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Acute Care for Elderly ACE (We certainly think we are)

Acute Care for Elderly ACE (We certainly think we are). Aim. Aim : To improve the care for over 85 year old acute geriatric patients by implementing an Acute Care for the Elderly model, as evidenced by – Decrease in Acute-Rehab LOS from 25 - 20 Days Decrease in ACE LOS from 8.5 - 7 Days

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Acute Care for Elderly ACE (We certainly think we are)

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  1. Acute Care for Elderly ACE (We certainly think we are)

  2. Aim • Aim: To improve the care for over 85 year old acute geriatric patients by implementing an Acute Care for the Elderly model, as evidenced by – • Decrease in Acute-Rehab LOS from 25 - 20 Days • Decrease in ACE LOS from 8.5 - 7 Days • Decrease in readmission rate from 6% - 4% • Decrease in step down of care rate from 14% - 8%

  3. Overview of ACE • What – Geriatrician led, comprehensive MDT care for acute elderly focusing on a sustainable return home • Who – >85yo, acute admission, excludes specialist conditions, frail, complex needs • How – Intensive MDT model, early screening, early and preventative rehab, comprehensive geriatric assessment, removal of a transition of care for those requiring rehab • Why – Vulnerable patient group, higher readmissions, high rate of step down in care, unmet need

  4. Challenges/Learnings • Defining an “ACE” patient • Refining our acceptance criteria • Getting ACE patients to the ward • Education • Operational shift • Culture change • Understanding what we had changed and if our baseline was still relevant

  5. Review of Baseline 50 patients per month 90 patients per month 150 patients per month 300 patients per month

  6. Successes • JaM tool – Quick identification of patients at risk of step down in care • Aim to get high value patients • Admission screen • Facilitates combined MDT approach leading to combined care planning • 9am Huddle • Improves regular ward communication and a team based approach

  7. Summary Data to Date

  8. Acute to Rehab Journey >85’s

  9. Acute to Rehab Journey >85’s Baseline 24.9 days Post ACE 16.9 days

  10. Case Study • Mrs W – Chest infection, delirium, dementia, pressure area, reduced mobility • Screening showed cognition declined, variable mobility, poor food intake • Cared for by daughter – burn out, not engaged and didn’t have the skills • Meeting with daughter/CN/SW • Day care and respite arranged • Daughter educated re pressure care, feeding and spent time with PT/Nursing to learn cares • D/C home

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