Acute Care for Elders (ACE) Units: Geriatric Care as a Team Sport

1. Acute Care for Elders (ACE) Units: Geriatric Care as a Team Sport Kellie L. Flood, MD Assistant Professor Division of Gerontology, Geriatrics, and Palliative Care UAB School of Medicine

2. Objectives Advocate to stakeholders the need for interdisciplinary team programs for care coordination Define the components of an Acute Care for Elders (ACE) Unit as an example of an interdisciplinary team model of care List outcomes from clinical trials evaluating ACE Units Access available tools for geriatric interdisciplinary team training

3. Why do we need interdisciplinary team models of care?

4. Silver Tsunami is Coming!! http://www.agingstats.gov/agingstatsdotnet/main_site/default.aspx

5. A Significant Portion of the Silver Tsunami is Frail and Complex

6. Multimorbidity Boult et al, The Permanente Journal Winter 2008;12:50-4; Boyd et al, Guided Care for Multimorbid Older Adults, Gerontol, 2007 . 62% of older Americans are experiencing multimorbidity Older adults experiencing multimorbidity consume 96% of the Medicare budget

7. Geriatric Syndromes • Dementia • Delirium • Depression • Gait and balance abnormalities/Falls • Frailty/Functional Decline • Malnutrition • Pressure ulcers • Polypharmacy • Incontinence • Caregiver Stress Geriatric Syndromes = Increased Risk for Adverse Outcomes Kresevic et al, Ger Nursing, 1998

8. Hospitalized Older Adults • Patients aged 65 and over account for ~ 49% of hospital days • Geriatric syndromes often go unrecognized during a hospitalization Counsell et al, JAGS, 2000; Palmer et al, Clin Geriatr Med, 1994; Palmer et al, Clin in Geriatr Med, 1998; Lyons, Landefeld, Ann of Long-Term Care, 2001

9. Frail part of the Tsunami is hitting hospitals ~35% have Cognitive Impairment on admission (65% unrecognized) Dementia: ~25% older inpatients Delirium: 10-15% on admission 10-40% in-hospital (new onset) Up to 60% of hip surgery patients Up to 80% of mechanically ventilated patients Naylor et al, AJN, 2005; Counsell et al, JAGS, 2000; Palmer et al, Clin in Geriatr Med, 1998; Lyons, Landefeld, Ann of Long-Term Care, 2001; www.cdc.gov/nchs/agingact.htm

10. Frail part of the Tsunami ishitting hospitals Depression: Minor depressive symptoms: 23% Depression + dementia: 22-54% 23-62% are under-nourished 25-35% are more dependent in their ADLs at discharge Up to 50% receive potentially inappropriate medications Higher 30-day re-admission rates Naylor et al, AJN, 2005; Counsell et al, JAGS, 2000; Palmer et al, Clin in Geriatr Med, 1998; Lyons, Landefeld, Ann of Long-Term Care, 2001; www.cdc.gov/nchs/agingact.htm

11. 30-Day Readmission Rates 2004 data: Unplanned rehospitalization cost Medicare $17.4 billion, making this a target for cost reduction Jencks et al, NEJM 2009;360:1418-1428

12. A Case: Ms. Jones • 78 yo AA Female living in an Assisted Living Facility • Multimorbidity: Hypertension, Hyperlipidemia, Congestive Heart Failure, Type II Diabetes, Renal Insufficiency, Spinal Stenosis that causes severe pain (she is not a surgical candidate) • Geriatric Syndromes: Frailty, Mild Cognitive Impairment, Depression, Polypharmacy • Limited Health Literacy: 8th grade education from rural Alabama

13. Ms. Jones: Example of Poorly Coordinated Hospital Care • Ms. Jones is hospitalized for pain and altered mental status • Admitted to a general medicine floor to a doctor who has never met her before • A traditional, multidisciplinary model of care • Day 1 she is diagnosed with a UTI • Antibiotics are started

14. Ms. Jones: Example of Poorly Coordinated Hospital Care • During her first 48 hrs of admission Ms. Jones is observed to be intermittently agitated and moaning • Receives repeated doses of benzodiazepine for agitation • Day 2 she suffers a fall while trying to get to the bathroom • She is restrained • Day 4 she has completed her course of antibiotics for her UTI • She remains confused and is still occasionally moaning as if she is in pain • Later that day she is discharged back to her Assisted Living Facility

15. Coordinating Person-Centered Care Across Disciplines

16. New quality mandates require coordinated care to achieve Patients deserve and demand it

17. Quality Timeline 2008 1999 2001: ACOVE Quality Indicators Published 2006: National Quality Forum releases “Never Events” 2003: Joint Commission’s initial National Patient Safety Goals 2008: CMS limits payments for “Hospital Acquired Conditions” 2001

18. ACOVE Quality Indicators Assesses care of vulnerable elders by evaluating processes of care Hospital Care QIs for vulnerable elders Admission evaluation of cognition and function Discharge planning initiated within 48 hrs Medication reconciliation Transfer of records across settings Decision-making capacity assessed prior to informed consent Evaluation for causes of delirium Avoidance of potentially inappropriate medications Shekelle et al, Ann Intern Med 2001;135:647-67

