HOW IT WORKS
The Acute Care for Elders (ACE) program uses an interprofessional, team-based approach to provide elder-friendly emergency and acute care services integrated with ambulatory, home, community-based, and transitional care programs. Targeting high-need, high-cost patients, the program promotes direct, early attention to patient needs to reduce the risk of functional and cognitive decline and future acute care use. ACE’s highly developed inpatient program focuses on supporting frail older adults with an acute illness that requires hospitalization, specifically targeting those with three or more of the following: a recent decline in function, a recent change in cognition or behavior, and one or more categorized problems common to older adults (e.g., falls, polypharmacy). Patients are recruited upon admission to the hospital and receive automatic consultation from social workers and therapists. Recruitment occurs through the assistance of electronic admission protocols that prompt identification of eligible and appropriate patients, supported by additional fail-safe mechanisms to ensure patients can be admitted to the program at anytime during their admission. Care for all older patients, and ACE program patients in particular, is highly protocolized to minimize risk and delivered by care providers with enhanced skills in geriatric care on the designated ACE Unit whenever possible. Discharge planning, which begins at admission, is designed to ensure durable discharges and the provision of appropriate ongoing primary care, specialist care, and home- and community-based supports.
ACE helps over 2,000 patients annually. The program collects performance monitoring data routinely through hospital databases and usual care processes. An analysis of 12,008 older patients admitted nonelectively for acute medical issues over a six-year period demonstrated that, despite a 53 percent increase in annual admissions of older patients between 2009–10 and 2014–15 (due to a rapidly growing population being served), the ACE program still decreased total lengths of stay, readmissions, and other adverse events. This enabled the closure of inpatient beds and reduced direct costs of care per patient, leading to net savings of Can$4.07 million in 2014–15 alone.
For providers. ACE’s interprofessional team-based approach to care is reflected in all its constituent care models and practices, supported by clear protocols for coordinating connections between the hospital and its primary and community-care partners. Once a patient is admitted, all hospital providers have access to the patient’s data. Using collaborative decision-making, nurses and therapists can also prompt medical decisions and directives. During discharge, patients with particularly complex needs have their primary and community-care providers involved and are assessed to determine if follow-up from an ACE-related provider would be of value.
For patients/caregivers. The ACE team is very focused on strong patient and caregiver engagement, promoting direct attention to their needs and wishes, encouraging self-management but also recognizing how they may benefit from additional supports. Patients and caregivers transitioning from hospital to home receive a copy of their discharge summary and ongoing care plan before they leave the hospital. Regular surveys of patient satisfaction are conducted by an external source.
The program is housed within a single hospital. Its governance sits with the program leader and a geriatrics steering committee, both reporting to other members of the senior management team. Strong, informal relationships with primary and community providers beyond the hospital are considered fundamental to success, but these are not formally represented in the program’s overall governance. Ultimate responsibility for the overall program lies solely within the hospital central to delivering most of its models of care.
Funding innovations like shared-savings programs could incentivize the program but have not yet been enabled to support initiatives like the ACE model. To counteract the potential of perverse incentives under fee-for-service payment, ACE’s leaders select staff who are “system thinkers” and have a special interest in geriatric care. Because ACE demonstrates that higher-quality, efficient care can meet hospitals’ quality, safety, and budget goals, the program maintains a high level of support from the hospital’s senior leadership team.
S. K. Sinha, et al., “Delivering Improved Patient and System Outcomes for Hospitalized Older Adults through an Acute Care for Elders (ACE) Strategy,” Health Management Forum 31, vol. 4 (July 2018):126–132.