(1) Canadian Institute for Health Information, A Focus on Seniors and Aging, 2011; (2) Dhalla et al, Toward Safer Transitions: How Can We Reduce Post-Discharge Adverse Events?, Healthc Q., 2012; (3) http://www.cfhi-fcass.ca/WhatWeDo/ace

ACE Project Coordinator: ace.cisssca@gmail.comPrincipal Investigator: patrick.m.archambault@gmail.com

● Seniors represent 30% of Emergency Departments (ED) patients in Canada (1). ● Seniors are vulnerable to health system failures and care coordination problems.● Discharge adverse events result in unplanned readmissions and loss of physical,

functional and/or cognitive capacity (2).

● ACE Program at Mount Sinai Hospital (Toronto, Canada) applied strategies which reduced lengths of hospital stay, reduced readmissions, increased patient satisfaction, and saved significant costs.

● Successful dissemination of best practices often remains an exception because human, technical and organizational barriers make context-adaptation difficult.

● Hôtel-Dieu de Lévis Hospital (Lévis, Quebec) is one of the 18 teams across Canada to take part in the ACE Collaborative to support local uptake.

● Adapt ACE program to the local context of a single hospital in Quebec;● Improve care transitions from hospital to home;● Decrease avoidable readmissions (medical units and emergency department).

● Local strategies from ACE program chosen to be implemented:○ Telehealth service;○ Transition coach model;○ Improve communication with community health providers;○ Wiki to facilitate knowledge management and context-adaptation of knowledge.

● Data collection:○ Continuous data collection to capture real-time practice change over 8 months

with 64 patients pre- and 64 post-intervention;○ Inclusion: >50 years; at risk of readmission (modified LACE score);○ Patients data collection at recruitment, 48h and 30 days post-discharge;○ Patient-level outcomes:

■ Functional autonomy (OARS Activities of Daily Living instrument);■ Clinical Frailty Score (CFS);■ Satisfaction with care transition (CTM-3 instrument);■ Quality of life (SF-12 scale);■ Caregiver strain (Caregiver Strain Index);

○ Hospital-level outcomes:■ 30-day post-discharge readmission rate;■ 30-day post-discharge ED visit rate.

Age (years ± SD) 74.4 ± 9.8

Women (%) 39.3

Education (%) Elementary school High school College or university degree

39.335.725.0

OARS (score ± SD) (0-28, independant to very dependant on ADLs/IADLs)

5.8 ± 4.8

CFS (score ± SD) (1-9, very fit to terminally ill)

3.9 ± 1.5

Self-rated health (%) Good to excellent Average Poor to mediocre

3.632.164.3

Figure 1: 30-days readmission rate for >50-years-old patients (29 financial periods from May-2014 to Jul-2016)

Figure 2: ED visit 30-days post-discharge rate for >50-years-old patients (29 financial periods from May-2014 to Jul-2016)

Table 1: Pre-intervention cohort patient characteristics (n=30)

● Growing readmission rate and high ED use among seniors is alarming.● Our context-adapted ACE intervention will be highly relevant to tackle these issues.● However, we still have many issues to deal with:

○ Major health reform that creates large integrated care centers, but that still lacks manpower and information infrastructure to manage change;

○ Overemphasis on confidentiality of information that prevents patients and clinicians from accessing the necessary information to guide timely decision making;

○ Transition coach model needs to be adapted to current lack of human resources;○ Need for more stakeholder buy-in to foster uptake of our local ACE project.