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Home > RNJ > 2007 > May/June > The Acute Care for Elders Unit: Taking the Rehabilitation Model into the Hospital Setting

The Acute Care for Elders Unit: Taking the Rehabilitation Model into the Hospital Setting
Luis F. Amador, MD Diana Reed, MSW LCSW Cheryl A. Lehman, PhD RN CRRN-A BC

Older Americans are living longer than ever before. Those over the age of 65 years account for almost 13% of the population and one third of all hospitalizations. Older adults are much more likely than younger adults to develop complications during hospitalization. With the increasing number of older adults at higher risk of hospitalization, it is more important than ever to study and develop ways to minimize the cascade of dependency that can occur during hospitalization. The Acute Care for Elders unit model has been shown to improve the processes of hospital care, discharge outcomes, and the prevention of functional limitations for the acutely ill older adult.

According to a recent U.S. Census Bureau report commissioned by the National Institute on Aging, dramatic changes are occurring in aging in the United States (He, Sengupta, Velkoff, & DeBarros, 2005). Today’s older Americans are living longer, having lower rates of disability, achieving higher levels of education, and less often living in poverty. The U.S. population aged 65 years and older is expected to double in the next 25 years. By 2030, almost one in five Americans will be 65 years or older. The age group 85 and older is now the fastest-growing segment of the U.S. population. One noteworthy trend is that the health of older Americans is improving. But 14 million people aged 65 and older still report some level of disability, mostly related to chronic conditions such as heart disease and arthritis (He et al., 2005).

In 1997 in the United States, those over the age of 65 years accounted for one third of all hospitalizations and were almost three times more likely to be admitted than younger adults. In addition, older adults accounted for less than 15% of the population in the United States while accounting for almost 50% of hospital expenditures (Elixhauser, Yu, Steiner, & Bierman, 2000).

Traditionally, geriatric medicine has been devoted to management of sickness and disability as well as disease prevention and health promotion in older adults. In geriatrics, one of the challenges is to treat the older adult’s acute illness in the hospital while preventing complications, maintaining baseline functional and self-care abilities, planning for a successful discharge to the least restrictive environment, and achieving a high level of patient satisfaction. Older adults face many risks and losses during hospitalization for acute illness. Complications can result from the unfamiliar setting, changes in routine, multiple tests and procedures, decreased mobility, and poor nutritional intake. These complications may include deconditioning, depersonalization, falls, delirium and agitation, depression, incontinence, and infection (Lehman, Tyler, & Amador, 2006).

The Acute Care for Elders (ACE) unit is a model of care aimed at minimizing risks and losses experienced by hospitalized older adults while maximizing positive outcomes. Rather than promoting ageism by isolating older adults, the ACE model addresses the deadly risk older adults face simply from being hospitalized and prevents nosocomial complications through a combination of environmental adaptations and an interdisciplinary team trained in geriatric care.

The ACE unit also offers more than patient care; it offers healthcare providers the opportunity to participate in gerontological education and research. In addition, as in other specialist units, staff on these units develop expertise. In the ACE unit, the expertise is in the area of common geriatric illnesses and problems associated with the hospitalization of adults 65 years and older such as delirium, falls, deconditioning, and the cascade toward dependency caused by functional loss (Creditor, 1993).

Hospitalization

Factors associated with hospitalization and bedrest may push a vulnerable older adult into irreversible functional decline (Creditor, 1993; Hoenig & Rubenstein, 1991). This functional decline can produce a cascade of dependency and changes in future lifestyle and quality of life. Older adults are more vulnerable to this decline because of the normal changes that may occur with advancing age. Some normal changes associated with age that may be exacerbated by acute illness and hospitalization are decline in muscle strength and aerobic capacity, reduced bone density, diminished pulmonary ventilation, and altered appetite and thirst (Creditor, 1993).

