely involves professional help from communications experts. Below are
some of the key messages for consideration.
1. ACE programs improve patient outcomes: Articulate improvements in patient’s
function, discharge destination, and reductions in iatrogenic events as described
earlier in this chapter. Align ACE outcomes with the institutional quality indica-
tors so that ACE programs become part of the usual operations, rather than “bou-
tique units.” Consider using patient and/or family testimonies. Thank you cards
and notes can be very helpful to put “faces” to the discussion.
2. ACE programs are efficient: Emphasize reductions in hospital length of stay
without increases in readmissions as demonstrated in the literature [3]. (Consider
graphical illustration of how ACE programs can improve utilization of health
services [7]).
3. The success of ACE programs requires adequate capacity: Use metrics effec-
tively, for example, quantify the patient flow in ACE in terms of how it affects
annual utilization of health services within the organization, as well as the rela-
tionship between flow and bed capacity and workload.
4. ACE programs can be cost saving (or at least cost neutral). The financial bottom-
line is attractive based on recent studies [3]. Much of the saving is driven from
the reduced length of stay.
5. ACE teams are able to identify systems’ flaws in patient care. The ACE leader-
ship team can efficiently and effectively work together to improve patient safety.
The Institute of Medicine Report “To Err is Human” estimate the national costs
of adverse events in acute care to be $37.6 billion and preventable adverse events
to be $17 billion.
126 R.Y. Wong et al.

Hospital A B C D E F G H I J K L M

N for indicators 1 through 6 1081 416 682 617 752 612 490 441 823 1975 6225 813 410  or More
% C.I.)

1. Beer’s Medication Ordered,% 10.4 6.3 9.1 11.0 8.9 12.1 7.8 7.0 7.0 7.3 9.8 7.5 6.8 Yes, AHC Avg.
(Care Process Metric) 8.5%

2.Beer’s Medication Administered, % 4.4 2.9 5.6 3.7 4.3 2.8 3.9 3.6 2.8 3.0 3.2 4.3 3.4 No, AHC Avg.
(Care Process Metric) 3.7%

3.Physical Therapy Consult,% 56.5 93.5 68.2 72.1 90.4 65.7 90.4 64.2 80.7 80.8 67.6 82.7 78.5 Yes, AHC Avg.
(Care Process Metric) 72.7%

4.Restraints, % 1.3 1.4 3.1 4.7 2.8 0.8 0.2 0.9 3.6 2.9 8.9 2.5 5.4 Yes, AHC Avg.
(Care Process Metric) 2.4%

5.Urinary Catheter, % 26.6 19.5 22.7 24.3 20.5 18.1 28.8 20.6 13.2 16.6 21.8 19.2 18.3 Yes, AHC Avg.
(Care Process Metric) 20.9%

6.Social Services Consult,% 90.0 85.6 85.0 84.6 96.7 97.3 99.4 89.6 83.6 81.2 57.4 87.3 71.0 Yes, AHC Avg.
(Care Process Metric) 87.1%

Reproduced with permission from Malone et al. [10], John Wiley & Sons, Inc.
Light highlighted represent outliers from the overall Aurora Mean in the more desirable direction

Darker highlighted represent outliers from the overall Aurora Mean in the less desirable direction

Fig. 7.1 ACE tracker analysis of means update (most RECENT 6 months) July 12–December 12

ACE Within an Integrated Service Line to Improve

Care for Seniors

Caring for a growing senior population presents an imperative for high quality, effi-
cient, and coordinated care. An integrated service line structure within a large health
system can be a vehicle to help accomplish this imperative. The most common
design for this type of structure is the matrix design. This allows authority, account-
ability, and resource control to be balanced between system level service line leaders
and local facility managers [17]. It is also imperative that this type of service line is
interdisciplinary, due to the complex and diverse needs of the senior population.
A good example of this structure is the Aurora Health Care System in Wisconsin.
They have built a senior service line that is interdisciplinary at the leadership level,
and serves the entire system. This system service line leadership team comprises a
geriatrician, a geriatric social worker with administrative credentials, and a nurse
with credentials of advance practice in geriatrics. They have a sanctioned cost center
that allows budgeting for dissemination of senior programs and system-wide geriatric
education and support. They are charged with improving care for seniors. The ACE
program is their primary model of care to accomplish this goal. ACE fits very well
with the senior service line culture, as a featured interdisciplinary model of care.
The senior service line structure functions well to develop, disseminate, and sup-
port ACE programs throughout the healthcare system. The leaders work with each
site to: (1) teach the principles of (ACE) care, (2) increase the number of health
professionals who use geriatrics principles as they care for older patients, and (3)
measure/improve patient experience. They also help develop and support site ACE
Advisory teams, described earlier. They have responsibility for tracking outcomes
of care and working with system and site leaders to improve those outcomes
(Fig. 7.1). They work in a matrix reporting relationship to system clinical leaders,
and through relationships built with site level teams.
7 How to Disseminate the ACE Model of Care Beyond One Unit 127

The benefit of this service line structure is to establish a standard of care for
seniors across all sites. So, whether the patient is at an urban teaching hospital, or
one of the small rural hospitals, they will have the same interdisciplinary model of
care. The data can be collected, displayed, and followed using quality improvement
strategies. The data tracking can identify small practice variation that can be
addressed as a (site) quality improvement project (Fig. 7.1). System leaders can
help connect teams to those with best practice outcomes. Tracking, managing, and
reporting outcome data is important to the success and sustainability of ACE pro-
grams. This involves identifying your outcomes dashboard, arranging for data
extraction, displaying the data in easy to read graphs or charts, and regular reporting,
both to system and site leaders. The strategy to develop reliable data collection pro-
cesses keeps the program focused on improvement in care. Likewise, the complete-
ness and accuracy of the outcomes demonstrates the program’s value, and provides
guidance for teams in their quality improvement efforts.

Formulary Changes to Optimize Safety for Older Patients

Across Health System

Older adults are at risk for ADE due to metabolic changes of aging, decreased renal
clearance, and the number of medications which they are prescribed. Chapter 3
describes ADEs in detail and the implications for vulnerable older patients. It is
important to collaborate with physicians and pharmacy leaders to reduce the risk of
ADE during hospitalization. ACE programs have successfully fostered a relation-
ship with pharmacy teams to begin working on automatic dose reductions and for-
mulary restrictions for medications known to put an older adult at greater risk. One
avenue to accomplish formulary changes in a hospital setting is utilizing an interdis-
ciplinary team approach by partnering with the Pharmacy team. A Pharmacy and
Nursing team can discuss and identify opportunities for improving medication
safety. Pharmacy data should be analyzed to identify which high risk medications
are being prescribed and patterns of use of the medications. Key stakeholders should
be included in the discussion and may need to be brought in to the team as neces-
sary. It is important to also include review of standing pathways or order sets used
in all settings as a strategy to eliminate or dose reduce high risk medications. Large
health systems successful in implementing formulary changes can impact the care
of thousand older patients by decreasing the risk of ADE during a hospital stay.

Future Directions

This chapter has reviewed multiple strategies to move ACE unit interventions into
the context of quality improvement. In the process of disseminating the ACE model
of care beyond one unit, we have to think about how to make ACE sustainable within
128 R.Y. Wong et al.

the organizational structure. One important consideration is to make use of every

educational opportunity to teach learners (health students, medical residents) about
ACE. We have previously shown that exposure to ACE can influence a learner’s
knowledge and attitudes towards older patients [18]. Another consideration is the
role of scholarly work or research within ACE programs. ACE can provide the venue
for a variety of clinical investigation projects, such as health systems research, and
research in mobility, medications, medical education, and quality improvement.


1. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care
in a hospital medical unit especially designed to improve the functional outcomes of acutely ill
older patients. N Engl J Med. 1995;332(20):1338–44.
2. Baztán JJ, Suárez-García FM, López-Arrieta J, Rodríguez-Mañas L, Rodríguez-Artalejo
F. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality
among older patients admitted to hospital for acute medical disorders: meta-analysis. Br Med
J. 2009;338:b50.
3. Fox MT, Persaud M, Maimets I, O’Brien K, Brooks D, Tregunno D, Schraa E. Effectiveness
of acute geriatric unit care using acute care for elders components: a systematic review and
meta-analysis. J Am Geriatr Soc. 2012;60(12):2237–45.
4. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013.
Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and
Human Services; 2013.
5. NICHE. Geriatric resource nurse. New York, NY: Hartford Institute for Geriatric Nursing, NY
University College of Nursing; 2012.
6. Fox M, Sidani S, Persaud M, Tregunno D, Maimets I, Brooks D, O’Brien K. Acute care for
elders components of acute geriatric unit care: systematic descriptive review. J Am Geriatr
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7. Wong RY, Chittock DR, McLean N, Wilbur K. Discharge outcomes of older medical in-
patients in a specialized acute care for elders unit compared with non-specialized units. Can J
Geriatr. 2006;9(3):96–101.
8. Wong RY, Miller WC. Adverse outcomes following hospitalization in acutely ill older patients.
BMC Geriatr. 2008;8:10.
9. Institute for Healthcare Improvement. Keynote speaker Maureen Bisgnano: an ounce of pre-
vention. 2012. http://www.ihi.org/knowledge/Pages/AudioandVideo/BisognanoSummit2012
Keynote.aspx. Accessed 8 Aug 2013.
10. Malone ML, Vollbrecht M, Stephenson J, Burke L, Pagel P, Goodwin J. Acute care for elders
(ACE) tracker and e-Geriatrician: methods to disseminate ACE concepts to hospitals with no
Geriatricians on staff. J Am Geriatr Soc. 2010;58(1):161–7.
11. Soto ME, Nourhashemi F, Arbus C, Villars H, Balardy L, Andrieu S, Vellas B. Special acute
care unit for older adults with Alzheimer’s disease. Int J Geriatr Psychiatry. 2008;23(2):
12. Allen KR, Hazelett SE, Palmer RR, Jarjoura DG, Wickstrom GC, Weinhardt JA, Lada R,
Holder CM, Counsell SR. Developing a stroke unit using the acute care for elders intervention
and model of care. J Am Geriatr Soc. 2003;51(11):1660–7.
13. Gonzalez-Montalvo JI, Alarcon T, Mauleon JL, Gil-Garay E, Gotor P, Martin-Vega A. The
orthogeriatric unit for acute patients: a new model of care that improves efficiency in the man-
agement of patients with hip fracture. Hip Int. 2010;20(2):229–35.
7 How to Disseminate the ACE Model of Care Beyond One Unit 129

14. Flood KL, Carroll MB, Le CV, Ball L, Esker DA, Carr DB. Geriatric syndromes in elderly
patients admitted to an oncology-acute care for elders unit. J Clin Oncol. 2006;24(15):
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16. Wisconsin Geriatric Psychiatry Initiative. The Wisconsin Star Method. http://wgpi.org/star-
method.cfm. Accessed 23 July 2013.
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physician leaders. Surg Innov. 2006;13(2):136–44.
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Chapter 8
How to Use the ACE Unit to Improve Hospital
Safety and Quality for Older Patients:
From ACE Units to Elder-Friendly Hospitals

Samir K. Sinha, Sandra Liliana Oakes, Selma Chaudhry,

and Theodore T. Suh

Abstract Acute Care for Elders (ACE) Units can serve as powerful vehicles
through which patient safety, quality improvement, and culturally competent
patient- and family-centered care principles and practices can be implemented at a
unit level and disseminated throughout an organization or health system. While the
demographics of the patient’s hospital continue to reflect the realities of an aging
society, our hospitals and health systems still provide traditional approaches to care
that often disadvantages older adults with chronic health issues. With these patients
representing our health system’s greatest users, the work conducted on ACE Units
is finding increasing relevance to the way care across an entire hospital or health
system will need to evolve. This chapter provides guidance on how ACE Units can
also be thought of as starting points towards the development of hospital-wide ACE
Strategies that support patient safety and quality improvement efforts. Effective
implementation strategies and case studies are presented that emphasize the need
to engage leadership at both the organizational and frontline levels, along with

S.K. Sinha, M.D., D.Phil., F.R.C.P.C. • S. Chaudhry

Department of Medicine, Mount Sinai and the University Health Network Hospitals,
Suite 475-600 University Avenue, Toronto, ON, Canada M5G 1X5
e-mail: ssinha@mtsinai.on.ca; schaudhry@mtsinai.on.ca
S.L. Oakes, C.M.D., A.A.F.P., A.G.S.F. (*)
Geriatrics and Palliative Care, Wellmed Medical Management, San Antonio, TX 78229, USA
Christus Santa Rosa Medical Center, Family and Community Medicine, University of Texas
Health Sciences Center, San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229, USA
Geriatrics Research Education and Clinical Center (GRECC), University of Texas Health
Sciences Center, San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229, USA
e-mail: oakes@uthscsa.edu
T.T. Suh, M.D., Ph.D., M.H.S.
Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of
Michigan Health System, 300 North Ingalls Drive, Ann Arbor, MI 48109, USA
e-mail: ted_suh@yahoo.com

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 131
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_8,
© Springer Science+Business Media New York 2014
132 S.K. Sinha et al.

frontline care providers, patients, their families and caregivers. We further note the
necessity of inter-professional team-based approaches to effectively implementing
and disseminating ACE care principles and practices and their related patient safety
and quality improvement initiatives.

Keywords Acute Care for Elders • Quality improvement • Patient safety • Hospitals
• Care strategies • Cultural competence • Inter-professional Care • Family- and
patient-centered care


AHRQ Agency for Healthcare and Research and Quality

CQI Continuous quality improvement
IHI Institute for healthcare improvement
IOM Institute of medicine
NICHE Nurses improving care of healthsystem elders
QI Quality improvement
RTC Releasing time to care
RWJF Robert Wood Johnson Foundation
TCAB Transforming care at the bedside


Acute Care for Elders (ACE) Units were first conceived and established 20 years
ago as a model to effectively respond to the unique needs of acutely ill hospitalized
older patients on specific hospital units designed to provide such care. While every
hospital that has established an ACE Unit incorporates the core principles and prac-
tices that distinguish the care that is provided on an ACE Unit, each does so within
their unique contextual factors as well. Therefore, with no two ACE Units being
exactly alike, it may therefore be more useful to think of ACE as more of a model
of care rather than a highly specific or rigid intervention. Hospitals throughout are
beginning to realize that a more elder-friendly approach to the way we will deliver
acute care to address the needs of our aging population can deliver even better
patient and system outcomes. This chapter will explore how the ACE philosophy
can underpin an effective hospital-wide approach to improve hospital safety and
quality of care for older patients.
ACE Principles of Care focus on five key domains: developing a prepared envi-
ronment to foster patient self-care and independent functioning; patient-centered
care including guidelines for maintaining or restoring patient functioning; multidis-
ciplinary collaboration and frequent inter-professional team rounds; comprehensive
geriatric assessment; and comprehensive discharge planning initiated early in the
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 133

patient’s hospital course which makes provisions for the transition of care from
hospital to home [1].
ACE Units have been noted in particular for their emphasis on supporting
expanded nursing roles and inter-professional collaboration. Furthermore, this
inter-professional collaboration on ACE Units has been demonstrated to be one of
its specific care principles and interventions that is likely associated with a decrease
in the prevalence of functional decline in hospitalized and medically ill older
patients. Indeed, structured hospital environments providing acute geriatric care,
based on all or part of the ACE care principles and components have since demon-
strated their ability to deliver better patient and system outcomes including the
ability to reduce the incidence of functional decline, falls, delirium, hospital
lengths of stay, and the subsequent risk of being admitted to a nursing home from
hospital [1–4].

Understanding the Demographic Imperatives That

Will Force a Redesign of Acute Care Services

ACE Units themselves can be influential settings where a real focus on high quality
and safe patient care can be exemplified, especially when the entire focus of a hos-
pital’s unit staff can be based around better meeting the needs of their frail older
patients. The challenge, however, is that older patients while representing a small
proportion of our overall population are amongst the greatest users of our acute care
services. Indeed, they represent approximately 40 % of our overall hospital admis-
sions and 60 % of overall inpatient bed days—as they tend to stay longer in hospital
than younger users [5].
However, what complicates things further is the well-documented but underap-
preciated heterogeneity of the older population and the impact that this has on their
use of health care services. For example, in examining hospitalization patterns
amongst the elderly, a number of longitudinal studies have consistently demon-
strated that only a small proportion of older adults are actually high users of hospital
In Wolinksy et al.’s landmark study that followed 7,527 older individuals who
were at least 70 years of age or older for close to a decade, 42.6 % of these individu-
als were never hospitalized while an additional 24.6 % were classed as consistently
low users (being hospitalized only once over that period). The remainder, however,
were found to be higher users, with 4.8 % being classed as consistently high users
and 6.8 % as inconsistently high users [6]. For these latter groups, the presence of
three factors appeared to characterize high users: polymorbidity, functional impair-
ment, and inadequate social supports at home. The economic burden that chronic
disease contributes should not be underestimated either; individuals with four or
more chronic illnesses account for over half of the annual hospitalizations that occur
within the United States [7]. This helps to explain why this population, which repre-
sents only 20 % of all Medicare beneficiaries in the United States, accounts for 80 %
134 S.K. Sinha et al.

of the program’s overall annual overall costs [8]—principally because they tend to
use more expensive types of health services, particularly in acute care settings.
Therefore, in order to deliver better overall patient and system outcomes, hospi-
tals and clinicians facing an aging demographic will have to focus greater attention
and efforts on better identifying and supporting the needs of vulnerable older patients
who in particular have polymorbidity, functional impairment, or social frailty.
Governments are increasingly being confronted with managing health care
spending with increasingly limited resources. This in turn puts pressure on our
health care systems and hospital administrators to consolidate services, with the
explicit agenda of reducing health care costs. In such an atmosphere, the opportu-
nity for innovation in health service delivery is sometimes limited to simply “doing
the same with less.” With annual per capita growth rates in acute care costs increas-
ing the fastest for older adults, and given that this growth rate is expected to con-
tinue to rise, it is imperative that we focus our efforts around developing new
cost-conscious models that are able to meet the complex needs of older patients
across the care continuum.
Our main problem is that while the patients have changed, our systems have not.
Our current acute care model, for example, was developed years ago when the aver-
age person was less than 30 years of age and tended to not live past 65 or be living
with chronic illnesses, and usually presented with only one active issue that brought
them to hospital. While this model still functions well for younger patients, it is
increasingly recognized that the way in which acute hospital services are currently
resourced, organized, and delivered often disadvantages older adults with chronic
health problems [9].
We are coming to understand how the loss of functional reserve experienced by
many older adults together with our traditional and costly models of usual care ren-
der many older patients particularly at risk for adverse outcomes such as falls, delir-
ium, drug–drug interactions, functional decline, and death. These outcomes are in
part due to higher rates of polymorbidity and polypharmacyin older adults and lon-
ger hospitalizations [10]. Covinsky and others have further demonstrated that almost
half of the older adults who are admitted acutely to hospital have already experi-
enced a decline in their functional abilities in the weeks prior to their admission and
that by the end of their hospitalization, just over one third are discharged at a level
of function that is below their baseline, with half failing to ever recover the function
they lost [11]. However, what is most concerning is that many individuals still have
not come to appreciate that many of these adverse outcomes are preventable.
Although there is a need for reform in the delivery of primary and community-
based care, older adults will still require hospitalization even under the best of cir-
cumstances. Therefore, there is an opportunity to reduce disease burden, improve
access and capacity, and ultimately promote health through the development, link-
age, and implementation of innovative care models within and beyond acute care
settings [12].
Early attempts made to provide guidance to hospitals on establishing geriatric
services often relied more on compelling anecdotes than compelling evidence [13–
15] and rarely demonstrated the efficacy of these services. However, research over
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 135

the past two decades has improved our understanding of risk factors for adverse
outcomes and effective interventions that can prevent such outcomes. Implementing
specific models and point-of-care interventions in single care locations of a hospital
such as the emergency department [16–18] and inpatient [3, 4, 19] transitional,
outpatient home [20], and community care [21, 22] settings can improve overall
outcomes and reduce lengths of stay, admissions, readmissions, and inappropriate
resource use. These models thereby improve the overall capacity and efficiency of
the system.
However, implementing innovative models of care that challenge deeply
ingrained traditional ways of providing care has proved to be a significant challenge
[23]. Nevertheless, now, more than at any other point, there is an imperative with
significant social and economic implications that requires us to develop comprehen-
sive, evidence-based care strategies to improve the acute care of older adults no
matter where they are being cared for.

From ACE Units to a Hospital-Wide ACE Strategy

The future goal is to develop an innovative, evidence-based, comprehensive, inte-

grated, proactive, and responsive elder-friendly hospital service delivery model.
This model promotes inter-professional collaborative practice and integrates inpa-
tient, outpatient, and emergency department care practices and processes across a
single setting. The model is in the context of the broader care continuum that
includes home and community care settings. There are no studies to that demon-
strate the implementation and cumulative effect of an integrated elder care strategy
across all the care settings within and beyond an acute care hospital. Therefore, we
see that the ACE model is one that could serve as a starting point in developing a
broader ACE Strategy.
In response to the challenge of addressing the complexities of caring for older
adults in acute care settings and across the continuum of care, a growing number of
hospitals are now working on establishing approaches to address this gap, starting
with having their hospitals identify geriatrics as a core strategic priority. However,
what will drive this overall agenda is a collective effort to develop an ACE Strategy,
which puts the needs of older patients and their families first, no matter where they
are receiving their care in a hospital. The ultimate aim is to transform current para-
digms of hospital care by developing, implementing, and demonstrating the wide-
ranging benefits of an elder-friendly hospital integrated service delivery model.
This strategy can contribute towards optimizing the outcomes of hospitalization for
older adults and the system as a whole.
Although a seemingly logical next step, few hospitals across North America
have made the needs of older adults a core strategic priority, despite the fact that
they represent a majority of inpatient bed days. With current health care reforms
increasingly rewarding efficiency and quality instead of quantity, hospital adminis-
trators are starting to take a very close look at ACE care principles and practices.
136 S.K. Sinha et al.

The premise of this approach is that small improvements in the way we care for
older adults can lead to important health, social, and economic benefits.
Successful ACE Units have been noted for their emphasis on continuous quality
improvement (CQI) using an inter-professional team-based approach. When exam-
ining the common factors that complicate the stay of an older patient in hospital, it
is often realized that it takes an inter-professional approach to best manage these
issues, and therefore, it will require a similar approach to prevent them as well.
Issues like falls with injury, functional decline, delirium, pressure ulcers, and com-
prehensive discharge planning are shown to benefit from an inter-professional
approach. The question that arises as a result, therefore, is how should we best
encourage the dissemination of inter-professional care principles and practices
across a hospital?

Establishing a Hospital Quality Improvement (QI) Program

Using an ACE Unit as a Clinical Laboratory for Change

The past decade has seen patient safety and quality become a real focus within the
field of acute care, given its proven ability to improve overall patient and system
outcomes, that could also help improve the sustainability of our system as well.
Indeed, legislative and regulatory changes that govern how health care is being
organized, financed, and delivered are being continuously introduced in a way that
can promote the active engagement of organizations and their clinicians in quality
improvement and patient safety activities.
The field of Quality Improvement (QI) can be defined as the combined and con-
tinuous efforts of everyone—health care professionals, patients, their families and
caregivers, researchers, payers, planners, and educators—to make the changes that
will lead to better patient outcomes (health), better system performance (care), and
better professional development [24]. The Institute of Medicine (IOM) further
expands its definition to describe the care it envisions being provided based on the
strongest clinical evidence and provided in a technically and culturally competent
manner with good communication and shared decision-making [25].
Because ACE Units are natural vehicles for QI activities, the staff of many of
these programs are more likely to seek out and receive additional training in patient
safety and quality improvement. This is especially relevant when the value proposi-
tion for organizations creating ACE Units is their potential to significantly improve
these domains of care. Acute care institutions are now using ACE Units as a nidus
to drive broader QI efforts to transform the care of older patients. The IOM that has
champion the QI agenda has play a vital role in casting a vision for the care of elders
and its challenges. It further has invited health care providers to continually reduce
the burden of illness, injury, and disability, and to improve the health and functioning
of people by adopting a shared vision of health care. This vision promotes continu-
ous improvement to focus around six specific core aims that allow it to be: safe,
effective, patient-centered, timely, efficient, and equitable [26].
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 137

Within existing ACE Units a collaborative and inter-professional team-based

approach becomes the powerful force for planning, implementing, evaluating, and
exchanging QI strategies. Indeed, successful, ACE Units often embody a cultural
approach to teamwork that promotes collaboration between team members, and an
understanding of the overall team and its individual member and discipline’s roles
and responsibilities as a core part of promoting innovation and safety. These ACE
Unit teams often approach team communication and development daily, as vital
processes in enhancing communication and addressing quality issues in a safe envi-
ronment that highlight specific incidents including near misses, reporting errors,
and communication challenges that offer an area for reflection and improvement.
Embedding CQI as a core aspect of the work of all staff on an ACE Unit often
challenges some deeply engrained ways of working, especially with older adults.
ACE Units to do this well by ensuring they have frontline staff well equipped with
the knowledge and skills needed to care for an older population and participate in
QI efforts, and that frontline staff are actively encouraged to lead the CQI efforts in
their settings as well. ACE Units that have made this a focus of their staff develop-
ment efforts often are characterized as having frontline staff that are empowered to
drive the development of care protocols and processes, lead inter-professional com-
munication and collaboration, and to share and evaluate processes and protocols
with others.
Three vehicles that ACE Units have employed to support a CQI agenda as it
relates to the care of older adults include Nurses for Improving Care of Healthsystem
Elders (NICHE), Transforming Care at the Bedside (TCAB), and the Releasing
Time to Care (RTC) Initiatives. NICHE was conceived at the John A. Hartford
Foundation Institute for Geriatric Nursing at New York University in 1992. The
goal of NICHE is to achieve systematic nursing change that will benefit hospitalized
older patients by encouraging the uptake of evidence-based care principles, learn-
ing, and quality improvement tools to stimulate a change in the culture of health
care facilities to achieve patient-centered care for older adults [27]. The focus of
NICHE is to drive change through the further development of programs and proto-
cols that are predominantly under the control of nursing practice which is why
together with an ACE Unit model; this has been seen as a powerful engine of change
and dissemination of best practices not only within the unit but across entire organi-
zations. Currently, NICHE reports having 450 active sites in the United States,
Canada, and The Netherlands. While not every NICHE institution has an ACE Unit,
those institutions that have ACE Units are likely to be NICHE institutions.
The last decade has also seen the emergence of other complementary programs
that are less geriatric focused, but serve as more general vehicles to successfully
promote CQI efforts at the unit level amongst frontline practitioners. In 2003, the
Institute for Healthcare Improvement (IHI) and The Robert Wood Johnson
Foundation (RWJF) launched their TCAB initiative. This initiative promoted the
leadership of frontline hospital personnel, mainly nurses who were often exhausted
and frustrated with poor work processes that impacted on the care they sought to
deliver, to lead QI efforts in settings they worked in. Through focusing on giving the
frontline staff the skills and permission to innovate and be more proactive in their
138 S.K. Sinha et al.

own solutions to improving the work processes they were a part of, this initiative
proved to be successful re-instating the frontline leadership that is often needed to
drive health care transformation activities [28]. Specifically, the TCAB initiative
trains its frontline teams in QI and patient safety practices, using case studies and
giving teams specific templates, tips, and resources to allow them to work into, or
refine their existing processes to incorporate, a better focus on evidence-based
quality-informed care.
In a similar way to the US TCAB Initiative, a number of hospitals around the
world are implementing the British National Health Service RTC Initiative. RTC is
a patient-centered approach to improving the quality of care on acute care nursing
units. This initiative—which focuses on freeing up care providers’ time for more
direct patient care—provides a step-by-step guide to improve common processes of
care using a variety of straightforward tools and techniques—some of which have
been adapted from LEAN methodologies [29]. Although RTC is designed around
nursing processes, everyone involved in providing care or services at the unit level
is encouraged to play an important role in RTC initiatives. RTC essentially helps
care teams identify where they are spending time on activities that do not add value
for patients. RTC also provides guidance on how to test and implement changes that
improve the patient’s experience, enhance staff well-being, and increase patient
safety and quality on the ward. In England, direct care time increased by up to 60 %
on one unit following implementation of RTC, allowing time to be reinvested into
safer and better care for patients. A number of units that have implemented RTC
have also seen a significant increase in direct care time achieved and a significant
improvement in the overall quality of care being achieved—emphasized by a reduc-
tion in falls, pressure ulcers, and infections such as C. difficile and MRSA. Staff
have also observed an increased level of patient satisfaction with the quality of care
received on the unit. With frontline staff in these units often reporting being more
engaged and empowered by the changes they themselves have implemented on their
own units, higher staff satisfaction levels have been achieved along with a positive
shift in the culture within these units and more broadly across the organization
being observed as well [30].
The common thread amongst organizations that have successfully seen the ben-
efits of implementing NICHE, TCAB, and RTC Initiatives is that each requires a
commitment from all levels of an organization to truly focus the agenda of deliver-
ing high quality and safe patient-centered care that is supported by a CQI agenda.
Not only does this require a significant amount of time, but it also challenges every-
one involved within a unit or across an entire organization to think differently. What
is reassuring is that if an organization appreciates the previous points, then often
getting the buy-in of frontline staff is not that difficult, when they understand what
the potential benefits of their investment of time could translate into for their patients
and themselves. Indeed, seeing the training of frontline leaders and direct care
providers as vital and necessary investments in a broader QI agenda will help estab-
lish a culture where frontline staff continuously seek to innovate, measure, and dem-
onstrate outcomes as a natural part of the care they deliver. Furthermore, our
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 139

collective experience with implementing these initiatives in our organizations

supports the notion that when care providers are involved in redesigning processes
of care, tremendous gains in patient care outcomes are possible. Furthermore, ACE
Units can serve as ideal sites to pilot the redesign of care processes.