19. 2009 National Patient Safety Goals for Hospital Care Improve the accuracy of patient identification Improve the effectiveness of communication among caregivers Improve the safety of usingmedications Reduce the risk of health care-associated infections Accurately and completely reconcile medications across the continuum of care Reduce the risk of patient harm resulting from falls Encourage patients’ active involvement in their own care as a patient safety strategy Identify safety risks inherent in its patient population Improve recognition and response to changes in patient’s condition www.jointcommission.org

20. FY 2009 CMS Hospital Acquired Conditions/Never Events Foreign object left in surgical patient Air embolism Incompatible blood transfusion Stage 3 or 4 pressure ulcers Catheter-associated UTIs Vascular catheter-associated infection Mediastinitis after coronary artery bypass grafting Injurious Falls Surgical site infections following certain elective procedures Extreme blood sugar derangement Deep venous thrombosis/Pulmonary embolism following knee and hip replacements www.cms.hhs.gov

21. Reimbursement is linked to quality mandates Hospital financial health is dependent on patient-centered, coordinated care

22. Are we trained to provide coordinated care for the Silver Tsunami?

23. Disaster Preparedness • Physicians • ~7,100 geriatricians and declining • ~1,600 geriatric psychiatrists • Only 0.5% of medical school faculty are geriatric specialists • < 10% of medical schools have a required geriatrics course IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

24. Disaster Preparedness • Registered Nurses • < 1% of 2.2 million practicing RNs are ANCC certified in geriatrics • Only 1/3 of BSN programs have a required geriatrics course • Associate degree programs - unknown • Advanced Practice Registered Nurses • About 2.6% of APRNs certified in geriatrics IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

25. Disaster Preparedness • Social Workers • Today, only 4% specialize in geriatrics (about 1/3 of the estimated need) • 40% of schools lack faculty in aging • Only 20% of BSW programs and 29% of MSW programs have any coursework in aging IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

26. Disaster Preparedness • Pharmacists • Less than 1% certified in geriatrics • 0 residency programs in geriatric pharmacy (out of 351) • Dieticians • 22% of undergraduate dietetics and nutrition programs offer courses in aging IOM Retooling for an Aging America: Building the Health Care Workforce, 2008; www.iom.edu/agingamerica

27. Crossing the Quality Chasm: A New Health System for the 21st Century IOM Crossing the Quality Chasm Brief Report, March 2001

28. Is there a need for interdisciplinary coordinated care? YES!!! Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51 • Crossing the Quality Chasm: A New Health System for the 21st Century • Health care teams play a central role • Multimorbidity + Geriatric Syndromes requires coordinated care from multiple disciplines • National Patient Safety Goals/Never Events require interdisciplinary approach to achieve • Cost containment imperatives/Limitations to reimbursement • Increase use of non-physician providers • Demand for quality requires interdisciplinary teams • Patients deserve it

29. Intersection of Quality and Finances = Momentum Slide by Michael D. Wang, MD, UC Irvine

30. Key Features of Models that Enhance Care Coordination Systematically assess patients’ functional, cognitive, and psychosocial status as well as expectations and wishes Target most vulnerable patients Coordinate care across settings Utilize interdisciplinary teams that meet patient in setting of care

31. What characteristics do winning teams have? • Clear leadership • Definite aim • Common enemy • Trust each other • Communication • Heterogeneity of members • Established rules • Plan to deal with barriers/change • Mutual respect • Flexibility/adaptability • Self-selected • Understanding of roles • Optimal team size • Able to cooperate • Measure performance • Self/team reflection

32. Types of Teams in Healthcare GITT Curriculum: Teams and Teamwork • Unidisciplinary: • Group of people all from the same discipline working together • Multidisciplinary: • Group of people from different disciplines who develop a treatment plan independently • Interdisciplinary: • Group of people from different disciplines assess and plan care in a collaborative manner

33. Acute Care for Elders (ACE) Unit are a proven interdisciplinary team model of coordinated care in the hospital setting and a site for training

34. Slide by SUMMA Health Care Traditional Acute Care Model LOS Cost Functional Older Person Acute Illness Possible Impairment Hospitalization Hostile Environment Depersonalization Bed Rest Starvation Medicines Procedures Institutionalization Depressed Mood Negative Expectations Physical Impairment ACE Acute Care for Elders Dysfunctional Older Person SUMMA Health System

35. Slide by SUMMA Health Care Model of Coordinated Care in the Hospital: Acute Care for Elders (ACE) Unit Functional Older Person Depressed Mood Negative Expectations Acute Illness, Possible Impairment Hospitalization: ACE Unit Prehab Program: Prepared environment Patient-centered, interdisciplinary care Multi-dimensional assessment and non-pharmacologic prescription Home planning/informal network Daily medical review Decreased Iatrogenic Risk Factors Improved Mood Positive Expectations Reduced Impairment ACE Acute Care for Elders Functional Older Person SUMMA Health System