Losses in activities of daily living (ADLs) often result from the effects of bed rest and comorbid conditions, especially in the older adult who already has lower cardiovascular, respiratory, musculoskeletal, and neuropsychological reserves (Harper & Lyles, 1998). Modifying the hospital environment and facilitating physical activity and socialization can prevent the cascade to dependency (Creditor, 1993). In a study of more than 2,000 older adults admitted to two teaching hospitals, 35% were discharged from the hospital with lower ADL function than 2 weeks before admission (Covinsky et al., 2003). Factors independently associated with risk for decline in ADL function include older age, especially 85 years and older, unsteadiness, malnutrition, cognitive impairment, lower functional status (preadmission), and depression (Lamont, Sampson, Mathias, & Kane, 1983; Landefeld, 2003; Sager et al., 1996).

ACE Unit Concept

The ACE unit concept is growing in popularity in the United States. The ACE model specifically addresses the needs of the older adult. A safe, homelike physical environment, patient- and family-centered care, discharge planning to the least restrictive environment, dedicated staff with expertise in aging, interdisciplinary teamwork, and patient satisfaction are key elements of an ACE unit (Lehman et al., 2006; Palmer, Landefeld, Kresevic, & Kowal, 1994). In contrast to skilled nursing facilities and rehabilitation facilities, the ACE unit is regulated and paid like any other acute care hospital unit. Table 1 illustrates the goals of an ACE unit.

The purpose of an ACE unit is to prevent the complications of hospitalization in a homelike setting with highly trained staff while addressing the biopsychosocial needs of the patient and family. In a randomized evaluation, Landefeld, Palmer, Kresevic, Fortinsky, and Kowal (1995) demonstrated that ACE improved several outcomes of hospitalization at discharge, including ADL function, ability to walk, and symptoms of depression, and reduced nursing home placement. For example, ADL function improved from admission to discharge in 34% of patients in the ACE unit and 24% of patients in traditional care (p = .009). For patients in the ACE unit, only 16% had worsening ADL function from admission to discharge, compared with 21% of patients in traditional care.

In a randomized trial, Counsell et al. (2000) demonstrated substantial improvements in several processes of care (e.g., reductions in prescription of high-risk medicines, restraints used, and days to discharge planning) and improvements in patient, family, nurse, and physician satisfaction. In this study and the Landefeld et al. (1995) study on ACE units, there was no association with a significant reduction in mortality or hospital costs.

The ACE unit at the University of Texas Medical Branch Hospital (UTMB) has a reputation for providing outstanding medical care to adults 65 years and older. It opened with 20 beds in 2000 and added 30 beds in June 2005. Initially, admission to the unit was limited to patients 80 years and older, but later it expanded to include patients 65 years and older. The admission criteria have changed over time to be more inclusive of the majority of older adults. All medical and surgical patients are accepted onto the unit except those receiving intravenous chemotherapy, those with severe acute myocardial infarction, and those who have undergone ear, nose, and throat or genitourinary surgery.

Physical Environment

A critical step in developing an ACE unit is the creation of a homelike environment to decrease depersonalization. A homelike environment fosters normalcy and counteracts a sense of institutionalization. A homelike environment also promotes orientation and mobility in patients with sensory deficits, both visual and aural.

On the ACE unit at the UTMB, spacious patient rooms with sleeper sofas enable family members to spend more time with the patient. Patient rooms are also staff-friendly. Many of the rooms have large windows onto the central hallways, enabling staff to observe patients and allowing patients a view of the hospital world outside their rooms. This feature is particularly helpful in managing patients at risk for falls and allows all ACE staff to participate in monitoring at-risk patients while passing patient rooms. Activities aimed at sustaining functionality, such as dressing and grooming, can be accomplished in the patient’s room. Calendars and large clocks in each room promote orientation. Reclining chairs, carpeted hallways, and wheelchair-accessible bathrooms enhance the homelike experience. Handrails in patient bathrooms and in the hallways promote independence and mobility. Common areas with tables and chairs, jigsaw puzzles, large-print reading material, an aquarium, a piano, and a CD player with music from the patients’ era also help to deinstitutionalize the medical setting. The music also enhances socialization and is effective in normalizing the environment.

