Jean M. Youngwerth, MD

For the frail older patient, hospitalization marks a period of high risk of poor outcomes and adverse events including functional decline, delirium, pressure ulcers, adverse drug events, nosocomial infections, and falls.1, 2 Physician recognition of elderly patients at risk for adverse outcomes is poor, making it difficult to intervene to prevent them.3, 4 Among frail, elderly inpatients at an urban academic medical center, doctors documented cognitive assessments in only 5% of patients. Functional assessments are appropriately documented in 40%80% of inpatients.3, 5

The Acute Care for Elders (ACE) unit is one of several models of comprehensive inpatient geriatric care that have been developed by geriatrician researchers to address the adverse events and functional decline that often accompany hospitalization.6 The ACE unit model generally incorporates: 1) a modified hospital environment, 2) early assessment and intensive management to minimize the adverse effects of hospital care, 3) early discharge planning, 4) patient centered care protocols, and 5) a consistent nursing staff.7 Two randomized, controlled trials have shown the ACE unit model to be successful in reducing functional decline among frail older inpatients during and after hospitalization.7, 8 While meta‐analyses data also suggests the ACE unit model reduces functional decline and future institutionalization, significant impact on other outcomes is not proven.9, 10

Several barriers have prevented the successful dissemination of the ACE unit model. The chief limitations are the upfront resources required to create and maintain a modified, dedicated unit, as well as the lack of a geriatrics trained workforce.7, 1113 The rapid growth of hospital medicine presents opportunities for innovation in the care of older patients. Still, a 2006 census demonstrated that few hospitalist groups had identified geriatric care as a priority.14

In response to these challenges, the University of Colorado Hospital Medicine Group created a hospitalist‐run inpatient medical service designed for the care of the frail older patient. This Hospitalist‐Acute Care for the Elderly (Hospitalist‐ACE) unit is a hybrid of a general medical service and an inpatient geriatrics unit.7 The goals of the Hospitalist‐ACE service are to provide high quality care tailored to older inpatients, thus minimizing the risks of functional decline and adverse events associate with hospitalization, and to provide a clinical geriatrics teaching experience for Hospitalist Training Track Residents within the Internal Medicine Residency Training Program and medical students at the University of Colorado Denver School of Medicine. The Hospitalist‐ACE unit is staffed with a core group of hospitalist attendings who have, at a minimum, attended an intensive mini‐course in inpatient geriatrics. The service employs interdisciplinary rounds; a brief, standardized geriatric assessment including screens of function, cognition, and mood; a clinical focus on mitigating the hazards of hospitalization, early discharge planning; and a novel geriatric educational curriculum for medicine residents and medical students.

This article will: 1) describe the creation of the Hospitalist‐ACE service at the University of Colorado Hospital; and 2) summarize the evaluation of the Hospitalist‐ACE service in a quasi‐randomized, controlled manner during its first year. We hypothesized that, when compared to patients receiving usual care, patients cared for on the Hospitalist‐ACE service would have increased recognition of abnormal functional status; recognition of abnormal cognitive status and delirium; equivalent lengths of stay and hospital charges; and decreased falls, 30‐day readmissions, and restraint use.

METHODS

Intervention

The Hospitalist‐ACE unit implemented an interdisciplinary team approach to identify and address geriatric syndromes in patients aged 70 and over. The Hospitalist‐ACE model of care consisted of clinical care provided by a hospitalist attending with additional training in geriatric medicine, administration of standardized geriatric screens assessing function, cognition, and mood, 15 minute daily (MondayFriday) interdisciplinary rounds focusing on recognition and management of geriatric syndromes and early discharge planning, and a standardized educational curriculum for medical residents and medical students addressing hazards of hospitalization.

The Hospitalist‐ACE service was a unique rotation within the Hospitalist Training Track of the Internal Medicine Residency that was developed with the support of the University of Colorado Hospital and the Internal Medicine Residency Training Program, and input from the Geriatrics Division at the University of Colorado Denver. The director received additional training from the Donald W. Reynolds FoundationUCLA Faculty Development to Advance Geriatric Education Mini‐Fellowship for hospitalist faculty. The mission of the service was to excel at educating the next generation of hospitalists while providing a model for excellence of care for hospitalized elderly patients. Important stakeholders were identified, and a leadership teamincluding representatives from nursing, physical and occupational therapy, pharmacy, social work, case management, and later, volunteer servicescreated the model daily interdisciplinary rounds. As geographic concentration was essential for the viability of interdisciplinary rounds, one unit (12 West) within the hospital was designated as the preferred location for patients admitted to the Hospitalist‐ACE service.

