Acute Care for Elders- Improving the Quality and Safety of Older Hospitalized Patients

Transcription

1 Acute Care for Elders- Improving the Quality and Safety of Older Hospitalized Patients Michael L. Malone, M.D. Aurora Health Care University of Wisconsin School of Medicine and Public Health January 14, 2012

2 Aurora at a Glance State s largest health care provider State s largest private employer with 30,000 employees State s largest provider of Medicaid Serving 31 counties, 90 communities 15 hospitals, 155 clinics More than 1,650 employed physicians State s largest homecare provider Nearly 100 pharmacies $4.3 billion in annual revenue 11 employed geriatricians, 5 in the community. 7 geriatrics nurse practicioners. One electronic medical record.

3 Hospitalized Medicare patients Aged >=65 years at Aurora Health Care in 2010: 34,309 hospital discharges. 223,496 hospital days, 4.7 mean length of stay. $354 million in reimbursements. Percent of all hospital admissions made up of older Medicare patients: 33% Percent of total hospital days made up by Medicare patients: 41%. 9,819 total Medicare observation patients. Jackie Gisch, Aurora Health Care, October 15,2011

4 JAGS 56(10): , October 2008

5 Characteristics that lead Aurora Health Care to adopt ACE: Comparison to the current practice. The innovation fit with our need and values. The model was not too complex to adopt. The model could be tested before broad implementation. Others had successfully adopted the innovation. IOM (Institute of Medicine) Retooling for an aging America: Building the health care workforce. Washington DC: The National Academy Press

6 ommon Problems of Hospitalized Older Persons: Unrecognized depression/ dementia. Delirium. Poly-pharmacy. Adverse drug events. Low mobility & functional decline. Pressure sores. Loss of independence. Falls. Infections that develop in the hospital. Restraint use. Multiple order sets. Lack of clear goals. An environment of care that is not seniorsfriendly. A focus only on the diseases. Boredom/ helplessness/ Poor communication loneliness among multiple providers. J Am Geriatr Soc 48: , 2000.

7 Rate of Adverse Events in Hospitals: 1 in 7 (13.8%). Department of Health and Human Services November, % of those who had an adverse event had a cascade of multiple related events in succession.

8 Hospital Care of Older Adults: Wisconsin U.S. Total Older Medicare Beneficiaries (2009) 756,400 36,672,200 % Medicare Spending Devoted to Hospital Care (2009) 51.0% 46.8% Total # of Hospital Discharges (2009) 185,380 11,508,690 Discharges Per 1,000 Part A Enrollees Total Days of Hospital Care (2009) 922,460 63,087,500 Total Days of Care Per 1,000 Part A Enrollees 1,429 1,834 Medicare 30-day Readmit Rate ( )* 17.0% 19.6% Total Number of SNF Covered Admissions Used by Medicare Beneficiaries (2009) 49,603 2,507,355 Total Number of SNF Covered Days (Thousands) 1,361 68,346 Medicare Spending Per Enrollee (2009) $8,908 $10,365 Kaiser Family Foundation statehealthfacts.org KFF Compare Medicare Data *Jencks SF et al. NEJM 2009, 360:

9 Acute Care for Elders Functional Older Person Acute Illness, Possible Impairment Hospitalization Depressed Mood Negative Expectations ACE Unit Prehab Program Interventions: Prepared environment with standard equipment for seniors Patient-centered, interdisciplinary care Multi-dimensional assessment and non-pharmacologic prescription Home planning/informal network Medical care review. Improved Mood Positive Expectations Reduced Impairment Functional Older Person Decreased Iatrogenic Risk Factors ACE Acute Care for Elders

10 Acute Care for Elders Functional Older Person Acute Illness, Possible Impairment Hospitalization Depressed Mood Negative Expectations ACE Programs Prehab Program Interventions: Prepared environment with standard equipment for seniors Patient-centered, interdisciplinary care Multi-dimensional assessment and non-pharmacologic prescription Home planning/informal network Medical review using real-time information technology tools Improved Mood Positive Expectations Reduced Impairment Functional Older Person Decreased Iatrogenic Risk Factors ACE Acute Care for Elders