Establishing a Quality Agenda and Its Areas of Focus

With an increasing interest in patient safety and quality, the last decade has seen
three particular areas related to the care of older adults receive the greatest attention.
Indeed, the prevention of falls, delirium pressure ulcers, and the ability to improve
transitions of care particularly amongst acutely ill older patients, have become core
areas of focus for practitioners, researchers, policy makers, and accreditors.
One in five inpatients falls at least once during a hospitalization, and these falls
can result in injuries, increased lengths of stay, malpractice lawsuits, and consid-
erable incremental costs [31]. Additionally, at least one in ten inpatients will
develop a hospital-acquired delirium during their hospitalization, which can result
in injuries, increased lengths of stay, and considerable incremental costs [32].
While fewer numbers of patients tend to develop hospital-acquired pressure
ulcers, their consequences are well understood and documented. Furthermore,
inattention to supporting the transitions of care for older adults has been largely
blamed for the high and avoidable readmission rates hospitals and emergency
departments have been experiencing with respect to the older patients for whom
they have cared [33].
As part of its overall strategy to better align quality of care with financial incen-
tives, the Centers for Medicare and Medicaid Services (CMS) announced on
October 1, 2008 that falls and pressure ulcers would be listed as “never-event” con-
ditions that would result in nonpayment for any related consequences that occurred
as a result of a fall or the development of a hospital-acquired pressure ulcer. There
was criticism from the outset about how preventable some “never-events” were. For
example, systematic reviews estimate that, at best, only about 20 % of falls in insti-
tutional settings can be prevented [34]. This difficulty perhaps became a primary
reason why falls and all other listed events were re-branded as “serious reportable
events” in 2011 (see Table 8.1). As for delirium, while it was being considered to be
listed originally as a “never-event” condition as well, it never made the CMS list as
the consensus was that it is very difficult to predict who and why a person may
develop a hospital-acquired episode of delirium. Nevertheless, the fact that delirium
often prolongs length of stay and is associated with worse patient and system out-
comes has made it a common area of focus, especially given that there is solid evi-
dence to show that it is often preventable with the implementation of rather common
sense approaches to care [19]. While previous health care financing reforms were
more geared to driving efficiency, the latest health care reforms in the US
Government’s Affordable Care Act are further emphasizing reimbursement models
140 S.K. Sinha et al.

Table 8.1 “Never-events” as originally defined by CMS with select preventative best practices
Never-events Select preventative best practices [36]
Hospital-acquired stage III Low pressure air flow mattresses
and IV pressure ulcers Frequent turning for immobile patients
Nutritional support for malnourished patients
Falls and trauma Multicomponent fall interventions
Frequent nurse or nursing aid rounding
Physical and restorative therapies
Surgical site infection after bariatric surgery Hand hygiene protocols
for obesity, certain orthopedic procedures, Meticulous surgical technique
and bypass surgery (e.g., mediastinitis) Appropriate use of preoperative antibiotics
Vascular catheter-associated infection Maintain catheter site dressing integrity
Practice good hand hygiene and aseptic technique
Use appropriate prophylactic antibiotics
Remove vascular catheters as soon as the need
for their use has ended
Catheter-associated urinary Limit use of Foley catheters
tract infection Consider use of intermittent straight
catheterization or diapers
Administration of incompatible blood Require positive donor-recipient identification at
blood collection and at blood product
Monitor for possible transfusion reactions
Air embolism Use air embolism prevention protocols
Require competency certification for staff
managing vascular catheters
Use equipment safety controls
Foreign object unintentionally retained Have consistent application and adherence to
after surgery standardized surgical item counting
Use X-rays, ultrasound, or bar-coding to detect
any retained foreign bodies in the
surgical field
Have protocols that support effective
communication between operative staff
Deep vein thrombosis (DVT)/pulmonary Use of pharmacologic agents and/or mechanical
embolism (PE) for total knee compressive devices for the prevention of
replacement or hip replacement venous thromboembolism
Promote early mobilization following

that equally value quality. For example, hospital reimbursement for care provided to
a patient that is readmitted within 30 days for the same condition to an acute care
facility will be limited or eventually eliminated. This is because the readmission
likely represents a failure to provide the appropriate comprehensive discharge plan-
ning or post-hospital support for a patient (their family caregivers) [35].
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 141

You Can’t Monitor What You Can’t Measure.

But Focus on the Issues That Matter!

Because falls are discreet events that seem easy to count, fall rates have been
increasingly used to signify the quality of care that is delivered by hospitals over the
past decade. In the short run, however, the easiest way to prevent falls is to reduce
their chance of occurring by limiting movement. Manufacturers have even responded
by developing new devices that actually inhibit free movement [31].
Preoccupation with preventing falls may have led us down the path of unintended
consequences. Some health care teams have concentrated on indicator-based
approaches to improving the quality of care, rather than the much more difficult task
of reducing the risks of patient-related causes of falls. To stay focused on issues that
matter, efforts should address preventing delirium, encouraging mobilization, and
mitigating the risk of skin breakdown. In other words, the understandable concern
for falling can lead to the active discouragement of mobilization, and the increased
chance that an older patient will experience a loss of independent functioning [37].
Caring for an ever-increasing aging population requires an understanding of the
important intersection between, age, function, and processes that deliver interven-
tions. Aging is often associated with functional changes such as declines in muscle
strength, aerobic capacity, bone density, and other factors that reduce an older
adult’s functional reserve. While bed rest remains a natural inclination when a per-
son feels unwell, it has long been recognized by Asher and others that “rest in bed
is anatomically, physiologically, and psychologically unsound” [38]. Hospital inter-
ventions that further enforce immobilization beyond bed rest include physical and
pharmacological restraints, and urinary and intravenous catheters. In fact, environ-
ments and care protocols that don’t promote upward mobility out of bed can con-
tribute to the rapid loss of function that in an older adult can occur at rates as high
as 5 % per day, compared to 10 % per week in younger adults. It is ironic that while
hospitals have become increasingly oriented to treating an older patient population
(with a higher propensity to fall), we have somehow created an “epidemic of immo-
bility” [39]. This immobility results in further functional decline that increases the
risk of falls, pressure ulcers, and delirium in the long run [40]. The unintended
consequence of the recent effort to reduce falls in hospitalized patients is that it has
likely contributed to this and other problems as well in other ways.
What we are increasingly coming to realize is that addressing the issue of falls
involves a trade-off. While falls are risky, immobility may be riskier. It may be bet-
ter to submit patients to the risk of falling by encouraging early mobilization, rather
than expose them to the risks of deconditioning, pressure ulcers, delirium, and other
adverse conditions by restricting mobility. Indeed, there have been suggestions that
mobility should be treated as a “vital sign” that needs to be monitored and attended
to appropriately throughout a patient’s hospital stay [31]. We therefore argue that a
focus on early and safe mobilization rather than falls prevention should become the
priority in our acute care settings and beyond. Indeed, this focus on mobilization has
been an essential focus of core ACE Unit processes aimed at preventing functional
decline [41].
142 S.K. Sinha et al.

Studies of inter-professional care models show that they can reduce functional
decline while delivering better patient and system outcomes [34]. We further argue
for an approach that promotes safer falls in the patient who is learning to become
upwardly mobile again with the goal of preventing falls that result in serious injury,
rather than all falls (see Table 8.1). This approach could include lowering the bed,
padding the floors, and providing grip socks; ways that can help ensure that falls
that do occur do not result in serious injury, the actual greater concern, while at the
same time promoting the ultimate goal of maintaining, restoring, or improving a
patient’s overall function. In addition, we advocate using socialization activities
with elderly patients to further encourage mobilization by having them eat meals in
groups at tables, and attend activities outside of their rooms during the day—a com-
mon practice on many ACE Units.
Payment reform will likely be the most powerful vehicle to help influence the
patient safety and quality agenda in hospitals. While some hospitals until now
focused their most intensive QI efforts a single setting like an ACE Unit, establish-
ing a more organization-wide approach towards the care of older adults will require
in our view similar but even more deliberate considerations when taking a
population-based patient safety and quality agenda hospital-wide.

Establishing a Hospital-Wide ACE Strategy

When establishing ACE care principles and practices across a hospital, the first chal-
lenge is that the further one gets from an ACE Unit—the more likely these princi-
ples and practices will compete with others at the hospital and unit level. While ACE
Units can focus their care protocols, practices, and educational training to those
issues of exclusive relevance to caring for an older adult, how does one maintain this
momentum on units and in other parts of the hospital that might be very specialized
around the needs of a specific medical or surgical specialty or population?
As older patients usually occupy beds throughout a hospital, stay the longest, and
present with the most complex care and discharge planning issues hospitals and/or
hospital systems have an incentive to improve care for these patients making care
more efficient, and less complicated and costly. Gaining support across the hospital
requires the support of hospital administration and key opinion leaders. Likewise,
managers and champions are needed to help facilitate the adoption and implementa-
tion of ACE principles/practices, especially amongst the frontline staff.

Establishing Elder-Friendly Hospital Policies

and Strategies: The Ontario Experience

At Mount Sinai Hospital in Toronto, Canada we addressed this approach towards

gaining organizational support for developing a more hospital-wide ACE Strategy
through two fundamental ways. We first used data to make the case to our hospital
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 143

and program leadership that the majority of care we were providing was related to
the care of older adults. We further outlined that the implementation of more elder-
friendly care policies, protocols, and processes would likely achieve better patient
and system outcomes. Likewise, we described that this strategy could significantly
benefit the organization financially as well. In essence, we presented an ACE
Strategy as a solution for the hospital to meet its patient safety, quality, and financial
We also decided to be strategic in our work in implementing ACE care principles
and best practices across the hospital, given the effort, work, and resources it often
takes in establishing new care processes that follow and enable a CQI framework.
In order to gain momentum, we thus were selective in choosing to work with those
programs that were most interested in adopting ACE care principles and practices
and where we thought we could achieve the best possible gains in patient and sys-
tem outcomes. A strategy that usually helped gain the interest of other parties was
to frame our innovative practices using a “what’s in it for me” approach. In other
words, by helping others understand how adopting these care principles and prac-
tices into their setting could help them better achieve their aims, helped to more
quickly gain their interest and active support. Given the evidence that exists around
the benefits of providing comprehensive geriatric assessments and care support to
older hip fracture patients—in our experience, orthopedic wards tend to be an eager
and willing adopter of ACE care principles and practices.
In working across an organization or within a new program or unit, it is best
advised to first of all review its care protocols and how these may affect the care of
older hospitalized patients in that setting. For example, if a hospital or its individual
units are using admission order sets—are there suggested medication choices and
care practices that are more appropriate for older adults? In our hospitals, working
with program or unit teams to ensure, appropriate pain, nausea, and constipation
management orders and protocols were in place, has helped to avoid the under treat-
ment of these issues, or the side-effects that less appropriate choices could render as
well. The prevention of functional decline, delirium, and pressure ulcers can also be
supported by careful attention to orders and care protocols. Such order sets and care
plans should limit the use of urinary, intravenous catheters, or physical restraints.
Likewise, they should encourage the early mobilization of patients—e.g., by recom-
mending the patient be up in a chair for their meals, thus maximizing physical func-
tioning and thereby minimizing functional loss and its associated consequences.

Hospital-Wide ACE Strategy

Another aspect to consider is how best to leverage an ACE Unit, if your organiza-
tion has one or is considering establishing one to enable a more hospital-wide ACE
Strategy. As was previously noted, ACE Units tend to be successful caring environ-
ments in themselves or are more likely to be able to achieve better patient and
144 S.K. Sinha et al.

system outcomes, because the entire unit has a shared aim and focus on better sup-
porting the needs of frail older adult patients. Indeed, virtually all successful ACE
Units have incorporated a focus on QI in delivering improved patient and system
outcomes as was discussed earlier. Therefore, when expanding this level of interest
and such a high degree of focus on the care of older adults across an entire hospi-
tal—understanding how to take this level of achievement beyond an ACE Unit will
be integral to doing so.
In our and other organizations, the leveraging of the ACE Unit to support
organization-level change has proven to be a successful method. Given that every
organization has its own care processes, protocols, and working cultures, it is often
easier to ensure the successful implementation of an organization-wide change
when it has been already implemented, tested, and refined further to working within
a setting within that organization. Seeing the successful implementation of an initia-
tive in one part of the organization makes it far easier to gain further organizational
support when other units and programs, see that it is possible and understand that
they have local implementation experts that they can get support from should they
need it as they implement the same initiative in their settings. Therefore, a core
benefit of using an ACE Unit to drive and support a wider ACE Strategy, is that it
can also serve as a resource for others, and a designated area where new ideas and
thinking are encouraged and can be tested and refined in a supportive setting before
determining if their broader roll-out would be of a wider organizational benefit.
In Ontario, Canada, the provincial government has emphasized the establish-
ment of elder-friendly hospitals as part of a broader strategy to enhance their com-
mitment to enhance the care of older adults within hospitals. In considering the best
evidence that relates to caring for older adults in hospitals, the provincial Senior-
Friendly Hospital Initiative has endorse a series of 12 overall recommendations
across five domains, outlined in Table 8.2 to support its hospitals in developing their
capabilities to deliver better care for their older patients and in planning efforts to
improve the overall care of older adults.
Table 8.3 further describes a number of evidence-based elder-friendly hospital
interventions that complement the ACE Unit model of care and can contribute
towards the development of a hospital-wide ACE Strategy (see Case Study, section
“Case Study: Implementing a Hospital-Wide ACE Strategy at Mount Sinai Hospital,
Toronto, Canada”).

Measuring What Matters as Way to Evaluate

Overall Effectiveness

Whether it be at the level of an ACE Unit or a more hospital-wide ACE Strategy, the
best way an implementation team can appropriately evaluate the effectiveness of
their efforts is to choose and track relevant metrics that are relatively easy to mea-
sure as well.
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 145

Table 8.2 Recommendations for hospitals to support the development of hospital-wide ACE
principles [42]
Organizational support
1. Establish board and/or strategic plan commitments for an elder-friendly hospital
2. Designate a senior executive/medical leader in the hospital to lead and be responsible for
elder-friendly initiatives across the organization
3. Train and empower a clinical geriatrics champion(s) to act as a peer resource and to support
practice and policy change across the organization
4. Commit to the training and development of human resources via seniors-focused skill
Processes of care
5. Implement inter-professional protocols across hospital departments to optimize the physical,
cognitive, and psychosocial function of older patients. These processes should include
high-risk screening, prevention measures, management strategies, and monitoring/evaluation
6. Support transitions in care by implementing practices and developing partnerships that
promote inter-organizational collaboration with community and post-acute services
Emotional and behavioral environment
7. Provide all staff, both clinical and nonclinical, with sensitivity training to promote an
elder-friendly culture throughout the hospital’s operations
8. Apply an elder-friendly lens to patient-centered care and diversity practices, so that the
hospital promotes maximal involvement of older patients and families/caregivers in their
care consistent with their personal values (e.g., cultural, linguistic, spiritual)
Ethics in clinical care and research
9. Provide access to a clinical ethicist or ethics consultation service to support staff, patients,
and families in challenging ethical situations
10. Develop formal practices and policies to ensure that the autonomy and capacity of older
patients are observed
Physical environment
11. Utilize elder-friendly design resources, in addition to accessibility guidelines, to inform
physical environment planning, supply chain and procurement activities, and ongoing
12. Conduct regular audits of the physical environment and implement improvements informed
by elder-friendly design principles and by personnel trained on the clinical needs of frail

The creation of an ACE Unit level or a broader Hospital-Level ACE Steering

Committee with representation from clinical and administrative leads, including
those from the hospital IT department, and those with experience in performance
measurement can be helpful to help provide a forum through which quality
improvement initiatives can be vetted for implementation based on their alignment
with organizational priorities, their perceived ease of implementation; and the abil-
ity to effectively measure outcomes. The Committee as a result also provides a
structure that can continuously monitor, review, and refine its implementation
efforts. Having frontline champions involved in these decision-making processes
can improve their overall effectiveness as they are often the ones who can provide
other frontline staff the motivation and support needed to understand, embrace, and
implement new initiatives as well.
146 S.K. Sinha et al.

Table 8.3 Examples of Evidence-Based Elder-Friendly Hospital Interventions

High-risk screening tools
Evidence-based screening tools like Identification of Seniors at Risk (ISAR) and the interRAI
Assessment Urgency Algorithm (AUA) have been designed for use with older adults
presenting to the ED to quickly and effectively identify those who are at an increased risk of a
variety of adverse outcomes including functional decline, readmission, and
institutionalization [43, 44]. Use of these tools must be linked to follow-up processes,
including a formal clinical evaluation
Geriatric Emergency Management (GEM) nurses model
GEM Nurses are ED-based advanced practice nurses who exclusively focus on assessing and
addressing the needs of frail older patients while helping to connect them with specialized
geriatrics services and home care and community support services as required. GEM Nurses
have been found to be helpful in preventing unnecessary admissions, while also facilitating
the care of older patients who may need further inhospital assessment and support [45]
Hospital at home
The Hospital at Home model provides acute hospital-level care in a patient’s home to substitute
for acute hospital care [16]. Patients receive physician and nursing care and diagnostic and
therapeutic interventions usually provided in the hospital, commensurate with their illness
severity [46]. This model delivers equivalent care for a lower cost, with fewer adverse events
like delirium or functional decline, and higher satisfaction levels. This model can also be
deployed to facilitate early discharge from the acute care hospital
Elder-friendly order sets
The implementation of elder-friendly order sets to guide the implementation of evidence-based
care protocols and practices can be effective ways to ensure ACE Principles of Care are being
supported. Each organization will implement order sets that work best within their local
contexts but observed best practices include those that have activity orders as well that
encourage early mobilization and influence the choice of safer pain management or nausea
treatment options, promote more appropriate bowel and bladder management routines, and
encourage proactive and comprehensive discharge planning
Hourly nurse rounding model
Nurses and nursing assistants though this model conduct hourly patient rounds designed to
improve safety and address needs that otherwise would prompt use of call lights. During the
rounds, they identify and address each patient’s pain level, position, and comfort; offer
toileting assistance; and ensure that all needed items are within reach. Several studies have
since demonstrated the ability of these programs to help reduce patient falls, pressure ulcers,
and call light use, and contributed to significant improvements in patient satisfaction [47]
Acute Care for Elders (ACE) units
ACE Units operate within a specially designated ward of the hospital that aims to combine
geriatric assessments, quality improvement, a specially planned environment, inter-
professional team rounds, frequent medical care reviews, and comprehensive discharge
planning. ACE Units have been shown to reduce lengths of stay, readmissions, and long-term
care placements and help hospitalized older adults maintain functional independence in basic
activities of daily living [48]
Orthogeriatrics services
Orthogeriatrics is a co-management model that brings geriatricians and orthopedic surgeons
together in the care of older patients with hip fractures. In enhancing the care of these patients
with comprehensive geriatric assessments at the time of admission, and ongoing support
through the length of stay, these models have shown an ability to reduce the incidence of
delirium and thus shorten lengths of stay [49–51]
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 147

Table 8.3 (continued)

Hospital Elder Life Program (HELP)
HELP is a volunteer-based model designed to prevent delirium by keeping hospitalized older
patients oriented to their surroundings; meeting their needs for nutrition, fluids, and sleep, and
keeping them mobile within the limits of their physical condition [52]. HELP has been shown
to be effective at reducing the incidence of delirium and functional decline in hospitals
Care transitions intervention model
In this model, hospital patients are assigned with a transitions “coach” who helps patients learn
self-management skills beginning at discharge [53]. The coach, a specially trained nurse,
helps patients learn to manage multiple prescriptions, follow post-hospital recommendations,
and present their health care providers the information they need
Nursing improving care for healthsystem elders (NICHE)
NICHE provides clinical and organizational tools and educational resources to support a
systematic change in the culture of health care facilities. NICHE supports organizations to
achieve patient-centered care for hospitalized older adult patients. NICHE has been used by
numerous hospitals across North America and other health care settings to foster system-wide
improvements in the care of older people [27]

In choosing relevant metrics, it is useful to ensure that they can be easily measured
whenever possible, ideally through existing data collection processes, and that those
chosen have face validity with everyone from patients to the senior leadership team
of an organization. Metrics that not only look at outcomes but processes may also
be useful in monitoring not only effect but efficiency as well. The use of balancing
metrics can be helpful to ensure that possible unintended consequences are not
occurring as well. For example, the drive to lower hospital lengths of stay has some-
times led to patients being discharged too soon, resulting in higher readmission
rates. In measuring both metrics, a group can more confidently feel that they can
effectively balance their efficiency and quality goals. Furthermore, by involving
those from informatics, they can sometimes be able to make minor adjustments to
the way data is already being collected within an electronic health record to aid with
program monitoring efforts. For example at Mount Sinai Hospital in Toronto, the
ability to monitor the impact of an inappropriate urinary catheter reduction strategy
was enabled by simply adding a check box in the daily nursing assessment that
asked nursing staff as part of their usual work flow to indicate whether the patient
had a urinary catheter in place. While some metrics will be organization specific,
there should also be a way to benchmark progress based on historical trends within
an organization or also by benchmarking one’s performance against a reasonable
comparator group at the hospital or regional level.
There are already well-established ways of objectively measuring patient satis-
faction through Press Gainey Surveys in the United States and NRC Picker Surveys
in Canada for example, and in some cases, the data can be stratified by age as well.
The challenge with these mechanisms is that sometimes it can take a long time to
receive valuable feedback. Therefore, certain programs like the RTC including a
patient satisfaction element that allows for a more real-time collection of patient
feedback and levels of satisfaction. The NICHE Initiative also has well-established
frontline staff knowledge and satisfaction survey known as the Geriatric Institutional
148 S.K. Sinha et al.

Table 8.4 A Sample Balance Access and efficiency

Scorecard framework for 1. Length of stay (total, acute)
evaluating ACE-related
2. Average length of stay/estimated length of stay
3. Proportion of patients discharged directly home
Quality and safety
1. Hospital-acquired pressure ulcers
2. Hospital-acquired delirium
3. Hospital-acquired falls that resulted in serious injury
4. Readmissions back to the Hospital within 30 days
of discharge (same diagnosis)
Patient and provider experience
1. Patient satisfaction through the Press Gainey or NRC Picker
2. Staff experience as per annual GIAP survey
Financial health
1. Direct costs per case

Assessment Profile (GIAP) that member hospitals can use to understand how their
staff are doing and feeling and how their experience compares with those within
other similar organizations across North America.
In many organizations, choosing metrics using a balanced scorecard approach
has proven to be an effective way to measure performance at a Unit, Program, or
Institutional Level. The four domains of the balanced scorecard and some sample
metrics are shared below in Table 8.4 that we believe any organization should be
able to easily measure and monitor.

Case Study: Implementing a Hospital-Wide ACE Strategy at

Mount Sinai Hospital, Toronto, Canada

Mount Sinai Hospital in Toronto took the lead in Ontario to become its first acute
care academic health sciences centre to make geriatrics one of its core strategic
priorities with a mandate to deliver excellence in patient care, teaching, and research
activities related to the care of older adults.
Mount Sinai, like other leading hospitals in this area, saw its clinical and admin-
istrative leaders and frontline providers come together through a Geriatrics Steering
Committee that has now been meeting monthly for over 5 years. Through its work,
the Committee successfully advocated that the care of older adults be deemed a
strategic priority with meaningful hospital support, and oversaw the implementation
of specific evidence-informed models and point-of-care interventions across its
continuum of care that aim to improve patient, provider, and system outcomes.
Mount Sinai’s ACE Strategy was launched in 2010 to improve how care to older
patients is delivered. The Hospital, under this Strategy, implemented a series of
evidence-informed but tailored interventions (i.e., ISAR, GEM, ACE Unit,
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 149

Orthogeriatrics, HELP, NICHE) all of which are highlighted in Table 8.3. However,
the hospital went one step further in linking all of the models to create a more seam-
less integrated service delivery model that spans the continuum of care and is
enabled by an inter-professional collaborative and team-based approach to care and
a number of information technology innovations. The hospital has also demon-
strated the importance and success that a collaboration with community partners
like the local home care and community support services organizations can have in
helping to transition and keep a greater number of older adults at home. This
Strategy is enabled by an inter-professional, team-based approach to care as well as
technological innovations with a focus on maintaining the independence of older
adults in our community for as long as possible.
To sustain and monitor its approach, Mount Sinai established a multi-year action
plan, which measures its progress using a balanced scorecard featuring key metrics
and a benchmarking system that has allowed the hospital to compare its perfor-
mance against regional comparators on a quarterly basis and to identify where fur-
ther improvements can be made.
The Strategy includes a multi-year action plan to evaluate progress and make
refinements using a balanced scorecard and a benchmarking system that allows for
quarterly, regional performance comparators to identify areas of improvement.
Since 2009/10, MSH has seen a 31 % increase in the number of admitted 65
years of age and older adults it serves on an annual basis on its medical units that are
now also operating with eight fewer inpatient beds than 4 years earlier. Over this
time, the hospital has attributed its overall ACE Strategy in allowing it to reduce its
Average Length of Stay (ALOS) per patient by 28.3 % which has subsequently
dropped its average Cost per Case down by 30.9 % and its overall ALOS/ELOS
Ratio from 95.6 to 72.4 %. Its patients are now more likely to go directly home as
well—an improvement from 71.1 to 79.1 %—are 13.4 % less likely to be readmitted
within 30 days and report being more satisfied with the care they are receiving.
Despite the increase in overall patient volumes, its approach which required mini-
mal financial investments but rather a different approach to the way the frontline
staff work, reduced the hospital’s net overall care costs by more than $6.2 million
on its medicine units 2012/13 alone after adjusting for inflation.