36. Who are members of ACE Unit Interdisciplinary Teams? • Geriatrician/Gerontological Advanced Practice Nurse • Nurses • Rehabilitation Services • Pharmacists • Dietician • Social Work/Care Manager • Pastoral Care/Psychologist • Complimentary therapists (art, pet, music) • Volunteers • Home Care representative • Palliative care/Hospice representative • Other • ??? Patient’s physician

37. How does it work? Frequent (daily) team meetings/rounds Clearly defined structure and goals for the rounds Requires training Method of communicating team recommendations Will patient’s physicians attend the rounds? Many units use informal communication sheets Ongoing geriatric and team functioning training Frequent feedback and revision to processes UAB Highlands ACE Unit Daily Interdisciplinary Team Meeting

38. UAB HIGHLANDS ACE ROUNDS NURSE REPORT FORM Room #:__________ Name:_____________________ Age:_____________ Lives in: House Apt Assisted Living Facility Nursing Home Other Lives with: __________________________________________

39. Goals of an ACE Unit Prevent, identify, and manage geriatric syndromes Elicit and respect patient/family preferences regarding goals of care Maintain functional status and return patients to home Prevent medication errors or adverse drug events Coordinate in-hospital and transitional care from the day of admission Training site for geriatric education for all health care disciplines Research “laboratory” for piloting geriatric team care interventions Increase philanthropy/grant support for hospital Other

40. ACE Unit Interdisciplinary Team Care Coordination Mobility Intervention Analgesic or Laxative Prescribed PT/OT Consulted Medication Error Corrected Adapted from Flood, et al. Am J GeriatrPharmacother 2009;7:151-58; Carroll, Solipuram, Li, Flood. Gerontological Society of America Annual Scientific Meeting Poster Presentation, Dallas, TX, November 2006 .

41. Landefeld et al, N Engl J Med 1995;332:1338-44 ACE Units: Randomized Controlled Trials Change in patients’ ability to perform ADLs from admission to discharge (p.009) Significantly fewer patients on ACE Unit were discharged to a nursing home compared to usual care (14% vs 22%; p.01)

42. ACE in a Community Hospital 1531 community-dwelling patients age ≥ 70 admitted for acute medical illness Randomized to ACE vs Usual Care Demonstrated improved processes of care Reduced use of restraints Fewer high risk meds Earlier and more frequent involvement of physical therapy and social work Improved patient and provider satisfaction Counsell et al, JAGS 2000; 48:1572-1581

43. ACE Units Reduce Mortality 254 patients age > 75 meeting a targeting criteria for frailty Randomized to ACE Unit vs Usual Care Saltvedt et al, JAGS, 2002;50:792-798

44. Health Care Utilization and ACE Retrospective, case-control study Academic urban hospital 680 ACE vs 680 non-ACE patients age ≥ 65 Matched for age, ethnicity, comorbidity, and DRG (CHF, pneumonia, UTI) ACE patients: Shorter mean LOS (4.9 ± 4.3 vs 5.9 ± 4.5 , p=0.01) 9.7 % reduced mean costs ($13,586 vs $15,040) 11% reduced readmission rate after controlling for age, race, comorbidity, and pre-admission rate Jayadevappa et al, Value in Health, 2006;9:186-192

45. Interdisciplinary Team Care in Hospitalized Older Adults Reduced mortality Improved functional performance More likely to be living at home after discharge Reduced use of restraints Reduced use of inappropriate medications Reduced delirium Reduced length of stay Reduced health care utilization costs Improved patient and provider satisfaction Baztan et al, BMJ ONLINE FIRST, 2009

46. Ms. Jones: Example of Well Coordinated Hospital Care • Ms. Jones is hospitalized for pain and altered mental status and diagnosed with a UTI • Admitted to ward utilizing an interdisciplinary team model of care • Patient initially placed in a low bed for periodic agitation • Symptom/care management discussed in daily team meeting • Team members included nurse, PT, OT, SW, RD, Pharm D, Psychologist, Chaplain, and Volunteers

47. Ms. Jones: Example of Well Coordinated Hospital Care Patient receives aggressive pain management and analgesics are scheduled and timed with physical therapy Patient experiences early mobilization and physical therapy is consulted on day 1 Agitation resolves with pain control and treating UTI; patient never restrained Volunteer services provide socialization during mealtime when daughter is at work Patient is discharged back to Assisted Living Facility with ongoing physical therapy arranged

48. Resources for Geriatric Interdisciplinary Team Training

49. Geriatric and Interdisciplinary Team Training • Geriatric Interdisciplinary Team Training (GITT) Curriculum: • www.gittprogram.org • www.americangeriatrics.org • Nurses Improving Care for Health System Elders (NICHE) • www.nicheprogram.org • Harford Institute for Geriatric Nursing: Try This Series • www.hartfordign.org/Resources/Try_This_Series

50. GITT Curriculum • Team and Team Work • Team Member Roles and Responsibilities • Team Communication and Conflict Resolution • Care Planning Process • Multiculturalism • Ethics and Teams UAB Highlands ACE Unit Interdisciplinary Team http://www.americangeriatrics.org/education/gitt/gitt.shtml