Transcript Cost Savings from an Acute Care for Elders (ACE) Unit

“ACEing” Complex Population
Management
Past, Present, and Possible Future for ACE
Models of Care
UNTHSC Geriatric Grand Rounds
March 25, 2015
Kellie L. Flood, MD
Associate Professor
Geriatric Quality Officer, UAB Hospital
Director, Geriatric Medicine Section
Division of Gerontology, Geriatrics, and Palliative Care
University 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
Page 2
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.
Page 3
1987
1987 Stock
Market Crash
Simpsons
Debut on TV
Gallon of Gas 88¢
BAD Album Released
Movie Good Morning
Vietnam Released
Page 4
2014: Healthcare Did Not Heed the Warning
Silver Tsunami is Here
10,000 Baby Boomers will turn 65 years
old every day until 2031
If you can’t stop the wave…
Learn to SURF!
Page 5
Is it just a numbers thing?
Older Adults Are A Different Patient Population Just
As Pediatric Patients Are
62% of older Americans are experiencing
multimorbidity
Medicare expenditures for beneficiaries with
different numbers of chronic conditions
1% 3%
6%
0
10%
1
2
3
12%
4
5+
68%
Older adults experiencing multimorbidity consume 96% of the
Medicare budget
Boult et al, The Permanente Journal Winter 2008;12:50-4; Boyd et al, Guided Care for
Multimorbid Older Adults, Gerontol, 2007
Page 7
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
Geriatric Syndromes = Increased Risk for Adverse Outcomes
Kresevic et al, Ger Nursing, 1998
Page 8
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)
Page 10
Why do We Need Evidence-Based Geriatric Care
Models??
Perfect
Storm
Page 11
We Must Think Outside the Box!!
Page 12
Coordinating Person-Centered Elder Care Requires
an Inter(Trans)disciplinary Team
Page 13
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
Interprofessional:
 Group of people from different disciplines
assess and plan care in a collaborative
manner
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
GITT Curriculum: Teams and Teamwork; Klarare A. et al, J Pall Med 2013;16(9):1062-1069
Page 14
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
Page 15
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
Page 16
What is an ACE Unit? A Model of Inter/Transprofessional Coordinated Care in the Hospital
Functional Older
Person
Depressed Mood
Negative
Expectations
Acute Illness, Possible
Impairment
Hospitalization: ACE Unit
Prehab Program:
Specialized environment
Patient-centered, interdisciplinary care
Multi-dimensional geriatric assessment and nonpharmacologic management with nurse driven care
Daily medical review
Care transition planning from day 1
Improved Mood
Positive
Expectations
Adapted from slide by SUMMA
Health Care
Reduced
Impairment
Functional Older Person
Decreased
Iatrogenic
Risk Factors
ACE
Acute Care for Elders
Page 17
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
Page 18
Admit to ACE
Bedside Fxn and
Cogn Screen
UAB Hospitalist ACE Unit Process
Discussed in daily
IDT
Care transition
planning begins Day
1 based on screens
- Katz ADLs
- Lawton IADLs
- Six Item
Screener
Formal geriatric
consult for complex
cases
ACE Coordinator
ensures plan
implemented
Existing/new/risks for
geriatric syndromes
identified
Geri care and
transition planning
revised daily
Page 19
Acute Care for Elders (ACE) Units are a team
model of coordinated geriatric care in the
hospital setting
originally designed to maintain patient
functional status during hospitalization
ACE Unit: Randomized Controlled Trial
Change in ADL performance from admission to discharge (p=0.009)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Much Worse
Worse
Unchanged
Better
Much Better
ACE Unit
Usual Care
Secondary Outcome
SNF/rehab/LTC placement: 14% ACE Unit vs 22% Usual Care (p=0.01)
Landefeld et al, NEJM, 1995
Page 21
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
Page 22
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 rate
Jayadevappa et al, Value in Health, 2006;9:186-192
Page 23
Page 24
UAB ACE Study
Comparison of ACE vs Usual Care: FY 10
ACE Unit
Usual Care
25
39.2%
20
40.3%
Unit nursing staff allotment (WHPPD)
9.75
9.75
Physical therapists FTE: bed ratio
1:19
1:26
Hospitalists
Hospitalists
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
No
Number of beds
% patients age  70
Attending Physician
Formal Geriatric Consultation available upon
request
Flood et al, JAMA Int Med 2013;173:981-7.
Page 25
Patient Characteristics ACE vs UC FY 10:
Age ≥ 70 who spent entire hospital stay on ACE or UC
Variables
Mean (SD) or %
ACE (N=428)
UC (N=390)
P value
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
Age (years)
No significant differences in patient
characteristics between groups
Flood et al, JAMA Int Med 2013;173:981-7.
Page 26
Cost and Readmission Outcomes ACE vs Usual Care FY 10:
Age ≥ 70 who spent entire hospital stay on ACE or UC
All DRGs
Top 25 DRGs
Variables
Mean (SD) or %
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
$2,109
$2,480
$1693
$2138
Variable Direct Cost/
Case ($); Mean (SD)
Daily Variable Direct
Cost/Case ($);
Mean (SD)
Patients readmitted to
UAB within 30 days of
discharge
0.009
<.001
($1,870)
($2,113)
($1063)
($1431)
$542
$595
$484
$545
0.01
($383)
($227)
7.9%
12.8%
<.001
($162)
($120)
7.3
11.2
0.02
Flood et al, JAMA Int Med 2013;173:981-7.
0.14
Page 27
Cost Savings from ACE Model
Variable Direct
Cost Savings =
$371/case
~ $371,000 savings
in variable direct
cost for every 1000
patients
If UC patients
experienced ACE
model
Number of patients age ≥ 65 discharged from ACE Unit
1461
1600
1134
1400
1200
1148
918
Inpts
1000
Obs
800
600
400
216
313
Total
200
0
FY 12
FY 13
Page 28
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.
Page 30
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.
Aren’t these
what ACE
Units
address?

