Guest Columns

ACE (Acute Care For Elders): Integrating acute, post-acute and LTC

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James Lomastro
James Lomastro

There are many challenges to integrating acute, post-acute and long-term levels of care around elders. In many ways when an elder admits to an acute care facility the facility often assigned them by their condition – orthopedic, neurological or general to floors except if they are children and then they admit to a specialized unit.  

Often, nurses and physicians assigned were not trained in the addressing issues related to the elderly. Some provide geriatric consultation if the elder presented a challenge (usually behavioral) to the staff. Some elders developed complications as a result of their stay in the acute units and declined, and many need to recover from their experience to return to their baseline or normal functioning.

Over the last 20 years, there is a movement to assign elders to units that specifically address their need. The units arose from the practitioner concerns that they were not addressing the needs of their patients. A substantial part of this effort stemmed from an organization titled NICHE – Nurses Improving Care for Health system Elders.

Initially, this was a program for improving how nurses improve the healthcare system for elder and gradually morphs to a program rather than practice perspective. While they aim their program at acute care, it adds value to post-acute and long-term support and services and care by addressing issues and concerns either before they occur or in their early stages of development. It arose from the recognition that the care was not only harming the needs of the elderly but also that it was resulting in identified and negative outcomes.

The structure and orientation are familiar to those involved in especially in accredited rehabilitation programming – person-centered care, interdisciplinary team and a focus on outcome and performance improvement. It also focuses on the patient experience with finding that positive patient experiences have favorable outcomes. They saw that they raised the scores on satisfaction scales– one of the primary tool to evaluate acute care performance.

Their structure in some ways resembles hospital-based skilled nursing units that developed in the 1990s and were phased out because of financial concerns. They also resemble less intensive rehabilitation units with medical coverage provided by geriatric physicians as primary with consultations from physiatrists. I became acquainted with these units some years ago while surveying a hospital-based rehabilitation unit in California.  The unit handled primarily elderly persons; they indicated that they had a close relationship with an ACE units in the hospital sharing staff; protocols and transferring patients from the ACE unit to the rehabilitation unit since they could participate in intensive therapy. A study in 2012 indicated that these units had fewer functional declines, a decrease in dementia, less falls, fewer restraints and for hospitals less cost. There is a good deal of antidotal information on their effectiveness.

So if they are effective, what is the reason that there are not many more? In many ways, it is as we continue to deal in two mindsets – one acute (short-term) and one long-term. At the same time, the person served is the same – elder. ACE units will appear to be an area in which both connect. 

When the hospital-based skilled units were operating, some synergies and understanding were occurring. It is both complicated and straightforward. Much of the program is routine and involves communication, planning and performing well and consistently simple processes on a daily basis. It becomes complicated when the acute realizes that the processes that work for most adults do not necessarily work for elders. Elders need more attention and care, and those needs do not become address because they are not critical and short term. While the care is less critical, much of the care demands consistent intervention and continual care over an extended time frame. It also involves an understanding of the recovery post-acute process and the importance of the handoff that occurs when discharging the elder.

The ACE unit may well represent a conduit for integrating long-term and acute care since they serve the same persons. It may provide those skilled facilities and LTSS not only with access to elders while in acute but also may assist the ACE unit is addressing issues and problems that long-term has particular expertise in addressing. It may also necessitate that we examine current programs such as LTACs and acute rehabilitation units and the role each plays as we move toward care that follows the person.

James Lomastro, Ph.D., has worked in a variety of acute, community-based and long-term care in healthcare for 35 years. He has held an administrator license since 1991. Before involvement in administration, he held academic and research appointments at Boston University School of Medicine and Northeastern University.

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