establishing an acute care of the elderly (ace) unit: challenges and successes · 2019-04-19 ·...
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EstablishinganAcuteCareoftheElderly(ACE)Unit:Challengesand
Successes
(Olivia)WendyZachary,MDGeriatricianandInternist
MedicalDirector,ACEUnitandHospitalElderLifeProgram(HELP)CaliforniaPacificMedicalCenter
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FinancialDisclosures• None
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LearningObjectives• Recognizeimportanceofspecializedcareforolderhospitalizedpatients
• ListgoalsthatanACEUnitaimstoachieve• DiscusshowACEUnitcarediffersfromusualcare• IdentifysuccessesandchallengesofestablishinganACEUnitatCPMC
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Whydoolderpatientsneedspecializedcare?ü 49.2MillionAmericans65yearsorolderin
2016
ü Thisrepresents1in7Americansor1in3hospitalizedpatientsinthisagegroup
ü By2020,therewillbe56.4millionAmericans65yearsorolder
ü Fastestgrowingpopulationisthoseaged85yearsandolder
Administration for Community Living and Administration on Aging
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Whydoolderpatientsneedspecializedcare?
Inouye, SK et al. JAGS. May 2007.
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WhatisanACEunit?
• Aspecializedunitforolderadultsover70yearsold
• Focusonpreventingfunctionaldeclineandimprovingthepatientexperience
• Continuousreviewofiatrogenicproblemsthatoccurfrequentlywiththeacutelyillelderlypopulation
• ItisNOTaSNF
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OurVisionStatement• Throughpatientcenteredcarebytrainedandcompassionateprofessionals,we
aimtomaintainandpromote functional independence ofelderlypatientsduringhospitalization.– Inorder toachievethis,wecommittodeveloping themembersofCPMC
Mission-Bernal campussoweare:• Acenterofexcellence forgeriatric careandaproviderofchoice forourpatients.• Thepartnerofchoice forourphysiciansinthedevelopmentofelderly careinitiatives.• Aproviderthatcaterstotheuniqueholisticneedsofelderly patientsandtheirfamilies.• Aunitofchoiceforemployees thatprovidesopportunitiesforgrowth,leadershipand
prestige.
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HaveACEUnits“Worked”inthePast?
§ Shorterlengthofstay§ Reduced30dayreadmissions§ Reducedcosts§ Increasedpatientsatisfaction§ Increasedretentionoffunctionalcapacity
References 4-8.
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GoalsandPriorities• ReduceFalls• ImprovePatientSatisfaction• ImproveLOSandReadmissionrates• DecreaseDelirium• DecreaseuseofRestraintsandpsychotropics
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HowdoesACEcaredifferfromusualcare?PhysicalSpace
• MBC’s5th floorisspecificallydesignedfortheneedsofthe
elderly• SpecializedGymforPT/OT
providesrehabspace• Activityroomallowsclientstohavesharedmealsandactivities
SpecializedStaff• RNs,CNAs,andsupportstaff
haveundergoneNICHEtraining
• ActivitiesCoordinator• ElderLifeNursingSpecialist• Geriatric-trainedLeadership
Team
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HowdoesACEcaredifferfromusualcare?
ThePhysicalSpace
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5beds7beds
7beds
6beds
6beds
3beds
MissionBernalCampus5th FloorACEUnit34beds,allofwhichhavetelemetrycapability
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MBC5thFloorACEunitrooms
• Largetextclocksandwhiteboards• Lowbedsareavailable• SpecialtyMattresses• Liftsineachroom• Railingsinhallways• Enhancedlighting• Proximitytoresources
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TheActivitiesRoom
• Musictherapy• Medicalclowning• IntegrativeHealingArtsInthenearfuture:• Mindfulness• Dance• GroupMeals
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Supplies
• iPodwithinterpreterservices• Pockettalkers,hearingaidbatteries• Tiltinspacewheelchairs• Instruments• Readingglasses• Magazineandlargeprintnewspaper
subscriptions• Essentialoils
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HowdoesACEcaredifferfromusualcare?
SpecializedStaff
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StaffDevelopment
NICHE =NursesImprovingCareforHealthsystem Elders
• Thisisanursingeducationandconsultationprogramdesignedtoimprovecareofolderpatients.
• NICHEprovidesoure-learningmodules.
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ACEUnit: NICHETraining
§ Theleadership teamwentthrough a6weektrainingprogram.§ ACEUnitRNswentthroughanintroductoryseminaranda21houronlinecourse.
§ EDRNswereoffereda4houronlinecourse.§ ALLRNsareencouragedtopursueGeriatricCertificationthrough theANCC.