Publicize Successes and Engage in Knowledge Translation

and Exchange Activities to Further the Embracement
and Dissemination of ACE Principles

We are often so busy in implementing ACE care principles and practices on a Unit
or across and entire organization that we sometimes forget to stop and take stock of
accomplishments and setbacks that may have characterized the recent journey
towards improving the care of older adults in our organizations.
Through our experience, taking time to reflect and review is enormously helpful
to understand what works and what doesn’t work within a particular institutional
150 S.K. Sinha et al.

setting. This can also inform and shape future implementation practices. When
individuals are recognized for their contributions in championing an initiative,
through announcements or more formal recognition programs and award ceremo-
nies, their recognition will help create further loyalty to the mission, and likely
motivate others to aspire to do the same.
Sharing one’s progress with the hospital or health system leadership, frontline
care providers and beyond can be helpful as well to garner more organizational sup-
port and momentum. We and others have observed this to be an effective way to
identify and develop ACE Champions throughout an organization. Therefore, find-
ing opportunities to publicize successes through internal or external media can help
towards improving an ACE Unit or an ACE Strategy’s overall profile within an
organization. This is especially relevant when much of what the ACE care princi-
ples and practices espouse require a significant shift in the traditional thinking that
still underpins the culture of most of our hospitals. Hospital foundations are finding
that ACE initiatives can provide fundraising opportunities to support innovations in
geriatric care. Therefore, engaging early in philanthropic strategies and opportuni-
ties can also represent a further effective strategy to garner support.
Knowledge translation and exchange activities are another way to share and dis-
seminate best practices and approaches to support the implementation of ACE care
principles and practices. Although conducting formal research and developing for-
mal publications has been helpful in publicizing and disseminating the ACE model,
it is not a requirement to effectively conduct QI initiatives. Nevertheless within
hospitals and beyond at the regional and national levels there are a growing number
of conferences and other forums such as interest groups where learnings can be
shared and networking can occur between organizations that are facing similar chal-
lenges and opportunities.
The annual conferences of the American Geriatrics Society (AGS), NICHE, and
others have provided excellent forums for knowledge exchange and dissemination.
The Ontario Hospital Association in Canada also organizes an annual Senior-
Friendly Hospital conference as well. More specific forums for those interested in
learning more about the ACE approach to care, as well ACE teleconferences and
webinars that have allowed others to more easily access knowledge translation and
exchange activities are also being organized. These forums are becoming vital for
those in the early stages of adopting and implementing ACE approaches to care.
As the number of ACE Units and organizations implementing broader ACE
Strategies expands, a critical mass of more experienced organizations able to pro-
vide advice and coaching or other forms of support is being developed. The
Medicare Innovations Collaborative (MED-IC) represents one of the first coaching
collaboratives where hospitals interested in implementing geriatric and palliative
models of care including ACE could receive intensive coaching and support from
model of care experts [54]. While there are broader aims to develop a more formal
network of ACE Units and hospitals interested in advancing ACE care principles
and practices, through a train-the-trainer approach, more informal networking,
coaching, and materials sharing efforts have still been found to be valuable for those
in the early stages of implementation.
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 151

Embracing Diversity and Cultural Understanding

in the Delivery of Safe and Quality Patient
and Family-Centered Care

The patient- and family-centered approach to health care delivery has sought to
redefine the relationships between patients and health care providers. The ACE
approach has always embraced families and caregivers as being part of the inter-
professional team. This approach actively encourages patients, their families, and
caregivers to play a supportive role in their own care or the care of the patient, and
in actively participating in comprehensive discharge planning processes to promote
more durable discharges.
Ethnogeriatrics refers to the delivery of culturally sensitive and appropriate
health care for older persons from diverse ethnic populations. ACE Units and hos-
pitals in general across North America are seeing an increasing trend towards treat-
ing an increasingly diverse population principally due to evolving immigration
patterns. The U.S. Census from 2010 showed Latinos (16.9 %) now represent the
largest ethnic minority group, followed very closely by African Americans (13.1 %)
and Asians (5.1 %). In focusing on the Latino population alone, we know that unlike
African Americans they are more likely to feel more comfortable communicating
around their health issues in a language other than English. This has particular
implications in the Southern and Western United States which now have the highest
numbers of Latino elders over 85 years of age [55]. Furthermore, in some larger and
urban centres like Toronto, health care institutions have indicated their need to com-
municate with their patients in over 170 languages in a given year.
Furthermore, ethnic minorities, which now represent 37 % of the US popula-
tion, are projected to comprise 57 % of its population by 2060, while their absolute
numbers will be more than double from 116.2 million to 241.3 million over the
same period. Of those projected to be 65 years of age and older in 2060, 56 % are
expected to be non-Hispanic white, 21.2 % Hispanic, and 12.5 % non-Hispanic
black, while the rest will likely represent an even more culturally diverse group that
we know today.
As hospitals are increasingly embracing patient safety and quality initiatives, we
are coming to realize that the ability to deliver high quality patient- and family-
centered care will depend on our ability to communicate and work with patients in
culturally sensitive and appropriate ways as well. Given their existing focus on pro-
viding patient- and family-centered care, ACE Units can serve as ideal vehicles to
foster cultural competence in the care being provided. In those hospitals that aim to
develop a broader ACE Strategy—embedding a focus on the importance of cultural
competence into broader patient- and family-centered care initiatives can also help
to ensure that these initiatives meet with greater acceptance and success especially
in culturally diverse patient environments.
Cultural competence has been recognized as an important goal of inpatient units
[56]. Language services for patients and their families are vital to providing patient-
and family-centered care. Some notable examples include the USCF ACE Unit in
152 S.K. Sinha et al.

Table 8.5 Culturally competent ACE unit patient- and family-centered care practices
Health literacy and language support
The Cultural Ambassador program was established to increase the ability of the bedside nurse to
give health care in ways that are acceptable and useful to older persons that is congruent with
their cultural background and expectations [58]
Training frontline provider to recognize flags for low health literacy in older adults and their
families—especially from those whose preferred language of communication is important [59]
The appropriate utilization of professional trained medical interpreters or interpretation services
should be encouraged
Nutritional support
Diets should be liberalized based on cultural preferences. Families can provide food and work
with dietician to provide appropriate textures
Spiritual care and advance care planning
Training for frontline providers should be pursued to understand the relevant and possible
cultural values and beliefs of those ethnocultural groups being served on and ACE Unit or
across and organization. This could include understanding spiritual and religious beliefs that
may influence care are understood early in the admission and that perceptions around advance
care planning and end-of-life rituals are appreciated as well. Ensuring access to appropriate
spiritual care supports can also aid the work of frontline practitioners in supporting their older
patients, their families and caregivers [60]

San Francisco which serves large numbers of seniors from East Asia, Russia, and
Italy as well as the Christus Santa Rosa ACE Unit in San Antonio which serves
large numbers of Hispanic elders [57].
Table 8.5 describes three examples of how ACE Units and hospitals can deliver
more culturally competent patient- and family-centered care.

Case Study: Implementing a Culturally Competent ACE Unit

Delirium Prevention Protocol at Christus Santa Rosa Medical
Center, San Antonio, Texas

Christus Santa Rosa Medical Center in San Antonio recently partnered with the
University of Texas Health Sciences Center to open the first ACE Unit in Southern
Texas in 2010. According to the 2010 US Census, while this region serves a large
Mexican American Community that makes up close to 38.2 % of the area’s popula-
tion, this number rises to 63.2 % in San Antonio [61].
In establishing its ACE Unit, the development of delirium prevention and educa-
tional initiatives were prioritized. In identifying the need to address language barri-
ers and to encourage the greater involvement of families and caregivers in delirium
prevention activities, the ACE Unit staff decided to develop bilingual protocols,
materials, and communication boards to better engage patients, families, caregivers,
and staff in preventing delirium. Engaging families and caregivers through focus
groups allowed the ACE Unit staff to develop accessible and easy-to-use resources
tailor to them in both English and Spanish.
8 How to Use the ACE Unit to Improve Hospital Safety and Quality… 153

This ACE Unit’s approach fully engages interested families and caregivers as
true members of the ACE Unit care team, by encouraging them to be educated in the
hazards of hospitalization that can lead to delirium and how they can support their
loved ones by supporting cognitive stimulation, early and safe mobilization, nutri-
tional support, etc. Furthermore, families and caregivers are allowed to sleep in the
room with those they are caring for, and to participate in care planning meetings
with the ACE Unit team as is required. The bilingual communication boards previ-
ously mentioned also helps to remind families and caregivers to bring in hearing and
visual aids, to encourage mobilization and to engage in cognitive stimulation activi-
ties as well with the older adults they are caring for. Upon discharge a bilingual
trained nurse is designated to speak with patient and their families and caregivers in
their preferred language to be certain that discharge information and next steps are
This QI nursing-led project ensures that all nursing staff consistently conduct
delirium screening has improved their recognition of those patients with cognitive
impairments. There has been an improvement in early mobilization activities and
the proactive use of hearing and visual aids as well. Delirium screening and
detection has improved through the consistent use of the CAM that has allowed
medical and other providers to better engage around detecting and managing
delirium [62].


The aim of this chapter was to demonstrate how ACE Units can serve as powerful
vehicles through which patient safety, quality improvement, and culturally compe-
tent care principles can be implemented and disseminated throughout an
Increasingly, the work conducted on ACE Units is finding relevance to the way
care across an entire hospital or health system will need to evolve. This chapter
provided guidance on how ACE Units can also be thought of as “starting points”
towards the development of hospital-wide patient safety and quality improvement
efforts. Inter-professional team-based approaches are necessary to effectively
implementing and disseminating these initiatives.
The growing interest in the cost benefits of ACE Units may lead to broader
uptake of ACE care principles and practices over the coming decade. In this chap-
ter we have presented several implementation strategies. Building the leadership at
both the organizational and frontline levels will also be necessary to effect system-
wide change. Active engagement of frontline care providers, patients, families,
and their caregivers can further transform care. Finally, better efforts to support
knowledge translation and exchange at regional and national levels will be wel-
come to support more hospitals and health systems to implement ACE approaches
to care.
154 S.K. Sinha et al.


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Chapter 9
ACE Unit Business Model

Kyle Allen, Peter DeGolia, Susan Hazelett, and Diane Powell

Abstract Building the business case for an Acute Care for Elders (ACE) Unit is
one of the key steps in ACE Unit development and follows the same steps as the
ABCs of ACE Unit implementation; agree, build, commence, document, evaluate,
and feedback. Essentially, ACE provides cost stabilization and quality standardiza-
tion in the era of value-based purchasing. To get “the agree” you must demonstrate
the scope of the problem and present the evidence base showing how ACE care
model has been shown to improve outcomes in randomized trials. However, this is
not sufficient in today’s value-based healthcare market place, a health system envi-
ronment of multiple, competing demands for limited capital. You must demonstrate
the financial benefits in addition to the impact on quality. The next step is to con-
struct a business plan to show the improvement in cost savings and cost efficiency
at your institution. In this chapter we provide the language you will need to know
when talking to stakeholders, particularly in finance and administration, as well as
an example pro forma which you can replicate to build a business plan to open an
ACE Unit at your institution. Using the principles and practices within the ACE

K. Allen, D.O., A.G.S.F. (*)

Department of Lifelong Health and Aging Related Services, Riverside Health System,
12200 Warwick Boulevard, Suite 490B, Newport News, VA 23601, USA
e-mail: Kyle.allen@rivhs.com
P. DeGolia, M.D.
Department of Family Medicine, University Hospitals Case Medical Center,
11100 Uclid Avenue, Cleveland, OH 44106, USA
e-mail: Peter.degolia@UHhospitals.org
S. Hazelett, B.S.N., M.S.
Seniors Institute, Summa Health System, 75 Arch Street, Suite G1,
Akron, OH 44304, USA
e-mail: hazelets@summahealth.org
D. Powell, B.S./A.C.C.
Department of Financial Analysis, Summa Health Systems,
168 East Market Street, Akron, OH 44308, USA

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 157
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_9,
© Springer Science+Business Media New York 2014
158 K. Allen et al.

model will help your institution achieve the three part aim (http://www.ihi.org/
offerings/Initiatives/TripleAim/Pages/default.aspx, Accessed 13 Aug 2013) of
improved experience, decreased cost, and increased quality.

Keywords Business case • Pro forma • Cost-effectiveness • Finances • Cost sav-

ings • Contribution margin


ACE Acute Care for Elders

ACH Akron City Hospital
ACOs Accountable care organizations
ALOS Average length of stay
CMS Center for Medicare and Medicaid Services
CNS Clinical nurse specialist
DRG Diagnosis-related group
HAC Hospital-acquired conditions
HCAHPS Hospital consumer assessment of healthcare providers and systems
IOM Institute of Medicine
NP Nurse practitioner
OIG Office of Inspector General
OT Occupational therapy
PT Physical therapy
SHS Summa Health System
VBP Value-based purchasing

Using the “ABCs” to Build the Business Case

Building the business case for an ACE Unit is one of the key steps in the Agree section
of the ABCs of ACE Unit implementation; agree, build, commence, document, evalu-
ate, feedback, and grow. The business case may be the most difficult thing to do for
some clinicians who may lack any formal training in finance or business plan develop-
ment. Clinicians and providers interested in ACE Units will clearly understand the
clinical virtues of an ACE Unit. Making the clinical and quality case for the ACE model
of care will be almost effortless for healthcare providers who are passionate about
improving older adult care. However, they must realize that to be successful in getting
an ACE Unit established and in bringing forth a new innovation that some stakeholders
may see as disruptive or at odds with other health system priorities, the business case
must clearly illustrate the interdependence of the cost savings, value, and quality. This
may require finding team members or third party professionals with financial and busi-
ness planning expertise who can help “translate” the clinical values to measureable
financial outcomes. The following outlines sequential steps in this process.
9 ACE Unit Business Model 159


Present the ACE Mission and How It Is Consistent

with the Mission of the Health System

The first step in obtaining “the agree” is to present the ACE mission to key stake-
holders. The ACE Unit’s mission is to provide the highest quality, compassionate
care using a specialized ACE model to serve the healthcare needs of the older adult,
their families, and our community. Stakeholders must agree that the mission of the
ACE Unit supports the overall mission of the institution. For example, a health sys-
tem’s mission could be “to provide the highest quality, compassionate care to its
patients, and contribute to a healthier community”. The ACE Unit supports this
mission by providing evidence-based geriatric care that optimizes outcomes for the
elderly population.

Demonstrate the Need

In 2010 there were 40.4 million Americans aged 65 and over. This number is
expected to rise to 55 million in 2020, then 72 million in 2030 [2]. The elderly
account for 31 % of all healthcare spending, much of that in the acute care setting
[3]. Indeed, compared to their younger counterparts, people over the age of 65 are
three times more likely to be hospitalized (3,395/10,000 vs. 1,149/10,000) and have
longer lengths of stay (5.6 days vs. 4.8 days) [2]. Much of this can be attributed to
the fact that 92 % of older adults have at least one chronic medical condition and
77 % have more than one [4]. Chronic medical conditions account for 75 % of
healthcare spending in the USA. These elderly chronically ill patients present with
multiple needs that, if left unmet, will result in functional decline and other adverse
outcomes at discharge [5]. Common adverse outcomes in frail elders related to a
hospital stay include functional decline, delirium, undernutrition, polypharmacy,
and other iatrogenic events [6–10].These adverse events, many of which are pre-
ventable, contribute to increased morbidity, increased risk of temporary or perma-
nent institutionalization for patients who were able to live at home prior to
hospitalization, and higher costs. In 2001 the Institute of Medicine (IOM) Report
Crossing the Quality Chasm: A New Health System for the 21st Century [11] high-
lighted the fact that our current healthcare system is not equipped to consistently
deliver evidence-based medicine to complex older adults with multiple chronic
conditions. Indeed the rate of adverse events in hospitals is 1 in 7 (13.8 %) [12].
A recent 2008 OIG report showed that 27 % of older adults who experience an
adverse event in the hospital “cascade” to having multiple events, which cumula-
tively impacts the older adult patient often leaving them too impaired to return to
their pre-hospital functional status and living condition. All too often, these patients
160 K. Allen et al.

Table 9.1 Definition of terms used in defining the business case for hospital-based geriatrics
Variable cost Costs related to direct patient care (salaries of unit staff, supplies,
drugs, implants, labs, imaging, room and board, surgery, PT,
OT, etc.)
Total variable costa Total variable cost per patient day × number of eligible
patients × average length of stay
Gross charge Accumulation of charges set by an institution for each service
Deductionsb The difference between payments received and charges billed
Net revenue Payments received—including payer settlementsc
Direct costs Department overhead (i.e., fixed labor costs, depreciation of
equipment, dietary services, environmental services, plus
variable costs)
Contribution to overhead Net revenue minus direct costs
(also known as the
contribution margin)
Indirect costs Corporate overhead (i.e., human resources, finance, insurance,
taxes, information technology services)
Net income Contribution to overhead less indirect costs
The greatest impact of ACE is on variable costs, especially from decreased length of stay and
fewer unnecessary procedures
Deductions may become a greater issue in the future as Medicare denies payment for certain iat-
rogenic illnesses and 30-day readmissions. ACE improves both of these
As payments from Medicare go down hospitals will have to decrease direct costs to have a positive
margin. ACE decreases direct costs through its effect on variable costs

are readmitted shortly after being discharged, leading to a downward spiral of

declining health and function. This cycle can be interrupted with treatment on an
ACE Unit where functional decline is minimized, preventative strategies are maxi-
mized, and avoidable readmissions are prevented. In these days of accountable care
and value-based purchasing (VBP), where Medicare rewards hospitals that provide
high quality care for their patients rather than just paying them for the quantity of
services they provide, any intervention that can decrease costs and improve both
processes of care and patient outcomes will help build the business case for the
ACE model.
After demonstrating the need in the new, valued-based healthcare environment,
you will have to make the business case for your individual institution which is
very dependent on quantitative data. You will need to know the number of patients
>65 and their most common DRGs, ALOS, indirect costs (see below), 30-day read-
mission rate, rate of hospital-acquired conditions (HAC), and discharge disposi-
tion. You will also need to know patient satisfaction and Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) scores [22] which
add to the value statement. You may also want to examine your payer mix which
can help you find opportunities. You will need to calculate how your ALOS com-
pares to the Medicare geometric mean LOS per DRG, average revenue per case,
indirect costs, contribution margin and average direct costs per case (see Table 9.1,
above “Build” for definitions of terms).
9 ACE Unit Business Model 161

Evidence-Based Geriatric Care Models

Serve as Cost “Stabilization Wedges”

• ACE units
Cost with care • ACE/Geri Consults
12 • Care Transitions
as usual
Health Care Costs

• ACE Tracker
10 • NICHE
• HELP Program
8 Stabilization Triangle • PACE Program
• Medical Home

Continuing Health Care Expenditures

2000 2010 2020 2030 2040 2050 2060

Fig. 9.1 Cost stabilization. Modified from Pacala, Socolow. Science 2004; 305: 968–72, with
permission. Modified version used with permission of Dr. M. Malone

Discuss Benefits to Patients, Provider, and the Health System

Once the need is demonstrated and the impact is quantified, the next step in obtain-
ing “the agree” from hospital administration is to clearly lay out the scope of the
problem—and the solution which ACE provides. Administrators must understand
that older patients as well as those with chronic and complex illness are going to
comprise a large and ever growing percentage of their inpatient population, yet they
can expect decreasing Medicare reimbursement and increased quality requirements.
Unless care is taken to attend to older adult’s special needs, the hospital will face
serious negative financial consequences. ACE Units will not necessarily provide a
means for increased incremental volumes and margin, however the value proposi-
tion for the hospital is that it will improve cost-effectiveness, decrease variable
costs, and improve outcomes (Fig. 9.1). Geriatric syndromes like falls, polyphar-
macy, pressure ulcers, delirium, and catheter-acquired infections are all too com-
mon in the hospital and require preventative and process improvement interventions
to prevent their occurrence. Many of these are directly or indirectly tied to VBP and
penalties hospitals can face with HAC. In preventing these events, variable costs
will decrease through shorter lengths of stay, fewer unnecessary labs, fewer unnec-
essary procedures, decreased never events or HACs, and increased safety. By estab-
lishing an ACE Unit model of care, the hospital provides a properly adapted
environment, improved processes, and specialized staff to minimize these iatro-
genic events. The improved quality and coordination of care has additional second-
ary benefits for the health system including decreased nursing staff turnover,
162 K. Allen et al.

increased patient and family satisfaction which results in a more positive public
image, improved HCAHPS survey scores which are aligned with VBP and account-
able care, fewer HAC, and minimized penalties under value-based purchasing. The
ACE Unit will afford improved efficiencies, such as decreased lengths of stay, just
as health systems struggle with decreasing reimbursement and the need for improved
throughput efficiency.

The Evidence Base for Improved Outcomes Associated

with ACE

There are numerous randomized trials that demonstrate that ACE Unit care has a
positive impact on processes of care, prescribing practices, physical function,
patient and provider satisfaction, patient health outcomes, institutionalization, and
costs [13]. A recent Health Affairs article summarizes the results of three of the
earliest ACE Unit randomized trials [14]. The first trial [15] increased function and
discharges to home without increasing costs and the second [16] improved pro-
cesses of care and patient satisfaction without increasing costs. The third [14] pro-
duced shorter hospital stays and maintained patients’ functional status at lower cost.
All three studies showed shorter length of stay (although it was statistically signifi-
cant only in the third study) which should translate into lower costs. Likewise, a
recent meta analysis of randomized trials of comprehensive geriatric assess-
ment wards [17] (which includes ACE Units) and comprehensive geriatric
assessment teams found better patient outcomes such as living at home, improved
cognition, and less death or deterioration compared to usual care; however, due to
the heterogeneity of the trials no conclusion could be drawn regarding the effect on
length of stay. Another meta-analysis [18] of randomized trials comparing units
using one or more components of the ACE model to usual care found that acute
geriatric care was associated with fewer falls, less delirium, less functional decline
fewer discharges to a nursing home, more discharges to home, shorter length of stay,
and lower costs.
A 2006 retrospective case controlled study on the cost-effectiveness of ACE Unit
care found that ACE was associated with a mean length of stay that was 1 day
shorter, the mean cost for ACE Unit care was 9.7 % lower, ACE care lowered costs
21 % over the year, and ACE was associated with an 11 % lower annual readmission
rate [3]. A more recent retrospective cohort study [13] found that the mean variable
direct cost per patient was $2,109 for ACE compared to $2,480 for patients in usual
care, saving $371 in direct costs per patient (p = 0.009). This study also showed that
fewer ACE patients were readmitted in 30 days (7.9 % for ACE vs. 12.8 % for usual
care, p = 0.02).
Unfortunately, the business case will still have to be made to health system
administrators to convince them to invest in an ACE Unit since such an investment
can be seen as a leap of faith [14]. Ironically, some critics and policy officials feel
the evidence is so strong that they wonder why there are not more ACE Units. One
concern might be the lack of geriatricians to staff the ACE Unit and to train the ACE
9 ACE Unit Business Model 163

team (although training could be done online). Another might be that the ACE Unit
would not function at full bed occupancy (requiring careful projections of the num-
ber of beds per unit). Alternatively, the ACE Unit could be too full, requiring older
adult patients to be admitted to other hospital units (mobile ACE teams might miti-
gate this problem, as would spreading ACE throughout the entire hospital). Finally,
some might argue that it would be more cost-effective to use ACE teams rather than
build an ACE Unit; however, meta-analyses suggest that ACE Units are more effec-
tive than mobile ACE teams [17]. All this evidence posits the question as to why the
ACE model of care has not become THE standard of care for a “unit-based” model
of care. It is cost-effective and improves quality and mortality. It is puzzling why
this transformation seems slow, but one strong accelerator for this type of transfor-
mational change is a good business case. Policy too needs to change to provide the
incentives for making the changes.

ACE in the Era of Accountable Care

and Value-Based Purchasing

It is not enough in this era of accountable care to show that you have decreased
costs. Of equal importance is whether you have improved quality. ACOs create
financial incentives for healthcare providers to work together across settings through
the Medicare Shared Savings Program which will reward ACOs that lower their
growth in healthcare costs while meeting performance standards on quality of care
[20]. An ACE Unit will help the ACO meet its objectives by preventing iatrogenic
illness, improving patient function, decreasing institutionalization, and improving
continuity of care.
Let’s take falls as an example of how an ACE Unit can benefit an ACO. The
American Geriatrics Society recommends that all people over the age of 65 be asked
on a yearly basis whether they have fallen in the last year [21]. ACOs have adopted
this recommendation and a yearly falls screening is one of the 33 quality indicators
ACOs must meet to be eligible to participate in shared savings. The ACE Unit not
only screens for falls risk, but it also employs high-risk medication review, early
mobility, decreased use of tethers, and an older adult-friendly environment to
decrease falls. The same can be said for other issues that are specifically impacted
upon by ACE interventions. For example, all patients are screened for depression
and tobacco use upon admission to the ACE Unit, both of which are quality indica-
tors for the ACO. The ACE Unit also emphasizes preventive health, especially with
respect to immunizations for influenza and pneumonia. Further, the pharmacists and
geriatricians on the ACE Unit use the results of the comprehensive geriatric assess-
ment and team process to ensure that patients are managed and discharged with
evidence-based therapies to optimize prescribing. These would include aspirin ther-
apy in diabetics, beta-blocker therapy post-MI, drug therapy for lowering LDL cho-
lesterol, and angiotensin converting enzyme inhibitor or angiotensin receptor
blocker therapy for patients with coronary artery disease and diabetes and/or left
164 K. Allen et al.

ventricular systolic dysfunction. The ACE Unit will also support the ACO in
meeting its patient experience quality indicators since ACE Units consistently have
shown improved patient satisfaction.
Apart from ACOs, the Center for Medicare and Medicaid Services (CMS) reim-
bursement policies for hospitals will soon negatively impact those with poor quality
by way of VBP [19]. Through VBP, Medicare rewards hospitals that provide high
quality care for their patients rather than just paying them for the quantity of ser-
vices they provide. With VBP hospitals will receive incentive payments from
Medicare based on either how well they perform on specific quality measures or
how much they improve their performance on specific measures compared to their
baseline rates. VBP scores clinical processes of care and patient experiences of care,
e.g., HCAHPS. ACE Unit interventions directly impact several of these HCHAPS
measures which will position the institution to receive their payment incentive.
Measures impacted by ACE include nurse communication, doctor communication,
hospital staff responsiveness, pain management, medicine communication, hospital
cleanliness and quietness, discharge information, and overall hospital rating.


