New Take on Elder Care

Medical staff in other departments immediately accepted the rationale for the unit.

Many expressed interest in expanding the concept to their departments, especially orthopedics, general surgery, and the ED. Although unfamiliar with specific interventions to improve care for hospitalized elders, the underlying concepts of patient-centered, team-delivered care with a focus on function resonated with most medical staff.

Next Steps

The unit is still in startup mode. Our major areas of focus are:

• Evaluating and improving team dynamics: We have engaged with researchers to evaluate our team dynamics and intervene where necessary to promote a high-functioning team.17
• Developing a culture of performance improvement: One of the hallmarks of high-functioning teams are measures of performance that are team-derived and reflect work product that the team can control.17

We are putting into place processes to measure key quality parameters including length of stay; nursing home placement; readmission rate, inappropriate catheter use; inappropriate medication prescribing; incidence of delirium, falls, and pressure ulcers; functional and cognitive status at admission and discharge; and patient satisfaction.

The orders set used by admitting residents are the standard general medical ward admission set and need revision for the ACE unit.

• Developing a research program: Our goal is to develop a research program evaluating interventions to prevent post-hospital degeneration of elders’ health. There is a dearth of research on improving hospital care for older, vulnerable adults.
• Expanding philanthropy support: The unit has benefited tremendously from philanthropy. In a relatively resource-poor setting, this allowed for rapid engagement with designers and vendors to remake the environment. We plan to expand our outreach efforts to interested philanthropists.

Summary

The ACE unit model can improve care for hospitalized older adults.

It requires a sustained level of commitment from hospital leaders, a focus on patient-centered, team-delivered care, sensitivity to communication modalities with primary caregivers, an awareness of the market for key professionals required, and flexibility to respond effectively to the many challenges that will emerge in implementing this model locally. TH

Dr. Pierluissi is medical director of the ACE unit at the San Francisco General Hospital. Susan Currin is the hospital’s chief nursing officer.

References

1. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51(4):451-458.
2. Gill TM, Allore HG, Holford TR, et al. Hospitalization, restricted activity, and the development of disability among older persons. JAMA. 2004 Nov 3;292(17):2115-2124
3. Landefeld CS, Palmer RM, Kresevic DM, 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 May 18;332(20):1338-1344.
4. State of California, Department of Finance. Race/Ethnic Population with Age and Sex Detail, 2000–2050; 2004: Sacramento, Calif.
5. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993 Feb 1;118(3):219-223.
6. Inouye SK. Delirium in older persons. N Engl J Med. 2006 Jun 8;354(23):2509-2511; author reply 2509-11. Comment on: N Engl J Med. 2006 Mar 16;354(11):1157-1165.
7. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370-376. Comment in: N Engl J Med. 1991 Jul 18;325(3):210.
8. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002 Mar 21;346(12):905-912. Comment in: Curr Surg. 2004 May-Jun;61(3):266-74. N Engl J Med. 2002 Aug 1;347(5):371-373; author reply 371-373; author reply 371-3: N Engl J Med. 2002 Mar 21;346(12):874.
9. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-676. Comment in: N Engl J Med. 1999 Jul 29;341(5):369-370; author reply 370. N Engl J Med. 1999 Mar 4;340(9):720-721.
10. Reuben DB, Borok GM, Wolde-Tsadik G, et al. A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients. N Engl J Med. 1995 May 18;332(20):1345-1350. Comment in: N Engl J Med. 1995 May 18;332(20):1376-1378.
11. Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005 Dec 6;143(11):798-808. Comment in: Ann Intern Med. 2005 Dec 6;143(11):840-1. Ann Intern Med. 2006 Mar 21;144(6):456. Summary for patients in:Ann Intern Med. 2005 Dec 6;143(11):I56.
12. Covinsky KE, Palmer RM, Kresevic DM, et. al. Improving functional outcomes in older patients: lessons from an acute care for elders unit. Jt Comm J Qual Improv. 1998 Feb;24(2):63-76.
13. Wieland D, Rubenstein LZ. What do we know about patient targeting in geriatric evaluation and management (GEM) programs? Aging (Milano). 1996 Oct; 8(5):297-310.
14. Spetz J, Dyer W. Forecasts of the Registered Nurse Workforce in California. 2005, University of California, San Francisco: San Francisco.
15. Fleming KC, Evans JM, Chutka DS. Caregiver and clinician shortages in an aging nation. Mayo Clin Proc. 2003 Aug;78(8):1026-1040.
16. Knapp KK, Quist RM, Walton SM, et al. Update on the pharmacist shortage: National and state data through 2003. Am J Health Syst Pharm. 2005 Mar 1;62(5):492-499.
17. Katzenbach JR, Smith DK. The Discipline of Teams. Harv Bus Rev. July-August 2005:1-9.