§ ACEUnitCNAswentthrough anintroductoryseminarandan11houronlinecourse.
§ AllAncillarystaffwereofferedanintroductoryseminaranda4houronlinecourse.
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ACEUnit:SpecializedStaffOuradvancedpracticeRNisourELNS(ElderLifeNurseSpecialist).She
isthehuboftheACEunit.TheELNS:• Helpsruninterdisciplinaryrounds• ProvidesontheflyteachingforallstaffaswellasstructuredlearningonmonthlybasisandinpreparationforGeriatricCertification
• Servesasaconsultforgoodgeriatricinpatientcare• Servesasaliaisontoourcommunitypartners• Collectsandanalyzesdatatoshowourstrengthsandareasinneedofimprovement
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HELP(HospitalElderLifeProgram)• Aprogramdesignedtodecreasedeliriuminolderhospitalized
adults• SinceitsinceptionatPACin2011andDaviesin2014,hasshown
decreasedlengthofstay,30dayreadmissionrate,andfalls• Comprisedofarmyofintenselytrainedvolunteersthatassistwith
cognitivelystimulatingactivities,reorientation,musictherapy,guidedimageryandearlymobilization(amongmanyotherthings).
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Whattheydo…
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ACEUnit:DaytoDayOperationsDailyInterdisciplinaryRounds
Generally,participantsinclude:• MedicalDirector• CNS• ChargeRN• AssignedMDandRN• Casemanagementandsocialwork• Therapy(PT,OT,speech)• Homehealthliaisons• Pharmacy• Dietary• PalliativeCare
Patient
Nurses
Physicians
CaseManagement
PT/OT/Speech
CNS
Pharmacy
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InterdisciplinaryPatientRounds
SPICEStool– dailyreportoutSleepissuesProblemseatingIncontinenceConfusionEvidenceoffallsSkinBreakdown
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SleepPromotion
• Nowaketimes12am-6am• Unlessabsolutely
necessary:• NoVitals• Nomeds• Nolabs
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CommunityPartners• SFVillage
– Support groupsbringing functionalolderpeople together, guidethroughhealthcareprocesses
– Forpatientsthatqualify,Suttersponsors themfor3months• 30th StreetSeniorCenter
– Exchangeofinformation toourmutualpopulation• DolbyBrainHealthCenter
– Referralsforpatientswithcognitiveimpairment thatappearstoextendbeyondhospitalization
• LongTermCareCoordinatingCouncil
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Successes• Quality,Patient-CentricCare• CultureChange• CommunityPartnerships• AttentiontoandInnovativeResourcesforan
UnderservedPopulation• StaffandFamilyEducation• PhilanthropicSupport
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Challenges• Nodedicatedcasemanagerandsocialworker• Changeswithinourhospitalsystemresultinginanunexpectedlyhighcensus
• Lackofdedicatedresearchteam• Postingpositionsfundedbyphilanthropicfunds
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Mission:
We,asateam,willprovideasafeandhealingplaceforolderindividuals by
continuouslydeveloping ourspecializedpractice.
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References1. www.acl.gov.“2017ProfileofOlderAmericans.”AdministrationofCommunityLivingand
AdministrationonAging.2. Inouye,SKetal.“GeriatricSyndromes:clinical,research,andpolicyimplicationsofacore
geriatricconcept.”JAGS. Volume55(5).pp.780-791.May20073. Creditor,MortonC.“HazardsofHospitalizationoftheElderly.”AnnalsofInternalMedicine.
Volume188(3).pp.219-223.February1,1993.4. Flood,Kellieetal.“EffectsofanAcuteCareforEldersUnitonCostsand30-DayReadmissions.”
JAMA. Volume173(11).pp.981-987.June10,2013.5. Jayadevappa,Ret al.“HealthResourceUtilizationandMedicalCareCostofAcuteCareElderly
UnitPatients.”ValueinHealth. Volume9(3).pp.186-192.2006.6. Covinsky,Ketal.“DoAcuteCareforEldersUnitsIncreaseHospitalCosts?ACostAnalysis
UsingtheHospitalPerspective.”JAGS. Volume45(6).pp.729-734.June1997.7. Barnes,DEetal.“Acutecareforeldersunitsproducedshorterhospitalstaysatlowercost
whilemaintainingpatients’functionalstatus.”HealthAff Proj Hope. Volume31(6).pp.1227-1236.2012.
8. AhmedNetal.“TheroleofanAcuteCarefortheElderlyunitinachievinghospitalqualityindictatorswhilecaringforfrailhospitalizedelders.Popul HealthManag. Volume15(4).pp.236-240.2012.
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Questions?