“aceing” complex population management past, present, and possible future for ace models of care...

“ACEing” Complex Population ManagementPast, Present, and Possible Future for ACE Models of

Care

UNTHSC Geriatric Grand RoundsMarch 25, 2015

Kellie L. Flood, MDAssociate Professor

Geriatric Quality Officer, UAB HospitalDirector, Geriatric Medicine Section

Division of Gerontology, Geriatrics, and Palliative CareUniversity of Alabama at Birmingham

Learning Objectives

Define the components of an Acute Care for Elders (ACE) Unit

List outcomes from clinical trials evaluating the ACE Unit model of care

Discuss the new role of ACE Units in reducing unplanned readmissions and complex population management

In what year did these statements appear in a health care administration publication?

“The overwhelming needs of the aging population have led to increasing expenditures for hospital care….”

“How this growing elderly population will obtain and pay for health care is emerging as a major social issue……”

“This changing financial and demographic trend, coupled with the limited resources provided for the elderly population, has been called the “Geriatric Imperative””

Bachman et al, Hospital and Health Services Administration 32(4):509-20.

19871987 Stock

Market Crash

Gallon of Gas 88¢

Simpsons Debut on TV

BAD Album Released

Movie Good Morning Vietnam Released

2014: Healthcare Did Not Heed the WarningSilver Tsunami is Here

If you can’t stop the wave…

Learn to SURF!

10,000 Baby Boomers will turn 65 years 10,000 Baby Boomers will turn 65 years old every day until 2031old every day until 2031

Is it just a numbers thing?

Older Adults Are A Different Patient Population Just As Pediatric Patients Are

Medicare expenditures for beneficiaries with different numbers of chronic conditions

1%3% 6%

10%

12%

68%

0

1

2

3

4

5+

Boult et al, The Permanente Journal Winter 2008;12:50-4; Boyd et al, Guided Care for Multimorbid Older Adults, Gerontol, 2007

Older adults experiencing multimorbidity consume 96% of the Medicare budget

62% of older Americans are experiencing multimorbidity

Older Adults are More Likely to Experience Geriatric Syndromes

Dementia Delirium Depression Gait and balance abnormalities/Falls Frailty/Functional Decline Malnutrition Pressure ulcers Polypharmacy Incontinence Caregiver Stress

Kresevic et al, Ger Nursing, 1998

Geriatric Syndromes = Increased Risk for Adverse Outcomes

Is it just an age thing?

Older Adults Are a More Heterogeneous Patient Population Than Younger Adults

Functionally and Cognitively Intact(some - maybe not much - room to spare)

Functionally or Cognitively Impaired (no margin for error = vulnerable)

Why do We Need Evidence-Based Geriatric Care Models??

Baby Boomers Baby Boomers

Lack of Geriatric

Training for all

Providers

Lack of Geriatric

Training for all

Providers

Reduced Reimbursement for Care

Reduced Reimbursement for Care

Slow Economy/Deficit

Slow Economy/Deficit

Perfect StormPerfect Storm

We Must Think Outside the Box!!

Coordinating Person-Centered Elder Care Requires an Inter(Trans)disciplinary Team

Types of Teams in Healthcare

Uniprofessional: Group of people all from the same discipline

working together

Multiprofessional: Group of people from different disciplines

who develop a treatment plan independently

GITT Curriculum: Teams and Teamwork; Klarare A. et al, J Pall Med 2013;16(9):1062-1069

Transprofessional:Although roles are specialized, everyone is prepared to step in/replace each other when necessary; Team leadership varies with the situation – OK to get outside your lane a bit

Interprofessional: Group of people from different disciplines

assess and plan care in a collaborative manner

Transprofessional

“I have learned the importance of the effects of polypharmacy in the care and treatment of UAB's geriatric patients…….. A patient's life may be changed due to medications.” - UAB Trauma Unit Occupational Therapist, 2013

Transprofessional

“One of the best things I have learned was about the different routes and half-life of IV compared to po pain meds. Last week I was able to counsel a patient and her daughter on the benefits of transitioning off IV pain meds.”

- UAB ACE Unit Social Worker, 2014

Adapted from slide by SUMMA Health Care

What is an ACE Unit? A Model of Inter/Trans-professional Coordinated Care in the Hospital

Functional Older Person

Acute Illness, Possible Impairment

Hospitalization: ACE Unit

Depressed MoodNegative

Expectations

ACEAcute Care for Elders

Prehab Program:Specialized environment

Patient-centered, interdisciplinary careMulti-dimensional geriatric assessment and non-pharmacologic management with nurse driven

careDaily medical review

Care transition planning from day 1

Reduced Impairment

Decreased Iatrogenic Risk Factors

Improved MoodPositive

Expectations

Functional Older Person

Participants: UAB ACE Interdisciplinary Team Meeting

Geriatrician/Geriatric NP

ACE Unit Coordinator

Nurses

Rehabilitation Services (PT, OT)

Pharmacist

Dietician (intermittently)

Social Worker

Pastoral Care (intermittently)

Psychology Interns (intermittently)

