Acute Care Models   35  

Elizabeth Capezuti, Ana Julia Parks, Marie Boltz, Michael L. Malone, and Robert M. Palmer

OVERVIEW

Advances in geriatric science, coupled with the increasing older adult patient population, have led to the development of several geriatric models of care across all health care settings. Acute care models addressing the unique needs of older hospitalized patients began with the comprehensive geriatric assessment (CGA) programs first developed in the 1970s (Palmer, 2014).

Geriatric acute care models aim to facilitate improved overall outcomes by promoting a rehabilitative approach while preventing adverse events that occur more commonly in older patients. Also known as geriatric syndromes, these are clinical conditions in older persons that do not fit into discrete disease categories (Palmer, 2014) and include functional decline, pressure ulcers, fall-related injury, undernutrition or malnutrition, urinary tract infection, and delirium (see Part III: Clinical Interventions). These syndromes or complications contribute to prolonged hospital stays as well as increased likelihood for rehospitalization, institutionalization, emergency department (ED) usage, and postacute rehabilitation therapy services. These complications rarely occur alone; the interrelationships among these various syndromes during hospitalization are well documented (Flood, Booth, Danto-Nocton, Kresevic, & Palmer, 2015; Inouye, Studenski, Tinetti, & Kuchel, 2007; Palmer, 2014).

Acute care models attend to the age-specific vulnerabilities (i.e., frailty, comorbidities, and cognitive impairment) of older hospitalized patients. These models also address the role of institutional factors that determine staff practices and the physical environment that can contribute to iatrogenic complications. Thus, the overall goals of acute geriatric models of care are (a) prevention of complications that occur more commonly in older adults and (b) address hospital factors that contribute to complications (Capezuti, Boltz, & Kim, 2011). This chapter provides an overview of care delivery issues that are addressed by acute models of care for older adults and a description of the most commonly employed hospital models.

OBJECTIVES OF GERIATRIC ACUTE CARE MODELS

There are several geriatric acute care models, each with its own approach to prevent complications and address institutional/staff practices that can contribute to complications. All of these models, however, share a common set of general objectives (Hickman, Newton, Halcomb, Chang, & Davidson, 2007; Hickman, Rolley, & Davidson, 2010). The six general objectives of geriatric acute care models are discussed herein.

Educate Health Care Providers in Core Geriatric Principles

Many health care providers have not received the core geriatric care principles, such as recognition of age-specific factors that increase the risk of complications, in their basic or continuing education (Berman et al., 2005; Wald, Huddleston, & Kramer, 2006). All acute care models require a coordinator with advanced geriatric education; however, successful implementation depends on direct-care staff with the knowledge and competencies to deliver evidence-based care to older patients. Thus, the coordinator or a clinician with geriatric specialization will facilitate staff learning via individual patient consultation, in-service group education, unit rounds, journal clubs, web-based discussion groups, conferences, and other internal institutional educational venues (Fletcher, Hawkes, Williams-Rosenthal, Mariscal, & Cox, 2007; Smyth, Dubin, Restrepo, Nueva-Espana, & Capezuti, 2001).

Target Risk Factors for Complications

The ideal method to prevent complications is timely screening of potential geriatric syndromes, early identification, and subsequent reduction of risk factors. Some of the models focus on a particular syndrome; however, because of the interrelationship of shared risk factors, reduction of one complication will affect the prevention of other geriatric syndromes. Standardized assessment tools are recommended to properly identify individuals who are at an increased risk of geriatric syndromes. The Portal of Geriatrics Online Education (www.pogoe.org) and the Hartford Institute for Geriatric Nursing websites provide assessment instruments (www.hartfordign.org). At the institutional level, incorporating these risk-assessment tools into the workflow of everyday practice requires hospital policies, procedures, and protocols that will promote usage such as embedding these tools within the electronic health record.

Incorporate Patient or Family Choices and Treatment Goals

Informed patient’s choices are essential whether they are decisions about activity level and medication use to more complex issues such as advance directives.

Family members of patients who can no longer participate in decision making must often deal with the complicated balance between quality-of-life considerations and potential length of life. The decision to employ life-sustaining treatments consistent with patients’ preferences is often only considered when the patient is hospitalized (Somogyi-Zalud, Zhong, Hamel, & Lynn, 2002). For this reason, many geriatric models work collaboratively or in conjunction with palliative care programs (see Chapter 37, “Palliative Care Models”).

