EstablishinganAcuteCareoftheElderly(ACE)Unit:Challengesand

Successes

(Olivia)WendyZachary,MDGeriatricianandInternist

MedicalDirector,ACEUnitandHospitalElderLifeProgram(HELP)CaliforniaPacificMedicalCenter

FinancialDisclosures• None

LearningObjectives• Recognizeimportanceofspecializedcareforolderhospitalizedpatients

• ListgoalsthatanACEUnitaimstoachieve• DiscusshowACEUnitcarediffersfromusualcare• IdentifysuccessesandchallengesofestablishinganACEUnitatCPMC

Whydoolderpatientsneedspecializedcare?ü 49.2MillionAmericans65yearsorolderin

2016

ü Thisrepresents1in7Americansor1in3hospitalizedpatientsinthisagegroup

ü By2020,therewillbe56.4millionAmericans65yearsorolder

ü Fastestgrowingpopulationisthoseaged85yearsandolder

Administration for Community Living and Administration on Aging

Whydoolderpatientsneedspecializedcare?

Inouye, SK et al. JAGS. May 2007.

WhatisanACEunit?

• Aspecializedunitforolderadultsover70yearsold

• Focusonpreventingfunctionaldeclineandimprovingthepatientexperience

• Continuousreviewofiatrogenicproblemsthatoccurfrequentlywiththeacutelyillelderlypopulation

• ItisNOTaSNF

OurVisionStatement• Throughpatientcenteredcarebytrainedandcompassionateprofessionals,we

aimtomaintainandpromote functional independence ofelderlypatientsduringhospitalization.– Inorder toachievethis,wecommittodeveloping themembersofCPMC

Mission-Bernal campussoweare:• Acenterofexcellence forgeriatric careandaproviderofchoice forourpatients.• Thepartnerofchoice forourphysiciansinthedevelopmentofelderly careinitiatives.• Aproviderthatcaterstotheuniqueholisticneedsofelderly patientsandtheirfamilies.• Aunitofchoiceforemployees thatprovidesopportunitiesforgrowth,leadershipand

prestige.

HaveACEUnits“Worked”inthePast?

§ Shorterlengthofstay§ Reduced30dayreadmissions§ Reducedcosts§ Increasedpatientsatisfaction§ Increasedretentionoffunctionalcapacity

References 4-8.

GoalsandPriorities• ReduceFalls• ImprovePatientSatisfaction• ImproveLOSandReadmissionrates• DecreaseDelirium• DecreaseuseofRestraintsandpsychotropics

HowdoesACEcaredifferfromusualcare?PhysicalSpace

• MBC’s5th floorisspecificallydesignedfortheneedsofthe

elderly• SpecializedGymforPT/OT

providesrehabspace• Activityroomallowsclientstohavesharedmealsandactivities

SpecializedStaff• RNs,CNAs,andsupportstaff

haveundergoneNICHEtraining

• ActivitiesCoordinator• ElderLifeNursingSpecialist• Geriatric-trainedLeadership

Team

HowdoesACEcaredifferfromusualcare?

ThePhysicalSpace

5beds7beds

7beds

6beds

6beds

3beds

MissionBernalCampus5th FloorACEUnit34beds,allofwhichhavetelemetrycapability

MBC5thFloorACEunitrooms

• Largetextclocksandwhiteboards• Lowbedsareavailable• SpecialtyMattresses• Liftsineachroom• Railingsinhallways• Enhancedlighting• Proximitytoresources

TheActivitiesRoom

• Musictherapy• Medicalclowning• IntegrativeHealingArtsInthenearfuture:• Mindfulness• Dance• GroupMeals

Supplies

• iPodwithinterpreterservices• Pockettalkers,hearingaidbatteries• Tiltinspacewheelchairs• Instruments• Readingglasses• Magazineandlargeprintnewspaper

subscriptions• Essentialoils

HowdoesACEcaredifferfromusualcare?

SpecializedStaff

StaffDevelopment

NICHE =NursesImprovingCareforHealthsystem Elders

• Thisisanursingeducationandconsultationprogramdesignedtoimprovecareofolderpatients.

• NICHEprovidesoure-learningmodules.

ACEUnit: NICHETraining

§ Theleadership teamwentthrough a6weektrainingprogram.§ ACEUnitRNswentthroughanintroductoryseminaranda21houronlinecourse.

§ EDRNswereoffereda4houronlinecourse.§ ALLRNsareencouragedtopursueGeriatricCertificationthrough theANCC.

§ ACEUnitCNAswentthrough anintroductoryseminarandan11houronlinecourse.