The Hospitalist‐ACE unit team consisted of one attending hospitalist, one resident, one intern, and medical students. The attending was one of five hospitalists, with additional training in geriatric medicine, who rotated attending responsibilities on the service. One of the hospitalists was board certified in geriatric medicine. Each of the other four hospitalists attended the Reynolds FoundationUCLA mini‐fellowship in geriatric medicine. Hospitalist‐ACE attendings rotated on a variety of other hospitalist services throughout the academic year, including the usual care services.

The brief standardized geriatric assessment consisted of six validated instruments, and was completed by house staff or medical students on admission, following instruction by the attending physician. The complete assessment tool is shown in Figure 1. The cognitive items included the Mini‐Cog,15 a two‐item depression screen,16 and the Confusion Assessment Method.17 The functional items included the Vulnerable Elders Survey (VES‐13),18 the Timed Get Up and Go test,19 and a two‐question falls screen.20 The elements of the assessment tool were selected by the Hospitalist‐ACE attendings for brevity and the potential to inform clinical management. To standardize the clinical and educational approach, the Hospitalist‐ACE attendings regularly discussed appropriate orders recommended in response to each positive screen, but no templated order sets were used during the study period.

Figure 1

Interdisciplinary rounds were attended by Hospitalist‐ACE physicians, nurses, case managers, social workers, physical or occupational therapists, pharmacists, and volunteers. Rounds were led by the attending or medical resident.

The educational curriculum encompassed 13 modules created by the attending faculty that cover delirium, falls, dementia, pressure ulcers, physiology of aging, movement disorders, medication safety, end of life care, advance directives, care transitions, financing of health care for the elderly, and ethical conundrums in the care of the elderly. A full table of contents appears in online Appendix 1. Additionally, portions of the curriculum have been published online.21, 22 Topic selection was guided by the Accreditation Council for Graduate Medical Education (ACGME) core geriatrics topics determined most relevant for the inpatient setting. Formal instruction of 3045 minutes duration occurred three to four days a week and was presented in addition to routine internal medicine educational conferences. Attendings coordinated teaching to ensure that each trainee was exposed to all of the content during the course of their four‐week rotation.

In contrast to the Hospitalist‐ACE service, usual care on the control general medical services consisted of either a hospitalist, a general internist, or an internal medicine subspecialist attending physician, with one medical resident, one intern, and medical students admitting every fourth day. The general medical teams attended daily discharge planning rounds with a discharge planner and social worker focused exclusively on discharge planning. The content of teaching rounds on the general medical services was largely left to the discretion of the attending physician.

This program evaluation of the Hospitalist‐ACE service was granted a waiver of consent and Health Insurance Portability and Accountability Act (HIPAA) by the Colorado Multiple Institutional Review Board.

RESULTS

Two hundred seventeen patients met the study entry criteria (Table 2): 122 were admitted to the Hospitalist‐ACE service, and 95 were admitted to usual care on the general medical services. The average age of the study patients was 80.5 years, 55.3% were female. Twenty‐eight percent of subjects were admitted for pulmonary diagnoses. The two groups of patients were similar with respect to age, gender, and distribution of primary diagnoses. The Hospitalist‐ACE patients had a mean MS‐DRG weight of 1.15, which was slightly higher than that of usual care patients at 1.05 (P = 0.06). Typically, 70% of Hospitalist‐ACE patients are admitted to the designated ACE medical unit (12 West).

DISCUSSION

We report the implementation and evaluation of a medical service tailored to the care of the acutely ill older patient that draws from elements of the hospitalist model and the ACE unit model.7, 14, 24 For this Hospitalist‐ACE service, we developed a specialized hospitalist workforce, assembled a brief geriatric assessment tailored to the inpatient setting, instituted an interdisciplinary rounding model, and created a novel inpatient geriatrics curriculum.

During the study period, we improved performance of important processes of care for hospitalized elders, including recognition of abnormal cognitive and functional status; maintained comparable resource use; and implemented a novel, inpatient‐focused geriatric medicine educational experience. We were unable to demonstrate an impact on key clinical outcomes such as falls, physical restraint use, and readmissions. Nonetheless, there is evidence that the performance of selected processes of care is associated with improved three‐year survival status in the community‐dwelling vulnerable older patient, and may also be associated with a mortality benefit in the hospitalized vulnerable older patient.25, 26 Therefore, methods to improve the performance of these processes of care may be of clinical importance.