Learn the Language

Most clinicians are strangers to the world of finance. In order to be able to commu-
nicate effectively with finance administrators, you will have to learn the correct
language to use. It is also imperative that a person from the institution’s finance and
business office be involved in the early ACE development or steering committee.
This person can help create the correct language and illustration for the business
case for the ACE Unit. Before we begin looking at the pro forma for ACE Unit
implementation, let us first become familiar with the terms you will need to under-
stand (see Table 9.1). Understand that cost categories between institutions may vary.


The Business Model

The model outlined below is based on Summa Health System’s ACE Unit and the
data is from 2009. Summa Health System (SHS) is a three-campus hospital system.
Summa is one of the largest organized delivery systems in Ohio. Encompassing a
network of hospitals, community health centers, a health plan, a physician-hospital
organization, research and a foundation, Summa is nationally renowned for excel-
lence in patient care and for exceptional approaches to healthcare delivery and clini-
cal research.
9 ACE Unit Business Model 165

Summa’s ACE Unit was established in 1994 at Akron City Hospital (ACH) as
part of a randomized trial supported by the Summa Health System Foundation.
Akron City Hospital is the flag ship tertiary regional medical center that is a level
I trauma center, major teaching hospital and site of most of the geriatric and pal-
liative care medicine services. As Summa and the ACE teams gained experience
the health system wanted to see expansion of the model. In 2007 Summa pur-
chased a local community hospital in a neighboring community as part of a growth
The model below demonstrates the potential costs and savings based on the
performance of matched patients on Summa’s ACH ACE Unit compared to medi-
cal/surgical patients from the newly acquired community hospital in the health
system that did not have an ACE Unit, nor any formal geriatric (nursing or medi-
cal) services, programs, or training. Summa compared all medical MSDRGs for
patients >65 years old admitted and discharged from the two units in 2009 (exclud-
ing critical care and telemetry transfers). Summa compared the number of cases,
the average age, average length of stay, total charges, deductions, total revenue,
total direct costs, % contribution to overhead, total indirect costs, net revenue, %
net revenue, and case mix index. The data assumes a 75 % capture rate of the ACE
eligible population for the hospital not having an existing ACE Unit. The financial
data presented is based on 2009 patient population with cost allocations in place as
of July 2010.


Table 9.2 shows that total variable cost per patient day were lower on the ACE Unit
than the comparable usual care medical/surgical unit. This can be attributed to many
aspects of ACE care that decrease the components of variable costs including:
1. Fewer medications since ACE Unit staff target and reduce polypharmacy and
iatrogenic events
2. Fewer supplies since ACE Unit staff minimize the use of such supplies as Foley
catheters, restraints, and IVs
3. Fewer labs since fewer iatrogenic events, defined goals of care and appropriate
evidence-based care
4. Lower room and board charges linked to decreased length of stay

Table 9.2 Comparison of two hospitals without and with Acute Care for Elders Units
Hospital A without Hospital B with
ACE n = 1,543 ACE n = 1,543 Difference
Total variable cost per patient day 411 326 85
Average length of stay (days) 4.42 4.22 0.2
Total variable cost 2,804,408 2,123,297 $681,111
166 K. Allen et al.

Table 9.3 Net cost savings opportunity for a hospital which deployed an ACE Unit when
compared to usual care
Year 1 Year 2 Year 3
Total ACE Unit cost savings opportunity 681,111 681,111 681,111
Professional support staff 279,808 247,253 242,133
Net cost savings opportunity 401,303 433,858 438,979

Table 9.4 Training and support costs for an Acute Care for Elders Unit
FTE Hours
Training CNS (2 weeks on an established ACE Unit) 80
Needs assessment by CNS 10
Year 1 ACE team prep by CNS (5 h/month) 60
Total CNS support hours—Year 1 0.072 150
CNS contract management support (5 h/month)—Year 2 0.029 60
CNS contract management support (5 h/month)—Year 3 0.029 60
Medical Director
Training 10
Needs assessment 5
Contract management support (5 h/week) Year 1 260
Total Medical Director support hours—Year 1 0.132 275
Medical Director support hours (5 h/month)—Year 2 0.029 60
Medical Director support hours (5 h/month)—Year 3 0.029 60
System level administrative support
Support (1 h/week)—Year 1 0.025 52
Support (1 h/week)—Year 2 0.025 52
Support (1 h/week)—Year 3 0.025 52

5. Fewer procedures linked to more appropriate use based on patient goals (e.g.,
avoiding G-Tube in end stage Alzheimer’s disease) and decreased iatrogenic
6. Decreased staff turnover, so less money spent on training
7. Decreased costs due to improved risk management
Lower length of stay on the ACE Unit also contributes to a lower total variable
cost which is calculated as; total variable cost per patient day × average length of
stay × number of patients. Subtracting the total variable costs of the ACE Unit from
the total variable costs of the usual care unit gives the cost savings opportunity. This
represents the amount of costs that the usual care unit could save if it were to imple-
ment an ACE Unit.
This cost savings opportunity does not include the start-up and operating costs
associated with opening an ACE Unit. Table 9.3 shows the net cost savings opportu-
nity when the cost of the ACE Unit clinical nurse specialist, physician, and NP provid-
ers and training and support of the main hospital staff are included in the cost savings
consideration. Note that this does not include the cost of renovation, if necessary.
Table 9.4 shows how the training and support costs used in Table 9.3 were calculated.
9 ACE Unit Business Model 167

The ACE interdisciplinary team is led by the Geriatric Clinical Nurse Specialist
and geriatrics trained or knowledgeable Medical Director. Some newer ACE models
are using hospitalists who have had formal training and experience in geriatric
medicine. Other members of the team include the pharmacist, a dietician, a physical
and/or occupational therapist, and a social worker. These costs for the time spent
with the team must also be accounted for, however these costs are minimal. The
simplest way is for the various departments to agree to pay for the 1 h 5 days per
week team meetings. Though hard to measure, interdisciplinary team members
reported improved efficiency in the rest of their job attributable to attendance at the
team, so there is a value to the individual departments in having members attend
ACE rounds by generating improved communications and productivity.


Table 9.5 shows the profit and loss estimates with and without an ACE Unit after
factoring in the net cost savings opportunity. This table assumes that you have cap-
tured 75 % of the eligible ACE population. As can be seen, the ACE Unit primarily
affects net income through its effect on total direct costs, which, in turn, are affected
by ACE mainly through reduced variable costs. This model assumes that total
deductions which include Medicare penalties are unchanged under the ACE model,
however, with new CMS funding rules a unit such as ACE which can prevent 30-day
readmissions and specific “never events” (such as urinary tract infections or decubi-
tus ulcers) may have a large impact on deductions in the future. These impacts are
hard to calculate but can be roughly estimated using observed reductions, pre- and
post-comparisons, and estimates of observed vs. actual penalties per case. Table 9.6
shows the beds needed for varying occupancies.

ACE Teams vs. an ACE Unit

While mobile ACE Teams have not been shown to be as effective as ACE Units,
some institutions have chosen to provide ACE programming through venues other
than a specific medical/surgical unit. The key benefits of ACE Teams include being
simple and efficient, cost-effective, and quick and easy to start up. The principle
costs associated with this approach are education and training, as well as staffing.
ACE nursing protocols are readily available and staff can be trained to implement
and monitor them. Training of new nurses and aides follows a similar process as
with a dedicated unit. University Hospitals Case Medical Center employs a Clinical
Nurse Specialist involved in the ACE program to train and orient all new staff.
Ongoing training of geriatric resource nurses (six 4 h sessions done three or four
times a year for Registered Nurses and Licensed Practical Nurses) is carried out at
many NICHE hospitals. This training helps meet the JCAHO standard for age-
specific care training.

Table 9.5 Profit and loss with and without Acute Care for Elders cost savings
Contribution to
Deductions overhead Net income
% of Total net Total direct % Net Total indirect % Net
Total charges Total charges revenue costs Total revenue costs Total revenue
Profit and loss 33,787,802 25,398,978 75.17 % 8,388,824 5,596,409 2,792,415 33.29 % 1,724,725 1,067,690 12.73 %
without ACE
cost savings
Net cost savings 401,303
Profit and loss 33,787,802 25,398,978 75.17 % 8,388,824 5,195,105 3,193,718 38.07 % 1,724,725 1,468,993 17.51 %
with ACE
cost savings
This is based on 1,543 patients with an average length of stay of 4.22 days
K. Allen et al.
9 ACE Unit Business Model 169

Table 9.6 Total beds needed Year 1 Year 2 Year 3

on an Acute Care for Elders
Total ACE eligible patients 1,543 1,543 1,543
Unit to account for varying
occupancy rates Average length of stay 4.22 4.22 4.22
Total patient days 6,507 6,507 6,507
Beds needed assuming 100 % 18 18 18
Beds needed assuming 90 % 20 20 20
Beds needed assuming 85 % 21 21 21

Table 9.7 Contribution margin of Summa Health System—Akron City Hospital compared to the
national average for selected conditions
National average margin Summa’s average margin
DRG on Medicare cases on Medicare cases
127: Heart failure and shock –$1,350 $866
89: Simple pneumonia and pleurisy –$1,517 $620
age >17 with CC
143: Chest pain –$868 $579
88: Chronic obstructive pulmonary disease –$1,330 $410
182: Esophagitis, gastroenteritis, and –$1,162 $668
miscellaneous digestive disorders
age >17 with CC

Existing hospital staff serves as the core team. Nursing, rehabilitation therapy,
social services, and nutrition staff are all active members of the ACE Team. As phy-
sicians are often the one discipline absent from team-based care in the hospital,
geriatricians should be retained to participate on each team. Inclusion of a Clinical
Nurse Specialist with geriatric and palliative care experience as well as routine
interdisciplinary team rounds (1 h twice a week per floor) is the standard of care on
the University Hospitals Case Medical Center ACE Teams. Managing medical or
surgical services often see the team rounds as opportunities to discuss complex or
complicated problems they have not been able to resolve otherwise.
The bottom line is that ACE principles can be incorporated into “usual care” by
hospital staff and within health systems without extensive new costs.

Contribution Margin

Initially, Summa’s ACH ACE Unit outperformed the rest of the hospital with
matched controls. However, overtime the gaps between the ACE Unit outcomes and
other units began to decrease. It was hypothesized that this was a result of “dissemi-
nation” of the ACE principles of care as well as other quality initiatives spurred by
the ACE model that spread to the rest of the facility and led to significant cost sav-
ings in DGRs with high Medicare populations (Table 9.7). In fact multiple other
medical surgical units replicated some parts of the ACE model and interdisciplinary
170 K. Allen et al.

approach to heart failure patients, pulmonary patients, orthopedic patients, and also
stroke (see below). This “ACE culture” of care coupled with other quality initiatives
had a direct impact on profit margins. This is very significant as health systems and
hospitals are seeing and will continue to see declining reimbursement, profit mar-
gins, and increased VBP penalties.


We created an ACE dashboard (Fig. 9.2), the results of which were shared with the
ACE staff monthly via time series graphs displayed on a bulletin board in a promi-
nent location on the unit. Process measures which were tracked included interdisci-
plinary team attendance, patient goals documented, ACE care plan utilization and
compliance, and ACE team suggestions followed. Outcome measures included
restraint use, falls, companion use, HAC, discharges to home with and without
home care, 7- and 30-day readmissions, diagnostic and ancillary costs, and inci-
dence of delirium. Satisfaction scores from patients, families, nurses, physicians,
and team members were also reported.


When the ACE concepts for the care of chronically ill older adults are applied to
other clinical areas, similar excellent results can be obtained. The ACE model prin-
ciples are not good for “just older adults” but an actual evidence-based approach
for caring with anyone with a serious and complex illness. This, then, proposes
another additional value proposition for investment in an ACE Unit and model of
care for the health system. There is the potential to create additional value system-
wide through the deployment of the proven ACE concepts. For example, in 1998
Summa created a Stroke unit using the same ACE concepts of prepared environ-
ment, medication review, early discharge planning, and interdisciplinary team care.
Table 9.8 shows the improvement in variable costs that were observed with the
Stroke unit comparing it to a Premier peer group and to national benchmarks. As
can be seen, mortality, readmissions, and average length of stay were all substan-
tially lower on the Stroke unit. Ultimately variable costs were reduced by 48 %.
Subsequently, the ACE concepts were extended to an ACE pulmonary unit, ACE
gero-psych, acute palliative care, an ACE heart unit, and an ACE orthopedic unit.
Beyond the hospital ACE principles have been extended into our insurance com-
pany’s home care (the STAR team), as well as into several area skilled nursing
facilities (Geriatric Evaluation (or rehab) Management GEM units). We have also
partnered with the local Area Agency on Aging to create a community-based inter-
disciplinary team where AAA care managers can bring complex medical issues to
geriatric medical specialists.
ACE Unit – Dashboard
Process Measures Outcome Measures
Interdisciplinary team attendance Reductions in:
Patient goals documented Restraint use
ACE Team suggestions followed Falls
Companion Use Hospital Acquired Conditions
Discharges to home
with / without home health care
Diagnostics and Ancillary Cost
7 and 30 day readmissions
Incidence of Delirium
Increases in Satisfaction:
Nurses, Physicians and Team Members

Rx Prescribing - High Risk Meds Reduction in IV Cost BEERS Meds

30 3000 15
20 2000 10
10 1000 5
0 0 0
M1 M2 M3 M4 M5 M6 M1 M2 M3 M4 M5 M6 M1 M2 M3 M4 M5 M6
High Risk Meds Average monthly cost (Average per patient/stay)

Restraints/Falls/Companions Bedrest (orders per month?)

40 40

20 20
Patient Satisfaction Index
0 80 0
M1 M2 M3 M4 M5 M6 M1 M2 M3 M4 M5 M6
Restraint Falls Companion Bedrest (orders?)
ACE Unit - Patient Care 30 Falls per month
200 6
M1 M2 M3 M4 M5 M6 4
100 Press Ganey
0 0
M1 M2 M3 M4 M5 M6 M1 M2 M3 M4 M5 M6
IPOC Atten % Doc of Pt. Goal % Falls
Care Plan Comp%
Numbers of HAC’s Length of Stay Foley Days
40 4 400

20 2 200

0 0 0
M1 M2 M3 M4 M5 M6 M1 M2 M3 M4 M5 M6 M1 M2 M3 M4 M5 M6
Nos. of HAC’s Length of stay Foley Days

Fig. 9.2 ACE Unit dashboard

Table 9.8 Ischemic stroke benchmarks 2005–2008a for Summa Health System—Akron City
Hospital compared to a national peer group
Summa Peer group Expected Index
Mortality 5.07 % 6.66 % 8.99 % 0.57 (43 % better)
30-day readmissions 2.0 % 1.9 % 2.52 % 0.8 (20 % better)
Average length of stay 5.1 days 6.4 days 6.6 days 0.77 (33 % better)
Variable cost $2,158 $4,361 $4,495 0.52 (48 % better)
n = 2,524
172 K. Allen et al.

Sustaining ACE Model with Changes

in Leadership/Team Members

It is very important to understand that the ACE model of care when first established
within a hospital becomes “a standard of care,” but is “not the standard of care.”
Thus an ACE Unit and model is always vulnerable to being thwarted by the inertia
of the status quo and requires active energy to maintain and sustain a “change”
model. The perceptions or realities that the standard of care is different on the ACE
Unit can sometimes create concern amongst leaders in administration and the medi-
cal staff. There are several ways to manage this concern. One is to envision and
deploy the first ACE Unit as a “learning laboratory” and alpha site from which to
teach and embed geriatric medicine principles into the hospital and health system.
The ACE Unit can become a living, learning laboratory to teach other staff includ-
ing nurses, social workers, medical students, residents, physicians, and administra-
tors about ACE Unit values and purpose. Then Phase II of ACE would be to design
how to take the principles from that unit and disseminate out to other floors or to use
as training site to create other ACE Units in the same hospital or other hospitals in
the health system. One can also leverage the ACE Unit as a place to design and test
quality improvement initiatives like delirium protocols. Likewise, leaders could
position the ACE Unit and strength of the interdisciplinary team as a quality
improvement pilot and dissemination site.
Another major issue and potential threat to ACE Units is when key leadership
changes either intrinsic to the ACE Unit team. An example of leaders who are key
to the ACE Unit include the advanced practice nurse, unit manager, and medical
director. Likewise, leaders who are extrinsic to the ACE Unit team, but instrumental
in the program’s success include the Chief Nursing Officer, VP of medical affairs or
Chief Medical Officer, and the Chief Operating Officer. Whether there are intrinsic
or extrinsic changes, the ACE Unit champions must return to the beginning of ACE
Unit development and again obtain the “AGREE” from these individuals. These
major stakeholders must be afforded the same process as was initially used to obtain
“the agree” and understanding of the value of the ACE Unit and the vision. They
also must be kept informed of the ACE Unit outcomes and process consistent with


It is of paramount importance to apply business planning and financial principles to

ACE Unit development and implementation. Without the business case, the stron-
gest PowerPoint presentation for improving care for hospitalized older adults will
be ignored. The clinical and quality case now has very strong and high level evi-
dence. The changes in health reform, the market changes in demographic trends,
9 ACE Unit Business Model 173

and the social demand for better quality creates a unique opportunity for geriatric
professionals. Geriatrics leaders must seize the moment to advance patient-centered
clinical programs. Developing the quality and business proposition for hospitals
will lead to overall improved safety and outcomes for older adults.


1. http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx. Accessed 13 Aug 2013.

2. http://www.aoa.gov/AoARoot?Aging_Statistics/Profile/2011/docs/2011profile.pdf.
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ity during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660–5.
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patients. J Am Geriatr Soc. 2000;48:1697–706.
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approach to understanding under-eating in homebound older adults: the importance of social
factors. Gerontologist. 2008;48(2):223–34.
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Crossing the quality chasm: a new health system for the 21st century. Washington, DC: The
National Academies Press; 2001.
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Elders Unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981–7.
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CS. Acute care for elders units produced shorter hospital stays at lower cost while maintaining
patients’ functional status. Health Aff. 2012;31(6):1227–36.
15. Landefeld S, Palmer R, Kresevic D, Fortinsky R, Kowal J. A randomized trial of care in a
hospital medical unit especially designed to improve the functional outcomes of acutely ill
older patients. N Engl J Med. 1995;332(20):1338–44.
16. Counsell S, Holder C, Liebenauer L, Palmer R, Fortinsky R, Kresevic D. Effects of a multi-
component 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 hospi-
tal. J Am Geriatr Soc. 2000;48(12):1572–81.
17. Barnes D, Palmer R, Kresevic D, Fortinsky R, Kowal J, Chren M, Landefeld S. Acute Care for
Elders units produced shorter hospital stays at lower cost while maintaining patients’ func-
tional status. Health Aff. 2012;31(6):1227–36.
174 K. Allen et al.

18. Fox M, Persaud M, Maimets I, O’Brien K, Brooks D, Tregunno D, Schraa E. Effectiveness of

acute geriatric unit care using Acute Care for Elders Components: a systematic review and
meta-analysis. J Am Geriatr Soc. 2012;60:2237–45.
19. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-
20. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Sharedsavingsprogram.
21. http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_
22. HCAHPS. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/
Chapter 10
Models of Care to Transition
from Hospital to Home

Ella Harvey Bowman, Kellie L. Flood, and Alicia I. Arbaje

Abstract The American Geriatrics Society has defined transitional care as “a set of
actions designed to ensure the coordination and continuity of health care as patients
transfer between different locations or different levels of care within the same loca-
tion.” A care transition represents a vulnerable time for older adults, especially
those experiencing cognitive or functional impairment, low health care literacy,
complex multimorbidity, or lack of caregiver support. There is an imminent need to
identify seniors at risk for an adverse transitional care event who would benefit from
targeted strategies to improve outcomes. Outcomes from newly developed transi-
tional care interventions are promising. These models incorporate common themes,
including a patient-centered approach, aggressive medication reconciliation, patient
coaching, and a formalized process for transfer of information across care settings.
New Medicare rules also support the feasibility of implementing a care transitions
intervention. The future will likely see the growth of these models in addition to the
use of new health information technologies as well as interventions originating from
sites of care other than hospitals.

E.H. Bowman, M.D., Ph.D. (*)

Division of General Internal Medicine and Geriatrics, Department of Medicine,
Indiana University School of Medicine, Sidney and Lois Eskenazi Hospital,
720 Eskenazi Avenue, Fifth Third Faculty Office Building, 2nd Floor,
Indianapolis, IN 46202, USA
e-mail: elbowman@iu.edu
K.L. Flood, M.D.
Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama
at Birmingham, 1720 2nd Avenue South, CH-19, Room 219H, Birmingham,
AL 35294-2041, USA
e-mail: kflood@uabmc.edu
A.I. Arbaje, M.D., M.P.H.
Division of Geriatric Medicine and Gerontology, Johns Hopkins University School
of Medicine, Mason F. Lord Building, Center Tower, 5200 Eastern Avenue, 7th Floor,
Baltimore, MD 21224, USA
e-mail: aarbaje@jhmi.edu

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 175
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_10,
© Springer Science+Business Media New York 2014
176 E.H. Bowman et al.

Keywords Care transitions • Models of care • Readmissions • Transitional Care

Model • Care Transitions Intervention® • Re-engineered discharge • Better out-
comes for older adults through safe transitions


In a 2003 position statement by the American Geriatrics Society (AGS), transitional

care was defined as “a set of actions designed to ensure the coordination and conti-
nuity of health care as patients transfer between different locations or different lev-
els of care within the same location” (Fig. 10.1) [1].
Optimal transitional care, comprising both the sending and the receiving features
of the transfer, is essential for patients with complex care needs and is dependent
upon a number of factors that are complementary to the traditional roles of primary
care, care coordination, discharge planning, and case management [3]. A national
study of Medicare beneficiaries found that 22 % experience at least one care transi-
tion over the course of a year. Half of these transitions involved a single hospitaliza-
tion followed by return to the original place of residence, but the remaining involved
a complex sequence of transitions to varied sites of care. Few predominant transition
patterns were present; most patterns were unique, which makes predicting
(and accommodating) patients’ care transitions difficult [4]. The heterogeneity of

Fig. 10.1 Care transitions commonly experienced by older adults in the health care environment
[2]. Reprinted with permission from Geriatrics Review Syllabus: A Core Curriculum in Geriatric
Medicine, 8th ed. New York, NY
10 Models of Care to Transition from Hospital to Home 177

transition patterns of older adults challenges approaches to improving transitions

outcomes, as it becomes inefficient to plan for all possible care patterns, when many
apply to a small number of individuals [2].
Discharge from a hospital is just one example of a health care transition, but these
transitions have gained heightened attention recently because of the focus on quality
and financial imperatives for the US health care system. Approximately 30 % of hos-
pitalized older adults will experience more than one transfer across care settings within
30 days of a hospital discharge, with almost 13 % experiencing 3 or more transitions.
In a 1997 sample of Medicare beneficiaries, 46 distinct care transition patterns were
observed during the 30-day period following hospital discharge [5]. Hence, for many
patients with multiple chronic comorbid conditions and geriatric syndromes, multiple
health care transitions can be an overwhelming flurry of changes for the patients, their
caregivers, and all of their health care providers involved across the continuum.
A widely utilized measure of hospitals’ successful care transitions for patients is
the 30-day readmission rate. A study of 2004 Medicare claims data revealed that
nearly 20 % of discharged beneficiaries were rehospitalized within 30 days; 34 %
were rehospitalized within 90 days. Half of patients discharged back to the com-
munity and rehospitalized within 30 days lacked a documented follow-up visit with
their primary care physician (PCP) prior to rehospitalization. The authors estimated
that the cost to Medicare for these unplanned readmissions in 2004 was $17.4 bil-
lion [6]. However, predicting which patients are at risk for 30-day readmission has
proven difficult. Kansagara et al. studied 26 unique models for predicting 30-day
hospital readmission and found most performed poorly. The authors noted that most
of the models included medical diagnoses as risk predictors, but few contained vari-
ables associated with overall health and function, illness severity, or the social deter-
minants of health [7].
In 2009, the American College of Physicians (ACP), Society of Hospital
Medicine (SHM), Society of General Internal Medicine, AGS, American College of
Emergency Physicians, and the Society for Academic Emergency Medicine pub-
lished a collaboratively developed Transitions of Care Consensus Policy Statement
in an effort to address the well-documented quality gaps in care during a transition
between inpatient and outpatient settings. This policy statement summarized prin-
ciples required for a quality care transition, including accountability, communica-
tion, timely information exchange, patient/family involvement, respecting the hub
of care coordination, providing a medical home for all patients/caregivers, empow-
ering the patient to know who is responsible for their care at every transitional point,
following national standards, and standardizing metrics to enable quality improve-
ment and accountability. Based on these guiding principles, this consensus panel
developed a set of standards describing necessary components for implementation
that included coordinating clinicians, care plans/transition record, communication
infrastructure, standard communication formats, transition responsibility, timeli-
ness, community standards, and measurement [8].
This chapter broadly summarizes these aspects of care transitions, including
a description of various sites of care involved, discussion of patient and system-
based factors contributing to adverse events, suggestion of minimum standards nec-
essary for optimizing care transitions, delineation of the importance of medication
178 E.H. Bowman et al.

management and accurate reconciliation, inpatient- and outpatient-based models

shown to improve care transitions, the role of health information technology in care
transitions, and a summary of potential next steps in care transitions in light of
Medicare rule changes regarding transitions.

Sites of Post-hospitalization Care

Older adults may require varying levels of care before and after hospitalization.
These sites of care include (1) private homes with or without home health or hos-
pice, (2) subacute rehabilitation in a skilled nursing facility (SNF), (3) acute inpa-
tient rehabilitation, (4) long-term acute care hospitals (LTACHs), or (5) long-term
care (LTC) in a facility (Table 10.1).