Employ Evidence-Based Interventions

The high proportion of complications in older hospitalized patients is partly attributed to the lack of evidence-based geriatric care practices. There is tremendous variability in the adoption of geriatric protocols (Neuman, Speck, Karlawish, Schwartz, & Shea, 2010). Issues with overuse or inappropriate medications (e.g., overuse of psychoactive drugs), unnecessary restraints, inadequate detection of cognitive or affective changes (e.g., delirium and depression), and poor pain control are examples of hospital factors that can lead to adverse outcomes. Thus, geriatric acute care models promote the use of standardized evidence-based protocols described in this book.

Promote Interprofessional Communication

The management of geriatric syndromes is not limited to medical intervention but requires other disciplines, such as nursing, pharmacy, social work, and physical and occupational therapy, to address the complex interaction of medical, functional, psychological, and social issues leading to these complications. Communication of the various disciplines’ input, facilitated by geriatric care models, is essential.

Emphasize Proactive Discharge Planning

Older hospitalized patients are more likely to experience delays in discharge, greater emergency service use, hospital readmission, and rehabilitation in an institution or at home (Coleman, Min, Chomiak, & Kramer, 2004). Hospital readmission for older patients is most likely associated with medical errors in medication continuity (Coleman, Smith, Raha, & Min, 2005; Foust, Naylor, Boling, & Cappuzzo, 2005), diagnostic workup, or test follow-up (Forster, Murff, Peterson, Gandhi, & Bates, 2003). Geriatric acute care models address the posthospital care environment and the care transition following hospital discharge by promoting coordination among health care providers, facilitating medication reconciliation, preparing patients and their caregivers to carry out discharge instructions, and making appropriate home care referrals (Bowles, Naylor, & Foust, 2002; Flacker, Park, & Sims, 2007; Moore, McGinn, & Halm, 2007). Two of the six models consider care transition as the primary focus of their programs.

TYPES OF ACUTE CARE MODELS

Although there are several types of geriatric acute care models that are used in U.S. hospitals, all address both common health problems and care delivery issues. Most consider all geriatric syndromes, whereas others target specific syndromes such as delirium. The models are implemented in various degrees from a hospital-wide to a unit-based approach, whereas others focus on specific processes of hospitalization such as discharge planning.

Geriatric Consultation Service

The consultants in a geriatric service may include a geriatrician, a geropsychiatrist, a geriatric advanced practice nurse (GAPN), or an interprofessional team of geriatric health care providers who conduct a CGA or evaluate a specific condition (older adult mistreatment), symptom (wandering), or situation (adequacy of spouse to care for patient at home). Some hospitals will require that all patients who are screened at high risk for geriatric-related complications or are admitted from a homebound program or a nursing home will receive a geriatric consult, whereas most are requested by another primary service for an individual patient (Hung, Tejada, Soryal, Akbar, & Bowman, 2015). A systematic review/meta-analysis of randomized and nonrandomized studies did not find a statistically significant reduction in functional decline, readmissions, or length of stay but did report fewer consult patients dying at 6 and 8 months following discharge (Deschodt, Flamaing, Haentijens, Boonen, & Millisen, 2013). A geriatric consultation service that proactively provided daily geriatric recommendations for older patients who were receiving care for hip fracture resulted in decreased rate of the development of delirium (Marcantonio, Flacker, Wright, & Resnick, 2001). It is difficult to evaluate any consultation service because their recommendations may not be followed or the hospital may not have the resources or staff to adequately implement the recommendations (Allen et al., 1986).

Acute Care for Elders Units

These discrete geriatric units provide CGA delivered by a multidisciplinary team with a focus on the rehabilitative needs of older patients. Team rounds and patient-centered team conferences are considered essential. The core team includes a geriatrician, GAPN, social worker, as well as specialists from other disciplines providing consultation—occupational and physical therapy, nutrition, pharmacy, audiology, and psychology. Geriatric evaluation and management (GEM) units developed in the U.S. Department of Veterans Affairs (VA) system have documented significant reductions in functional decline and suboptimal medication use as well as return to home postdischarge and, more recent, decreased rate of nursing home placement among hospitalized veterans on GEM units compared with general medical units (Phibbs et al., 2006).