Spacious rooms are functional in that patient–family–team conferences can be held in the patient’s room. Equipment such as bedside commodes, lifts, and wheelchairs can be housed easily in the patient’s room, enhancing accessibility and safety. Caregiver education, particularly regarding ADLs, can also be accomplished in the homelike setting of the patient’s room. Chalkboards allow staff to write their names. Families also use the chalkboards to leave messages for staff.

Other considerations are aesthetic. Artworks, primarily paintings, depict scenes from life in past decades. These are selected to prompt reminiscence. A dog laying beside the hearth, a young boy fishing from a pier, and quilts hanging on the backyard clothesline are examples of pictures that have a powerful ability to evoke memories.

Nursing pods are placed along the hallways at two- to four-room intervals, ensuring easy and timely access to patient rooms and rapid response to patient needs. A pod consists of a desk, chair, computer, telephone, and storage for charts and protocol manuals. Carpeting and decreased use of overhead paging keep noise levels at a minimum.

Patient- and Family-Centered Care

The environment contributes to care in other ways. It serves as a comfortable and welcoming space for family and friends to visit patients. Daily care, care planning, and discharge planning are improved by the availability of those who are essential to the processes.

Although the hospital has policies and procedures on most aspects of care, the ACE unit develops its own protocols for implementing those policies and procedures specifically with older adults. Protocols are interdisciplinary and cover an array of topics, including functional assessment, fall prevention, discharge planning, advance directives, elder abuse, exploitation, and neglect. Protocols identify staff responsibilities and are available to all staff at each ACE unit nursing pod. This availability is particularly useful when orienting new staff, including house staff and visiting faculty, to ACE-specific protocols.

Team Members

Large academic hospitals, such as the UTMB at Galveston, often have complex administrative structures with complex, layered lines of authority. Traditional administrative structures require professionals to report to a profession-defined department: physical therapists report to a physical therapy or rehabilitation department, social workers report to a social work or care management department, pharmacists report to the pharmacy, and so forth. To develop and operate a unit based on a concept of care, each administrative department must share that vision and agree about its priorities. In a large facility, this task can be daunting. Add the necessity of financial planning and budgeting to the issues of staffing, and coordination becomes increasingly complex.

Some aspects of traditional structure remain at the ACE unit at UTMB. Bedside nurses report to a charge nurse, who reports to an assistant nurse manager, who reports to a nurse manager. The nurse manager reports to a nurse administrator specifically assigned to ACE. However, other team members, including rehabilitation staff, social workers, and pharmacists, also report to the nurse administrator. That administrator has the ACE concept foremost in mind when addressing issues of development and operation and when advocating for ACE at policymaking levels.

ACE staff are dedicated to the ACE. Initially, 65% of registered nurses held certification in geriatrics. With expansion, the new nurses are training in geriatrics. The physical therapists are certified in geriatrics, as is the pharmacist. Licensed professional social work staff members have experience and education in gerontology. Continuing education programs in geriatrics are ongoing and available to all. The open relationship between the medical and allied health schools and the UTMB clinical operation encourages exchange of knowledge and ideas in geriatrics and related fields. The research component of the medical school adds to education possibilities for all staff members. Seminars and lectures are offered regularly, providing knowledge about the latest in the field.

In an increasingly complex healthcare environment, patient care routinely requires the combined efforts of many disciplines. The complexities of caring for adults age 65 years and older make a unidisciplinary approach inappropriate in many instances. Two models of care that feature teamwork are the multidisciplinary team model and the interdisciplinary team model, which share some characteristics. Both include a variety of healthcare disciplines working toward a common goal. Also, both aim to optimize patient care by doing more collectively than could be accomplished by individual team members acting separately. Finally, both are concerned with maximizing patient satisfaction, and both are committed to team processes.

