The U.S. population is aging at an unprecedented rate. By 2035, the U.S. Census Bureau projects there will be more people over 65 than under 18 for the first time in U.S. history. As the Baby Boomers age, they will bring different expectations regarding their health care – and new challenges for physicians.
Thomas Dalton, M.D.
Internal Medicine - Geriatrics
At UT Southwestern, we care for older adults who are referred to us with complex conditions that require a coordinated, patient-centered approach – one that simultaneously works with the patient's preferences and values. These needs inspired the creation of the Acute Care for Elders (ACE) Unit at William P. Clements Jr. University Hospital.
The ACE model of care was developed in the 1990s with a goal of helping hospitalized older adults maintain independence during activities for daily living (ADL). We take that concept a step further in the ACE Unit, which was launched in 2014.
Here, we bring together a multidisciplinary team of specialists and experts who convene for daily rounds covering each ACE patient to allow departments such as physical therapy, nursing, and pharmacy to develop care improvement solutions collaboratively.
Together, we focus on intervention and risk reduction, as well as continuously working to develop and improve best practices for geriatric care.
How ACE Helps Patients
When an older adult has an acute medical issue, it often occurs in addition to chronic comorbidities that might not be well controlled.
Traditionally, disease-focused models – wherein only the new issue is addressed – have been found to result in rehospitalization, reduced independence, and overall health decline. A study published in GeriatricCare found that 30% to 40% of older adults hospitalized for acute conditions leave the hospital with new disabilities under the disease-focused care model.
However, the ACE model has been shown to reduce readmissions and patient costs by focusing on interventions such as adjustments to hospital environments and proactively assessing for common issues or syndromes for older adults. This allows diagnosis and treatment to occur earlier, which leads to better outcomes.
The ACE Unit is less of a seismic shift in geriatric care and more of a restructuring of approaches. Here, we consider a holistic view of the patient's health and treatment needs, including extrinsic factors that can affect older adults’ health trajectory, such as socialization and sleep hygiene.
The 4 Ms and ACE
With every patient, ACE program providers assess four simple principles that help providers frame the way they care for older adults. We call these the 4 Ms.
We follow a set of protocols to identify and treat patients at risk for mental health concerns that can arise as a result of hospitalization, such as dementia, depression, and delirium, as well as general cognitive impairments.
For example, we examine patients for delirium symptoms a minimum of twice a day using a validated delirium screening tool called the Confusion Assessment Method (CAM). The CAM process involves a formal cognitive assessment interview, as well as observations of patient behavior or responses. The goal is to recognize patients that develop symptoms so we can address reversible factors early, as well as to identify those with a higher risk so we can potentially prevent complications.
Assessing the risk upon admittance can alert the entire care team to subtle signs of these conditions and offer opportunities for earlier intervention.
There is significant evidence that some medications older adults receive in the hospital are inappropriate for their condition and can cause more harm than benefit. Additionally, contraindications such as or drug interactions or adverse side effects can result in extended hospitalization, severe illness, or even death.
The ACE Unit includes “geriatrics champions,” experts in nursing, nutrition, pharmacy, and social work who are specially trained to provide informed care and identify and reduce common risks for older adults. This is another key component of the ACE approach.
We look for opportunities to help our older patients retain their mobility at home and in their communities. To accomplish this, we develop a mobilization action plan that is personalized to each patient based on their pre-existing level of function. This is typically achieved by replacing bedrest with periods of activity based on baseline functionality and their health goals. Ideally, we’d like them to leave the hospital with a level of mobility comparable to the level they had upon admittance.
4. What Matters Most
Above all, we look for opportunities to understand each patient’s needs and preferences. North Texas is home to one of the most diverse patient populations in the U.S. We have ample experience in creating personalized care plans that encompass a wide variety of cultural and personal expectations.
For example, some patients would like to decrease their dependence on medication, and others want to become well enough to enjoy activities with their grandchildren. No matter the goal, we can create a plan to help them achieve their desired outcome.
This range of experience allows our ACE Unit to serve as an incubator for ideas. Many of the data-driven care improvements we’ve developed have been incorporated by care teams at other medical centers. One example is the UT Southwestern Perioperative Optimization of Senior Health (POSH) Program, which was developed using lessons from ACE implementation.
Continuously Improving Outcomes for Older Adults
ACE Unit providers work every day to improve the mobility and cognitive function of our patients through process improvements and data analysis.
Our focus in recent years has been retooling how we hire and train workers for positions such as mobility technicians, aides, or physical therapy technicians. With better training, we can identify more at-risk patients and dedicate resources to getting them moving and working their minds sooner, more, or differently than in a typical inpatient experience.
For example, we regularly assess the extent to which admittance to the ACE Unit decreases length of hospital stay and risk of being discharged to a post-acute care facility. Using these data, we continuously improve the program’s quality of care and patient outcomes.
The ACE Unit provides a data-informed solution for clinicians looking to refer hospitalized older patients and their families to manage a wide range of health challenges. With a multidisciplinary approach, we combine effective acute treatment with personalized care to help seniors preserve and reclaim their function and independence.