Rethinking the traditional hospital model for elder care

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While older adults currently represent 14.6 per cent of Ontario’s population, they account for over one-third of the province’s acute care hospitalizations and 60 per cent of its hospital days. This is largely because older adults, more often that other patients, experience inter-related chronic and acute health and social issues and require more complex types of health services, particularly in acute care settings. With Canada’s older population expected to double in the next 20 years, the imperative is clear, acute care hospitals need to transform how they resource, organize, and deliver care for older adults.

Over the past few years, our team at Mount Sinai has seen significantly improved outcomes for older patients as a result of rethinking existing care models and integrating new approaches in every clinical area of the hospital. In 2010 we launched an Acute Care for Elders (ACE) Strategy, aimed to improve the quality of life and care for older patients during the acute phase of their illness and after they leave the hospital. Now three and half years later, as the first acute care hospital in Canada to make geriatrics a core priority, our ACE strategy has garnered national attention for delivering dramatically better results. I am particularly pleased to be working with a number of hospitals across the country, and as far away as China, to help replicate elements of our ACE Strategy. It is great to see how new ideas in health care practices can spread and strengthen the entire system.

ACE: Better care, less time and money

Since 2009/10 Mount Sinai has seen a 32 per cent increase in the number of patients 65 years of age and older it serves annually. However, despite this increase in older patient volumes, Mount Sinai’s ACE strategy has also allowed the hospital to reduce its average total lengths of stay per patient by 28 per cent and decrease its ALC days by 18 per cent. Our older patients are now more likely to go directly home from the hospital instead of nursing homes, and are less likely to be readmitted. Older patients are also more satisfied with our care. Indeed, through integrating geriatric care principles into every area of the hospital, the hospital is now delivering clearly better patient and system outcomes.

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What has been most impressive, were the minimal financial investments required to support this transformative model. Instead it required a different approach to the way we work. Indeed, the ACE strategy has reduced our overall care costs for the older patents we serve by more than $6.4 million in 2012/2013 alone.

ACE: How it works

The ACE Strategy at Mount Sinai ensures caring for older patients is maximized with an inter-professional, team-based approach, no matter where the patients are cared for. This helps ensure every aspect of their care gets addressed accurately and efficiently in the emergency, inpatient, outpatient and home-based settings. Much of this collaborative work has been facilitated through the development of innovative IT communication tools, and the implementation of screening and ‘geriatricized’ care protocols that promote mobility, and the use of the most appropriate medications in older patients.

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Under the ACE strategy, Mount Sinai has implemented a series of other evidence-informed tailored interventions to create a seamless continuum of care throughout the hospital. Here are some examples:

• All patients 65 and older presenting to our Emergency Department are screened first for geriatric issues so their treatment plan can be tailored accordingly with the support of a Geriatric Emergency Management (GEM) Nurse when needed.  Mount Sinai now has the largest GEM Nursing Program in Ontario that operates seven days a week and helps more patients get home with the appropriate ongoing community and outpatient supports.

• As the latest ACE Strategy model to be recognized by Accreditation Canada as a Leading Practice, the hospital’s Ben and Hilda Katz ACE Unit, offers hospitalized frail elders care that is tailored specifically to their unique needs in an environment specifically designed to support frail older adults. Patients admitted to this unit are seen by all members of the inter-professional team and are encouraged to be more active and independent during their hospital stay, for example, by walking to the bathroom instead of using a commode chair and staying out of bed most of the day including during their meal times.

• Hip fractures can be devastating for older adults. Therefore, a first-of-its kind Orthogeriatrics Hip Fracture Service at Mount Sinai brings together an integrated team of orthopaedic surgeons, geriatricians and hospitalists to comprehensively treat older patients with hip fractures, and to better avoid common complications like delirium and institutionalization.

• We know that older adults may need extra support during hospitals stays, which is why a unique program called Maximizing Ageing Using Volunteer Engagement (MAUVE) was developed to train volunteers to offer an extra layer of emotional and functional support to hospitalized older adults. This program has also been named a Leading Practice by Accreditation Canada with other hospitals now following our lead as they implement similar programs.

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ACE: Helping elders return to the community

Recognizing that our patients not only come from the community, but that when they leave the hospital they often need support to remain active and independent, Mount Sinai’s ACE Strategy embraces strong and meaningful collaborations with community care organizations like the Toronto Central Community Care Access Centre (TC-CCAC) and the SPRINT Senior Care Community Support Services Agency. Mount Sinai has also partnered with a unique program called House Calls that brings primary and specialty care directly into the homes of older housebound patients allowing even nursing home eligible patients to have the opportunity to age in the place of their choice, which is at the heart of what ACE is all about.

Indeed, Mount Sinai has much to be proud of but what is exciting is that its clinicians are looking to continually build on what it learns and achieves to ensure living longer and living well remains something we can all achieve together.