The multidisciplinary team is more dependent on chart notes and written recommendations for information sharing between team members. The multidisciplinary team usually is led by a physician, who operates in a position of authority. In contrast, the interdisciplinary team typically has shared leadership responsibility, and leadership may shift depending on patient needs. The interdisciplinary team relies heavily on verbal communication, and role boundaries are flexible. It has been noted that interdisciplinary conferences provide structure for maintaining continuity of care in the ACE unit (Panno, Kolcaba, & Holder, 2000). However, both models require membership stability and attention to team process to function effectively and efficiently (McCallin, 2001).

The ACE healthcare team uses an interdisciplinary team model. The team consists of representatives from several disciplines, including nursing, physical therapy, occupational therapy, nutrition, pharmacology, and social work. Others available to join the team include speech therapists, ethicists, clergy, and psychologists. Geriatricians join the core team to communicate regarding their patients. This team model is described for acute care and palliative care (Beers & Berkow, 2000; Cooper & Fishman, 2003; McCallin, 2001; Storey & Knight, 2003).

The team meets daily to enhance and formalize communication opportunities about care and discharge planning. Succinct case presentations and updates lead to economical use of time. The structure and process for team meetings, developed by team participants, are presented in Table 2, and new patient communication guidelines are presented in Table 3.

Integration of roles is a feature of the interdisciplinary team. Shared decision making occurs through information exchange and interactive discussion. Team members share responsibility for leadership. Older patient care routinely combines the efforts of different disciplines. Healthcare team structure has evolved from that of a hierarchy with the physician in the lead position to a group of professionals who collaborate to achieve a common goal. Multiple disciplines working together with a patient-centered approach is an essential part of ACE unit care, which has been shown to improve functional outcomes at discharge in older adults (Covinsky et al., 1998).

Discharge to Least Restrictive Environment

Effective discharge planning is a vital aspect of ACE unit activity. The entire interdisciplinary team is involved in the process. UTMB ACE data on discharge disposition support trends of 60%–70% of elder patient discharges to home. The oldest old and patients admitted from long-term care institutions and skilled nursing facilities to ACE are less likely to return home (Amador et al., 2005). Additional studies on the UTMB ACE are in progress to determine other potential predictors for discharge disposition.

Factors associated with discharge planning affect patient outcomes, including patient satisfaction. In a study aimed at examining the difference in outcomes for older adults hospitalized with heart failure and caregivers who participated in a professional–patient partnership model of discharge planning, older adults in the intervention cohort reported feeling more prepared to manage care, reported more continuity of information about care management and services, felt they were in better health, and spent fewer days in the hospital when readmitted (Bull, Hansen, & Gross, 2000a).

In another study of hospitalized older adults and caregivers, caregivers who reported more involvement in discharge planning had higher scores on satisfaction, feelings of preparedness, and perception of care continuity (Bull, Hansen, & Gross, 2000c).

A study of older adults’ satisfaction with discharge planning, assessed through posthospitalization follow-up telephone calls, concluded that continuity of care and the extent to which they felt prepared to manage their care after hospitalization were the best predictors of patient and family caregiver satisfaction with discharge planning (Bull, Hansen, & Gross, 2000b).

To determine the effects of a comprehensive discharge planning protocol specifically designed for older adults and implemented by nurse specialists, a clinical trial at the Hospital of the University of Pennsylvania examined differences in patient outcomes: its findings supported the need for comprehensive discharge planning designed specifically for the older adult (Naylor et al., 1994).

Based on data from the Thunderbird Samaritan Medical Center in Phoenix, which participates in the Press-Ganey Associates posthospitalization survey method of measuring patient satisfaction, patient satisfaction with discharge was noted to include the patients’ perception of their readiness for discharge, clear instructions on how to care for themselves at home, assistance with arranging home care services, and the speed of their discharge (Laughlin & Colwell, 2002). UTMB uses the Press-Ganey Associates patient satisfaction postdischarge survey mechanism to gather and benchmark data regarding this aspect of patient outcome. Initially ACE scores were high when compared with other areas of UTMB and when benchmarked against other facilities in the region. Expansion has posed challenges, but the UTMB ACE unit scored in the top 99th percentile nationwide for Press-Ganey patient satisfaction in the third quarter of 2006.

