The Art and Science of Acute Care for Older Adults - American ...

Acute Care for Elders (ACE) as a
• Michael Malone, MD
Aurora Health Care
University of Wisconsin School of
Medicine & Public Health
• S. Liliana Oakes, MD, CMD
University of Texas Health Science
Center San Antonio
• Ella Bowman, MD, PhD
Indiana University
Wishard Hospital
Geriatrics Safety and Quality
• Kyle Allen, DO, AGSF
Riverside Health System, Newport
News, VA
Improvement Program
• Albert L. Siu, MD, MSPH
Mount Sinai School of
Medicine
• Liz Capezuti, PhD, RN, FAAN
New York University College of
Nursing

A Real-time, Quality Improvement
Checklist: The ACE Tracker
Michael L. Malone, M.D.
Aurora Health Care
University of Wisconsin
School of Medicine and Public Health
May 4, 2012

Acute Care
for Elders-
1995
Depressed Mood
Negative Expectations
Improved Mood
Positive Expectations
Functional Older Person
Acute Illness,
Possible Impairment
Hospitalization
ACE Unit
Prehab Program Interventions:
Prepared environment with standard equipment for seniors
Patient-centered, interdisciplinary care
Multi-dimensional assessment and non-pharmacologic prescription
Home planning/informal network
Medical care review.
Reduced Impairment
Functional Older Person
Decreased Iatrogenic
Risk Factors
ACE
Acute Care for Elders

What will happen to me if the ACE Unit is full?

Learning objectives:
• Describe how to incorporate the ACE
principles into the electronic medical
record.
• Describe how to produce real-time reports
on quality and safety for older adults.
• Describe some initial outcomes.
• Discuss strategies to implement this
program at your medical center.

The Conceptual Model:
The Challenges:
• Our ACE program was
confined to one unit.
• Our quality measures provided
data that was several weeks
old.
• Our nurses were putting
information in the electronic
medical record, but no one was
using the data.
Our Response:
• Use a report to guide the
replication of the ACE program,
without having to build more
units.
• Provide a real-time report of the
unique needs of our older
patients.
• Use the report to identify the
most vulnerable older patients

Best Care for Hospitalized Older Patients:
Implementation
of high quality,
simple care
Rapid Adopter
Simplified Care for
the Patient
Best practices
partially applied
Rapid adopter of best
practices / services
Leading edge health care
Best care everywhere
Rapid implementation of
different care delivery
models
Simple & easy to use
Smooth transitions
coordinated care
Complex, fragmented
episodic care experience
All patients, same care,
same way
Different services for different
needs/groups
Care designed around
patient needs
Designed for You
Designing different
care delivery models
facilitates simplified
care based on patient
needs and
characteristics

Acute Care
for Elders-
2012
Depressed Mood
Negative Expectations
Improved Mood
Positive Expectations
Functional Older Person
Acute Illness,
Possible Impairment
Hospitalization
ACE Programs
Prehab Program Interventions:
Prepared environment with standard equipment for seniors
Patient-centered, interdisciplinary care
Multi-dimensional assessment and non-pharmacologic prescription
Home planning/informal network
Medical review using real-time information technology tools
Reduced Impairment
Functional Older Person
Decreased Iatrogenic
Risk Factors
ACE
Acute Care for Elders

Using Health Information Technology
to Identify Vulnerable Older Patients

ACE Tracker:
ACE Tracker software to
identify vulnerable elders:
Malone ML, Vollbrecht M, Stephenson J, et al, J Amer Geriatr Soc 2010: 58:161-167
• Harvests “real-time” information
from the older patients’ electronic
medical record.
• Provides a computer-generated
checklist of key indicators of risk
for hospitalized older patients.
• Does not require a new activity of
the nurse or pharmacists.
• Is available at all med-surg units of
all Aurora hospitals.
• Used to disseminate the ACE unit
model broadly.

The Measures Included
in ACE Tracker:
Name.
Room.
Age.
Length of hospital stay.
Cognitive impairment.
Delirium.
Number of medications.
Beers list medications.
Risk of falls.
Fall prior to hospital.
Therapy ordered.
Pressure sore.
Activities of daily living score.
Risk of pressure sore.
Urinary catheter in place.
Physical restraint.
Serum albumin.
Social service evaluation.
Advanced directive.
30 day readmission.
Risk of re- hospitalization.

Three Strategies to Incorporate
ACE into the Electronic Medical
Record:
• A real-time report of all older patients on a
medical-surgical unit.
• A tab in every older patient’s electronic
medical record describing their unique
vulnerabilities.
• A snap-shot assessment of the quality of care
on day two of every older hospitalized
patient.