Trainees from all disciplines

UAB Hospitalist ACE Unit Process

Acute Care for Elders (ACE) Units are a team model of coordinated geriatric care in the hospital settingoriginally designed to maintain patient functional

status during hospitalization

Change in ADL performance from admission to discharge (p=0.009)

Landefeld et al, NEJM, 1995

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ACE Unit Usual Care

Much Worse

Worse

Unchanged

Better

Much Better

Secondary Outcome

SNF/rehab/LTC placement: 14% ACE Unit vs 22% Usual Care (p=0.01)

ACE Unit: Randomized Controlled Trial

ACE in a Community Hospital

1531 community-dwelling patients age ≥ 70 admitted for acute medical illness

Randomized to ACE vs Usual Care

Demonstrated improved processes of care in the intervention unit

Reduced use of restraints

Fewer high risk meds

Earlier and more frequent involvement of physical therapy and social work

Improved patient and provider satisfaction

Counsell et al, JAGS, 2000

Health Care Utilization and ACE

Retrospective, case-control study

Academic urban hospital

680 ACE vs 680 non-ACE patients age ≥ 65

Matched for age, ethnicity, comorbidity, and DRG (CHF, pneumonia, UTI)

ACE patients:

Shorter mean LOS (4.9 ± 4.3 vs 5.9 ± 4.5 , p=0.01)

9.7 % reduced unadjusted mean costs ($13,586 vs $15,040; p=0.012)

No difference in mean number of unadjusted readmissions 11% reduced readmission rate after controlling for age, race,

comorbidity, and pre-admission rateJayadevappa et al, Value in Health, 2006;9:186-192

UAB ACE StudyComparison of ACE vs Usual Care: FY 10

ACE Unit Usual Care

Number of beds % patients age 70

2539.2%

2040.3%

Unit nursing staff allotment (WHPPD) 9.75 9.75

Physical therapists FTE: bed ratio 1:19 1:26

Attending Physician Hospitalists Hospitalists

Formal Geriatric Consultation available upon request

Yes Yes

Evidence-based delirium prevention care processes Yes No

Volunteer mealtime assistance program Yes No

Daily Geriatrician led IDT Rounds for Geriatric Care Management

Yes No

Counselor for patients/families Yes NoFlood et al, JAMA Int Med 2013;173:981-7.

Patient Characteristics ACE vs UC FY 10:Age ≥ 70 who spent entire hospital stay on ACE or UC

VariablesMean (SD) or %

ACE (N=428) UC (N=390) P value

Age (years) 81.6 (6.9) 80.9 (6.8) 0.11

Gender (Female) 69.4% 65.9% 0.29

Race (White) 64.5% 59.2% 0.30

Comorbidity Score 3.4 (3.2) 3.1 (3.0) 0.14

Case Mix Index 1.1 (0.5) 1.1 (0.6) 1.00

No significant differences in patient characteristics between groups

Flood et al, JAMA Int Med 2013;173:981-7.

Cost and Readmission Outcomes ACE vs Usual Care FY 10:Age ≥ 70 who spent entire hospital stay on ACE or UC

VariablesMean (SD) or %

All DRGs Top 25 DRGs

ACE (N=428)

UC (N=390)

P Value

ACE(N=260)

UC(N=214)

P Value

LOS (days); Mean (SD)4.0 (2.7) 4.2 (2.8) 0.34 3.7 (2.4) 4.1 (2.8) 0.11

Variable Direct Cost/Case ($); Mean (SD)

$2,109

($1,870)

$2,480

($2,113)0.009

$1693

($1063)

$2138

($1431)<.001

Daily Variable Direct Cost/Case ($); Mean (SD)

$542

($383)

$595

($227)0.01

$484

($162)

$545

($120)<.001

Patients readmitted to UAB within 30 days of discharge

7.9% 12.8% 0.02 7.3 11.2 0.14

Flood et al, JAMA Int Med 2013;173:981-7.

Cost Savings from ACE Model

~ $371,000 savings in variable direct

cost for every 1000 patients

If UC patients experienced ACE

model

0

200

400

600

800

1000

1200

1400

1600

FY 12 FY 13

9181148

216 313

1134

1461

Inpts

Obs

Total

Number of patients age ≥ 65 discharged from ACE Unit

So how can the ACE model, originally designed to maintain patient

functional status, possibly impact readmissions?

Readmission Patterns for Older Adults with AMI, CHF, and Pneumonia

Medicare claims data from 2007-2009 to determine patterns

Mean age of readmitted patients = 80 yrs for all DRGs studied

Most readmits within first 15 days for all studied DRGs

Dharmarajan et al, JAMA 2013;309(4):355-63.

Study Authors’ Thoughts: “The broad range of acute conditions responsible for readmission may

reflect post-hospitalization syndrome – a generalized vulnerability to illness among recently discharged patients, many of whom have developed new impairments both during and after hospitalization.”

Losses in mobility/functional status, nutritional status, delirium, adverse

drug events, etc.

“The heightened vulnerability to a diversity of illnesses may explain why interventions that are broadly applicable to many conditions with multiple components or are delivered by a multidisciplinary team are more likely to reduce readmissions.”