The finding of increased use of DNAR orders in the face of equivalent documentation of code status is of interest and generates hypotheses for further study. It is possible that the educational experience and use of geriatric assessment provides a more complete context for the code status discussion (one that incorporates the patient's social, physical, and cognitive function). However, we do not know if the patients on the ACE service had improved concordance between their code status and their goals of care.

We believe that there was no difference in key clinical outcomes between Hospitalist‐ACE and control patients because the population in this study was relatively low acuity and, therefore, the occurrence of falls and the use of physical restraints were quite low in the study population. In particular, the readmission rate was much lower than is typical for the Medicare population at our hospital, making it challenging to draw conclusions about the impact of the intervention on readmissions, however, we cannot rule out the possibility that our early discharge planning did not address the determinants of readmission for this population.

The ACE unit paradigmcharacterized by 1) closed, modified hospital units; 2) staffing by geriatricians and nurses with geriatrics training; 3) employing geriatric nursing care protocolsrequires significant resources and is not feasible for all settings.6 There is a need for alternative models of comprehensive care for hospitalized elders that require fewer resources in the form of dedicated units and specialist personnel, and can be more responsive to institutional needs. For example, in a 2005 report, one institution reported the creation of a geriatric medicine service that utilized a geriatrician and hospitalist co‐attending model.14 More recently, a large geriatrics program replaced its inpatient geriatrics unit with a mobile inpatient geriatrics service staffed by an attending geriatricianhospitalist, a geriatrics fellow, and a nurse practitioner.27 While these innovative models have eliminated the dedicated unit, they rely on board certified geriatricians, a group in short supply nationally.28 Hospitalists are a rapidly growing provider group that, with appropriate training and building on the work of geriatricians, is poised to provide leadership in acute geriatric care.29, 30

In contrast to the comprehensive inpatient geriatric care models described above, the Hospitalist‐ACE service uses a specialized hospitalist workforce and is not dependent on continuous staffing by geriatricians. Although geographic concentration is important for the success of interdisciplinary rounds, the Hospitalist‐ACE service does not require a closed or modified unit. The nursing staff caring for Hospitalist‐ACE patients have generalist nursing training and, at the time of the study, did not utilize geriatric‐care protocols. Our results need to be interpreted in the light of these differences from the ACE unit model which is a significantly more intensive intervention than the Hospitalist‐ACE service. In addition, the current practice environment is quite different from the mid‐1990s when ACE units were developed and studied. Development and maintenance of models of comprehensive inpatient geriatric care require demonstration of both value as well as return on investment. The alignment of financial and regulatory incentives for programs that provide comprehensive care to complex patients, such as those anticipated by the Affordable Care Act, may encourage the growth of such models.

These data represent findings from a six‐month evaluation of a novel inpatient service in the middle of its first year. There are several limitations related to our study design. First, the results of this small study at a single academic medical center may be of limited generalizability to other settings. Second, the program was evaluated only three months after its inception; we did not capture further improvements in methods, training, and outcomes expected as the program matured. Third, most of the Hospitalist‐ACE service attendings and residents rotate on the UCH general medical services throughout the year. Consequently, we were unable to eliminate the possibility of contamination of the control group, and we were unable to blind the physicians to the study. Fourth, the study population had a relatively low severity of illnessthe average MS‐DRG weight was near 1and low rates of important adverse events such falls and restraint use. This may have occurred because we excluded patients transferred from the ICUs and other services. It is possible that the Hospitalist‐ACE intervention might have demonstrated a larger benefit in a sicker population that would have presented greater opportunities for reductions in length of stay, costs, and adverse events. Fifth, given the retrospective nature of the data collection, we were not able to prospectively assess the incidence of important geriatric outcomes such as delirium and functional decline, nor can we make conclusions about changes in function during the hospitalization.

While the outcome measures we used are conceptually similar to several measures developed by RAND's Assessing Care of Vulnerable Elders (ACOVE) project, this study did not explicitly rely on those constructs.31 To do so would have required prospective screening by clinical staff independent from the care team for vulnerability that was beyond the scope of this project. In addition, the ACOVE measures of interest for functional and cognitive decline are limited to documentation of cognitive or functional assessments in the medical record. The ACE service's adoption of a brief standardized geriatric assessment was almost certain to meet that documentation requirement. While documentation is important, it is not clear that documentation, in and of itself, improves outcomes. Therefore, we expanded upon the ACOVE constructs to include the need for the additional evidence of a treatment plan when abnormal physical or cognitive function was documented. These constructs are important process of care for vulnerable elders. While we demonstrated improvements in several of these important processes of care for elderly patients, we are unable to draw conclusions about the impact of these differences in care on important clinical outcomes such as development of delirium, long‐term institutionalization, or mortality.

