Listen to Dr. Farber
With our aging population, the challenges of meeting the unique needs of frail elderly patients will continue to mount. In the current issue of the Journal of Hospital Medicine, authors from Mount Sinai Medical Center in New York City report on their adaptation of the acute care for the elderly, or ACE, approach.1 They found that by bringing geriatrics-focused, team-based care to the patient (instead of locating the patient only in the ACE unit), they were able to reduce costs by an average of $4,943 per patient.
And, beginning in year two of the study, when the team incorporated hospitalists into their model, the ACE team decreased length of stay (LOS) by 1.6 days per patient.
From ACE to MACE
Since the mid-1990s, studies have shown that the ACE unit model can be effective in meeting the unique needs of frail, elderly patients. But even at institutions where these geriatric-focused units have been established, hospitals might not have enough dedicated beds for every elderly patient.
“A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital,” says lead author Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile ACE Service at Mount Sinai.
Dr. Farber and his colleagues began their mobile ACE (MACE) approach in 2007. Their retrospective cohort study compared outcomes of 8,094 hospitalized elderly patients cared for in the traditional ACE, the general medical service, or the MACE over a three-year period. To compare ACE and MACE patient outcomes, they limited their study sample to patients who already had been seen as part of their outpatient geriatrics service. Besides the shorter LOS, the MACE model also realized a net savings of $2,081 in direct hospital costs, $9,37 in nursing costs, and $223 in pharmacy costs in year two.
The MACE team, comprised of a geriatrician-hospitalist, geriatric medicine fellow, social worker, and nurse coordinator, met daily or twice a day. The nurse coordinator identified and resolved complex family and living situations, and daily check-ins with the patients’ caregivers or family members ensured that care plans and discharge plans were clearly understood before the patient left the hospital, Dr. Farber explains.
A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital.
—Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine, director, Mobile ACE Service, Mount Sinai Medical Center, New York City
Gathering pre-hospitalization history is facilitated by the linkage of the hospital’s electronic health record with that of the Mount Sinai outpatient geriatrics practice and the hospital’s affiliated nursing home. Dr. Farber admits the integrated system confers an advantage to the geriatrics service. But community-based hospitalists can increase their odds of having accurate pre-hospitalization information by concerted outreach to referral sources in their community, he says.
Commenting on the study’s results, Heidi Wald, MD, MSPH, associate professor of medicine in the division of healthcare policy research at the University of Colorado Denver School of Medicine, notes that “hospitalists are great at providing efficient care, and geriatricians are good at preserving function and mitigating harm, so it was only logical that hybrids of the two models might achieve both sets of aims.”
One model that she and her UC Denver colleagues have studied utilizes “geriatricized” hospitalists (through focused geriatrics and CME programs), which allows the physicians to feel comfortable managing the unique needs of these patients. She says that functional outcomes warrant attention in the next generation of studies in this area.