Dharmarajan et al, JAMA 2013;309(4):355-63.

Aren’t these what ACE

Units address?

ACE Unit Models of Care Have Been Shown to:

Improved functional performance at discharge

Improved likelihood of living at home after discharge

Reduced restraint use

Reduced high-risk medication use

Improved nutritional support during hospitalization

Improved patient and provider satisfaction

Reduced length of stay

Reduced health care utilization costs

Reduced 30-day readmissions

Landefeld et al, N Engl J Med 1995; Counsell et al, JAGS 2000; Jayadevappa et al, Value in Health, 2006; Flood et al, Crit Rev Onc/Heme 2010; Flood, et al, Am J Geriatr Pharmacother 2009; Baztan et al, BMJ

2009; Flood et al, JAMA Int Med 2013.

What is the future for ACE?

Helping hospitals address complex population management via:

Higher Valued Care

Quality

Cost

Possible Means of Leveraging ACE Model for Higher Valued Care Hospital-Wide

ACE for non-general medical patient populations

Oncology-ACE

Stroke-ACE

Ortho-ACE

ACE of Hearts

Etc, etc

“e-Geriatrician” using ACE Tracker

“Mobile ACE” Consultative Care

UAB “Virtual ACE” Pilot

“Acefying” a Hospital via “Virtual ACE”

First UAB Virtual ACE Unit:Orthopedic Surgery

Geriatric Info Now Feeds into theUnit ACE Tracker Report

Key Geriatric Syndromes in Virtual ACE Training and Intervention

The “Why”

Function/Safe Mobility

Pain Management

Delirium

Care Transitions

Delirium Toolbox

Virtual ACE Ortho Unit Staff Feedback “Before the ACE we had delirium cases so frequently, now cases

have tremendously subsided.”

“Getting them moving early on has increased their satisfaction with the care at UAB and makes their pain much better. Appetite improves too.”

“Just the awareness of delirium prevention has opened our eyes to things we wouldn’t have noticed before. As a unit it seems everyone is working well together by implementing these initiatives. It’s easy to become complacent if you don’t know how to work effectively with a geriatric patient, but the ACE initiative has made us excited to make changes and actively see results.”

“Toolbox is a great thing to have ”

Measuring Outcomes: Pre- and Post- Pilot Test of Virtual ACE Intervention

Variable* Pre (N=31) Post (N=94) P-Value

Age Mean Range

71.5 ± 5.9

65-8974.2 ± 7.1

65-94P=.055

Gender 55% F 54%F NS

H/o Fall in last 3 months

48% Yes 48% Yes NS

Baseline Katz Score (Mean)

9.89 ± 3.7 9.9 ± 3.5 NS

Current Katz Score (Mean)

6.55 ± 5.1 6.9 ± 4.3 NS

% Abnormal Six Item Screen on Admission

21% 20% NS*Variables have missing data for some patients

Early Process Outcomes: 8 Weeks Pre- and 20-Weeks Post-Training

45%

0%

74%

88%88%94%

0%

20%

40%

60%

80%

100%

Both Baseline and Current KatzCompleted

NUDESC Completed

Pre-Intervention

Post-Intervention (wks 1-4)

Post-Intervention (Katz - wks 5-12; NUDESC wks 5-20)

Mobility in the Prior 24 Hours: All Patients

Pre: 43 assessments in 31 patients; Post: 30 assessments in 26 patients Pre vs Post Baseline Katz 10.4 ± 3.2 vs 11.23 ± 2.3, p=.278Pre vs Post Current Katz 7.0 ± 5.1 vs 7.3 ± 4.3, p=.831

2014 Ortho Unit Fall Rate for ≥ 65 years of age

Virtual ACE Safe Mobility Training

39% Relative Reduction in Delirium Prevalence

Pre-Training: 38 NUDESC Screens in 31 patientsPost-Training: 62 NUDESC Screens in 68 patients

2014 Ortho Unit Restraint Usage

Virtual ACE Delirium Training

Potential Cost Savings from Delirium Prevention

UAB Hospital Discharged 19,880 patients age ≥ 65 in FY 13

*Rubin JAGS 2006

Learning Objectives Revisited Define the components of an Acute Care for Elders (ACE) Unit

Interdisciplinary, patient-centered, multi-dimensional geriatric assessment, non-pharmacologic management, daily medical review, and care transition planning from day 1

List outcomes from clinical trials evaluating the ACE Unit model of care

Improved functional status, processes of care, med safety, likelihood of living at home after discharge, and reduced costs

Discuss the new role of ACE Units in reducing unplanned readmissions and complex population management

ACE appears to reduce readmissions via recognition and management of “post-hospitalization syndrome”

Improved outcomes provide leverage to disseminate ACE to non-medical patient populations and throughout an entire hospital

QUESTIONS?

UAB Hospital

1,156 beds of complex population management

“aceing” complex population management past, present, and possible future for ace models of care...

Documents

multimorbidity slide

birmingham slide

vulnerable slide

geriatric care models

hospital care

acute care

guided care

ace unit model of care