“Prehab” gives Edmonton geriatric team an ACE up its sleeve

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While Edmonton’s Capital Health region is expecting its population to grow by about 30 per cent over the next 15 years, the region expects the population over age 65 to expand by as much as 79 per cent in the same time frame. That statistic alone highlights the importance of planning to address the complex challenges of serving an aging population.

The geriatric care team at the Royal Alexandra Hospital (RAH) has launched a new initiative that forms part of that planning. ACE – Acute Care for the Elderly – is a program designed to intervene early in the patient’s care path to reduce readmission, shorten length of stay, reduce dependence on complex combinations of drugs, and maximize independence and quality of life after discharge from hospital.

“We’ve known for a long time that early intervention after an injury or illness will contribute to a speedier recovery,” explains Dr. Kathy Lechelt, RAH Site Leader for Geriatrics. “We target patients over 65 years of age with an acute illness, two or more additional pre-existing medical conditions, and/or delirium.”

The team doesn’t wait for functional decline to appear. This quick intervention, known as ‘Prehab’, helps pre-empt deconditioning, the major risk facing seniors who are hospitalized or in long-term care.

ACE was modeled on an approach used in the US and introduced at RAH in 1995, to help deal with steadily rising acuity. The secret to the program’s success is two-fold: a dedicated multi-disciplinary team, and strict screening criteria developed by the team to target the highest-risk seniors most likely to benefit from early intervention.

“We screen over 200 patients every month for our 30-bed unit,” says Kathleen Hunter, an ACE Nurse Practitioner. “The screening process is critical. A personal interview can pick up subtle psychosocial and acute functional factors that can be missed by the usual medical model. When you can listen to the patient and see their medications, you can pinpoint the problems and target your interventions more effectively.” The criteria have been reviewed and refined over the years, improving screening results for appropriate patients from 50 per cent to 80 per cent success.

“Beyond physician care, our multidisciplinary team offers assessment services which consist of nursing, rehabilitation, dietary, social work and pharmacy,” says Dr. Lechelt. “This team approach helps us deliver coordinated communication throughout the patient’s stay, which is the key to caring for patients with complex problems. Focusing on only one set of problems at a time, an individual professional can sometimes miss issues that will bring the patient back.”

“Another feature of working with a dedicated staff is our ability to provide enhanced training and support specifically for the needs of the frail elderly patient,” explains Donne Wulf, ACE Senior Therapist. “By focusing on areas like delirium, dementia, falls, restraints, and medication management, we can build a truly dynamic, pro-senior environment.”

The unit is involved in many initiatives to improve senior care, including a falls-prevention protocol and the only self-medication program for select patients in the hospital’s Medicine program. This assures staff that patients know how to manage their medications once discharged.

The program has achieved outstanding results, returning more than 40% of frail elderly patients to their homes. In the future, the team wants to champion ACE as a model for the region as a whole. “We want to integrate the ACE approach into all medical units, to provide early intervention to all patients who can benefit at the point of admission,” Dr. Lechelt explains.

As well, the team wants to ensure that seniors presenting in Emergency but not admitted are assessed, for interventions aimed at avoiding future problems. This will include working with the region’s own community health programs and other care providers to ensure seniors’ needs are being met in the community. These are the issues ahead for a team committed to finding the best possible answers for seniors. It’s a big job, but one this team takes on with boundless enthusiasm.