Since the 1990s, acute care for the elderly (ACE) units have been implemented in non-VA hospitals. An interprofessional team consisting of staff with geriatric expertise works collaboratively using strategies such as team rounds and family conferences. Most ACE units have made physical environment adaptations to address age-related changes (e.g., flooring to reduce glare), support orientation (white boards indicating staff names and discharge goals), and promote staff observation (e.g., alarmed exit doors and communal space for meals). Led by geriatricians and/or GAPNs, the interprofessional team facilitates care coordination and identification of modifiable risk factors for geriatric syndromes and prevents avoidable discharge delay (Flood et al., 2015; Fox et al., 2013; Malone, Capezuti, & Palmer, 2014).

Compared with other medical units, patients hospitalized on ACE units have maintained prehospital or demonstrated improved functional status at discharge without increases in hospital or postdischarge costs and are less likely to be discharged to nursing homes (Fox et al., 2012; Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995). Other important positive outcomes associated with ACE units include improved drug prescribing (Spinewine et al., 2007), fewer falls (Fox et al., 2012), less delirium (Bo et al., 2009; Fox et al., 2012), and reduced mortality (Saltvedt, Mo, Fayers, Kaasa, & Sletvold, 2002). In addition, reduced costs have been reported in those on ACE units as a result of shorter hospital stays (Barnes et al., 2012; Fox et al., 2012) and fewer 30-day readmissions (Flood et al., 2013).

These positive outcomes are attributed to processes of care more likely found in ACE units: less restraint use, early mobilization, fewer days to discharge planning, and less use of high-risk medications (Counsell et al., 2000). A 2013 systematic review suggested that the best outcomes from ACE programs were those that included patient-centered care, medical review, and early mobilization (Fox et al., 2012). In a recent shift, more hospitals are using ACE units for those at the highest risk of age-related complications with ACE staff also providing consultation, while exporting ACE principles, throughout the health system to reach a greater number of older hospitalized patients. These “virtual” and/or “ACE without walls” consult teams work similarly to a geriatric consultation service except for the fact that there is also an inpatient ACE unit within the hospital or health system. In another variant, the Mobile Acute Care for Elders (MACE) service, an outpatient geriatric team (attending geriatrician hospitalist, geriatric medicine fellow, social worker, and clinical nurse specialist), also provides primary care to its patients when hospitalized (Hung, Ross, Farber, & Siu, 2013). An evaluation of this model in one hospital reported that MACE service patients experienced fewer adverse events (catheter-associated urinary tract infection, pressure ulcers, restraint use, and falls) and had shorter hospital stays when compared with similar older patients cared for on medical units (Hung et al., 2013).

Nurses Improving Care for Healthsystem Elders

A national program aimed at system improvement to achieve positive outcomes for hospitalized older adults, Nurses Improving Care for Healthsystem Elders (NICHE), seeks to improve the quality of care provided to older patients and improve nurse competence by modifying the nurse practice environment with the infusion of geriatric-specific (a) core values into the mission statement of the institution; (b) special equipment, supplies, and other resources; and (c) protocols and techniques that promote interprofessional collaboration (Boltz et al., 2008b; Bub, Boltz, Malsch, & Fletcher, 2015; Capezuti, Bricoli, & Boltz, 2013; Capezuti et al., 2012). NICHE includes several approaches that promote dissemination of evidence-based geriatric best practices into hospital care. The system-level approach of NICHE provides a structure for nurses to collaborate with other disciplines and to actively participate in or coordinate other geriatric acute care models. A NICHE coordinator acts in a leadership role by facilitating, teaching, and mentoring others and changing systems of care (Fletcher et al., 2007). In some hospitals, a GAPN functions in this role as well as providing direct clinical consultation for evaluating and managing patients. The geriatric resource nurse (GRN) model is foundational to NICHE; it is an educational intervention whereby the NICHE coordinator or the GAPN prepares staff nurses to be the clinical resource person on geriatric issues to other nurses on the unit (Capezuti et al., 2012; Lee, Fletcher, Westley, & Fankhauser, 2004). The GRN model provides staff nurses, via education and role modeling (e.g., nursing bedside rounds) by a GAPN or NICHE coordinator, with content focusing on care management for geriatric syndromes. Application of evidence-based practice at the bedside is facilitated by organizational strategies such as incorporation of institution-wide clinical protocols as provided in this book.

The GRN model fosters professional development and enhanced work satisfaction for nurses who feel that they have institutional support in providing quality care. These supports include geriatric-specific resources (continuing education, equipment, and specialty services); interprofessional collaboration; as well as patient, family, and nurse involvement in treatment-related decision making. Evaluation in NICHE hospitals has reported improved clinical outcomes, rate of compliance with geriatric institutional protocols, cost-related outcomes, and improved nurse knowledge (Boltz et al., 2013; Bub, Boltz, Marlsch, & Fletcher et al., 2015; Capezuti et al., 2013; Hendrix, Matters, West, Stewart, & McConnell, 2011; Pfaff, 2002; Swauger, & Tomlin, 2002; Turner, Lee, Fletcher, Hudson, & Barton, 2001; Wald, Bandle, Richard, Min, & Capezuti, 2014a, 2014b). The GRN model is associated with positive outcomes such as reduced delirium in a NICHE orthopedic unit (Guthrie, Schumacher, & Edinger, 2006) and reduced complications among hospitalized older adults with dementia (Allen & Close, 2010). In studies aggregating results from several NICHE hospitals, NICHE implementation is associated with improved processes of care (Fulmer et al., 2002; Mezey et al., 2004) as well as higher nurse-perceived quality of care (Boltz et al., 2008a).

NICHE also promotes implementation of the ACE model. The ACE model as promoted by NICHE, emphasizes nurse-driven protocols and geriatric continuing education of all nursing staff. Similar to other ACE units, study of a NICHE–ACE unit found lower fall and pressure ulcer rates and lower length of stay when compared with overall hospital rates (LaReau & Raphelson, 2005).

The Hospital Elder Life Program

The Hospital Elder Life Program (HELP) is an intervention program using clinicians (geriatric specialists of various disciplines) working together as an interprofessional team with trained volunteers who target risk factors for delirium (mental orientation, therapeutic activities, early mobilization, vision and hearing adaptations, hydration and feeding assistance, and sleep enhancement). Protocols based on several well-designed clinical trials are employed to reduce incidence of delirium and, among those who did develop delirium, reduce total number of episodes and days with delirium, functional decline, costs of hospital services, and use of long-term nursing home services (Babine, Farrington, & Wierman, 2013; Inouye, Baker, Fugal, Bradley, & for the HELP Dissemination Project, 2006; Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000; Inouye et al., 1999; Yue, Kshieh, & Inouye, 2015). The HELP program has also been successfully adapted for the community-hospital setting as well specifically for older surgery patients who have a high occurrence of delirium (Chen et al., 2014; Zaubler et al., 2013). Currently, the HELP protocols have been adapted to incorporate the NICE (National Institute for Health and Clinical Excellence) guidelines (National Clinical Guideline Centre, 2010).

The program depends on hospital volunteers who are well trained and closely supervised to deploy patient care interventions (Bradley, Webster, Schlesinger, Baker, & Inouye, 2006b) that are coordinated by elder life nurse specialists. The elder life nurse specialist typically has advanced geriatric nursing education and will supervise the implementation of nursing-related assessments and tracking of delirium risk-factor-protocol adherence.

Transitional Care Models

Transitional care models address the needs of older adult patients with complex medical and social needs and their caregivers as they move from hospital to postacute care. Two models with demonstrated positive outcomes include the advanced practice nurse (APN) transitional care model (Naylor & Keating, 2008) and the care transitions coaching or care transitions intervention (Coleman, Parry, Chalmers, & Min, 2006; Coleman, Smith, et al., 2004). (These are described in more detail in Chapter 36, “Transitional Care.”)

Combination and Specialty Geriatric Acute Care Models

In some hospitals, a combination of geriatric models is implemented such as a geriatric consultation team and transitional care (Arbaje et al., 2010) or inpatient geriatric assessment and intensive home care (Buurman, Parlevliet, van Deelen, de Haan, & de Rooij, 2010). In others, a core geriatric interprofessional team provides direct consultation as well as screens patients for other related services, such as palliative care, rehabilitative services, or pain management programs. Some hospitals have developed dual-function units, such as merging an ACE unit with a palliative care (Gelfman, Meier, & Morrison, 2008; Tomasovic, 2005), stroke (K. R. Allen et al., 2003), or oncology (Flood, Brown, Carroll, & Locher, 2011) unit, as well as incorporating a “delirium room” within an ACE unit (Flaherty et al., 2003), whereas others have developed programs that incorporate geriatric comanagement with other specialties such as rehabilitation, orthopedics, trauma, and oncology (Allen et al., 2003; Gelfman et al., 2008; Kammerlander et al., 2010; Mendelson & Friedman, 2014). These programs have demonstrated increased detection of and reduced incidence of delirium, as well as reduced length of stay, readmission rates, morbidity, and mortality (Flaherty et al., 2003; Flood et al., 2011; Kates, 2014; Milisen et al., 2001; Pareja et al., 2009).

