An Acute Care for Elders Quality Improvement Program for Complex, High-Cost Patients Yields Savings for the System
BACKGROUND: Acute Care for Elders (ACE) programs improve outcomes for older adults; however, little is known about whether impact varies with comorbidity severity.
OBJECTIVE: To describe differences in hospital-level outcomes between ACE and routine care across various levels of comorbidity burden.
DESIGN: Cross-sectional quality improvement study.
SETTING: A 716-bed teaching hospital.
PARTICIPANTS: Medical inpatients aged ≥70 years hospitalized between September 2014 and August 2017.
INTERVENTION: ACE care, including interprofessional rounds, geriatric syndromes screening, and care protocols, in an environment prepared for elders
MEASUREMENTS: Total cost, length of stay (LOS), and 30-day readmissions. We calculated median differences for cost and LOS between ACE and usual care and explored variations across the distribution of outcomes at the 25th, 50th, 75th and 90th percentiles. Results were also stratified across quartiles of the combined comorbidity score.
RESULTS: A total of 1,429 ACE and 10,159 non-ACE patients were included in this study. The mean age was 81 years, 57% were female, and 81% were white. ACE patients had lower costs associated with care ranging from $171 at the 25th percentile to $3,687 at the 90th percentile, as well as lower LOS ranging from 0 days at the 25th percentile to 1.9 days at the 90th percentile. After stratifying by comorbidity score, the greatest differences in outcomes were among those with higher scores. There was no difference in 30-day readmission between the groups.
CONCLUSION: The greatest reductions in cost and LOS were in patients with greater comorbidity scores. Risk stratification may help hospitals prioritize admissions to ACE units to maximize the impact of the more intensive intervention.
© 2019 Society of Hospital Medicine
Interprofessional ”ACE Rounds”
Interprofessional ACE Rounds occurred every weekday. As one ACE analyst has noted, “the interdisciplinary team…ensures that the multifactorial nature of functional decline is met with a multicomponent plan to prevent it.”18 Rounds participants shifted over time but always included a geriatrics physician assistant (PA) or geriatrician (team leader), a pharmacist, staff nurses, and a chaplain. The nurse educator, dietician, research assistant, and patient advocate/volunteers attended intermittently. Before rounds, the PA reviewed the admission notes for new ACE patients. Initially, rounds were lengthy and included nurse coaching. Later, nurses’ presentations were structured by the SPICES tool (Sleep, Problems with eating/feeding, Incontinence, Confusion, Evidence of falls, Skin Breakdown)19 and tracking and reporting templates. Coaching and education, along with conversations that did not require the full team, were removed from rounds. Thus, the time required for rounds declined from about 75 minutes to 35 minutes, which allowed more patients to be discussed efficiently. This change was critical as the number of ACE patients rose following the shift to the larger unit. The pharmacist reviewed medications focusing on potentially inappropriate drugs. Following rounds, the nurses and pharmacist conveyed recommendations to the hospitalists.
Patient-Centered Activities to Prevent Functional and Cognitive Decline
Project leaders coached staff about the importance of mobility, sleep, and delirium prevention and identification. The nurses screened patients using the Confusion Assessment Method (CAM) and reported delirium promptly. Specific care sets for ACE patients were implemented (see supplementary material).
The project was enhanced by several palliative care components, ie tracking pain, noting psychiatric symptoms, and considering prognosis by posing the “Surprise Question” during rounds.20 (“Would you be surprised if this patient died in the next year?”). As far as staffing and logistics allowed, the goals of care conversation were held by a geriatrics PA with patients/families who “screened in.”
Prepared Environment
The ACE program’s unit was remodeled to facilitate physical and cognitive functioning and promote sleep at night (quiet hours: 10 PM-6 AM).
In accordance with quality improvement processes, iterative shifts were implemented over time in terms of checklist, presentation format, timing, and team participation. In December 2016, the program relocated to a unit with 34 ACE beds and 5 end-of-life beds; this move markedly increased the number of eligible ACE patients.
Study Design, Data Source, and Patients
Since we were implementing and measuring our ACE program with a quality improvement lens, we chose a descriptive cross-sectional study design to generate hypotheses regarding our program’s impact compared to usual care. Using a hospital-wide billing database (McKesson Performance Analytics, v19, Alpharetta, Georgia) we sampled inpatients aged >70 years with a medical Diagnosis Related Group (DRGs) admitted through the emergency department and discharged from a medical unit from September 22, 2014 to August 31, 2017. These criteria mirrored those in the ACE unit. Older adults requiring specialized care (eg, those with myocardial infarct) were excluded, as were those with billing codes for mechanical ventilation, admission to critical care units, or discharge to hospice. Because one of our outcomes was readmission, we excluded patients who died during hospitalization. Patient characteristics collected included demographics and insurance category. To evaluate comorbidity burden, we collected ICD-9/ICD-10 diagnostic codes and generated a combined comorbidity score as described by Gagne, et al.21 This score was devised to predict mortality and 30-day readmissions and had better predictive ability in elders than the Elixhauser or Charlson scores. Scores ranged from −2 to 26, although values >20 are rare.