11 Best Care for Hospitalized Seniors: Simplified Care for the Patient Implementation of high quality, simple care Best practices partially applied Rapid adopter of best practices / services Leading edge health care Best care everywhere Rapid implementation of different care delivery models Simple & easy to use Smooth transitions coordinated care Complex, fragmented episodic care experience All patients, same care, same way Different services for different needs/groups Care designed around patient needs Designing different care delivery models facilitates simplified care based on patient needs and characteristics Rapid Adopter Designed for You

12 ACE Tracker ACE Tracker software to identify vulnerable elders: Malone ML, Vollbrecht M, Stephenson J, et al, J Amer Geriatr Soc 2010: 58: Used to disseminate the ACE unit model broadly. Harvests real-time information from the older patients electronic medical record. Provides a computer-generated checklist of key indicators of risk for hospitalized older patients. Does not require a new activity of the nurse or pharmacists. Is available at all med-surg units of all Aurora hospitals.

13 ACE Tracker software to identify vulnerable elders: Malone ML, Vollbrecht M, Stephenson J, et al, J Amer Geriatr Soc 2010: 58:

14 Using Health Information Technology to Identify Vulnerable Older Patients

15 Comparison of Processes and Outcomes Before and After Institution of ACE Tracker at a Remote Hospital 6 Months Before (%) n = Months After (%) n = 406 P-Value Urinary Catheter * 125/478 (26.2) 81/403 (20.1) Physical Therapy * 129/478 (27.0) 156/399 (39.1) <0.001 Restraints * 3/478 (0.6) 3/396 (0.8) 1 High Risk Meds * 21/478 (4.4) 16/399 (4.0) Social Work Evaluation * 411/478 (86.0) 332/399 (83.2) Length of Stay (mean + SD) 3.7 +/ / Day Readmission 80/471 (14.5) 59/406 (12.7) * These processes were utilized on day two of hospitalization.

16 ACE Tracker disseminated to all hospitalized older patients. Gonzolez,Geni

17 Current Status of Acute Care for Elders: Aspirus Health Care Aurora Health Care geriatricians ACE units at two hospitals in Milwaukee. Acute Care for Elders programs at 13 of 15 medical centers. Total of 44 medical surgical units within Aurora (two at Wausau Aspirus Hospital) practicing Acute Care for Elders model. e-geriatricians join interdisciplinary teams for scheduled teleconferences at 9 remote/ rural sites (2 more in January,2012). ACE Tracker software integrates the model of care into the system-wide electronic health record. NICHE model in 4 hospitals, 3 SNF s, homecare, and clinic. ACE Consult Programs at three hospitals. ACE Cards & Palliative Care Pocket Cards help to educate the staff. Annual education conference. ACE and NICHE app for iphone and Smart phones.

18 Outcomes for ACE unit & Older Medicare Patients : Total number of discharges per year and total reimbursement. Percent of all hospital discharges per year. Total observation patients per year and reimbursement. Total hospital days and average length of stay. Total costs. 30-day re-hospitalization rate for older patients. Process outcomes. Rate of new SNF placement. Rate of homecare referral. Patient satisfaction for those age >=65. Rate of in-hospital falls with injury, new pressure ulcers, and CAUTI.

19 Acute Care for Elders at 12 Aurora Health Care Hospitals: Automated clinical quality measures on the second hospital day for 15,337 patients age >=65 years.

20 Administrative data for quality improvement purposes. Comparisons of Processes of Care During and After the Institution of ACE Tracker and e-geriatrician at 14 Aurora Health Care Hospitals P e r c e n t Physical Therapy evaluation by day 2 Social Service evaluation by day 2 An estimated 2400 fewer urinary catheters per year. Urinary Catheter on day 2 30,707 patients Oct, 2007-Sept, ,996 patients in ,317 patients in 2011

21 Hospital Acquired Conditions: Aurora Health Care 2009: Aurora Health Care 2010: Aurora St. Luke s Medical Center 2009: Aurora St. Luke s Medical Center 2010: CAUTI (Catheter Associated Urinary Tract Infections) Falls in the Hospital Pressure Ulcers that develop in the hospital Jackie Gisch, Aurora Health Care, October 15, 2011

22 Lessons Learned: ACE provides a strategy to assess and improve patient safety for hospitalized older patients. Measure outcomes both at the ACE unit level and at the hospital level. Provide a regular ACE advisory team to monitor and address the outcomes. Use the electronic medical record to provide realtime monitoring of patients at risk for poor outcomes.

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24 Michael L. Malone,M.D., Aurora Health Care, Decision support Address the unique needs of acutely ill older persons.