ACE Tracker software to identify
vulnerable elders:
Malone ML, Vollbrecht M, Stephenson J, et al, J Amer Geriatr Soc 2010: 58:161-167

ACE Tracker disseminated to all hospitalized older patients.
Gonzolez,Geni

Geriatrics principles in the electronic
medical record of each older patient:

Using ACE Tracker as a
Quality Measurement Tool:
Day two-snapshot of all older patients in a hospital.
Assess key features of the ACE program.
Follow the progress over time.
Compare the practice patterns of multiple hospitals.
Take responsibility for populations of older patients.

Acute Care for Elders at 12
Aurora Health Care Hospitals:
Automated clinical quality measures on the second
hospital day for 15,337 patients age >=65 years.

Initial outcomes of the project:

Comparison of Processes and Outcomes Before and
After Institution of ACE Tracker at a Remote Hospital
6 Months Before
(%)
n = 478
6 Months After
(%)
n = 406
P-Value
Urinary Catheter * 125/478 (26.2) 81/403 (20.1) 0.035
Physical Therapy * 129/478 (27.0) 156/399 (39.1)

Comparisons of Urinary Catheter Rate During and
After the Institution of ACE Tracker and
e-Geriatrician at 14 Aurora Health Care Hospitals

Comparisons of Physical Therapy Assessment
Rate During and After the Institution
of ACE Tracker and
e-Geriatrician at 14 Aurora Health Care Hospitals

Comparisons of Social Service Assessment Rate
During and After the Institution of ACE Tracker and
e-Geriatrician at 14 Aurora Health Care Hospitals

P
e
r
c
e
n
t
Comparisons of Processes of Care During and After the
Institution of ACE Tracker and
e-Geriatrician at 14 Aurora Health Care Hospitals
80
70
60
50
40
30
20
10
0
Physical
Therapy
evaluation by
day 2
Social Service
evaluation by
day 2
An estimated 2400 fewer
urinary catheters per year.
Urinary
Catheter on
day 2
Administrative data for quality improvement purposes.
30,707 patients Oct,
2007-Sept, 2008
30,996 patients in 2010
23,317 patients in 2011

The Dissemination of ACE-
with the ACE Tracker:
No need to keep renovating units.
Available throughout the hospital.
Available to all the hospitals in the system.
Provides an opportunity to link geriatricians with
teams in rural hospitals.
Does not require a geriatrician.
Imbed the report into a tab on the medical record of
every older patient.

Current Status
of Acute Care for Elders:
Aspirus Health Care
Aurora Health
Care
geriatricians
• ACE units at two hospitals in Milwaukee.
• Acute Care for Elders programs at 12 of 15
medical centers.
• Total of 37 medical surgical units within
Aurora (two at Wausau Aspirus Hospital)
practicing Acute Care for Elders model.
• “e-Geriatricians” join interdisciplinary
teams for scheduled teleconferences at 6
remote/ rural sites (2 more in May, 2012).
• ACE Tracker software integrates the model
of care into the system-wide electronic
health record.
• NICHE model in 4 hospitals, 3 SNF’s, and
clinic.
• ACE Consult Programs at three hospitals.
• ACE Cards & Palliative Care Pocket Cards
help to educate the staff.
• Annual education conference.
• ACE/ NICHE app for iPhone and Smart
phones.

Learning Objectives:
Describe how to incorporate the ACE principles into
the electronic medical record.
Describe how to produce real-time reports on quality
and safety for older adults.
Describe some initial outcomes.
Discuss strategies to implement this program at your
medical center.

Lessons Learned:
Discuss the concepts with the chief information officer.
Define if there are other real-time or “clarity” reports.
Develop a health IT inter-disciplinary advisory team to guide the
project.
Start with “version 1.0”.
Determine who will use the tool and study their current practice.
Build the conceptual model.
Adjust as you go.

Limitations of the Project:
There is no randomized controlled study of the use of
the electronic medical record to improve care of older
adults.
The outcomes shown are processes of care and not
health outcomes.
There is no information on cost-effectiveness of the
interventions.
Multiple interventions occurred during the six year
period.

Acknowledgements:
Jeff Stephenson, MS
Marsha Vollbrecht, MS, CSW, NHA
Patti Pagel, MSN, RN, GCNS-BC
James Goodwin, MD
Ariba Khan, MD, MPH
Ellen Danto-Nocton, MD
Soryal Soryal, MD, FACP
Mary Hook, PhD, RN

ACE NICHE App for Android Phones: