nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

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1 EFFECTIVENESS OF AN INTERDISCIPLINARY MOBILE ACE TEAM IN REDUCING LENGTH OF STAY AND HOSPITAL READMISSION RATES Nicole Caldwell, MSN, APRN, BC, NP-C Julie Campbell, MSN, APRN, BC, CNS APRIL 2016 OBJECTIVES 1.) Differentiate between the ACE Unit and Mobile ACE Team models. 2.) List examples of reportable data that can be used to support the MACE Team in its endeavors. 3.) Describe the challenges in both starting and expanding the MACE Team. nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

2 THE CHRIST HOSPITAL Acute Care Hospital in Cincinnati, Ohio 555 bed facility Clinical Services Surgery Women s Health Cardiovascular Comprehensive medicine and primary care 4 admitting services: -Geriatric Hospitalists -IM Hospitalists -UC Family Medicine -Critical Care Service Oncology Emergency Services Orthopedics/Spine Psychiatry Palliative Care WHAT W E KNOW Growing population of older adults More complex/ill patients Few nurses/aprns certified in geriatrics Shortage of geriatricians CMS and private payers have placed increased pressure on health care systems to show value in the care we deliver to their populations THE INTERDISCIPLINARY TEAM Why do interdisciplinary teams work?» Point of contact collaboration» Specialized medicine role blurring» Improved communication nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 2

3 ACE / MACE / PALLIATIVE CARE AT THE CHRIST HOSPITAL ACE Unit MACE Team Palliative Care Team ACE/ MACE / PALLIATIVE CARE, CONT D Population ACE Unit MACE Team Palliative Care Communitydwelling vulnerable older adult Often longterm care fragile older adult Any with serious illness Floor 10-bed unit Any Any Attending Any Geriatrician Any Approach Unit design, focus on physical, cognitive activity, early d/c planning, daily IDT rounds 3-pronged: Geriatric syndromes, goals of care, early d/c planning & care coordination Goals of care, psychosocial and spiritual support, symptom management Nursing involvement Crucial Crucial Crucial M-ACE / ACE PROGRAMS IN OTHER SYSTEMS No standard definition: Mt. Sinai M-ACE Team Geriatrician, APRN, fellow, nurse coordinator directly attend the patients who are otherwise followed by OP practice University of Wisconsin ACE Consult Program Geriatrician, APRN, pharmacist, SW, PT provide geriatric consults throughout the hospital University of Colorado Hospital ACE Service Staffed by team of physician, 2 nd year IM resident, and intern Eskanazi Health ACE Unit physical unit staffed by IDT nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 3

4 THE 3-PRONGED MACE APPROACH 1.) Surveillance and recommendations for the geriatric syndromes: a.) Delirium b.) Dementia c.) Depression d.) Malnutrition e.) Bowel / bladder issues f.) Insomnia g.) Pain h.) Deconditioning/falls i.) Pressure ulcers j.) Caregiver stress THE 3-PRONGED MACE APPROACH, CONT D 2.) Assessment and alignment of goals of care Treating frail elderly takes time and resources:» When a life-threatening or life-changing illness occurs, helping patients/surrogates weigh benefits and burdens of treatment options is an ongoing process.» Ability to prognosticate and explore with patient and surrogates what life will be like following hospitalization often requires developing a rapport with patient and surrogates.» Determining and procuring a legal decisionmaking process can be complicated and require an interdisciplinary approach. THE 3-PRONGED MACE APPROACH, CONT D 3.) Discharge planning starting on admission Based on these premises: Hospital may be hostile Every unnecessary day = increased exposure to nosocomial complications Early discussions regarding expectations, including disposition, with patients and surrogates improve the chance for better outcomes and patient/ family satisfaction. Dedicated SW is imperative to team success. Care coordination! nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 4

