Kyle R. Allen

Effects of a Multicomponent Intervention on Functional Outcomes and Process of Care in Hospitalized Older Patients: A Randomized Controlled Trial of Acute Care for Elders (ACE) in a Community Hospital

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization.

Physician Knowledge, Attitude, and Experience With Advance Care Planning, Palliative Care, and Hospice: Results of a Primary Care Survey

Purpose: To evaluate primary care physicians’ understanding of and experience with advance care planning (ACP), palliative care, and hospice and how this might affect their utilization of these services. Methods: Investigator-generated survey. Results: Older age, more years in practice, and more personal and professional experience with ACP were correlated with an increase in the percentage of patients with progressive, chronic life-limiting diseases with whom physicians discussed advance directives. Overall, 97.5% of physician’s expressed comfort in discussing ACP yet reported discussing advance directives with only 43% of appropriate patients. Discussion: Often, discussions about ACP or referrals to palliative care or hospice do not occur until the patient is near the end of life. Our results indicate that primary care physician’s personal and professional experience with ACP may be contributing to some of the barriers to these discussions.

Developing a Stroke Unit Using the Acute Care for Elders Intervention and Model of Care

The Acute Care for Elders (ACE) model of care is a multicomponent intervention that improves outcomes for older patients hospitalized for acute medical illnesses. Likewise, stroke units improve outcomes for patients with acute stroke, yet the descriptions of their structure and approach to stroke management are heterogeneous. The purpose of this article is to describe how implementing the ACE model of care, using a continuous quality‐improvement process, can serve as a foundation for a successful stroke unit aimed at improving stroke care. The ACE intervention (a prepared environment, interdisciplinary team management, patient‐centered nursing care plans, early discharge planning, and review of medical care) was amplified in a community teaching hospital for stroke‐specific care by creating a stroke interdisciplinary team, evidence‐based stroke orders and protocols, and a redesigned environment. Administrative data show that the ACE model can be successfully adapted to create a disease‐specific program for stroke patients, having the potential to improve the process of care and clinical stroke outcomes.

The Promoting Effective Advance Care for Elders (PEACE) Randomized Pilot Study: Theoretical Framework and Study Design

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohios community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagners Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.

Prevention, detection and intervention with delirium in an acute care hospital: a feasibility study

Background.  The prevalence of delirium in acute care hospitals ranges from 5-86%. Delirious patients are at greater risk of negative health outcomes and their care is often more costly. Aim.  To determine the feasibility of a full-scale trial to test the effectiveness of an intervention designed to improve delirium prevention, detection and intervention in an acute care hospital. Design.  A delirium prevention protocol was designed by an interdisciplinary group of clinicians and implemented on intervention unit patients who passed a mental status screen, were at high risk for delirium according to the modified NEECHAM scale, and met other eligibility criteria. These patients were reviewed at daily interdisciplinary team meetings and team recommendations were placed in the patients chart. On the usual care unit, physicians were notified if their patients were at high risk, but the delirium protocol was not implemented. Methods.  The delirium protocol was pilot tested with 35 high risk patients on an Acute Care for Elders (ACE) unit. Outcomes were compared to 35 high risk patients on a similar medical unit without the delirium protocol. Results.  The main outcome examined whether there is a difference in average day 3 modified NEECHAM scores comparing the intervention and control groups. The mean modified NEECHAMs on day 3 were not statistically significantly different (intervention group 3.76 and control group 3.24) (P= 0.368). Baseline NEECHAM scores did not correlate well with development of delirium (P = 0.204). A history of confusion during a previous hospitalization was the strongest predictor of developing delirium during the current hospitalization. Conclusion.  This pilot study was not powered to detect an effect of the intervention, however, feasibility for a fully powered trial was established. Relevance to clinical practice.  Completion of the NEECHAM screen every shift was not considered burdensome for either nurses or patients and may help identify acute delirium.