Table 10.1 Sites of care delivery [9, 10]

Site Care provided requirements Financing
Independent living
• House or • Patients managing ADLs, • Older age for • Self-pay or some
apartment IADLs, and medical care admission to CCFs LTC insurances
with or without home • Home-bound status cover CCFs,
health or hospice and need for skilled paid caregivers
services for home
• Congregate • CCFs often offer group • MD certified • Medicare Part A
care facilities activities and may provide terminal diagnosis covers home
(CCFs: higher level of services and anticipated health and
senior living (meals, medication life-expectancy of hospice
complex, assistance) for additional <6 months for
independent costs hospice
Assisted living facility (ALF)
• Free • Services provided varies, • Need for • Self-pay or LTC
standing or but most offer assist with assistance with insurances
housed in a meals, medications, IADLs and/or • Medicaid waiver
LTC facility housekeeping, laundry, ADLs program
some ADLs, and provide available in
group activities/ some states
• Specialty socialization • Most require • Medicare Part A
Care residents still be covers home
Assisted able to ambulate or health
Living self-propel
Facility wheelchair
(SCALF) for
patients with
10 Models of Care to Transition from Hospital to Home 179

Table 10.1 (continued)

Site Care provided requirements Financing
Subacute care/skilled nursing facility (SNF)
• Free • Skilled nursing or • Documented need • Medicare Part A
standing rehabilitation services such for daily skilled covers up to 100
facility or as IV medications, enteral care following a days (co-pay for
housed tube feedings, wound care, qualifying hospital days 21–100)
within a or physical/occupational stay of at least
hospital or therapy three inpatient
long-term days within the
care facility prior 30 days
• Some may provide
higher levels of care
such as trach/
ventilator care
Inpatient (acute) rehabilitation
• Free • Licensed as an acute • Need for MD • Medicare Part A
standing hospital supervision of care payment based
facility or • Comprehensive rehabilitation • Approved diagnosis on CMS
housed services (physical, and able to tolerate prospective
within a occupational, and speech) and benefit from 3 h payment system
hospital of therapy/day, 5 for rehabilitation
days/week OR, in diagnoses
certain cases, 15 h of
therapy over a 7-day
• Does not require
Long-term acute care hospital (LTACH)
• Free • Licensed as an acute • Need for daily MD • Medicare Part A
standing hospital and skilled care for
facility or • Extended medical care that patients who may
housed requires prolonged services improve with time
within a (e.g., ventilator weaning, • Does not require a
hospital TPN, wound care) preceding
Custodial care/long-term care (LTC)
• Long-term • Comprehensive medical, • Vary by state but • Self-pay, LTC
care facility/ personal, and social in general persons insurance, or
nursing services care no longer able to Medicaid
home live in community • Medicare Part A
due to functional covers hospice
dependencies and/
or chronic illness
ADL activities of daily living, IADL instrumental activities of daily living, CI cognitive impair-
ment, IDT interdisciplinary team, CMS Centers for Medicare and Medicaid Services, TPN total
parenteral nutrition
180 E.H. Bowman et al.

The appropriate site of care following a hospitalization should be determined

based on patient medical and intensity of caregiving needs. Facility and licensed
caregiver services in the home require documentation of need, justification for level
of care, a payer source, and in some settings, documentation of a timely face-to-face
evaluation by the certifying physician.

Factors Contributing to Adverse Events During

Care Transitions

A care transition from a hospital to one of these sites of care represents a vulnerable
time and exposes patients to risks for adverse clinical events, increased health care
utilization, and preventable rehospitalizations [3]. In a 2003 prospective study of
400 patients discharged to home following hospitalization, Forster et al. found 19 %
of patients experienced an adverse event from care management during the care
transition; 30 % of these events were deemed preventable; and 31 % ameliorable.
The authors identified key targets for improvement during a care transition includ-
ing (1) recognition and communication of unresolved problems across care settings,
(2) enhancing patient education and self-management of treatment plans, (3) post-
discharge medication therapy monitoring, and (4) overall clinical condition moni-
toring during the care transition period [11]. A growing body of literature has also
identified several additional patient and system-level risk factors among older adults
for suboptimal care transitions (Table 10.2).
In addition to these risk factors, the traditional fee-for-service payment models
in a fragmented health care environment may discourage providers from spending

Table 10.2 Patient- and system-level factors associated with suboptimal care transitions or early
readmission [2, 11–16]
Patient-level System-level
• Age >80 years • Failure in implementation of plan of care (durable
• Prior recent hospitalization (30 days) medical equipment, home health care, follow-up
• Longer hospital length of stay appointments, medications, tests)
• Increased number of comorbidities • Communities with high hospital admission rates
• Functional disability • Patient having a usual place to receive health care
• Unmet functional needs • Homelessness
• Male gendera • Lack of discharge education
• Older age
• Insufficient communication across care settings
• Member of racial/ethnic minoritya
• Unmarrieda
• Low income
• History of depression
• Living alone
• Lack of self-management ability
• Limited education
• History of substance abuse
• Lower self-reported health status
Mixed results in the literature
10 Models of Care to Transition from Hospital to Home 181

the time required to collaboratively develop an optimal care transition plan and
therefore unintentionally contribute to adverse events experienced by the
patients discharged to home [11]. Disease-based models of inpatient care and
reimbursement leads to some patients too frail to return home but also no longer
“qualifying” for inpatient or rehabilitation settings and therefore at risk for a
vulnerable care transition and unplanned readmission. Uninsured patients have
even fewer post-hospital care options.

Common Themes in Optimal Care Transitions

A well-documented and comprehensive plan of care and communication transfer, as

well as the availability of health care providers trained in caring for patients with
complex needs, is the central backbone of the care transition. Furthermore, the
health care practitioner will ideally have some knowledge about the patient’s goals
of care, preferences, and current clinical status as well as baseline level of functioning.
Finally, the transition should also take into account the logistical arrangements, care
coordination by all health care professionals involved in both sides of the transition,
and also address the need to educate both patient and family or other involved care-
givers. The ideal transition of care thus offers an interdisciplinary approach to
address the patient’s individualized care needs, provides accurate and timely medi-
cation reconciliation accounting for changes made during the transitional care event,
engages patients and families throughout the transitional process using techniques to
verify that instructions are understood, and emphasizes the timely and accurate pro-
vision of information to the providers at the receiving site of care. This process has
been described as “the Discharge Transitions Bundle” [17].

Communication Across Care Settings

Studies reveal delayed or incomplete transfer of clinical information to PCPs fol-

lowing a hospitalization is common and may contribute to medical errors and rehos-
pitalizations [18, 19]. A successful transition from hospital to a new care setting
requires efficient, accurate, and timely communication of hospital discharge
information from the sending to the receiving care providers. A systematic review
of communication regarding a patient’s hospitalization found that only 12–34 % of
PCPs received a discharge summary by the time of the patient’s first post-
hospitalization follow-up appointment. Additionally, hospital discharge summaries
frequently lacked information essential to a safe care transition including discharge
medications, tests pending at discharge, and counseling provided to patients and
families [20]. To address information transfer, many of the studied care transitions
interventions utilize a brief personal health record with vital medical and hospital-
ization information that is transported by the patient across care settings.
182 E.H. Bowman et al.

Patient/Caregiver Self-Management

Patient activation, or one’s ability and willingness to manage their own medical
problems and health care, is increasingly recognized as a factor in health care utili-
zation, costs, and outcomes. According to a 2007 survey conducted by the Center
for Studying Health System Change, only 41 % of US adults are highly activated in
their health care [21]. Lack of self-management ability has been identified as a risk
factor associated with early rehospitalization among Medicare beneficiaries [14].
During a care transition, the only person(s) who are present at all points in time
across all settings are the patient (and possibly informal caregivers). The concept of
patient activation is seen in many of the studied care transitions interventions
through the use of “coaching” patients and caregivers. Various methods of patient
coaching have been employed, including the use of personal nursing coaches or
checklists that the patient can use to be reassured they are transitioning with the
critical information they need to accurately follow through with the next stage of
their health care [22]. One of the most often used tools is Eric Coleman’s Discharge
Preparation Checklist® (Fig. 10.2) [23].
How information is communicated to patients and families is important. Despite
elders often reporting comprehension of discharge plans, many factors combine to
hinder patient understanding and adherence, including cognitive impairment,
functional illiteracy and low health care literacy, multimorbidity, cultural barriers,

Fig. 10.2 Discharge preparation checklist®. © 2007 Care Transitions Program; Denver, Colorado.
http://www.caretransitions.org/documents/checklist.pdf. Accessed August 2, 2013. Credit, Eric
A. Coleman, MD, MPH—The Care Transitions Program®. Permission granted by UC Denver
10 Models of Care to Transition from Hospital to Home 183

absent caregivers, and physical limitations [24, 25]. Research demonstrates many
elders and caregivers misunderstand discharge instructions, lack appropriate fol-
low-up care, and do not receive complete, accurate, and legible medication lists at
the time of hospital discharge. Health care professionals also increasingly recognize
the crucial role that culture plays in the health care of patients and families, and the
need to communicate in a culturally competent manner [26]. Various strategies and
resources must therefore be employed when developing any transitional tool
designed to engage the patient to assist in self-management during the care transi-
tion. Likewise, tools can be employed to help determine patient comprehension of
instructions in a manner that is sensitive to all cultures, levels of education and
health care literacy. One of these methods is the “teach back” concept, also known
as the “show me” method or “closing the loop” in which the health care provider
confirms that information has been explained to the patient in a way that is truly
comprehended, regardless of education or literacy level.

Medication Management and Medication Reconciliation

in Care Transitions

Alterations in medication regimens during and after hospitalization are common

and lends to another source of vulnerability for patients. Research demonstrates
that medication-related care transitions adverse events are common. Forster and
colleagues in their prospective study found that 66 % of adverse events from a
hospital care transition were adverse drug events [11]. Moore and colleagues
found medication continuity errors (discrepancy between hospital discharge
medications and medications patient was taking at time of first follow-up visit)
were present in 42 % of patients within 2 months of a hospital discharge [19].
Recurring in the 2013 National Patient Safety Goals is the mandate for hospitals
to “maintain and communicate accurate patient medication information.”
Incorporated in this goal are the following elements of performance: (1) obtain
and document a reconciled medication list upon admission to the hospital; (2)
provide the patient (or caregiver as needed) with written medication instructions
at the time of hospital discharge; and (3) coach the patient (or caregiver) in key
elements of medication management, such as the importance of keeping an
updated list and taking this list to outpatient appointments [27]. Some key strate-
gies for preparing a patient’s discharge medication list include providing: (1) an
indication for each medication, stop dates or tapering schedules as appropriate,
and clear behavioral triggers for as-needed psychiatric medications; (2) tapering
or discontinuation of medications added during the hospital stay (such as analge-
sics, proton pump inhibitors, or laxatives with as-needed orders); and (3) formal
reconciliation of the discharge regimen with the preadmission regimen [2].
Reconciliation results in clear documentation of which medications on the
discharge list are new (relative to the preadmission regimen), which of the pread-
mission medications have been stopped, and which dosages of continued medica-
tions have been changed (Fig. 10.3).
184 E.H. Bowman et al.

Fig. 10.3 Medication reconciliation form template. Thorough medication reconciliation will
guide the patient to understand which new medications to start, which old medications to continue
or stop taking, assess patient comprehension of instructions, and offer contact information for
future questions

Roles of Interdisciplinary Team Members, Patients,

and Families in Care Transitions

The 2009 Transitions of Care Consensus Policy Statement comments on the “lack of
a single clinician or clinical entity taking responsibility for coordination across the
continuum” [8]. The roles of clinicians during care transitions remain poorly defined.
10 Models of Care to Transition from Hospital to Home 185

A recent study described a conceptual framework summarizing clinicians’ roles

during care transitions to address this gap in the literature and found incongruence
between clinicians’ perceptions of their routine versus ideal roles during care transi-
tions (e.g., routine: sending a discharge summary to the receiving clinician; ideal:
calling the receiving clinician and discussing the patient’s case). The investigators
identified factors prompting clinicians to act closer to their ideal roles, such as per-
sonally knowing the receiving clinician or major decisions having been made in the
hospital regarding goals of care. The conceptual framework highlights the continued
ambiguity in accountability during transitions [28]. In addition to the physician role,
newly published care transitions interventions emphasize use of all team members.
In 2011, Naylor and colleagues published a systematic review of care transition
intervention (CTI) studies focusing on chronically ill adults transitioning from a hos-
pital. Eighteen of the 21 randomized controlled trials (RCTs) included in the review
utilized either a registered or advance practice nurse as the intervention leader or
coordinator [3]. Social workers, pharmacists, and other disciplines have also been uti-
lized in interventions. For example, an intervention developed at Rush University, the
Enhanced Discharge Planning Program, employs master’s-prepared social workers to
intervene by phone with patients within 48 h of discharge to support the care plan,
address unmet needs, and connect them with needed providers [29]. Several care
transitions studies also include family members or caregivers in the intervention [3].
In May 2013 the Centers for Medicare and Medicaid Services (CMS) issued new
guidelines effective immediately regarding discharge planning for Condition of
Participation (CoP) for hospitals. The new requirements are extensive in expanding
the scope of “discharge planning” to “transition planning,” and emphasize the goal
to “consideration of transitions among multiple types of patient care settings that
may be involved at various points in the treatment of a given patient.” This new CoP
requires that “a registered nurse, social worker, or other appropriately qualified per-
sonnel must develop, or supervise the development of, the evaluation” of care tran-
sition needs. The guidelines cite the benefits of an interdisciplinary team approach
to hospital discharge planning, scheduling follow-up appointments and filling
prescriptions prior to discharge, and follow-up phone calls within 24–72 h of dis-
charge to ensure adherence to the care transition plan and identify any barriers [30].
These are functions that may be performed by non-physician team members, should
be coordinated with patients and families, and are crucial components of a successful
care transition.

Interventions to Improve Care Transitions


Recently developed innovative models of transitional care have targeted the previ-
ously identified processes in need of improvement during a care transition and have
shown promise that specialized programs emphasizing certain key elements includ-
ing patient and caregiver coaching, early transition planning, and meticulous medi-
cation reconciliation can improve outcomes. The majority of published studies
186 E.H. Bowman et al.

regarding care transitions interventions have been in the last 10 years. In Naylor’s
2011 systematic review, care transition RCTs were examined in terms of how results
(positive or negative) can inform implementation of health care reform objectives.
All but one study had at least one positive outcome; nine included beneficial out-
comes related to hospital readmissions. Each of these nine studies impacting read-
missions utilized a nurse as the intervention coordinator and six of the nine utilized
home visits [3].
Based on results of prior research, four primary models of care transitions
originating in the hospital setting have emerged and are summarized here: (1)
Transitional Care Model (TCM); (2) Care Transitions Intervention® (CTI); (3)
Re-Engineered Discharge (Project RED); and (4) Better Outcomes for Older Adults
Through Safe Transitions (BOOST). In addition, recent research of Acute Care for
Elders (ACE) and Mobile ACE models of care has demonstrated promising impact
on care transitions outcomes.

Transitional Care Model

The TCM by Mary Naylor and colleagues provides comprehensive, evidence-based

transitional care coordination for chronically ill high-risk older adults [31, 32]. The
heart of this model is the Transitional Care Nurse (TCN), an advanced practice
nurse who follows enrolled patients from in-hospital planning meetings to home,
focusing on caregiver and patient needs. The TCN conducts an initial hospital visit
and assessment, followed by subsequent home visits focusing on medication
management, coaching patients for follow-up visits and even accompanying them to
the visits, and conducting follow-up phone calls during weeks without planned
home visitation. In this fashion the TCN is available 7 days a week via both home
visits and telephone access for 1–3 months of post-hospital follow-up. Findings
from multi-site RCTs demonstrate reduced readmissions, total hospital days, and
costs in addition to increased patient, caregiver, and provider satisfaction [32, 33].

Care Transitions Intervention

The CTI by Eric Coleman and colleagues is a 4-week program addressing four pri-
mary pillars of a successful care transition: (1) improved communication via a por-
table record (Personal Health Record) of essential health information the patient
carries across care settings; (2) medication reconciliation and self-management
training; (3) patient-scheduled follow-up appointments; and (4) improved patient
knowledge regarding clinical symptoms signaling worsening status (“red-flags”)
and how to respond [34, 35]. These components are taught by a nurse Care
Transitions Coach®, who provides individualized coaching by conducting an initial
hospital visit and assessment, working with the patient to complete the Discharge
10 Models of Care to Transition from Hospital to Home 187

Preparation Checklist®, coaching the patient how to utilize their own personal health
records, and providing oversight of medication management. The Care Transitions
Coach® follows the patient for 4 weeks post-discharge via home visits and three
follow-up phone calls. An RCT of the CTI demonstrated significantly lower 30- and
90-day rehospitalizations, reduced mean hospital costs at 90 and 180 days, and
improved patient disease self-management and increased confidence about their
role during care transitions [36].

Re-engineered Discharge

Project RED developed out of a safety net hospital research group at Boston
University Medical Center that develops and tests strategies to improve the hospital
discharge processes through promoting patient safety and reducing rehospitalization
[37, 38]. Project RED strives to minimize rehospitalizations by seeking to engage
patients in disease self-management training, medication reconciliation, matching
discharge plans with published clinical guidelines, improving communication
through expedited transmission of discharge summaries, and transporting patient
health records to all care settings. Patient coaching is again performed by a nurse;
post-discharge phone calls by a pharmacist ensure medication reconciliation and
reinforcement of the discharge plan. The RED Toolkit is founded on 12 discrete,
mutually reinforcing components of a discharge, provides guidance to implement
the RED processes for all patients, including those with limited English proficiency
and from diverse cultural backgrounds, and helps hospitals reduce readmission rates
by replicating the discharge process. In a randomized study, Project RED patients
experienced a 30 % decrease in 30-day hospital utilization (combined emergency
department (ED) visits and readmissions) compared to usual care. Project RED
patients reported being more prepared for discharge and had significantly improved
knowledge regarding their diagnosis and PCP name. They were also significantly
more likely to follow-up with their PCP. The intervention was most effective in
patients with a prior hospitalization within the last 6 months [39].

Better Outcomes for Older Adults Through Safe Transitions

Project BOOST is an SHM-led initiative where a multidisciplinary leadership team

provides hospitals with year-long mentoring in developing evidence-based best care
transitions practices [40]. As with Project RED, BOOST also provides a toolkit for
improving hospital discharge processes, including screening and assessment tools,
a discharge checklist, transitional care record, teach-back processes, risk-specific
interventions, and written discharge instructions. As of August 2013, the BOOST
Toolkit had been downloaded over 5,000 times and the year-long mentoring pro-
gram was in place at 183 hospitals nationwide. Pilot sites indicate that BOOST tools
188 E.H. Bowman et al.

improve communication and collaboration between hospitals and outpatient physicians,

while patients state they perceive an increased level of service and medical atten-
tion. Outcomes have not yet been published in clinical trials; according to the SHM
BOOST website as of August 2013, preliminary aggregate outcomes from sites
which implemented BOOST for at least 6 months reveal a reduction in 30-day read-
mission rates from 14.2 % before BOOST to 11.2 % after implementation [40].

ACE/Mobile ACE

Multiple published studies have demonstrated improved clinical outcomes and cost
savings from the ACE Unit model of care. More recent studies have also pointed
toward the additional benefit of an ACE model on care transitions. Flood et al. dem-
onstrated lower costs and fewer all-cause rehospitalizations within 30 days for ACE
unit patients compared to similar patients cared for on a usual care unit [41]. Hung
et al. describe a Mobile Acute Care for Elders (MACE) service utilizing a mobile
interdisciplinary team that seeks to decrease the hazards of hospitalization, facili-
tate transitions of care, and provide patient and family education. MACE service
patients were less likely to experience adverse events, had shorter length of stay
(LOS), and rated the quality of their care transition higher than matched general
medicine patients [42]. Researchers at Johns Hopkins University also sought to
develop and pilot-test a model that combined the strengths of inpatient geriatric
evaluation, co-management, and transitional care in a cluster-randomized trial of
717 hospitalized older adults on 4 general medicine services. In the 2 treatment
groups, a geriatrician–geriatric nurse practitioner dyad assessed patients, co-
managed geriatric syndromes, provided staff education, encouraged patient self-
management, communicated with PCPs, and followed up with patients soon after
discharge. The intervention was associated with greater patient satisfaction with
inpatient care and slightly higher quality care transitions (though not statistically
significant) [43].
Other studies have produced mixed results. In a 2012 published systemic review
and meta-analysis of over 6,800 hospitalized elderly patients, Fox et al. demonstrate
that acute geriatric unit care based on all or part of the ACE model improves patient-
and system-level outcomes, including fewer fall risks, less delirium, less functional
decline at discharge from baseline 2-week pre-hospital admission status, shorter
LOS, fewer discharges to nursing home, lower costs, and more discharges to home.
There were no significant differences found in hospital readmissions, mortality, or
post-hospitalization functional status compared with functional baseline before hos-
pital admission [44]. Sennour et al. described a proactive geriatrics consultation
service implemented in collaboration with hospitalists that incorporated the basic
principles of ACE to prevent functional decline and improve the care of older hos-
pitalized patients admitted with geriatric syndromes. This proactive consultation
service demonstrated high level of satisfaction by hospitalists—96 % rated the ser-
vice as excellent in helping them provide better care—while analysis of hospital
10 Models of Care to Transition from Hospital to Home 189

administrative data revealed a shorter LOS and reduced hospital costs in patients
receiving a geriatrics consultation [45]. This study was not designed to examine
post-hospitalization care transitions or rehospitalization outcomes though the reduc-
tion in LOS is promising and evaluating the impact of this intervention on care
transitions is a next step.

Outpatient-Based Models Shown to Reduce Unnecessary


One method of reducing unplanned readmissions in older adults is to prevent an

unnecessary initial hospitalization. Several interventions that are outpatient based
follow the principles of Guided Care (GC) and have demonstrated comprehensive
geriatric care while preventing unnecessary hospitalization and/or readmissions.
These include Hospital at Home®, Program for All-Inclusive Care for Elders
(PACE), Geriatric Resources for Assessment and Care of Elders (GRACE), and
Palliative Care Programs for patients with life-limiting illness/injury.
Guided Care (GC) is an outpatient-based interdisciplinary team model of care
led by a specially trained registered nurse in partnership with PCPs and caregivers
to support a practice’s most complex patients by assessing the patient and primary
caregiver at home, creating an evidence-based care plan for providers and an action
plan for patients and caregivers, promoting patient self-management, monthly mon-
itoring of patients’ conditions, coordinating efforts of care providers in all settings,
smoothing transitions between sites of care, educating and supporting family
caregivers, and facilitating access to community resources. Studies suggest imple-
menting GC is feasible and improves patient, caregiver, and provider satisfaction as
well as patient ratings of the quality of chronic care. In a clustered RCT, GC patients
tended to utilize less home health services but there was no difference in hospital,
emergency department (ED), and SNF services or 30-day readmission rates com-
pared to usual care patients [46]. However this trial targeted patients known to be
high risk for health care utilization based on predictive models. A lower or moderate
risk target population may have benefited more from GC in terms of reducing health
care utilization.
Subsequently developed models of care coordination that have been shown to
impact care transitions use principles found within GC. Hospital at Home® pro-
vides hospital-level care for an acute illness in-home for patients meeting medical
eligibility criteria, thereby avoiding admission to an acute care facility. Necessary
medical equipment (oxygen, infusions, lab, and radiology testing) is provided.
Patients receive nurse and physician visits daily, with additional visits as needed
[47]. Hospital at Home® programs demonstrate improved patient and caregiver sat-
isfaction and reduced costs with comparable or improved clinical outcomes com-
pared to traditional hospital admission [48, 49]. The PACE Program is a capitated
Medicare and Medicaid community-based managed care program that provides
interdisciplinary team care to frail adults. Persons age 55 and over are eligible for
190 E.H. Bowman et al.

PACE if they live in a PACE catchment area and meet state Medicaid criteria for
nursing home eligibility. PACE enables frail elders to continue community living
via an interdisciplinary team with development of comprehensive, individualized
medical, psychosocial, and functional care plans [50]. PACE is associated with
improved survival, quality of life, functional status, patient satisfaction, and reduced
hospitalizations and nursing home placement [51]. Similar in concept, GRACE
helps frail community-dwelling elders age in place by incorporating in-home geri-
atric assessment of patient and caregiver(s) through a geriatric nurse practitioner
and social worker team in conjunction with the PCP. Individualized care plans
addressing geriatric syndromes developed by the GRACE team (geriatrician, phar-
macist, mental health liaison, nurse practitioner/medical social worker dyad) are
approved by the PCP prior to implementation. GRACE has demonstrated improved
patient-centered care transitions and reduced hospital readmissions and nursing
home placement [52].
Patients with chronic or life-limiting illnesses have many complex post-discharge
needs that often do not include the common discharge destination of a rehabilitation
facility; therefore this patient population is at risk of readmission due to unmet
symptomatic needs. For patients not yet meeting the guidelines for Medicare
Hospice Benefit, a palliative care (PC) approach focusing on patient-centered goals
of care is often more appropriate. The National Consensus Project (NCP) defines
PC as care that is focused on “seriously ill patients and those with advanced disease,
who are unlikely to be cured, recover, or stabilize, and their caregivers” [53]. PC
focuses on aggressive symptom management as well as providing interdisciplinary
support for patients and families with the goal of improving quality of life when
cure might not be possible. PC is not exclusively end-of-life care, should be
provided at any stage of illness that symptom burden occurs, and should be offered
in conjunction with all other appropriate forms of medical treatment, including
curative therapies.
The NCP offers a means by which PC can be operationalized through eight dif-
ferent domains to effectively manage pain and other distressing symptoms, while
also incorporating psychosocial and spiritual care with consideration of patient/
family needs, preferences, values, beliefs, and cultures (Table 10.3). PC is provided

Table 10.3 Domains of Domain 1 Structure and processes of care

quality palliative care Domain 2 Physical aspects of care
Domain 3 Psychological and psychiatric aspects of care
Domain 4 Social aspects of care
Domain 5 Spiritual, religious, and existential aspects of care
Domain 6 Cultural aspects of care
Domain 7 Care of the imminently dying patient
Domain 8 Ethical and legal aspects of care
Table adapted with permission by the National Consensus
Project Clinical Practice Guidelines for Quality Palliative Care,
2nd ed. Pittsburgh, PA
10 Models of Care to Transition from Hospital to Home 191

by an interdisciplinary team and can be delivered in all care settings. The Medicare
Hospice Benefit, just one component of PC, can be activated when the patient’s life
expectancy is anticipated to be 6 months or less. Research reveals patients receiving
PC experience improved symptom control and satisfaction, reduced ED visits and
hospitalizations, reduced costs, and greater likelihood of dying at home compared
to those receiving conventional care [54, 55].