Collaboration With Hospitalists

Considering that hospitalists provide care for an increasing number of older acutely ill Medicare patients, some hospitals have initiated a proactive geriatrics consultation service implemented in collaboration with hospitalists (Sennour, Counsell, Jones, & Weiner, 2009). After 4 years and more than 1,500 consults, this service reported a high level of satisfaction by hospitalists while resulting in a shorter hospital stay and less hospital costs in patients receiving a geriatrics consultation (Sennour et al., 2009). A program in which hospitalists are trained to lead transitional care teams (BOOST—Better Outcomes for Older adults through Safer Transitions) has shown preliminary evidence to suggest prevention of postdischarge complications and readmissions within 30 days and increased confidence in self-management (Dedhia et al., 2009). In an analysis of the initial hospitals participating in the quality-improvement program, BOOST was associated with a modest but significant reduction in 30-day hospital readmissions from 14.7% at baseline to 12.7% after the intervention (Hansen et al., 2013). Administered by the Society of Hospital Medicine, the BOOST program provides technical support to optimize the hospital discharge process and diminish discontinuity and fragmentation of care (Williams & Coleman, 2009).

Models of Senior ED Care

Organizational models have emerged to address the specialized needs of older adults using the ED, and their families. Core components of these models include interprofessional collaboration, the use of evidence-based clinical interventions, and the central role of the nurse in coordinating care. Interprofessional teams (geriatrician, nurse practitioner, rehabilitation therapists, and social worker) evaluate high-risk patients in the ED (and follow them throughout the hospital stay; Gold & Bergman, 1997). A prospective, randomized, controlled trial conducted in a medical school–affiliated urban public hospital in Sydney, Australia, found that older adults sent home from the ED who received a CGA demonstrated positive outcomes. Although there was no difference in admission to nursing homes or mortality, patients randomized to the intervention group maintained a greater degree of physical and mental function (Caplan, Williams, Daly, & Abraham, 2004). In the randomized controlled trial of SIGNET (Systematic Interventions for a Geriatric Network of Evaluation and Treatment), an intervention (CGA) conducted in the ED by an APN resulted in very modest reductions in the risk of 90-day admission of elderly patients to a nursing home and in the mean number of hospital days among high-risk patients who received the intervention (Mion et al., 2003).

Mobile interprofessional teams in the ED conduct a brief geriatric assessment and develop a comprehensive plan. Two types of recommendations have been made: (a) medical recommendations for diagnosis and treatment of the presenting illnesses, and other geriatrics syndromes; and (b) gerontological recommendations for social and home needs. Outcomes reported include shortened hospital stay and early discharge from the ED (Launay, Decker, Hureaux-Huynh, Annweiler, & Beauchet, 2012).

Geriatric emergency management (GEM) nurses provide targeted geriatric assessment and intervention for older adult patients (aged 65-plus years) in the ED. At-risk patients are identified through the Triage Risk Factor Screening Tool (TRST) and the Identification of Seniors at Risk (ISAR) tool. Interventions include support for staff to implement geriatric care strategies in the ED, linkage to community support services, referral for specialized geriatric services, and collaboration with the family physician. GEM nurses have provided timely development of care plans and initiation of needed referrals (Asomaning, Loftus, & Ramsden, 2012; Rogers, 2009).

The first senior-friendly ED, a self-contained unit within a larger ED, was created by Holy Cross Hospital in Maryland in 2008. The physical environment is adapted to age-related changes (warm colors with select use of color contrast; thick mattresses; indirect light; glare-free floors; large, easy-to-use call light/TV remotes, telephones, and clocks; and documents with larger print). Dedicated, gerontologically prepared nursing staff, nurse practitioners, and social workers staff the unit and volunteers provide comfort measures. Evidence-based clinical protocols are used. A geriatric pharmacist reviews the medications of seniors who receive seven or more medications. The staff provides follow-up calls or home visits after discharge from the ED and care coordination is provided as indicated. The trend of senior-friendly EDs is growing and future research is planned to evaluate clinical and organizational effectiveness (Hwang & Morrison, 2007). The elder-friendly hospital conceptual framework offered by Parke and Brand (2004) provides guidance in efforts to develop a senior-friendly ED. This framework includes four major components to consider when developing a senior-friendly ED, and is described in Table 35.1.

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