§ AllAncillarystaffwereofferedanintroductoryseminaranda4houronlinecourse.

ACEUnit:SpecializedStaffOuradvancedpracticeRNisourELNS(ElderLifeNurseSpecialist).She

isthehuboftheACEunit.TheELNS:• Helpsruninterdisciplinaryrounds• ProvidesontheflyteachingforallstaffaswellasstructuredlearningonmonthlybasisandinpreparationforGeriatricCertification

• Servesasaconsultforgoodgeriatricinpatientcare• Servesasaliaisontoourcommunitypartners• Collectsandanalyzesdatatoshowourstrengthsandareasinneedofimprovement

HELP(HospitalElderLifeProgram)• Aprogramdesignedtodecreasedeliriuminolderhospitalized

adults• SinceitsinceptionatPACin2011andDaviesin2014,hasshown

decreasedlengthofstay,30dayreadmissionrate,andfalls• Comprisedofarmyofintenselytrainedvolunteersthatassistwith

cognitivelystimulatingactivities,reorientation,musictherapy,guidedimageryandearlymobilization(amongmanyotherthings).

Whattheydo…

ACEUnit:DaytoDayOperationsDailyInterdisciplinaryRounds

Generally,participantsinclude:• MedicalDirector• CNS• ChargeRN• AssignedMDandRN• Casemanagementandsocialwork• Therapy(PT,OT,speech)• Homehealthliaisons• Pharmacy• Dietary• PalliativeCare

Patient

Nurses

Physicians

CaseManagement

PT/OT/Speech

CNS

Pharmacy

InterdisciplinaryPatientRounds

SPICEStool– dailyreportoutSleepissuesProblemseatingIncontinenceConfusionEvidenceoffallsSkinBreakdown

SleepPromotion

• Nowaketimes12am-6am• Unlessabsolutely

necessary:• NoVitals• Nomeds• Nolabs

CommunityPartners• SFVillage

– Support groupsbringing functionalolderpeople together, guidethroughhealthcareprocesses

– Forpatientsthatqualify,Suttersponsors themfor3months• 30th StreetSeniorCenter

– Exchangeofinformation toourmutualpopulation• DolbyBrainHealthCenter

– Referralsforpatientswithcognitiveimpairment thatappearstoextendbeyondhospitalization

• LongTermCareCoordinatingCouncil

Successes• Quality,Patient-CentricCare• CultureChange• CommunityPartnerships• AttentiontoandInnovativeResourcesforan

UnderservedPopulation• StaffandFamilyEducation• PhilanthropicSupport

Challenges• Nodedicatedcasemanagerandsocialworker• Changeswithinourhospitalsystemresultinginanunexpectedlyhighcensus

• Lackofdedicatedresearchteam• Postingpositionsfundedbyphilanthropicfunds

Mission:

We,asateam,willprovideasafeandhealingplaceforolderindividuals by

continuouslydeveloping ourspecializedpractice.

References1. www.acl.gov.“2017ProfileofOlderAmericans.”AdministrationofCommunityLivingand

AdministrationonAging.2. Inouye,SKetal.“GeriatricSyndromes:clinical,research,andpolicyimplicationsofacore

geriatricconcept.”JAGS. Volume55(5).pp.780-791.May20073. Creditor,MortonC.“HazardsofHospitalizationoftheElderly.”AnnalsofInternalMedicine.

Volume188(3).pp.219-223.February1,1993.4. Flood,Kellieetal.“EffectsofanAcuteCareforEldersUnitonCostsand30-DayReadmissions.”

JAMA. Volume173(11).pp.981-987.June10,2013.5. Jayadevappa,Ret al.“HealthResourceUtilizationandMedicalCareCostofAcuteCareElderly

UnitPatients.”ValueinHealth. Volume9(3).pp.186-192.2006.6. Covinsky,Ketal.“DoAcuteCareforEldersUnitsIncreaseHospitalCosts?ACostAnalysis

UsingtheHospitalPerspective.”JAGS. Volume45(6).pp.729-734.June1997.7. Barnes,DEetal.“Acutecareforeldersunitsproducedshorterhospitalstaysatlowercost

whilemaintainingpatients’functionalstatus.”HealthAff Proj Hope. Volume31(6).pp.1227-1236.2012.

8. AhmedNetal.“TheroleofanAcuteCarefortheElderlyunitinachievinghospitalqualityindictatorswhilecaringforfrailhospitalizedelders.Popul HealthManag. Volume15(4).pp.236-240.2012.

Questions?