Introduction:
Elderly individuals face a risk of losing self-care abilities during acute medical illnesses leading to hospitalization. The acute care for elders (ACE) unit employs a quality improvement model to prevent hospital-associated disability. ACE intervention includes a prepared environment, clinical guidelines for bedside care, and transition planning. Supported by trials and reviews, ACE demonstrates reduced disability, lower nursing home admission risk, and decreased hospitalization costs. These principles could enhance elderly care in various acute settings, emphasizing the structured process, interdisciplinary teamwork, and patient-centered approaches integral to the ACE model.
What Is the Acute Care for Elders Unit (ACEU) Model of Care?
The ACE program is a team-based approach for elderly patients needing hospital care. It focuses on those with recent function decline or cognitive changes, providing specialized support. Patients are identified upon admission, receiving automatic social work and therapy consultation. The care is protocolized and delivered by skilled geriatric providers. Discharge planning starts early, aiming for lasting support in primary care, specialists, and home-based services. The goal is to reduce functional and cognitive decline in diseases like Alzheimer's disease and dementia (memory loss), ensuring effective care for elderly individuals during and after hospitalization.
What Is the Significance of the ACE Unit Model?
The significance of the ACE Unit Model is:
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ACE Unit's Patient-Centered Approach: Creating the ACE unit means significant changes in how hospitals care for older people. Instead of just treating diseases, it puts patients first. This shift involves changing the hospital setup to help patients be more independent and safe. The approach switches from a group of different specialists to a team that works together. To make this happen, it is essential to have a good plan that convinces the hospital leaders. Showing how the ACE unit adds value and improves the hospital's reputation is crucial for making this culture shift successful.
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Shifting to Interdisciplinary Team-Based Care: The initial steps involve forming an advisory council of leaders from relevant departments in senior care. This council guides program development and facilitates interdisciplinary team care. Collaboration is emphasized, creating a sense of shared ownership among healthcare providers. Periodic meetings of the advisory council assess ACE unit progress and review metrics related to hospital costs, quality, and prevention of hospital-acquired conditions.
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Designing for Patient Well-Being: The physical environment, termed the "prepared environment," is created with a focus on patient well-being and safety. Innovations include features such as carpeting, handrails, uncluttered hallways, and specific lighting to minimize falls, confusion, and anxiety (excessive worry). While the original ACE unit required extensive remodeling, these design principles are increasingly becoming standard in modern hospitals.
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Collaboration and Personalized Services: Patient-centered care is a core principle emphasizing respect for individual preferences, needs, and values. The interdisciplinary team collaborates to coordinate care, ensuring efficient and personalized services. This approach contrasts with traditional silo-based (fragmented healthcare with isolated and uncoordinated specialized services) and multidisciplinary care. Nurses, especially those trained as geriatric resource nurses, are pivotal in overseeing patient care and implementing protocols for optimal care of older adults.
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Focus on Patient Mobility: The ACE unit's focus on patient mobility is crucial, recognizing the correlation between immobility and functional decline in hospitalized older adults. The interdisciplinary team assesses baseline and current functional status, implementing preventative and restorative protocols.
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Reinforcing Bedside Nursing Care: Daily team rounds are necessary to reinforce bedside nursing care and address uncertainties regarding patient preferences, prognosis, and specialty consult recommendations.
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Functional Trajectory: The functional trajectory, a daily assessment during team rounds, guides the patient's care plan. Mobility status is key, emphasizing preventing decline and enhancing independent functioning. The ACE unit's attention to physical functioning has implications for patient outcomes, post-acute care transitions, and addressing challenges like delirium (acute confusion and altered consciousness), depression, and end-of-life care decisions.
Clinical trials reveal ACE units' efficiency, reducing costs and functional disability in elderly patients. A meta-analysis supports shorter hospital stays, fewer nursing home discharges, and lower costs. Retrospective cohort studies affirm ACE units' economic benefits, with lower costs and reduced readmissions compared to traditional care.
How Does ACE Unit Model Care Help Elders?
The ACE unit model care can help elders in the following ways:
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Impact on the Elderly: The ACE program annually aids more than 2,000 patients, utilizing routine performance monitoring data collected through hospital databases and standard care processes. An analysis encompassing 12,008 older patients admitted for acute medical issues over six years revealed a remarkable achievement. Despite a 53 percent surge in annual admissions of older patients from 2009 to 2010 and 2014 to 2015, the ACE program substantially reduced total lengths of stay, readmissions, and adverse events. This allowed for the closure of inpatient beds and led to a noteworthy reduction in direct care costs per patient, resulting in net savings of 4.07 million dollars from 2014 to 2015 alone. The success of the ACE program has prompted its replication across Canada, spearheaded by the Canadian Foundation for Healthcare Improvement.
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Innovation Elements Include the Following:
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For Providers: The ACE program embodies an interprofessional team-based approach, evident in all constituent care models and practices. Clear protocols facilitate seamless coordination between the hospital and primary or community-care partners. All hospital providers can access patient data upon admission, enabling collaborative decision-making. Nurses and therapists, through cooperative efforts, can influence medical decisions. During discharge, patients with complex needs involve their primary and community-care providers, assessing the potential value of follow-up from an ACE-related provider.
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For Patients and Caregivers: ACE prioritizes robust patient and caregiver engagement, directing attention to their needs and preferences. The program encourages self-management while recognizing the potential benefits of additional support. Individuals and caregivers transitioning from the hospital to home receive their discharge summary and ongoing care plan before leaving. Regular external surveys assess patient satisfaction.
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Governance: The program is housed within a single hospital, with governance vested in the program leader and a geriatrics steering committee reporting to senior management. Informal relationships with primary and community providers are integral to success but must be formally represented in overall governance. Given its central role in delivering most care models, the hospital is responsible for the program.
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Supportive Policies: While funding innovations like shared-savings programs could incentivize the program, they have yet to be enabled to support ACE initiatives. ACE's leaders prioritize hiring staff with a systemic mindset and a special interest in geriatric care to counter potential perverse incentives under fee-for-service payment. Demonstrating that high-quality, efficient care aligns with hospitals' quality, safety, and budget goals ensures sustained support from the hospital's senior leadership team.
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What Are the Barriers to the ACE Unit?
Problems adopting ACE unit include:
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Individuals think it is too ordinary, does not match the usual medical way, and focuses on just one unit.
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Limited spreading happens because there is little money and insufficient doctors for elderly care. There is a misperception that ACE is a complex intervention, and the absence of standardized measures hinders wider adoption.
Overcoming these barriers requires recognizing ACEs as a continuous improvement program, creating financial incentives for value-based care, addressing the geriatrician shortage, and establishing standardized measures for the older population.
Conclusion:
The ACE unit emerges as a beacon of success in revolutionizing care for elderly individuals facing acute medical illnesses. Demonstrating exceptional efficiency, ACE reduces costs and significantly diminishes functional disability, fostering a paradigm shift in hospital care. Its interdisciplinary approach, patient-centered principles, and commitment to continuous improvement mark it as a model for enhanced healthcare delivery. Despite dissemination challenges, ACE's potential to thrive lies in recognizing its value, aligning with evolving healthcare frameworks, and addressing workforce and measurement issues. The ACE Unit stands poised to contribute substantially to improved quality of life and care for the aging population.