Other Sites of Care Transitions

For patients residing in nursing facilities, the Interventions to Reduce Acute Care
Transfers (INTERACT II) program shows promise in preventing avoidable nursing
home to hospital transitions through proactive identification and management of
changes in resident clinical status. The program utilizes a series of clinical practice
tools targeting three primary areas identified in the literature as key drivers of rehos-
pitalizations in this patient population: (1) staff communication of change in clinical
status to the appropriate provider in a timely manner; (2) evidence-based clinical
care pathways triggered by changes in clinical status; and (3) advanced care plan-
ning. These targeted interventions are implemented through ongoing staff training
and reinforcement led by an identified program champion based in the nursing facil-
ity. A quality improvement project in 25 nursing homes over a 6-month period
found INTERACT II reduced hospital admissions by 17 % [56].
The ED is another site for care transitions. Older adults have a higher risk of
return ED visit or hospitalization within 30 days of ED discharge compared to
younger adults. Preliminary studies have investigated the roles of screening tools
and geriatric assessments in the ED to target elders at risk for poor care transitions.
The most studied screening tools for identification of high-risk elder ED patients
are the Identification of Seniors At Risk (ISAR) tool and the Triage Risk
Stratification Tool (TRST) [57, 58]. These brief screens are designed to be com-
pleted within a few minutes by ED staff and assess for geriatric syndromes such as
cognitive, functional, and visual impairments; difficulties with medication man-
agement; and prior history of ED visits or hospitalizations. The TRST also allows
for ED staff to include any concerns for patient safety. To date these tools have
demonstrated moderate predictability for identifying elders at risk for return ED
visit or hospital admission following ED discharge [58, 59]. Preliminary studies
have examined use of screening and targeted geriatric assessment in the ED. In
2001, Mion et al. describe the implementation of the Systematic Intervention for a
Geriatric Network of Evaluation and Treatment (SIGNET) program, using the
TRST to identify elders discharging from ED to home who are at risk of poor out-
comes or readmission to receive a geriatric assessment by a geriatric clinical nurse
specialist (GCNS). The GCNS coordinates patient and caregiver education and
needed referrals to community agencies, PCPs, and/or outpatient geriatric assess-
ment. In a feasibility study SIGNET significantly reduced the proportion of elders
with return ED visits within 30 days and significantly increased the number of
192 E.H. Bowman et al.

referrals to community agencies [60]. The Discharge of Elderly from the Emergency
Department (DEED) program does not use a screening tool for targeting patients,
but instead utilizes comprehensive geriatric assessment (CGA) performed by a
nurse for patients aged 75 and older who are discharged from the ED to home.
Based on the CGA findings, an interdisciplinary team develops a care plan, in
coordination with the patient, caregivers, PCP, and community resources, and fol-
lows the patient for 4 weeks, including home visits. In an RCT, the DEED II study
demonstrated a significantly reduced rate of hospitalization within the first 30 days
and reduced rate of ED admission for 18 months following index ED visit.
Intervention patients also experienced a significantly longer time to the first repeat
ED visit [61].

Health Information Technology as a Tool to Assist

with Care Transitions

Electronic Health Record and Discharge Summaries

Advances in health information technology and increasing use of electronic medi-

cal records (EMRs) provide opportunities to improve timeliness of information
transfer following hospitalization. Kripalani and colleagues note in their review
that discharge summaries generated electronically (information systems merging
administrative and clinical information) tended to result in more complete and
timely information transfer from a hospitalization to the PCP compared to dictated
summaries. The authors concluded that hospitals should use information technol-
ogy to populate discharge summaries with required clinical information such as
medications, diagnoses, and test results (and pending tests) wherever possible and
that discharge summaries should be sent or be available for direct access by the
PCP on the day of discharge [20]. In keeping with the crucial theme of timely and
accurate information transfer, the SHM’s Hospital Quality and Patient Safety
Committee assembled an expert consensus panel to develop the Ideal Discharge of
the Elderly Patient Checklist. This checklist focuses on the key transition safety
elements of patient status (including function, cognition, and resuscitation status),
medication reconciliation, patient education, and follow-up (including pending
tests) that should be included in discharge summaries. This checklist has been for-
mally endorsed by the SHM [62]. Additionally, in 2009 a collaborative working
group consisting of members from the American Board of Internal Medicine
Foundation, ACP, SHM, and the Physician Consortium for Performance
Improvement® (PCPI) published the Care Transitions Performance Measurements
(CTPM) [63]. The working group defined six process measures that have since
been endorsed by the National Quality Forum and should be incorporated into con-
tinuous quality improvement efforts to improve care transition outcomes. These
process measures are:
10 Models of Care to Transition from Hospital to Home 193

Measure 1: Reconciled medication list received by discharged patients

Measure 2: Transition record with specified elements received by discharge patients
Measure 3: Timely transition of transition record (to facility or PCP for follow up
Measure 4: Transition record with specified elements received by discharged
patients for ED discharges
Measure 5: Discharge planning/post-discharge support for heart failure patients
Measure 6: Promote improved patient understanding of and adherence to treatment
plans via addition of appropriate questions to patient satisfaction measures
This set of process measures were chosen because they are linked to the follow-
ing identified indicators of success in improving care transitions:
1. Reduction in adverse drug events
2. Reduction in patient harm related to care transition medical errors
3. Reduction in unnecessary health care utilization (e.g., hospital readmissions)
4. Reduction in redundant tests/procedures
5. Achievement of patient goals including functional status and comfort care
6. Improved patient understanding of and adherence to the treatment plan
A list of the SHM-endorsed minimal key data elements that should be included
in all discharge summaries and the corresponding process measure is summarized
in Table 10.4.

ACE Tracker

To address the barriers in dissemination of the ACE Unit model of care, Michael
Malone and colleagues from the Aurora Health Care System have developed the
software program ACE Tracker for use in several EMR systems. The ACE Tracker
program collects existing data from a patient’s EMR in real time to generate an
individual patient-level summary of geriatric clinical data and a unit-based sum-
mary spreadsheet of key geriatric risk factors in all hospitalized patients age 65 and
older. These items include information such LOS to date, total number and poten-
tially inappropriate medications prescribed, risk of falls and skin breakdown based
on nursing assessment screens, use of urinary catheters, and formal consultation to
disciplines such as physical and occupational therapy and social services. In 2010
Malone and colleagues published a descriptive pilot study using ACE Tracker as a
means of disseminating the ACE model of care to hospitals and units that did not
have consistent access to a geriatrician. Units using ACE Tracker experienced sig-
nificant reductions in use of urinary catheters and significant increase in consulta-
tions for physical therapy. While this preliminary study did not demonstrate changes
in LOS or 30-day readmissions, this was not the primary objective of this study and
the use of this novel health information technology in improving care transitions
remains an area for further research [64].
194 E.H. Bowman et al.

Table 10.4 Crosswalk summarizing minimal key data elements for: (1) inclusion in all discharge
summaries for next site of care/provider and, (2) related Care Transition Process Measures
SHM-endorsed key Care Transition
elements to be included in Process Measure
Data element discharge summaries [62] [63]
Transition record of hospitalization or ED visit
Problem that precipitated hospitalization or chief X 2,4
Brief hospital/ED course with key events/ X 2
findings, consultant recommendations, and
anticipated problems and suggested
Results of key tests/procedures X 2,4
Discharge diagnoses X 2,4
Condition at discharge, including status of X
geriatric syndromes such as function and
Discharge Destination X
Transition Record transmitted to facility, PCP, or 3
other provider designated for follow-up care
within 24 h of discharge
Medication reconciliation
Discharge medication list reconciled with X 1,2,4
patients list of medicines prior to
hospitalization (medications to be continued,
medications not to be continued, new
medications added)
Discharge medication doses, frequencies, X 1
instructions, and stop dates (if applicable)
included for each continued and new
Medication cautions (allergies, adverse X 1
Follow-up information
Follow-up care needed, including appointments X 2,4
made or needed, provider name(s), contact
information, and date of appointment
Tests/studies pending at discharge and contact X 2
information for obtaining results
24/7 call back number for questions or new X 2
problems related to hospitalization
Patient/caregiver teaching
Patient education/instructions provided X 2,4
Documentation of patient/caregiver level of X
Advance care planning
Summary of goals of care discussions including X 2
but not limited to code status, advance
directives, surrogate decision maker
X required element, SHM Society of Hospital Medicine, ED emergency department, PCP primary
care physician
10 Models of Care to Transition from Hospital to Home 195

Telehealth and Readmissions

The high cost of caring for many patients with certain chronic diseases such as conges-
tive heart failure (CHF) is due largely to frequent rehospitalization for exacerbations.
Some studies have looked at disease-specific populations to examine the effect of
home-based interventions on readmission rates; results have been mixed. In an attempt
to compare the effectiveness of discharging patients hospitalized with CHF exacerba-
tions home with usual outpatient care, nurse telephone calls, and home telecare deliv-
ered via a two-way videoconference device with an integrated electronic stethoscope,
a small 1-year randomized trial of 37 patients demonstrated a significant 86 % decrease
in CHF-related readmissions in those receiving telecare, as well as an 84 % decreased
rehospitalization rate in those receiving post-discharge phone calls. However, the dif-
ference between the groups was not statistically significant, implying that in this small
study population, home telecare did not offer incremental benefit beyond telephonic
follow-up which can also be done at a significantly lower cost burden [65].
In another study evaluating the efficacy of a telehealth-facilitated post-
hospitalization support program in reducing resource use in patients with CHF,
patients from the Department of Veterans Affairs were randomized to telephone,
videophone, or usual care for follow-up care after hospitalization for CHF exacer-
bation. The combined intervention group (telephone and videophone) experienced
significantly longer time to readmission, but had no change in readmission rates,
mortality, hospital days, or urgent care clinic use compared to usual care. Thus,
rigorous evaluation is needed to determine whether any target patient population
will benefit from specific telehealth applications, as well as identify which tech-
nologies are the most cost-effective [66].

Medicare Rule Changes Regarding Care Transitions

and Impact on Hospitals

In a fee-for-service payment model, interventions that decrease rehospitalizations

have not been financially rewarded in the past due to the time required by providers
to coordinate care transitions. However, the Patient Protection and Affordable Care
Act (PPACA), commonly called the Affordable Care Act (ACA), was signed into
law in 2010 and institutes new quality-based Medicare rules encouraging hospitals
and providers to improve care transitions [67]. The support for adoption of evidence-
based care transition models that improve outcomes and lower costs is an area of
focus as hospitals anticipate increasing numbers of elders.

New Financial Rules

Beginning January 1, 2013, CMS implemented new Transitional Care Management

codes for PCPs to receive compensation for time spent in the outpatient setting see-
ing patients who require moderate or high complexity decision making following
196 E.H. Bowman et al.

discharge from an acute care setting (hospital, psychiatric hospital, inpatient reha-
bilitation, LTACH), SNF, community mental health center, or observation status in
a hospital to a community living setting (home, domiciliary, rest home, ALF living)
[68]. The goal of the new codes is to improve care coordination through incentives
for care transition management in the outpatient care setting rather than risk hospi-
tal readmission. Another provision of the ACA designed to reduce costs related to
unplanned readmissions is the Hospital Readmission Reduction Program (HRRP)
[69]. Under this program, hospitals with above average 30-day readmission rates for
three diagnoses (acute myocardial infarction, heart failure, and community acquired
pneumonia) began incurring financial penalties in the form of reduced reimburse-
ments in 2013. The number of conditions and the amount of the financial penalties
is anticipated to increase annually in the coming years. The readmission rates for
specific conditions are publically reported on the Medicare Hospital Compare web-
site. These new financial rules may be contributing to recent slight downward trends
in readmissions as hospitals prepared for the penalty phase of the HRRP. From 2006
to 2011 the all-cause 30-day readmission rates declined from 16.0 to 15.3 % for
Medicare patients. Also in 2011, 12.3 % of Medicare beneficiaries experienced a
potentially preventable readmission (PPR), a decrease from 13.4 % in 2006. These
2011 PPR rates ranged from 9.9 % in the highest performing hospitals to 15.3 % in
lowest performing hospitals [70].
The ACA also includes the Bundled Payments for Care Improvement Initiative
with the goal to reduce fragmentation of care by aligning acute care and post-acute
care settings and providers through “bundling” payments that require financial and
performance accountability. Participants in these new bundled payment models will
begin testing their programs in 2013 [71]. Additionally, the Community-Based Care
Transitions Program provides up to $500 million in funding from 2011 to 2015 to
community-based organizations partnering with hospitals to improve care transi-
tions services while reducing costs [3, 72]. Finally, the ACA calls for the develop-
ment of Accountable Care Organizations (ACOs). The new ACOs will be groups of
care providers and hospitals that develop a collaborative partnership with the goal to
improve coordination of care to ensure patients are receiving the right care at the
right time, especially for the chronically ill and complex patient population [73].
Updates on new funding opportunities and the stage of development of ACOs and
all of the new ACA care coordination initiatives can be found on the CMS Innovation
Center website [74].

New Process Rules

In addition to financial rules, CMS is also addressing the quality of transitions

through new process mandates. The 2013 CMS CoP guidelines hold hospitals
accountable for four primary phases of care transition planning: (1) developing a
formal care transition plan for every inpatient, or screening to identify patients at
risk for adverse transitions outcomes; (2) evaluating the post-discharge needs of
high-risk patients, or any patient upon patient or physician request; (3) developing
10 Models of Care to Transition from Hospital to Home 197

an individualized care transition plan; and (4) initiating the care transition plan
prior to discharge. To achieve these mandates hospitals are expected to assess the
patients’ functional and cognitive abilities, types of post-hospital care that will be
needed, and the patient’s caregiver/support system in order to determine the
patient’s capacity for self-care (or need for care providers) and needs for appropri-
ate post-hospitalization care setting. Encouraged is the development of collabora-
tive relationships between hospitals and facilities and providers who care for
discharged patients [30].

Future/Next Steps in Care Transitions

A consensus document by the National Transitions of Care Coalition outlines three

perspectives from which information needs to be obtained in order to fully address
optimal care coordination and transitions: (1) patient/family; (2) health care profes-
sional; and (3) health care system [75]. Ongoing culture change driven by this
diverse group of stakeholders will likely be required to continue to improve care
transitions at the patient, caregiver, provider, system, and community levels [76].
Broader thinking represents moving beyond targeting diagnosis-specific readmis-
sion rates (e.g., CHF), because individual patients are diverse and diagnoses alone
do not define risk. Focusing excessively on one targeted outcome as opposed to a
holistic methodology may have unintended consequences. Reducing readmissions
has been a prioritized outcome due to related risk to patients and costs to the health
care system. However, a hospital readmission may not represent poor quality and
may in fact result in improved outcomes for some patients. For example, hospitals
with higher readmission rates for CHF have lower CHF mortality rates, highlighting
that these patients are living longer and therefore will require hospitalizations.
Furthermore, some studies have indicated that as care coordination improves,
patients may experience more hospitalizations as their overall access to health care
improves [77]. Also, there is a complex relationship between patients’ socioeco-
nomic status and risk for readmission. A hospital’s share of low-income patients is
a strong predictor of 30-day readmissions, and hospitals with large shares of low-
income patients tend to have higher readmission rates. Policy makers must guard
against deterring hospitals from caring for poor patient populations while also not
accepting lower quality standards for hospitals with a larger proportion of
low-income patients.
In a 2013 publication, a modified Delphi consensus technique was used to iden-
tify five key measurable outcomes of a quality care transition: (1) readmission
within 30 days of discharge; (2) seeing a PCP within 7 days of discharge for high-
risk patients; (3) medication reconciliation completed upon hospital admission and
repeated prior to discharge; (4) readmission within 72 h of discharge; and (5) time
from hospital discharge to first visit by home care nurses [78]. Additional work is
also essential in standardized measurement of patient and family needs and experi-
ences during a care transition. One metric used for the purpose of assessing the
quality of care transitions is either the 3- or 15-item Care Transitions Measure
198 E.H. Bowman et al.

(CTM) [79]. This questionnaire can be administered over the phone or by mail to
patients recently discharged from the hospital. The CTM has been endorsed by the
National Quality Forum. Like many survey tools, the CTM may be difficult for
patients with cognitive impairment to understand. While the 15-item version can be
administered to caregivers in place of the patient, the 3-item version cannot.
While results of care transition studies to date are promising, the number of
RCTs is small, and many have an intervention sample size of less than 100 patients
or other study limitations [80]. The June 2013 Medicare Payment Advisory
Committee Report to Congress recommends a broader research plan that includes
the association of readmissions and mortality, health literacy, and patient frailty as
well as expansion of research and policy to additional groups such as observation
patients and post-acute providers [70]. Additional research is also needed regarding
care transitions from EDs and SNFs and the use of information technology. Finally,
the health care workforce, including informal care providers, will require additional
training in care transitions. Currently this training is not required in health care
provider licensure and certification processes [3].


To date, published transitional care interventions incorporate common themes,

including information transfer strategies, patient/caregiver coaching for self-
management, aggressive medication reconciliation, and portable health records.
Next-generation interventions may incorporate additional use of health information
technology and telemedicine as well as additional sites of care. Ultimately, the “per-
fect” hospital transitional care program will provide a comprehensive set of key
elements that providers and systems are charged with developing and incorporating
into their daily practice and will result in improved adherence with discharge
instructions, timely outpatient follow-up, and improved patient functioning and sat-
isfaction with reduced adverse medical events, readmissions, costs, and caregiver
burden [81]. Given the declining number of geriatricians, exemplary models of care
will also provide the means of educating trainees and providers across all disci-
plines to work as interprofessional teams across the care continuum. While existing
care models show promise, none succeed in achieving all of these outcomes, hence
fueling the impetus for ongoing research.


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Chapter 11
What Is the Role of Hospitalists
in the Acute Care for Elders?

Heidi L. Wald and Melissa L.P. Mattison

Abstract Over the past 15 years healthcare delivery has changed from one in
which primary care physicians (PCPs) oversaw the care of their patients in the
hospital to one in which hospital medicine specialists—hospitalists—have
assumed this role. Hospitalists, who are mainly trained in internal medicine with
little formal geriatric training, now provide much acute care for older patients. To
address the needs of the older inpatient population, hospitalists—often in partner-
ship with geriatricians and gerontology nurses—have developed or participated in
care innovations for acutely ill elders, harnessing the shared mission of improving
quality of and decreasing harm from acute care. This chapter provides an overview
of care innovations for acutely ill frail elders including modifications or interac-
tions with classic models of geriatric care (ACE units, consult services, periopera-
tive care, nursing best practice) and newer models of geriatric care (population-based
identification, QI paradigms, transitional care, train the trainer). Engagement of
this important group of care providers will be critical for improving care for
acutely ill elders.

Keywords Hospitalist • Acute care • Geriatrics • Models of care • Hip fracture

H.L. Wald, M.D., M.S.P.H. (*)

Division of Health Care Policy Research, Department of Medicine,
University of Colorado School of Medicine, Campus Box F480,
13199 East Montview Boulevard, Suite 400, Aurora, CO 80045, USA
e-mail: Heidi.wald@ucdenver.edu
M.L.P. Mattison, M.D.
Beth Israel Deaconess Medical Center, Harvard Medical School,
330 Brookline Avenue, Boston, MA 02215, USA
e-mail: mmattison@bidmc.harvard.edu

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 203
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_11,
© Springer Science+Business Media New York 2014
204 H.L. Wald and M.L.P. Mattison


ACE Acute Care for Elders

AGESP Advancement of Geriatrics Education Scholars Program
BOOST Better outcomes for older adults through safe transitions
CAM Confusion assessment method
CHAMP Curriculum for the hospitalized aging medical patient
CMS Center for Medicare and Medicaid Services
CPOE Computerized physician order entry
GRACE-AC Global Risk Assessment and Care Plan for Elders—Acute Care
GRN Geriatric resource nurse
HAC Hospital-acquired condition
IOM Institute of Medicine
NICHE Nurses Improving the Care of Health System Elders
PAGE Program for Advancing Geriatrics Education
PCP Primary care physician
QI Quality improvement
QuILT Quality improvement leadership team
SHM Society of Hospital Medicine
SNF Skilled nursing facility
TTT Train the trainer
UAB University of Alabama at Birmingham
UCH University of Colorado Hospital
UCSF University of California San Francisco

The Changing Acute Care Workforce

Adults over 65 comprise only 13.2 % of the US population, but account for over
30 % of hospital discharges and about 50 % of hospital days [1–3]. With an antici-
pated increase in the older adult population, it will be critical to ensure an acute care
workforce competent in geriatrics care principles. However, the number of geriatri-
cians has been dropping for the last decade. In 2011 there was 1 geriatrician for
every 2,620 Americans >75 years of age. It is anticipated that by 2030, there will be
1 geriatrician for every 3,798 Americans >75 years [4]. Moreover, at least anecdot-
ally, many geriatricians spend little to no time in the acute care setting, working in
primary and post-acute care leaving many hospitals without access to geriatrics
medical specialists. At the same time, the number of hospitalists has skyrocketed
(Fig. 11.1). Hospitalists have outnumbered geriatricians since 2001 [4, 5]. As a
result, hospitalist involvement in acute geriatrics care is increasingly common;
between 1997 and 2006, the odds that a hospitalist would treat a hospitalized
Medicare patient rose 29 % per year [6].
11 What Is the Role of Hospitalists in the Acute Care for Elders? 205

Number of Participating Hospitals

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Fig. 11.1 Growth of hospital medicine. The number of hospitalists in the United States has grown
rapidly since the specialty was identified in the late 1990s. Hospitalists far outnumber active geri-
atricians and care for increasing numbers of acutely ill elders. Reproduced with permission of
Growth of Hospital Medicine, Chart. Society of Hospital Medicine, 2013. All rights reserved

Introduction to Hospitalists

Hospital medicine is a new and growing internal medicine specialty. Because

primary care physicians (PCPs) often have limited direct care responsibility for
inpatients, hospitalists now oversee care of most acutely ill inpatients. There are
more than 30,000 hospitalists in the United States working in 80 % of hospitals
nationwide [6]. Hospitalists generally complete the same residency training as
internal medicine PCPs, but choose to practice primarily in the inpatient setting.
Like internists, nearly all hospitalists lack specialized training in geriatric medicine
[7]. In 2004, fewer than a dozen hospital medicine programs in the country offered
formal collaborative mechanisms with geriatric medicine partners to address the
needs of older inpatients [8]. Thus, most older hospitalized patients are cared for by
hospitalists with no geriatrics training and who frequently lack access to geriatric
medicine specialists.
The growth of hospital medicine has occurred at the same time that patient safety
and quality of care have become central concerns of policymakers, payers, and the
public. Hospitalists and geriatricians’ interests are aligned to promote and improve
patient safety. While geriatricians have used the term “hazards of hospitalization”
for several decades, a hospitalist may be more likely to use the term “preventable
adverse events” in the elderly (Fig. 11.2). To address these events, the Society for
Hospital Medicine (SHM) has promoted the implementation of quality and safety
initiatives including programs designed to address the needs of older patients, such
as Project BOOST (Better Outcomes for Older Adults Safe Transitions) based on
the Care Transitions Model [9, 10].
206 H.L. Wald and M.L.P. Mattison

Fig. 11.2 The overlap of

geriatric and hospital
medicine. Despite differing
paradigms of care, geriatric
medicine and hospital
medicine share closely Geriatric Hospital
aligned goals with regard to Medicine Medicine
the prevention of common
hazards of hospitalization in
the elderly, also referred to as
preventable adverse events or
hospital-acquired conditions

Hazards of Hospitalization
• Delirium
• Falls
• Pressure ulcers
• Functional delcine
. . . and others

Strategies of Hospitalists in Caring for Older Patients

More than a third of older adults admitted to hospitals in the United States experience
health declines resulting in longer hospital stays or placement in extended care
facilities [11]. Patients cared for by hospitalists have slightly shorter lengths of stay
and corresponding lower acute care costs when compared to non-hospitalist provid-
ers [6, 12]. Hospitalists have the additional potential to improve the care and out-
comes of older adults through the adoption and/or dissemination of geriatrics care
principles that have demonstrated results in closed models of care, such as Acute
Care for the Elderly (ACE) units. These principles include functional and cognitive
assessment, evidence-based medication management, multidisciplinary teamwork,
and patient-centered care planning [13]. Employing such principles will require
innovative approaches by hospitalist groups.
In 2005, a cross-sectional survey of hospitalist groups sought to identify geriatric
care strategies [8]. This inventory resulted in a taxonomy of geriatric care innova-
tions by hospitalist groups. The taxonomy identified five characteristics of geriatric
care innovations: (1) focus, (2) staffing model, (3) patient targeting, (4) organiza-
tion, and (5) tools. The focus of a geriatric care innovation describes the acute care
service line. Innovative staffing models include the use of generalist-hospitalists,
geriatrician-hospitalists (those with geriatric medicine fellowship and board certifi-
cation), embedded geriatrics advanced-practice nurses, and/or consultation with
geriatricians. Targeting commonly occurs by age, by diagnosis, or hospital unit.
Organization can be unit- or service-based or global. Examples of innovations in
11 What Is the Role of Hospitalists in the Acute Care for Elders? 207

tools are interdisciplinary rounds, training curricula, quality improvement methods,

and geriatrics assessment. Because hospitalist roles have expanded since the origi-
nal list of interventions was compiled, additional geriatric care strategies may now
be performed by hospitalist groups. Table 11.1 provides a summary of many of the
models of interest. In the following sections, we will highlight some of the most
common and promising approaches currently used by hospitalist groups.

The Acute Care for the Elderly Model of Care

Many hospitals have implemented the ACE model, which involves the creation of
dedicated geriatric care units. While there is ample evidence the ACE model can
improve outcomes for acutely ill frail elders [14], barriers may include sufficient
resources, physical plant, or staffing constraints. Adaptations of the ACE model
have appeared with hospitalists integrated into the staffing model.
For example, the Hospitalist-ACE Service at the University of Colorado Hospital
(UCH) has implemented an adapted model that includes the following core ele-
ments: (a) geographic concentration of patients without a closed unit; (b) use of a
standardized brief geriatrics assessment; and (c) a teaching curriculum for residents.
The service is staffed by hospitalists and multidisciplinary team rounds occur daily.
In the first year, the service demonstrated no increased LOS or costs, but increased
recognition and treatment of functional and cognitive impairments [15]. Additional
enhancements have included a standardized geriatrics admitting order set and an
expansion in number of beds from 12 to 20 to allow the majority of patients admit-
ted to the ACE service to be collocated on the unit.
The University of Alabama at Birmingham (UAB) utilizes another adaptation of
the ACE model. In this non-teaching consultative model, multidisciplinary rounds
are run by a staff geriatrician who provides consultation for the hospitalist attend-
ing. Of note, the hospitalist is not present at the multidisciplinary rounds. Geriatrics
assessments are performed by a geriatrics resource nurse (GRN). Recommendations
stemming from rounds are provided to the primary team and/or outlined in the chart.
An evaluation of this model demonstrated a mean reduction in total direct costs per
patient of $371 and an absolute reduction in the rate of 30-day readmissions to UAB
Hospital of 4.9 % when compared to usual care [16].

From Consultation to Co-management: Perioperative Care

for Hip Fracture

Traditionally, medically complex patients with surgical conditions such as hip frac-
ture have been managed in consultation with an internist or geriatrician. Beginning
in the mid-2000s, new models for the care of hip fracture patients involving hospi-
talists emerged. These ranged from hospitalist medical consultation for surgeons, to

Table 11.1 Summary of selected geriatric acute care models incorporating hospitalists
Model Focus Staffing Targeting Organization Tools
Hospitalist-ACE [15] Medical Hospitalist or geriatrician/ >70 years Medical Service/ Assessment, IDT
hospitalist Unit rounds, curriculum
Consultative or Medical Geriatrician and hospitalist >70 years Medical Unit Assessment, IDT
co-managed ACE [16] rounds
Co-management [17] Surgical Hospitalist and surgeon Hip fracture or other Surgical Service Assessment
Consultation [18] Medical Geriatrician and nurse > years and functional Consult service Assessment
practitioner with impairment for any
hospitalist medical patient
ACE tracker and Medical/surgical Geriatrician with unit-based At risk for hospital Consult to medical ACE tracker;
e-Geriatrician [19] teams with hospitalists acquired conditions units e-Geriatrician
GRACE-AC [20] Global All nurses and doctors >80 yo Global Geriatric clinical
decision support;
daily delirium
QuILT [22] Medical Multidisciplinary QI >70 years Medical service/ QI dashboard; PDSA
Leadership team unit cycles
Project BOOST [9, 10] Transitions Multidisciplinary teams Varies Units BOOST toolkit
Post-acute hospitalist Post-acute care Hospitalists and/or At skilled nursing Skilled nursing Assessment
(SNFist) [27] geriatricians facility facility
NICHE [28] Medical, surgical, GRN and hospitalist Varies Unit based or NICHE evidence-
or global global based tools
Train the trainer [29–31] Medical Hospitalist Vulnerable elder Teaching services Curriculum and tools
H.L. Wald and M.L.P. Mattison
11 What Is the Role of Hospitalists in the Acute Care for Elders? 209

hospitalist co-management of surgical patients, to hospitalists as the primary

admitting physicians for surgical patients. In a 2008 meta-analysis, hospitalist mod-
els resulted in length of stay reductions of 1.45 days (95 % CI 2.45–0.41) when
compared to usual care [17].