5 ROLES OF THE TEAM MEMBERS Advance Practice Registered Nurse: Responsible for majority of geriatric assessment, obtaining collateral information, goals of care conversation, education, documentation, nursing education/support Advising Physician: Responsible for more challenging care coordination (amongst other MDs), attending/assisting in family meetings when additional MD input necessary, medical input Licensed Social Worker: Responsible for initial home assessment and contact with NOK or decision-makers for collateral information, initiation of d/c planning, higher level discussion about advance directives, documentation, patient and family education, care coordination Bedside Nurse: Responsible for hour-by-hour care, reporting changes, creating a calm/healing environment, educating families, and providing collateral information AN AVERAGE DAY Screen for / accept patients One year demonstration project 6-10 patients on average Depending on existing caseload, maximum of two new consults for any given clinician MACE IDT Rounds every morning Monday-Friday Follow up visits, new consult visits, family meetings RESULTS Metric Baseline FY 14 Results FY 15 Target Length of stay (LOS) 6.1 days 4.7 days 5.7 days Readmission rate 13.8% 7.6% 13.52% Advance Care Planning discussions New initiative 60% 66% Consults New initiative LOS Savings New initiative $491,780 $450,000 nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 5

6 ADDITIONAL FINDINGS Delirium Dementia Depression Percentage of patients FY 15 34% 39% 22% Advance Care Planning Family Meeting Percentage of patients FY 15 71% 24% HOW DID YOU DO IT? Getting started 1.) Administrative (financial, executive) AND physician backing 2.) Gain physician buy-in 3.) Determine staff needs / hire appropriate personnel 4.) Train staff (MOLST, GeriTalk, 1:1 with geriatrician) 5.) IT documentation/note template creation to maximize efficiency 6.) Determine work flow 7.) Billing/coding if applicable 8.) Educate the hospital CHALLENGES Gaining support to start your own MACE Team Revenue-sparing service Non-billable Support services challenges Working with nursing staff throughout entire hospital Confusion between 3 services nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 6

7 CHALLENGES, CONT D Physician challenges Individual physicians have their own way of doing things must approach as another customer of the service Growing pain With success, challenge is expanding the service to other parts of the hospital WITHOUT compromising the quality of the consult NEXT STEPS Expanding our reach Delegation to these services:» Pharmacist: Responsible for geriatric appropriate recommendations, med reconciliation both at admission and discharge, assessment of understanding of meds, education» Dedicated PT/OT: Lower caseload to allow for therapists to contact family or facility for collateral information, attend family meetings re: disposition» Protected MACE MD time: To allow MD to see patients as well Expanding our service ICU callout patients and geriatric outliers NEXT STEPS, CONT D Hold nursing workshop Via grant, MACE, ACE, and outpatient geriatric assessment center clinicians to attend NCCDP training which will allow us to offer hospitalwide education and certification in dementia care EPIC Enhancements Automatic screening / Best Practice Alert MACE D/C recommendations added to a shared discharge summary Connecting the hospital to the post-acute care network PCP and office nurses, case managers pick up the ball to keep it rolling nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 7

8 MACE IN ACTION Patient L.R., 77 yr old female PMH: SHF EF 35%, cholecystitis s/p cholecystostomy tube placement, obesity, OSA w/ poor recent poor tolerance cpap 2/2 anxiety, dermatomyositis on chronic low-dose steroids, hx PE, HTN, severe TR. Presented for CHF- 4 th admit to us in 2 months, had 2 others to OSH Patient/family had been refusing SNF despite therapy recommendations for the same on past admissions Family highly anxious, accusatory concerned no one talking Patient depressed, anxious, not sleeping, anorexic, c/o memory problems, on multiple meds After MACE interventions - patient had no further readmissions and ultimately learned that several months later the patient/family enrolled with hospice care. REFERENCES Butterfield, S. (2011). ACE in geriatric care. ACP Hospitalist, Eskenazi Health. Acute Care for the Elders (ACE). Retrieved from Hall, P. & Weaver, L. (2001). Interdisciplinary education and teamwork: A long and winding road. Medical Education(35), Labella, A. M., Merel, S. E., Phelan, E. A. (2011). Ten ways to improve the care of the elderly patients in the hospital. Journal of Hospital Medicine(6), Mount Sinai Hospital. (2016). Mobile Acute Care for the Elderly. Retrieved from aging/areas-of-care/mobile-acutecare-for-the-elderly The American Geriatrics Society. (2013, March).The demand for geriatric care and the evident shortage of geriatrics healthcare providers. Retrieved from care.pdf University of Colorado Anschutz Medical Campus. Acute Care for the Elderly. Retrieved from linicalcare/hospitalmedicine/qualitycare/pages/acute-care-for-the-elderly-(ace).aspx University of Wisconsin Health. Acute Care for Elders (ACE). Retrieved from nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 8