Age‐Friendly Health Systems: Their Time Has Come

In a Special Article in this issue of the Journal of the American Geriatrics Society, Dr. Terry Fulmer, PhD, RN, FAAN, President of the John A. Hartford Foundation (JAHF), and colleagues suggest that there is an urgency and an opportunity to address a monumental challenge facing our country and the world: How do we apply what we know is effective in improving quality of life, quality of healthcare, and safety for all of us as we age successfully? The urgency and opportunity result from the confluence of an aging society that is celebrating unprecedented longevity, a post-World War II baby boom that has created a population shift for the next several decades, and the antiquated health policy structure of Medicare and Medicaid. When enacted in 1965, these programs were hailed as innovative social policy, but they are now in serious need of modification and re-engineering to catch up with advances in healthcare science and care delivery, particularly for an aging society. The recent focus on the triple aim—improving the experience of care, improving the health of populations, and reducing per capita costs of health care—affords the field of geriatrics a golden opportunity to be a major force in achieving these goals. The JAHF and the Institute for Healthcare Improvement (IHI) deserve credit for their vision and leadership in using their collective wisdom and expertise to focus on this looming social and healthcare challenge. The IHI-JAHF: Creating an Age Friendly Health System Initiative has assembled some of the leading experts, organizations, and professionals from around the nation to provide insights, opinions, debate, and expertise on how to envision and feasibly apply best-practice and evidence-based models to create what we all desire for our parents, families, patients, and ourselves. As the authors suggest, there is a clear moral imperative for this project, and stakeholders from a variety of organizations must be involved for success. IHI is a proven organization that has the experience and expertise to lead an initiative of this magnitude and importance. They can apply decades of what they have learned works in the real world of health care to bring about large-scale transformation and adoption with the use of implementation science, social campaigns, and quality improvement methods that will ultimately sustain the new Age Friendly Health System (AFHS) standard that will be defined by this broad quality improvement and safety initiative. IHI achieved remarkable success in influencing the patient safety culture though The 100,000 Lives Campaign. This same framework can be applied to the AFHS Initiative to accomplish similar benefits, including a more effective, patient-directed, safer delivery system for older adults and their caregivers. The use of a “4 M model” of what matters most, mobility, medications, and mentation framework is a creative and simple way to bundle many of the evidencedbased, effective models of geriatric care. The health and psychosocial concerns of older adults are most often multifactorial, and using this basic 4 M premise to consider the multimorbidity that makes caring for this population so challenging. The “What Matters Most” question refers to person-centered care—a major focus of geriatrics, and establishing person-centered goals of care. This concept is fundamental to successful age-friendly health care and can improve value-based care of older people. Lack of advance care planning and advance directives, for example, is a major factor in potentially avoidable hospitalizations of nursing home residents. “Mobility” reminds us of the importance of function to health and quality of life in older people and the potentially devastating consequences of falls. Even small gains in mobility, such as the ability to transfer in and out of bed may, make the difference between living at home and having to move to a long-term care institution. Many falls that result in devastating injuries such as hip fracture are preventable; programs in AFHS can reduce falls and the morbidity, mortality, and costs that can result from these events. “Medications” is one of the major conundrums in geriatrics. As more practice guidelines recommend effective drug therapy for individuals with specific conditions, older adults with multimorbidity are often prescribed too many medications. The effect of polypharmacy and adverse drug reactions on health and quality of life in older adults has been recognized for decades. The American Geriatrics Society has updated the Beers Criteria, and there are new paradigms and resources available for judicious de-prescribing for older people who are taking potentially unnecessary or harmful medications that should be helpful in the AFHS. “Mentation” refers to the cognitive and affective disorders that are prevalent in older people. Depression can affect physical health and reduce adherence to various effective interventions and is associated with cognitive impairment and dementia. A simple 2-item screen is sensitive in identifying older people with depressive symptoms and should be standard in all AFHSs. Although the U.S. Preventive Task Force does not recommend screening for cognitive impairment, this recommendation is controversial. Dementia has enormous implications for This editorial comments on the article by Fulmer et al.

ACE Unit Business Model

Building the business case for an Acute Care for Elders (ACE) Unit is one of the key steps in ACE Unit development and follows the same steps as the ABCs of ACE Unit implementation; agree, build, commence, document, evaluate, and feedback. Essentially, ACE provides cost stabilization and quality standardization in the era of value-based purchasing. To get “the agree” you must demonstrate the scope of the problem and present the evidence base showing how ACE care model has been shown to improve outcomes in randomized trials. However, this is not sufficient in today’s value-based healthcare market place, a health system environment of multiple, competing demands for limited capital. You must demonstrate the financial benefits in addition to the impact on quality. The next step is to construct a business plan to show the improvement in cost savings and cost efficiency at your institution. In this chapter we provide the language you will need to know when talking to stakeholders, particularly in finance and administration, as well as an example pro forma which you can replicate to build a business plan to open an ACE Unit at your institution. Using the principles and practices within the ACE model will help your institution achieve the three part aim (http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx, Accessed 13 Aug 2013) of improved experience, decreased cost, and increased quality.