Continuous process improvement (CPI) is a routine ACE activity. CPI meetings address issues that arise in daily unit life, including interdisciplinary team communication, protocol development, follow-up patient survey results, fall prevention, and complications. CPI provides a forum for interchange about processes, for problem identification, and for resolution of issues. If an issue arises concerning a department of the hospital not usually involved in clinical operations, representatives from that department are invited to participate, thus broadening the range of improvement opportunities.

The Future of ACE

In a cost-conscious environment, the ACE unit is challenged to show that patient care for older adults, based on the criteria outlined in this article, can be cost-effective. An emphasis on shorter lengths of stay and rapid turnover of beds runs counter to clinical wisdom about the care of older adults. The ACE model can show its benefits in patient satisfaction, medication compliance, and in decreased readmissions, particularly with the most frequently appearing diagnoses of chronic obstructive pulmonary disease, pneumonia, and heart failure. To date, research about readmission, patient medication compliance, and benefits of medical management of individual conditions is limited.

At UTMB, specifically, the challenge is to attain positive outcomes with the expansion of the ACE from 20 to 50 beds. Communicating the ACE concept to new staff, gaining physician acceptance, and exploring new methods of teamwork and staff job satisfaction are agenda items for the coming months. Efforts have been made to educate healthcare professionals in the care of hospitalized older adults. Nursing education measures in the patient-centered care of older adults, such as the use of protocols to prevent hospitalization-related problems and hospital-wide campaigns to avoid the use of certain medications associated with delirium, are part of the strategy to improve care. The value of implementing these ACE concepts throughout the hospital system is still unknown.

With the increasing number of older adults who are at higher risk of hospitalization, it is more important than ever to study and develop ways to minimize the cascade of dependency that can begin during hospitalization. The ACE model has been shown to improve the processes of hospital care and discharge outcomes, prevent functional limitations, and provide better patient satisfaction. The ACE model is interdisciplinary, and emphasis is on the patient’s medical problems and functional and psychosocial needs.

Nursing Implications

Not all facilities have the means to dedicate an entire nursing unit to the care of older adults. Nurses in all settings therefore have an important role to play in providing competent care to hospitalized older adults and preventing the complications they face during hospitalization. The American Nurses Association (ANA) has recognized the special needs of older adults and the vital role nurses play in their care. GeroNurse online (http://www.geronurseonline.org) is a Web site aimed at improving nursing competencies in caring for older adults. Funded by the Atlantic Philanthropies, Inc., the initiative is cosponsored by the ANA, American Nurses Credentialing Center, and the John A. Hartford Foundation Institute for Geriatric Nursing at New York University (NYU).

The NYU College of Nursing also supports many endeavors aimed at improving the care of hospitalized older adults. Their Nurses Improving Care for Health-System Elders (NICHE) initiative forms the backbone of the nursing efforts of our own ACE unit, and their protocols are the basis for the care we deliver. Many resources are available through the NICHE group, including advice on assessing the care your facility delivers to your geriatric patients and advice on developing geriatric resource nurses throughout healthcare systems. The Web site can be accessed through http://www.hartfordign.org.

About the Authors

Luis F. Amador, MD, is a medical director in the ACE unit at the University of Texas. Address correspondence to him at the University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0460 or lfamador@utmb.edu.

Diana Reed, MSW LCSW, is a supervisor of geriatric services social work at the University of Texas Medical Branch, Galveston.

Cheryl A. Lehman, PhD RN CRRN-A BC, is an assistant professor at the University of Texas Health Science Center at San Antonio School of Nursing.

References

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