Medical Care Beyond the ACE Unit: Population-Based

Approaches Involving Hospitalists

Central to the ACE model is the proactive recognition and management of geriatrics
syndromes in a high-risk population. However, the ACE model is inherently limited
by the number of patients that it can serve due to geographic realities of the model
while at-risk patients may be found throughout the hospital. Other models, includ-
ing consultative and population-based approaches may reach more at-risk patients.
In particular, population-based approaches to disseminate geriatric care can be
deployed through the use of information technology.

Consultative Approaches

While many geriatrics consultative services cover surgical and psychiatric patients,
they can be designed to partner with hospitalist groups serving medical patients
throughout the hospital. Sennour et al. described a “proactive” consultation service
(led by a geriatrician and geriatrics nurse practitioner) to bring specialized care to
high-risk patients identified in daily clinical team rounds [18]. This consultative
team is unique because the geriatrician is allowed to write direct patient care orders.
This model was well accepted by the hospitalists.

Electronic Identification of At-Risk Elders

At Aurora Health Care in Wisconsin, an e-Geriatrician consults with unit-based

staff at remote locations to provide input in to the care of geriatric patients [19].
The e-Geriatrician makes use of a proprietary “ACE Tracker” software program
that provides surveillance of older patients at risk for functional decline and poor
outcomes. Examples of ACE Tracker items include fall, pressure ulcer risk assess-
ments, and confusion assessment method (CAM) score. The e-Geriatrician uses
ACE Tracker data to identify treatment options for the hospital team. Using this
model, reductions in urinary catheter use and an increase in physical therapy use
were identified at one hospital in the absence of changes in length of stay or
210 H.L. Wald and M.L.P. Mattison

Standardized Assessment and Order Sets

The Global Risk Assessment and Care Plan for Elders—Acute Care (GRACE-AC)
program at the Beth Israel Deaconess Medical Center provides standardized care
plans for geriatric (aged 80 and older) medical and surgical patients. Embedded
within the computerized provider order entry (CPOE) system are modifications on
default order sets which ensure that the default value for orders are appropriate for
most older inpatients. Additional physician decision support is embedded within the
CPOE system to guide providers when ordering antipsychotic or analgesic medica-
tions in GRACE-AC patients. Moreover, nurses are able to easily generate compre-
hensive care plans for GRACE-AC patients focused on maintaining physical and
cognitive functioning. Central to this care plan is a daily standardized delirium
assessment. If the patient screens positive, the nurse notifies the primary team who
performs an in-person assessment of the patient and the primary attending physician
is notified of the change in status. While the GRACE-AC program is mainly focused
on improving the quality of care delivered to a vulnerable population, it has been
shown to improve medical resident knowledge specifically around diagnosing and
treating delirium in hospitalized elders [20].

Applying the Quality and Safety Paradigm to Improve

the Care of Hospitalized Elders

Nearly all hospitalist careers have developed in the period following the Institute of
Medicine (IOM) report on medical errors that launched the modern patient safety
movement [21]. Many hospitalists see their role of stewards of inpatient quality
and safety. They likely have received training in QI methodologies, lead local proj-
ects, and serve in administrative leadership roles in hospitals and clinical depart-
ments. The SHM helps cultivate this role by offering courses for its members on
quality and patient safety. Some academic hospital medicine programs encourage
QI leadership locally. At UCH, the Hospitalist-ACE service leadership convened a
multidisciplinary QI leadership team (QuILT) with the goal of employing QI prin-
ciples to improve outcomes for the entire unit [22]. The QuILT team meets monthly
to review the ACE unit dashboard, select priorities for performance improvement,
and initiate QI projects, such as a hand washing compliance initiative [23]. The
dashboard (Fig. 11.3) includes rates of readmissions, hand hygiene compliance,
central line-associated bloodstream infections, catheter-associated urinary tract
infections, falls, early and late stage pressure ulcers, and patient satisfaction.
Preliminary data suggests strong professional satisfaction stemming from QuILT
involvement [22].
What Is the Role of Hospitalists in the Acute Care for Elders?

Fig. 11.3 Sample quality and safety performance dashboard for an ACE Service. Shown here are typical data for readmissions, hand hygiene, hospital acquired
infections, patient satisfaction scores, pressure ulcers, falls, and deliriums. Quality improvement projects are initiated to address performance in each domain

on the dashboard
212 H.L. Wald and M.L.P. Mattison

Improving Transitional and Post-acute Care

for Hospitalized Frail Elders

With increased national attention focused on reducing hospital readmissions, hospi-

talists have taken an interest in transitions to home and post-acute care. Challenges
in transitions are common to frail elders with nearly 30 % of Medicare beneficiaries
readmitted to the hospital within 30 days of discharge [24].

Care Transitions

Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a
program designed to support hospitalist programs with the goal of reducing rehos-
pitalization rates and lengths of stay in older patients. The intervention consists of
a 12-month process of self-assessment, planning and mentored implementation of
selected evidence-based interventions from the BOOST toolkit based on hospitals’
unique needs [9]. External physician mentors facilitate these efforts and provide
support throughout the project. In an analysis of Project BOOST looking at 30-day
all-cause rehospitalizations and length of stay, the mean rehospitalization rate for
BOOST study units dropped by 2 %, from 14.7 % pre-implementation to 12.7 %
post-implementation (p = 0.010) compared to no change in rehospitalization rates
on control units, although only one hospital experienced large improvements
while most sites saw no real change in rehospitalization [25]. There was no statis-
tically significant difference in length of stay between BOOST study and control
units [10].

Post-acute Care

When the hospital medicine movement first began, hospitalists practice was limited
to acute inpatient care. Increasingly, hospitalists are now working in the post-acute
care environment. According to a 2011 survey, over 7 % of hospitalist medical
groups now provide services in skilled nursing facilities (SNFs), among other sites
of care [26]. Only one study in the published literature has described a hospitalist
model in a Baltimore SNF and compared outcomes with usual care provider by
community-based physicians. In this prospective study with historical controls, the
post-acute care hospitalist model resulted in increased laboratory costs and nonsig-
nificant reductions in pharmacy costs [27]. As large hospital medicine groups plan
to expand into the post-acute care arena, post-acute care specialization by non-
geriatricians is likely to grow [26].
11 What Is the Role of Hospitalists in the Acute Care for Elders? 213

The Nurses Improving the Care of Healthsystem

Elders (NICHE) Program

The geriatrics care innovations described above are successful because of the close
collaboration between hospitalists, nurses, and often geriatricians. In addition to
physician-centric care models included in the 2005 inventory of interventions [8],
hospitalists also interact with geriatrics nursing programs such as Nurses Improving
the Care of Healthsystem Elders (NICHE). This national program aims to improve
geriatrics nursing practice and prepare nurses to actively participate in interdisci-
plinary geriatrics care using evidence-based clinical protocols [28]. NICHE advo-
cates training GRNs to be clinical resources on geriatrics issues to other personnel
on their unit.
A 2012 survey of coordinators at NICHE hospitals identified opportunities and
barriers to effective collaboration between geriatrics nursing and hospitalist pro-
grams (personal communication, Brower, 2013). Twenty-eight percent of respon-
dents reported direct hospitalist involvement with NICHE activities, particularly
where ACE units operated. This suggests a sizable opportunity for more interaction
between geriatrics nurses and hospitalists to collaborate on the care of acutely ill
older patients. While additional detail on hospitalist interaction with geriatric nurs-
ing programs was limited, the survey did ask respondents to rate on a 5-point Likert
scale 17 clinical geriatrics competencies with respect to their importance of hospi-
talists possessing these skills and the frequency with which hospitals demonstrate
them. The mean importance rating was 4.6 ± 0.2 and the mean frequency rating was
2.8 ± 0.2 for a 1.8 point difference across competencies.

Closing the Knowledge Gap—Educational Programs

for Hospitalists Can Impact Outcomes for Frail Elders

Several hospitals utilize faculty development programs to deliver geriatrics training.

These programs use train-the-trainer (TTT) models, educating hospitalist and inter-
nal medicine physicians on geriatrics topics and clinical education strategies. These
clinician-educators in turn educate residents and medical students on care of older
patients. Evaluation of one such program, the Curriculum for the Hospitalized
Aging Medical Patient (CHAMP) program at the University of Chicago faculty
found that faculty participants developed increased self-confidence in geriatrics care
delivery, improved attitudes to geriatrics, and enhanced clinical teaching skills [29].
Other TTT programs include the Advancement of Geriatrics Education Scholars
Program (AGESP) at Beth Israel Deaconess Medical Center [30] and the Donald
W. Reynolds Program for Advancing Geriatrics Education (PAGE) at the University
of California, San Francisco (UCSF) [31]. The notion of training generalist clini-
cian-educators to provide specialty geriatrics clinical training holds great promise as
a model to address an inadequate geriatrician workforce in the United States [32].
214 H.L. Wald and M.L.P. Mattison


The geriatrics community has spent considerable effort identifying the components
of effective care for acutely ill frail elders. Geriatrics researchers have additionally
created many models of effective care delivery employing these principles [33]. Siu
et al. presented a business case for geriatrics service lines with an eye to enhancing
adoption of such models to improve outcomes and control costs [34]. Despite this,
there is palpable frustration at what is perceived as the piecemeal implementation of
such models [13, 35]. Partnership with hospitalists may be a way forward. In answer
to the question posed in the title of this chapter, the role of the hospitalists in caring
for frail elders is extensive and dynamic. As such, hospitalists make natural partners
in adapting and implementing interventions to improve care of this vulnerable pop-
ulation. In many cases, they are leading the charge.
There are substantial barriers for hospitalists adopting geriatrics care principles
[8]. First and foremost, the acute care paradigm—of which hospitalists are an inte-
gral part—is one largely centered on diagnosis and cure. Hospital medicine devel-
oped out of a need for subspecialization by site of care, with the intentional
introduction of discontinuity between inpatient and outpatient care. Hospitalists
with training in Internal Medicine receive little education in geriatric medicine com-
petencies such as functional assessment, multidisciplinary teamwork, and commu-
nication skills. In addition, the structures required for collaborative care frequently
are not embedded in acute care settings. The classic geriatrics paradigm is, in con-
tradistinction, focused on maximization of function and symptom control, and
requires multidisciplinary care coordinated across the care continuum.
Nonetheless, recent history would suggest that many hospitalists are surmount-
ing these barriers. It would behoove the geriatrics community to identify areas of
common interest such as the preventable adverse events identified by the Centers for
Medicare and Medicaid Services (CMS) as hospital-acquired conditions (HACs)
and to provide the technical assistance and mentorship that would allow hospitalists
to raise the quality of care for acutely ill frail elders.


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Chapter 12
How to Improve Care for Seniors
in the Emergency Department

Soryal Soryal, Marie Boltz, Scott Wilber, and Michael L. Malone

Abstract Clinicians and health system leaders have recognized the unique and
increasingly important role of the emergency department (ED) in addressing the
needs of older adults. This chapter describes the context of care for older adults in
the ED, and the common challenges to providing person-centered care. In addition,
best practices that reflect ACE principles of interdisciplinary, evidence-based care
are offered to improve the outcomes and experience for older adults.

Keywords Emergency department • Older adult • Quality

S. Soryal, M.D. (*)

University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
Aurora West Allis Medical Center, West Allis, WI, USA
Village of Manor Park Nursing Home, Milwaukee, WI, USA
e-mail: Soryal.soryal@aurora.org
M. Boltz, Ph.D., R.N.
New York University College of Nursing, New York, NY 10003, USA
e-mail: Marie.boltz@nyu.edu
S. Wilber, M.D.
Northeast Ohio Medical University, Rootstown, OH USA
Emergency Medicine Research Center, Summa Akron City Hospital, Akron, OH 44304, USA
e-mail: wilbers@summahealth.org
M.L. Malone, M.D.
University of Wisconsin School of Medicine & Public Health, Madison,
Aurora Senior Services & Aurora Visiting Nurse Association of Wisconsin,
Aurora Health Care, 1020 N. 12th Street, Milwaukee, WI 53233, USA
Aurora Sinai Medical Center, Milwaukee, WI, USA
e-mail: Michael.malone.md@aurora.org

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 217
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_12,
© Springer Science+Business Media New York 2014
218 S. Soryal et al.

Why Is the ED Important in Providing Excellent

Care for Older Patients?

The emergency department [ED] has a unique and increasingly important role in the
healthcare system including the care of the older patient. Over the past decade, there
has been an increase in hospital admissions from the ED coupled with a decline in
admissions from physician offices and other outpatient settings [1]. Outpatient phy-
sicians increasingly direct patients to the ED rather than directly admitting them,
and EDs support outpatient physicians by performing complex diagnostic work-
ups, and by handling overflow and off-hours care [1]. The ED is now the source of
approximately half of all hospital admissions [1]. For these reasons, it has been
suggested that increased efforts be placed on integrating the ED into the healthcare
system, both inpatient and outpatient [1].
Those 65 and older make up 15 % of ED visits nationally including 9 % of ED
visits by those 75 and older. The ED visit rate for the 75 and older population is
62/100 persons, making it the second only to (children) age under 1 year in visits
per 100 population [2]. One in five patients aged 65–74 years and one in four
patients aged 75 and older visit the ED each year [3]. Patients 65 and older are
admitted in 42 % of visits [3]. Half of nursing home patients with an ED visit are
admitted (49 %) [2]. Common ED presentations for older patients include serious
complaints such as injury, dyspnea, chest pain, and abdominal pain; but also non-
specific complaints (such as weakness, fatigue, and dizziness) that may indicate
serious disease [4]. Older ED patients are more likely to have laboratory studies,
x-rays, and advanced radiological tests such as CT scans and MRIs [3, 5–7]. This
results in the 65 and older age group having the highest median expenditures of any
age group [3].

Unique Challenges of Caring for Older Patients in ED

Modern Emergency Departments were designed based on principles developed in

the early 1960s to rapidly evaluate and treat the emergent needs of acutely ill and
injured patients [4]. Traditionally, the care process focuses on a single chief com-
plaint. Rapid diagnosis, treatment, and turnaround time are emphasized. This
model is often not sufficient to care for older patients for a number of reasons.
First, the patient’s presentation is often complex and serious diseases may present
atypically or nonspecifically. Second, patients often have comorbidities and this
leads to polypharmacy with increased risk of adverse drug effects. Third, acute
change in cognition (delirium) is common, serious, and frequently undiagnosed.
Fourth, decreased functional reserve results in functional decline associated with
acute illness that may limit a patient’s ability to remain independent. Lastly, social
support systems need to be assessed when planning care. For these reasons, a
12 How to Improve Care for Seniors in the Emergency Department 219

more holistic, biopsychosocial model is important for the optimal care of the older
ED patient [8].
The physical environment of older emergency departments may also be
detrimental to the care of older patients. Open wards are generally loud and have
limited privacy, with rooms separated only by curtains. Older ED gurneys posi-
tion patients uncomfortably, and the mattresses may be thin, with nonpressure
redistributing foam [9]. Older patients frequently complain that the ED tem-
perature is too cold. Concrete floors may be covered only by slippery tiles, and
direct overhead fluorescent lighting is typical. Bathrooms may not be located in
close proximity, and curtained cubicles may not be conducive to using a bedside
ED providers are, in many cases, attracted to the fast paced excitement of the
acute, critically ill patients. They may find themselves to be challenged by the older
patient with complex biopsychosocial needs. Surveys suggest that emergency phy-
sicians find older patients more time-consuming, more difficult, and requiring more
resources compared to younger patients [10]. They often feel poorly trained and
ill-equipped to deal with these complex needs [10]. Communication between pro-
viders and older ED patients may be difficult due to poor vision, limited hearing,
and cognitive impairment.
Traditionally, EDs have not had direct linkages to outpatient services such as
skilled nursing, rehabilitation, homecare, physical therapy, and durable medical
equipment. Even when such linkages have existed, they are often only be available
for limited times during the traditional work week. Emergency providers may there-
fore be unfamiliar with such resources and find it difficult to navigate the regula-
tions required to initiate such services. The ED visit may represent a culmination of
problems and concerns which lead to crisis; many caregivers are physically and
emotionally drained from their efforts to address the patient’s needs at home. For
these reasons, hospital admission is often required due to a lack of safe alternatives
for care.
These challenges can lead to adverse consequences in this population. The ED
environment increases the risk for iatrogenic complications resulting from falls,
indwelling bladder catheters, restraints, and medications. The loud, sometimes cha-
otic environment can be unsettling to older patients with cognitive impairment. The
lack of clues as to the time of day, such as windows or skylights, can be disorienting.
Serious medical issues such as delirium and functional decline may be missed, lead-
ing to increased morbidity and mortality [11–13].
Fortunately, the emergency medicine community has long recognized these chal-
lenges. In the early 1990s, the Society of Emergency Medicine convened a Geriatric
Task Force to address these issues. They conducted a series of research studies and
proposed a new model of care for older ED patients [8]. This model has evolved
over time. With the development and growth of Acute Care for Elders units, emer-
gency physicians began to suggest that the ACE model could be incorporated into
the ED visits [4, 14]. The significant growth in geriatric EDs is a direct result of
these efforts.
220 S. Soryal et al.

Best Practice Models of Emergency Department

Care for Seniors

Several innovations in seniors care in ED have been conducted with initial

Senior Friendly Emergency Department was created first by Holy Cross Hospital
in Maryland in 2008 [15]. The model was initiated by the CEO of the organization.
The unit was designed to be quiet with: ambient colors, thick mattresses on the
patient beds, indirect light, glare-free floors, and large easy-to-use call light/TV
remotes. The staff received additional training in the care of older patients. New
dedicated personnel were hired including a geriatrics nurse practitioner and geriat-
rics social worker. The geriatric nurse practitioner’s role was to educate other care-
givers in unique aspects of older adults. She furthermore assessed vulnerable older
patients for additional physical or psychosocial needs (elder abuse or neglect) and
linked patients and their families to community resources. A geriatrics trained phar-
macist reviewed the medications of seniors who receive seven or more medications.
The team received additional education sessions to emphasize community resources
available to older patients. The staff implemented follow-up calls after discharge
from the emergency department. Eight patient rooms of the senior friendly ED were
typically staffed with two RNs, one LPN or tech, the geriatric nurse practitioner, the
geriatric social worker, and the ED physician. Volunteers were integrated into the
care. Their focus was to provide comfort to patients by providing books, magazines,
papers, and companionship as needed.
The trend of senior friendly ED is growing and now there are more than 50 senior
friendly emergency departments across the United States [16]. Leaders in this field
are now reviewing the criteria for defining that a hospital emergency department is
“senior friendly.” These guidelines should be released in 2014. The Center for
Medicare and Medicaid Innovations has recently funded a multi-site project to
study several interventions to improve care of vulnerable older patients in the emer-
gency department.
The Geriatrics Emergency Department Consult Service, another model of care in
ED, was described at a tertiary care hospital (454 beds). The team consisted of a
geriatrician, a geriatrics fellow, a part-time physical therapist, a part-time occupa-
tional therapist, and a social worker. This interdisciplinary team provided the con-
sultation from 10 AM till 6 PM weekdays and 10 AM till 4 PM on weekends. The
team saw patients 70 years and older who were deemed ready to transition by the
ED physician. Older patients who were eligible for this service had any of the fol-
lowing red flags: a history of falls, multiple health issues, memory problems, behav-
ioral health problems, or more than three ED visits in 6 months. The geriatrics team
functioned as a gatekeeper of admissions to the acute geriatrics ward, and coordi-
nated the patient’s follow-up care in the hospital or in the community. The follow-
up strategies linked patients to outpatient geriatrics clinics, to home visits, or to
additional community resources [17].
12 How to Improve Care for Seniors in the Emergency Department 221

A mobile geriatrics team at Angers University Hospital in France performed a

brief geriatric assessments and made recommendations in the care of vulnerable
older patients. This intervention was noted to change the trajectory of the hospital
stay. Those who received the mobile geriatrics team assessment had a shortened
hospital stay. Others who did not require admission had an early discharge from ED
as well. The team recommendations addressed the patients’ medical and social
needs [18].
As leaders of Emergency Departments have begun to focus on geriatrics princi-
ples, there is likewise an effort to incorporate palliative care principles in the
ED. The Center to Advance Palliative Care (CAPC) implemented the Improving
Palliative Care in Emergency Medicine (IPAL-EM) project in 2010. This is a free
online site that shares best evidence including practical resources, quality monitor-
ing tools, and policies/protocols. Some of the tools include pocket cards, order-sets,
pain assessment/management tools, family-conference note templates, and links to
patient/family resources [19].

Assessment of the Older Adult in the Emergency Department


Atypical presentation of disease as well as the communication challenges (hearing,

vision, and cognitive) commonly experienced by older adults often complicate their
triage process in the ED [20]. Additionally, as a result of this clinical complexity, it
takes longer to triage older adults [20]. Delays in triage result in increased waiting
time and discomfort, and more critically, delays in treatment [20, 21]. These delays
increase the risk of mortality, especially in older trauma patients. Consequently
there is a need for accurate initial assessment and triage classification that promotes
prompt treatment [22]. Although the ACE clinician may not participate in the triage
process, knowledge of the patient’s classification level is important in order to guide
the treatment plan.
Five-level triage systems such as the Emergency Severity Index (ESI) and the
Canadian Triage and Acuity Scale (CTAS) are widely used as emergency patient
triage tools for accurate classification. The ESI includes a comprehensive algorithm
that describes symptoms and physiological indicators as well as the resources antic-
ipated to be used [23]. However, it has been criticized for not predicting which older
adults will need immediate life-saving treatment. In a recent study, the failure to
follow established ESI guidelines may have contributed to the apparent under-triage
[23]. In contrast, the CTAS has demonstrated high validity for older adults and it is
an especially useful tool for categorizing severity and for recognizing older adults
who require immediate life-saving intervention [24, 25]. See Table 12.1 for the
CTAS levels and associated descriptions, examples of conditions, and recommended
time to be seen by a physician [24].
222 S. Soryal et al.

Table 12.1 The Canadian Triage and Acuity Scale (CTAS) with Descriptions, Examples,
and Urgency:
Canadian Emergency
Department Triage and
Acuity Scale (CTAS) Time to be seen
level CTAS Level Conditions that Examples by a physician
Resuscitation Pose threats to life or Cardiac/respiratory arrest, Immediately
limb (or imminent major trauma, shock 98 % of the
risk of deterioration) states, unconscious time
requiring immediate patients, severe
aggressive respiratory distress,
interventions severe dehydration
Emergent Pose potential threat to Altered mental states, head ≤15 min 95 %
life limb or function, injury, severe trauma, of the time
requiring rapid MI, overdose, and CVA
medical intervention
or delegated acts
Urgent Could potentially Moderate trauma, asthma, ≤30 min 90 %
progress to a serious GI bleeds, acute of the time
problem requiring psychosis and/or
emergency suicidal thoughts, and
intervention. May be acute pain
associated with
discomfort or
affecting ability to
function at work or
activities of daily
Less urgent/ Are related to patient age, Headache, corneal foreign ≤1 h 85 % of
semi-urgent distress, or potential body, and chronic back the time
for deterioration or pain
complications would
benefit from
intervention or
reassurance within
1–2 h
Non-urgent May be acute but Sore throat, URI, mild 120 min 80 %
non-urgent as well as abdominal pain (chronic of the time
conditions which or recurring), with
may be part of a normal vital signs,
chronic problem with vomiting alone, and
or without evidence diarrhea alone
of deterioration

Clinical Evaluation

Despite overall higher consumption of resources in the ED, older adults are more
likely to experience missed or incorrect diagnoses (including undetected delirium,
depression, and dementia) [20], incur hospital-acquired infections [26], and
12 How to Improve Care for Seniors in the Emergency Department 223

experience inadequate pain management [27, 28]. The emergency department

clinician may call upon the ACE team to collaborate in evaluation and clinical
decision-making, using evidence-based assessment tools. Older persons often pres-
ent to the emergency department with multiple medical conditions with associated
fatigue and pain. Acute illnesses may be superimposed upon multiple interrelated
medical comorbidities. Sensory aging changes, particularly vision and hearing, can
threaten the accuracy of responses. To adequately assess the older adult, sensory
adaptations, such as magnifying glasses or hearing amplifiers, may be necessary
and should be accessible. Additionally, formal and informal (family) provide criti-
cal information [29].

Cognition and Mood

Approximately one quarter of all older patients presenting to the ED demonstrate

impaired mental status as a result of delirium, dementia, or both [30, 31]. The
Geriatric Emergency Medicine Task Force recommends a mental status assessment
for all older adults presenting to the ED [32]. The Six Item Screener (immediate
recall of three words; orientation to year, month, day of the week; recall of three
words) is short and easy to use and detects cognitive impairment with a sensitivity
of 94 % and a specificity of 86 % in the ED context [33]. If cognitive impairment is
detected, the family or formal caregiver should be questioned as to the baseline
cognition; abrupt onset suggests delirium. The Confusion Assessment Method [34]
is quick and easy to use and has a high specificity (100 %) and sensitivity (86 %) for
the diagnosis of delirium [35].
Depression may be present in up to one third of older ED patients [36, 37]. It
may interfere with the clinical presentation of acute medical disorders and results
in a greater number of ED visits [36–38]. The ED-DSI is appropriate for the detec-
tion of depression in the ED because it is brief (three questions) and has a sensitiv-
ity of 79 % and a specificity of 66 % compared with the longer Geriatric Depression
Scale [38].

Physical Function

According to Kresevic [39], assessment of physical function provides (1) baseline

functional capacity and recent changes in level of independence indicative of pos-
sible illnesses; (2) information to benchmark patients’ response to treatment as they
move along the continuum from the ED to acute care unit to post-acute care; and (3)
information regarding care needs and eligibility for services including safety, physi-
cal therapy, and post-hospitalization needs. Physical function is appraised using a
valid measure of basic (e.g., Katz ADL Index [40] or Barthel Index [41]) and instru-
mental activities of daily living (Lawton IADL [42]). Regardless of the instrument
used, basic ADL and IADL function should be assessed for each patient including
224 S. Soryal et al.

capacity for dressing, eating, transferring, toileting, hygiene, ambulation, and

medication adherence [39]. Measurement needs to capture baseline function (before
the acute admitting problem, typically 2 weeks prior to admission) as well as cur-
rent functional performance.


