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Mount Sinai Hospital's Acute Care for Elders (ACE) Strategy Improves Outcomes & Reduces Costs

Rationale / Objectives

As the Canadian population ages, the ability to provide consistent and effective medical care for older adults becomes increasingly necessary. Since many older adults have a complicated medical profile of inter-related chronic and acute conditions, the need for more effective and collaborative care is critical. Over the past six years, Mount Sinai Hospital has become Canada’s most elder-friendly hospital due to its Acute Care for Elders (ACE) strategy. This strategy integrates various hospital departments together to care for hospitalized and at-risk for hospitalization older adults. Mount Sinai’s integrated care strategy allows various healthcare providers to work together to provide a system of coordinated care for this population. Other organizations are also focused on addressing the needs of the older adult population (see a relevant case study of a geratric emergency medicine model here) and developing senior-friendly emergency rooms and associated guidelines.

Project/Program Description & Major Achievements

Mount Sinai developed interventions in key areas to successfully improve the health of older adults. With this strategy, Mount Sinai implemented a variety of evidence based, currently in-use models and modified them to allow the organization to collaboratively treat older adults. By making small changes across the organization including clustering frail seniors on one ward, handing out no-slip socks, lowering beds to decrease falls and empowering geriatric-emergency-management nurses at the front door of the hospital – Mount Sinai has managed to discharge more patients over the age of 65 home more quickly, slashing the cost of care per patient by 23%. These interventions were implemented in three main areas: the emergency department, inpatient care at the hospital, and when transitioning from the hospital to home care. Improvements in a number of metrics were observed including length of stay, alternate level of care days, patient satisfaction, readmission rates, pressure ulcers and catheterization rates. The ACE strategy saved the hospital $6.7-million in 2014.

Lessons Learned

Three main challenges presented themselves in implementation of the ACE strategy. Changing the way of thinking of care was required, educating front-line workers was important and ensuring consistency of care across all levels was necessary for effectivenesss of this model. 

People / Organizations Involved

Further Description

Mount Sinai hospital is the first hospital in Canada to achieve the international MAGNET Recognition for Nursing Excellence and Patient Care with the ACE Strategy. Magnet hospitals report greater patient satisfaction, higher rates of nurse retention and better patient outcomes, including reduced mortality, lower rates of falls and reduced rates of pressure ulcers. The various aspects of the ACE strategy include emergency department components, inpatient care components, and transitional community-based care components.

The Emergency department care components include three interventions. A screening tool called the Identification of Seniors at Risk (ISAR) High-Risk Screening System is used. Additionally, the hospital employs Geriatric Emergency Management (GEM) nurses who specialize in treating frail older patients. There is also specialized training on geriatric issues called GERI-EM provided to all healthcare providers.

In the inpatient department, a specialized ACE unit was created (consisting of 11 existing beds on the same floor) was set up for high-risk medical patients along with an Integrated Orthogeriatrics Service hip fracture service. Resources to establish a patient-centred approach are used, these include an hourly nurse rounding model, the Hospital Elder Life Program (HELP), and Inpatient Behavioural Management Strategies to Promote Patient and Staff Safety. The use of the ACE tracker which is a checklist that is used to flag areas of concern is also a key element. Education is also provided to staff on reducing catheter use. Patients on the unit were also encouraged to walk around the unit and to socialize with one another and sit at a table for meals.

Transitional community-based care components include the assignment of a coach during discharge who assists patients to follow relevant instructions. Home visits by providers are also utlilized. Nurse-led outreach to long-term care homes and intensive care mangement are additional resources that are used. 

Major Achievements

The ACE strategy has been effective in a number of areas. Patient satisfaction from the period of 2009-2010 to 2012-2014 increased from 95% to 97%. Additionally, the table below highlights a number of additional achievements. Notably hospital admissions increased by 37%, however, the effectiveness of the strategy is evident in the associated cost-savings of $6.7 million in 2014 as a result of the interventions. In terms of spread, 17 hospitals and health-care organizations in Canada and one in Iceland are beginning to implement Mount Sinai’s ACE approach. They are part of a “care collaborative” jointly led by the Canadian Frailty Network and the Canadian Foundation for Healthcare Improvement (CFHI)

Measure (Age 65+)

F2009/10

F2013/14

Patient Volumes

1573

2155

Length of Stay

11.5

8.25 (-28%)

ALOS/ELOS Ratio 

95.6%

72.8 (-24%)

% Return Home At Discharge

71.1%

79.1%

Average ALC Days Per Patient 

2.0

1.6 (-20%)

Medicine Bed Counts

88

80

Readmission W/N 30 Days

14.8%

12.8%

Catheter Utilization Ratio

56%

14.7%

Pressure Ulcer Incidence

 

down 93%

Patient Satisfaction

95.4%

96.9%