“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.
Page 31
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.
Page 32
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
Page 34
“Acefying” a Hospital via “Virtual ACE”
First UAB Virtual ACE Unit:
Orthopedic Surgery
Geriatric Info Now Feeds into the
Unit ACE Tracker Report
Page 36
Key Geriatric Syndromes in Virtual ACE Training
and Intervention

The “Why”

Function/Safe
Mobility

Pain
Management

Delirium

Care Transitions
Delirium Toolbox
Page 37
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 ”
Page 38
Measuring Outcomes: Pre- and Post- Pilot Test of
Virtual ACE Intervention
Variable*
Pre (N=31)
Age
Mean
Range
Gender
H/o Fall in last 3
months
Baseline Katz Score
(Mean)
Current Katz Score
(Mean)
% Abnormal Six Item
Screen on Admission
Post (N=94) P-Value
71.5 ± 5.9
65-89
74.2 ± 7.1
65-94
P=.055
55% F
54%F
NS
48% Yes
48% Yes
NS
9.89 ± 3.7
9.9 ± 3.5
NS
6.55 ± 5.1
6.9 ± 4.3
NS
21%
20%
NS
*Variables have missing data for some patients
Page 39
Early Process Outcomes:
8 Weeks Pre- and 20-Weeks Post-Training
100%
88%
80%
88%
94%
74%
60%
45%
40%
20%
0%
0%
Both Baseline and Current Katz
Completed
NUDESC Completed
Pre-Intervention
Post-Intervention (wks 1-4)
Post-Intervention (Katz - wks 5-12; NUDESC wks 5-20)
Page 40
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=.278
Pre vs Post Current Katz 7.0 ± 5.1 vs 7.3 ± 4.3, p=.831
Page 41
2014 Ortho Unit Fall Rate for ≥ 65 years of age
Virtual ACE Safe
Mobility Training
Page 42
39% Relative Reduction in Delirium
Prevalence
Pre-Training: 38 NUDESC Screens in 31 patients
Post-Training: 62 NUDESC Screens in 68 patients
Page 43
2014 Ortho Unit Restraint Usage
Virtual ACE
Delirium Training
Page 44
Potential Cost Savings from Delirium Prevention
UAB Hospital Discharged 19,880
patients age ≥ 65 in FY 13
Reducing
Delirium from
18% to 11%
Reduces
delirium cases
from
3,578 to 2,187
+ $2,500*
cost/patient
$3,477,500
saved
JUST from
delirium
aspect of
their care
*Rubin JAGS 2006
Page 45
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
Page 46
QUESTIONS?
UAB Hospital
1,156 beds of complex population management
Page 47