Falls are the main cause of ED admissions for older adults [43]. A targeted inter-
view with the patient and the caregiver should address previous falls as well as the
location, activity, and symptoms proceeding the actual fall. This description distin-
guishes between an isolated episode and a fall as a result of an underlying pathology
or general frailty [43]. Falls may be the chief symptom of orthostatic hypotension,
cardiovascular syncope, or carotid sinus syndrome [44]. Other responsible patholo-
gies may include acute myocardial infarction, sepsis, medication toxicity, acute
abdominal pathology, or elder abuse [45]. Hip fractures can be under-detected on
radiographs in older adults, and admission for further evaluation should be consid-
ered when there is hip pain [46]. Older adults with back pain should undergo radio-
graphic evaluation for vertebral fractures [47].
Altered mental state, focal neurologic deficits, headache, and falls may indicate
the presence of a chronic subdural hematoma [48]. Acute subdural hematoma is
mostly encountered in younger patients after severe trauma and typically presents
with initial coma [49]. Older adults who have experienced blunt head trauma should
receive brain imaging and extensive monitoring [50].

Polypharmacy and Adverse Drug Events

Systematic screening for polypharmacy and use of inappropriate medications

according to the Beers criteria prevents and detects adverse drug events in the ED
[43]. Communicating with the patient’s primary physician is critical [43]. A recent
study based on the National Electronic Injury Surveillance System–Cooperative
Adverse Drug Event Surveillance system showed that three medication classes
caused 48 % of all ED visits for adverse drug effects in patients older than 65 years:
oral anticoagulant or antiplatelet agents, antidiabetic agents, and agents with a nar-
row therapeutic index (digoxin and phenytoin) [51].

Coronary Disease

According to the American Heart Association, “because of the high prevalence of

atypical features and associated worse outcomes in the elderly, a high index of sus-
picion for acute coronary disease is advisable.” [52] Acute myocardial infarction
12 How to Improve Care for Seniors in the Emergency Department 225

presentation in older patients is frequently atypical, presenting as shortness of

breath, syncope, nausea and vomiting [53, 54], and falls [45]. EKG changes can be
nonspecific and it’s advised to acquire previous EKGs whenever possible for com-
parison [54].

Abdominal Pain

Older patients with abdominal pain experience higher morbidity and mortality than
younger patients [55, 56]. This poorer prognostic profile and the common atypical
presentation in older adults manifest the need for timely evaluation including the
use of radiography. The American College of Radiology suggests abdominal com-
puted tomography (CT) scan for lower quadrant and left upper quadrant pain, and
ultrasonography as a first-choice examination for suprapubic pain, right upper
quadrant pain and jaundice [57–59]. Ultrasonography and abdominal CT without
contrast may be most appropriate for patients at high risk for renal complications
such as chronic kidney disease, diabetes, chronic heart failure, or significant volume
depletion [60].


Older adults with infection frequently demonstrate atypical presentation. Acute

mental status changes or falls may be the only clinical sign of otherwise serious
infections, whereas more classic symptoms such as tachycardia and fever may be
absent [61].

Elder Mistreatment

The emergency clinician needs to be vigilant to recognize the clinical features of

elder mistreatment (EM), and to know their organization’s policies for reporting
suspected EM, as required by Joint Commission on Accreditation [62]. EM includes
physical, verbal sexual, and psychological abuse, as well as abandonment, exploita-
tion, and neglect [63]. The clinician should look for red flags of mistreatment—
delays in seeking treatment, signs of withholding or giving too much medication,
missed appointments, use of several hospitals, driving to a hospital farther away
from their own home, description of an event that does not fit the injury sustained,
and repetitive injuries. The emergency personnel should pay attention to the patient
and caregivers interaction with each other observing for clues of indifference, berat-
ing or threatening comments, caregiver hyper vigilant/possessive behavior, or
excessive concerns over finances [64].
226 S. Soryal et al.

When EM is suspected, it is recommended to separate the older adult from the

caregiver and obtain a detailed history and physical assessment [63]. Interviewing
the patient about their feelings of safety is important screening questions. Care
needs to be taken by clinicians to secure a careful medical history, including base-
line conditions, and conduct a comprehensive physical examination [65]. Physical
exam cues may include poor hydration, poor hygiene, suspicious injuries in unusual
locations, and bruises in various stages of healing, unexplained abrasions and/or
markings on skin including human bite marks, skin tears, pressure ulcers, or genital
complaints including infections or injury [65].

Substance Misuse

The drug most commonly misused by older adults is alcohol, followed by tobacco
and psychoactive prescription drugs. There is some data which indicates an
increase in the numbers of older individuals using marijuana [66]. Misuse is
defined as the use of a drug for purposes other than that for which it was intended.
Alcohol abuse is present in 6–11 % of older persons admitted to the hospital and
14 % of older adults presenting to the emergency department have diagnosable
alcoholism [67].
Validated screening instruments for older adults include the Alcohol Use Screen
and Assessment in Older Adult has shown to have good to excellent sensitivity and
specificity [68]. Patients who report use of marijuana and/or other drugs should
have toxicology tests to determine blood levels [69].

Risk Assessment to Prevent Adverse Outcomes

Two commonly used tools, the Identification of Seniors at Risk (ISAR) [70] and the
Triage Risk Screening Tool (TRST) [71] evaluate the presence/absence of risk fac-
tors for adverse outcomes. These tools are useful in preventing avoidable complica-
tions during the ED stay, if admitted during hospitalization, and after an ED visit,
when transitioning to home or another setting. The ISAR tool identifies older adults
who are at increased risk of death, institutionalization, functional decline, and both
repeat ED visit and hospital admission in the following 6 months after an ED visit
[70]. The TRST screening has been found to be predictive of subsequent ED use,
hospitalization, and nursing home admission [71]. The TRST is considered positive
when an older adult has cognitive impairment or has two or more of the remaining
risk factors (difficulty walking/transferring or recent falls, five or more medications,
ED use in previous 30 days or hospitalization in previous 90 days, and ED staff
concerns about geriatric syndromes).
12 How to Improve Care for Seniors in the Emergency Department 227

Role of the Nurse in the Emergency Department

Specialized Nursing Roles

A nurse dedicated specifically to discharge planning for older adults has reduced the
proportion of unscheduled ED return visits and facilitated the transition from ED
back home and into the community [72]. Similarly, nurse-led case finding with for-
mal linkage to community agencies was determined to be feasible and effective in
promoting follow-up care in at-risk older adults [73]. A two-step screening and
intervention model using ISAR, with follow-up after discharge by an ED use has
yielded more uptake of post-acute services [74].

Role of the Geriatric Resource Nurse

Nurses Improving Care for Health system Elders (NICHE) [75] is a national nursing
program of the Hartford Institute for Geriatric Nursing at New York University
College of Nursing. NICHE provides staff training programs and educational
resources, clinical protocols, evaluation tools and methods, and project manage-
ment tools—all designed to bring evidence-based practice to care of the older adult.
The foundation of the NICHE program is the Geriatric Resource Nurse (GRNs). In
the ED, GRNs act as peer consultants to other nurses and staff, provide ongoing
training, and lead quality initiatives [75, 76]. The ACE unit may be the “training
ground” for the GRNs; in some cases the Mobile ACE program GRNs serve the
ED. In much evolved NICHE programs, the ED has unit-based GRNs who assume
the role of gerontological nursing leaders.
GRNs assume the role of gero–expert clinicians, educators, and coordinators,
adapted to the specialized needs of older adults. As clinician, the GRN is aware of
the age-related changes that impact function and health. In addition to addressing
the acute presenting problem, the GRN institutes interventions to prevent and man-
age common “geriatric syndromes”: delirium, pressure ulcers, falls/fall injuries,
functional decline, and elder mistreatment. As educator, the GRN becomes the
“teacher” providing the patient, their significant other, or their caregiver with educa-
tion regarding the patient’s treatment plan and diagnostics, available resources, self-
care, and safety needs. As coordinator, in addition to partnering with the ED
physician and primary care physician, the GRN often collaborates with and coordi-
nates other disciplines. GRNs also provide leadership in policy and practice devel-
opment. One critical area for their oversight and quality improvement activity is the
handoff process. Key process measures that GRNs monitor include the content of
handoff information (all assessment indices, advanced directive information, and
identification of family involvement) between ED and hospital units, community-
based agencies, and long-term care providers.
228 S. Soryal et al.

Summary Points

The emergency department is a critical access point for health care for North
America’s aging population. Excellent care for older individuals requires that the
providers take into account the biopsychosocial needs of the patient. The assess-
ment of vulnerable older patients in the emergency department includes their cur-
rent and baseline function, their current and baseline cognition, their social needs,
their behavioral health needs, and their use of community resources. Several models
of care provide examples of best practice for hospitals in North America.


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Chapter 13
How to Improve Care for Older Patients
in the Intensive Care Unit

Leanne Boehm, E. Wesley Ely, and Lorraine Mion

Abstract A large proportion of hospital days are spent in the intensive care unit
(ICU). Growing numbers of this critically ill patient population are elderly, and have
baseline vulnerabilities putting them at an increased risk of having poor short- and
long-term outcomes. Use of interdisciplinary collaboration in the care of elderly
ICU patients is of utmost importance. This chapter reviews the unique needs of
elderly ICU patients, methods for applying interdisciplinary Acute Care for Elders
(ACE) interventions into ICU practice, and specific nursing considerations for elder
care in the ICU. The chapter also reviews end-of-life needs and strategies for
improved transitions of care for critically ill elderly patients.

Keywords Elderly • Intensive care • Delirium • Weakness • Interdisciplinary

protocol • ABCDE bundle

L. Boehm, M.S.N., R.N., A.C.N.S.-B.C. (*)

School of Nursing, Vanderbilt University,
1880 Portway Road, Spring Hill, TN 37174, USA
e-mail: leanne.boehm@vanderbilt.edu
E.W. Ely, M.D., M.P.H.
Pulmonary and Critical Care Medicine, Geriatric Research Education Clinical Center
(GRECC) of the VA Tennessee Valley Healthcare System, Vanderbilt University
Medical Center, 1215 21st Avenue South, Medical Center East, Suite 6100,
Nashville, TN 37232, USA
e-mail: wes.ely@vanderbilt.edu
L. Mion, Ph.D., R.N., F.A.A.N.
Independence Foundation Professor of Nursing, Vanderbilt University, School of Nursing,
461 21st Avenue South, Nashville, TN 37240, USA
e-mail: lorraine.c.mion@vanderbilt.edu

M.L. Malone et al. (eds.), Acute Care for Elders: A Model for Interdisciplinary 233
Care, Aging Medicine, DOI 10.1007/978-1-4939-1025-0_13,
© Springer Science+Business Media New York 2014
234 L. Boehm et al.


ICU Intensive Care Unit

ACE Acute Care for Elders
ADL Activities of daily living
SAT Spontaneous Awakening Trial
SBT Spontaneous Breathing Trial
CAM-ICU Confusion Assessment Method for the Intensive Care Unit
ICDSC Intensive Care Delirium Screening Checklist


Annually in the USA, there are an estimated 18 million days of intensive care unit
(ICU) care [1]. Older patients (age >65) account for half of all ICU admissions and
60 % of ICU days [2] with increases anticipated over the next 15 years. Complex
ICU treatment modalities can result in a cycle of over sedation, immobility, and
delirium with deleterious consequences that can extend up to years after hospital
discharge [3]. Older adults are especially vulnerable to chronic and debilitating
problems following critical illness resulting in frailty, institutionalization, depres-
sion, post-traumatic stress disorder, long-term cognitive impairment, and reduced
quality of life [4–7]. In this chapter, we describe the unique needs of older criti-
cally ill patients, interdisciplinary processes of care, end-of-life needs, and nursing

The Unique Needs of Older ICU Patients

Physical Reserve

Age-related changes in physiology and anatomy reduce the older adult’s ability to
respond to illness and treatment and contribute to higher likelihood of adverse con-
sequences [8]. Respiratory decline, decreased hepatic blood, decline in glomerular
renal function, and change in lean:fat ratio all impact drug clearance. Decreased
subcutaneous and connective tissue, vascular supply, skin turgor, and muscle mass
and strength increase the likelihood for pressure ulcer development. Cardiovascular
changes impede older adults’ ability to react to stress. Changes in immune/hemato-
poietic systems alter the ability to respond to infections. Age-related changes also
alter the presentation of critical illness; older ICU patients often present with non-
specific symptoms, leading to delays in treatment.
13 How to Improve Care for Older Patients in the Intensive Care Unit 235

Cognitive Reserve

Aging changes in the brain structure include decreased brain size, number of
neurons and dendrites, and cerebral blood flow. Cognitive decline is not inevitable
and varies greatly among older individuals [9]. Nevertheless, many critically ill
older adults have a reduced cognitive reserve due to existent cognitive impairment
or dementia and genetic predisposition in the form of apolipoprotein E genotype,
resulting in an increased vulnerability to the development of new cognitive impair-
ment [7, 9–11]. Pre-existing cognitive impairment exists in up to 37 % of older ICU
patients and often goes unrecognized by clinicians [10].

Family Support

Families are an integral part of the hospitalized patients’ care and recovery [12, 13].
For the critically ill older adult, family members provide essential information not
only on the patient’s past medical history and medications, but also on his ability to
perform activities of daily living (ADL), cognitive function, and end-of-life prefer-
ences. For many hospitalized older adults, family members are likely to be older
spouses with their own health issues or aging adult children with other competing
family responsibilities [13]. Hence, family involvement may be quite limited for
critically older adults.

Applying ACE Concepts in the Intensive Care Unit

The Acute Care of Elders (ACE) framework focuses on maintaining or promoting

function through interdisciplinary team collaboration, geriatric assessment, and
management of common syndromes and diseases (e.g., delirium), patient-centered
therapies, and environmental manipulation [14]. These principles apply to the criti-
cal care setting as well.
Interdisciplinary Collaboration. The severity of illness, multiple comorbid condi-
tions, and diminished cognitive and physical reserve among older critically ill
patients necessitate the collaboration and cooperation among multiple disciplines
that include physicians, nurses, and allied health providers. Studies have demon-
strated that ICU interdisciplinary teams with focused patient-goals are associated
with or predictive of improved patient outcomes [15].
Comprehensive Geriatric Assessment and Management. A comprehensive assess-
ment is conducted to determine the older adult’s preadmission and admission base-
lines of physical and cognitive function. Physical function includes mobility, ADL,
and instrumental ADL (e.g., shopping, cooking, transportation). Cognitive function
236 L. Boehm et al.

is assessed for pre-existing cognitive impairment of dementia and/or delirium.

Additional parameters for assessment include nutritional status, depression, and
medications. Because many critically ill older adults have communication difficul-
ties, family members, or caregivers are a critical source of information [8] and
efforts must be made to contact these individuals. A number of instruments are
available to standardize and assist in gathering the above information (see Try This
Series, http://hartfordign.org/Resources/Try_This_Series).
Patient-Centered Therapies. Information gathered from the comprehensive geriatric
assessment will provide direction to determine goals at time of ICU discharge and
hospital discharge, including end-of-life care. Information will also provide direc-
tion for the implementation of therapies to prevent iatrogenic events and maintain
function. Use of protocols or bundles can standardize complex critical care and
improve outcomes, such as sepsis and ventilator-acquired pneumonia; but their use
must be tailored to the heterogeneity found among older critical adults and their,
oftentimes, competing care goals [16, 17].
Environmental Manipulation. The importance of the hospital physical environment
on the recovery of patients has been known since the time of Nightingale. Aspects
of the environment that hinder recovery and negatively affect physical and cognitive
function include noise, temperature, and light. In this regard, the ICU is perhaps the
most noxious environment in the hospital with its cacophony of sounds and alarms,
bright harsh lights, cool temperatures, and noxious odors [18]. Older adults are
especially vulnerable to environmental stressors. Equipment and furniture to
enhance physical functioning, such as early mobilization, are other important con-
siderations for the older critically ill adult.

The ABCDE Bundle: Case Exemplar

Critical illness and the use of sedatives during mechanical ventilation can lead to
prolonged mechanical ventilation and delirium. Likewise, critical illness, the use of
sedatives, and occurrence of delirium also instigate ICU-acquired weakness. The
multicomponent ABCDE bundle (Awakening and Breathing Coordination, Delirium
Monitoring and Management, and Early Mobility) is a method of applying the ACE
components in the ICU. The ABCDE bundle brings synergy to a group of evidence-
based practices to break the cycle of over sedation and prolonged mechanical venti-
lation leading to delirium and ICU-acquired weakness. It provides order to and
alignment for currently existing people, processes, and technology within the ICU
to improve collaboration among disciplines and standardize processes of care in the
ICU (Table 13.1). Importantly, the ABCDE bundle is designed to move patients
toward a return to baseline physical and cognitive function [19].
Awakening and Breathing Coordination (ABC). These practices include the
daily performance of a Spontaneous Awakening Trial (SAT, sedation cessation)
13 How to Improve Care for Older Patients in the Intensive Care Unit 237

Table 13.1 ABCDE bundle: an interdisciplinary approach

Name Element Disciplines involved
ABC Awakening and Breathing Coordination Nurse
Respiratory Therapist
C Choice of sedative regimensa Nurse
D Delirium monitoring and management Nurse
Rehabilitation Therapist
E Early mobility Rehabilitation Therapist
Respiratory Therapist
The ABCDE (Awakening and Breathing Coordination or Choice of sedative regimens, Delirium
monitoring/management, and Early mobility) bundle is a multicomponent interdisciplinary ICU pro-
tocol designed to mitigate ICU delirium and weakness and improve collaboration among disciplines
Choice of sedative is sometimes left out of the bundle

followed by a Spontaneous Breathing Trial (SBT, trial of independent breathing

with minimal ventilator support). We found this “Wake up and Breathe” approach
capitalizes on a more alert, cooperative patient during an SBT and resulted in
reduced hospital length of stay, reduced prevalence of coma, absolute risk reduction
in death at 1 year, and reduced incidence of cognitive impairment at 3 months [21].
Choice of Sedative Regimens (C). Mechanically ventilated patients frequently
require the use of sedatives, which can play a role in the duration of mechanical
ventilation as well as cognitive function, especially benzodiazepines. Guidelines
recommend analgosedation (i.e., analgesia-first), sedation regimens that employ the
sedative qualities of analgesics (e.g., fentanyl), for the management of agitation in
mechanically ventilated patients [20]. Non-benzodiazepine sedatives, either propo-
fol or dexmedetomidine, are recommended rather than benzodiazepines like mid-
azolam and lorazepam [20]. Dexmedetomidine and propofol use can lower the
prevalence of delirium in high risk mechanically ventilated patients [20].
Delirium Monitoring and Management (D). Delirium is an acute brain dysfunc-
tion that disrupts brain neurotransmission leading to disturbances of consciousness,
inattention, fluctuations in mental status, and changes in cognition [22]. Often,
delirium is accompanied by evidence of a medical condition, substance intoxica-
tion, or medication in the medical history or physical work-up. Delirium occurs in
up to 80 % of mechanically ventilated and 50 % of lower severity ICU patients [23].
It goes undiagnosed in three out of four occurrences, especially in the absence of an
assessment tool, because of the higher prevalence of hypoactive subtype (e.g., quiet
delirium). Associated financial and societal burdens related to delirium include
increased morbidity, prolonged hospitalization, higher reintubation rates, and higher
238 L. Boehm et al.

costs of care [23]. Delirium is also a predictor of long-term cognitive impairment,

akin to acquired dementia, which occurs in 50–66 % of ICU survivors [4, 6].
Delirium screening improves the recognition of delirium, provides a common lan-
guage for the communication of cognitive function, and indicates the need to evalu-
ate and change aspects of critical care therapy to improve cognitive function.
Early Mobility (E). Early mobilization of critically ill adults is both feasible and
safe to perform [24]. Schweickert and colleagues utilized a “Wake up, Breathe, and
Move” approach in which SATs and SBTs were combined with early mobilization
in mechanically ventilated patients [25]. Patients receiving the early mobility inter-
vention were out of bed 5 days sooner compared to patients receiving usual care. In
addition, patients who received early mobility had a shorter duration of delirium
(median 2.0 vs. 4.0 days, p = 0.02) and were more likely to return to independent
functional status by hospital discharge (p = 0.02).
Effectiveness of ABCDE Bundle. In a recent study, implementation of the ABCDE
bundle resulted in 3-day reduction in average duration of mechanical ventilation,
50 % reduction in incidence of delirium, and a 26 % increase in likelihood of mobi-
lization at least once during the ICU stay [26, 27]. High-value patient outcomes
related to the application of ABCDE bundle components include improved likeli-
hood of survival, reduced length of hospital stay, and improved physical function.
A similar program at one institution demonstrated a net financial benefit of $4.3
million in 4 months in addition to an improvement in neurological outcomes and
double the number of days without delirium (53 % vs. 21 %, p = 0.003) [28].

End-of-Life Needs of Older Patients in ICU

The changing demographics of our society will result in increasing numbers of criti-
cally ill older adults for whom ICU complex therapies and technologies will be of
little to no avail. Patient-centered, indeed family-centered, care is the ideal model for
managing end of life in the ICU [29]. The American College of Critical Care
Medicine provides recommendations for clinicians’ knowledge and competence in
the practical and ethical aspects of withdrawing treatment, withholding treatment,
family communication, and bereavement [29]. Many older adults have discussed
end-of-life preferences with family members, but communication and documenta-
tion of the patient’s and family’s preferences are low [30]. Systems need to be put in
place to include end-of-life preferences as part of the admission process to the ICU.

Strategies for Improved Transitions of Care

Transition of care, or care transition, is the process of moving between settings or

providers and has been identified as a major quality and safety issue in health care.
Indeed, The Joint Commission has a number of standards related to safe transition
13 How to Improve Care for Older Patients in the Intensive Care Unit 239

of care, including medication reconciliation with each transfer. Older ICU adults
often undergo a number of transitions within the same hospitalization [31, 32];
moreover, ICU older adult survivors who transition to home often have major
changes to their functional ability and residence [32]. Poor handoffs from the ICU
to other hospital units or home can result in adverse consequences including medi-
cation errors, unnecessary testing, falls, and unmet needs resulting in prolonged
hospitalizations. The Transitions of Care Consensus policy statement [33] identified
several standards for the safe transition of care: coordinating between clinicians,
care plans with minimal data elements, a communication infrastructure, standard-
ized communication formats, determining transition responsibility, timeliness, and
measurement. Within each setting, establishing a policy and procedure for handoffs
of older ICU patients with attention to functional recovery as well as medical recov-
ery will enhance the likelihood of successful transition to home.

Nurses Role

ICU nurses have an essential role in the assessment and care of critically ill older
adults. Many hospital based programs and models for acute geriatric care are medi-
ated through nursing (http://www.nicheprogram.org). As the health care provider at
the bedside 24/7, nurses are able to assess for early subtle changes in cognition,
communicate and coordinate care among all health care professionals, inform fami-
lies, and encourage physical mobility.
Delirium Assessment. Delirium assessment is recommended each shift and as
needed [20]. The ICU delirium screening tools with the best validity and reliability
data are the Confusion Assessment Method for the ICU (CAM-ICU, sensitiv-
ity = 93–100 %, specificity = 89–100 %) [34] and the Intensive Care Delirium
Screening Checklist (ICDSC, sensitivity = 99 %, specificity = 64 %) [35] (Figs. 13.1

1 Point for each symptom that occurs

during an 8 or 12 hour shift:
Fig. 13.1 Intensive Care
Altered level of consciousness
Delirium Screening Checklist
(ICDSC) [35]. The Intensive Inattention
Care Delirium Screening Disorientation
Checklist (ICDSC) is a
checklist utilized to assess for
the presence or absence of Psychomotor agitation or retardation
delirium symptoms over a Inappropriate speech
period of time, usually an 8
Sleep/wake cycle disturbances
or 12 h shift. The patient
screens positive for delirium Symptom fluctuation
if four or more symptoms
manifest during the course of Score ≥ 4 = Delirium
the designated timeframe
240 L. Boehm et al.

Fig. 13.2 Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The CAM-
ICU assesses for the four features of delirium. Feature 1 is an acute change in mental status or a
fluctuating mental status, feature 2 is inattention, feature 3 is altered level of consciousness, and
feature 4 is disorganized thinking. A patient screens positive for delirium if features 1 and 2 and
either feature 3 or feature 4 are present. Used with permission from www.icudelirium.org

and 13.2). Patients responsive to verbal stimulation can be assessed for delirium.
Once delirium is recognized, swift discussion of potential etiologies and manage-
ment approaches should ensue. The THINK mnemonic is a helpful tool to guide a
discussion of likely delirium etiologies (Fig. 13.3). Nonpharmacologic (e.g., early
mobility, cognitive stimulation, environmental modification) and pharmacologic
strategies should be considered. There are no FDA approved medications for the
treatment of delirium, and there is no evidence to support pharmacologic preven-
tion, or the use of haloperidol for the treatment of delirium [20]. Atypical antipsy-
chotics may be beneficial and a large multicenter trial is currently underway to
determine the efficacy of antipsychotics for the treatment of ICU delirium (clinical-
trials.gov NCT01211522).
Physical Function. Preventing prolonged periods of immobility through mobility in
the earliest days of critical illness is a primary step in maintaining baseline physical
function. Critically ill patients should be evaluated daily to determine the safety of
receiving early mobility. Typical mobility exclusions include an FiO2 > 60 %,
13 How to Improve Care for Older Patients in the Intensive Care Unit 241

Fig. 13.3 Troubleshooting delirium etiologies and risk factors—THINK. Once delirium is iden-
tified, the THINK mnemonic can serve as a guide for discussion and consideration of potential
delirium etiologies and risk factors and can serve as a guide for directing management strategies.
Examples of nonpharmacologic interventions include cognitive stimulation, early mobility,
environmental modifications, and sleep promotion strategies. Used with permission from www.

PEEP > 10cmH2O, increases in vasopressor infusion rate, active myocardial

ischemia, symptomatic arrhythmias, or another contraindication [36]. Patients can
be mobilized according to a protocol progressing from active range of motion, sit-
ting on the edge of the bed, standing, active transfers, to walking in accordance with
the patient’s highest functional ability and the absence of stop criteria (e.g., respira-
tory distress, sustained tachycardia/bradycardia). Successful application of early
mobility relies on sedation practices that prioritize lighter levels of sedation and
tight sedative titration to achieve light sedation targets.


The care of critically ill older adults is complex and challenging. Application of
ACE principles in a thoughtful and systematic approach can make a significant
impact on patient outcomes. Critical care nurses as the frontline providers have an
essential role in conducting frequent assessments, coordinating care among multiple
disciplines, and implementing evidence-based practices (see Table 13.2 for avail-
able resources).
242 L. Boehm et al.

Table 13.2 Web-based resources for elder care in the ICU

www.icudelirium.org Comprehensive website detailing assessment and
management of delirium. Contains resources for
medical professionals, patients, and family members
www.hospitalelderlifeprogram.org Resource for nonpharmacologic interventions for
delirium that have been used successfully in
noncritically ill elders
www.aacn.org/pearl American Association of Critical Care Nurses resource
for application and implementation of the ABCDE
www.nicheprogram.org Nurse led program designed to improve the care of
hospitalized elders
http://consultgerirn.org/resources Hartford Institute for Geriatric Nursing series offers
suggested assessment tools for a variety of clinical
issues with video demonstrations


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