CONCLUSIONS

The risks of hospitalization for older persons are numerous, and present challenges and opportunities for inpatient physicians. As the hospitalized population agesmirroring national demographic trends and trends in use of acute care hospitalsthe challenge of avoiding harm in the older hospitalized patient will intensify. Innovations in care to improve the experience and outcomes of hospitalization for older patients are needed in the face of limited geriatrics‐trained workforce and few discretionary funds for unit redesign. The Hospitalist‐ACE service is a promising strategy for hospitalist programs with sufficient numbers of older patients and hospitalists with interest in improving clinical care for older adults. It provides a model for hospitalists to employ geriatrics principles targeted at reducing harm to their most vulnerable patients. Hospitalist‐run geriatric care models offer great promise for improving the care of acutely ill elderly patients. Future investigation should focus on demonstrating the impact of such care on important clinical outcomes between admission and discharge; on model refinement and adaptation, such as determining what components of comprehensive geriatric care are essential to success; and on how complementary interventions, such as the use of templated orders for the hospitalized elderly, impact outcomes. Additional research is needed, with a focus on demonstrating value with regard to an array of outcomes including cost, readmissions, and preventable harms of care.

For the frail older patient, hospitalization marks a period of high risk of poor outcomes and adverse events including functional decline, delirium, pressure ulcers, adverse drug events, nosocomial infections, and falls.1, 2 Physician recognition of elderly patients at risk for adverse outcomes is poor, making it difficult to intervene to prevent them.3, 4 Among frail, elderly inpatients at an urban academic medical center, doctors documented cognitive assessments in only 5% of patients. Functional assessments are appropriately documented in 40%80% of inpatients.3, 5

The Acute Care for Elders (ACE) unit is one of several models of comprehensive inpatient geriatric care that have been developed by geriatrician researchers to address the adverse events and functional decline that often accompany hospitalization.6 The ACE unit model generally incorporates: 1) a modified hospital environment, 2) early assessment and intensive management to minimize the adverse effects of hospital care, 3) early discharge planning, 4) patient centered care protocols, and 5) a consistent nursing staff.7 Two randomized, controlled trials have shown the ACE unit model to be successful in reducing functional decline among frail older inpatients during and after hospitalization.7, 8 While meta‐analyses data also suggests the ACE unit model reduces functional decline and future institutionalization, significant impact on other outcomes is not proven.9, 10

Several barriers have prevented the successful dissemination of the ACE unit model. The chief limitations are the upfront resources required to create and maintain a modified, dedicated unit, as well as the lack of a geriatrics trained workforce.7, 1113 The rapid growth of hospital medicine presents opportunities for innovation in the care of older patients. Still, a 2006 census demonstrated that few hospitalist groups had identified geriatric care as a priority.14

In response to these challenges, the University of Colorado Hospital Medicine Group created a hospitalist‐run inpatient medical service designed for the care of the frail older patient. This Hospitalist‐Acute Care for the Elderly (Hospitalist‐ACE) unit is a hybrid of a general medical service and an inpatient geriatrics unit.7 The goals of the Hospitalist‐ACE service are to provide high quality care tailored to older inpatients, thus minimizing the risks of functional decline and adverse events associate with hospitalization, and to provide a clinical geriatrics teaching experience for Hospitalist Training Track Residents within the Internal Medicine Residency Training Program and medical students at the University of Colorado Denver School of Medicine. The Hospitalist‐ACE unit is staffed with a core group of hospitalist attendings who have, at a minimum, attended an intensive mini‐course in inpatient geriatrics. The service employs interdisciplinary rounds; a brief, standardized geriatric assessment including screens of function, cognition, and mood; a clinical focus on mitigating the hazards of hospitalization, early discharge planning; and a novel geriatric educational curriculum for medicine residents and medical students.

This article will: 1) describe the creation of the Hospitalist‐ACE service at the University of Colorado Hospital; and 2) summarize the evaluation of the Hospitalist‐ACE service in a quasi‐randomized, controlled manner during its first year. We hypothesized that, when compared to patients receiving usual care, patients cared for on the Hospitalist‐ACE service would have increased recognition of abnormal functional status; recognition of abnormal cognitive status and delirium; equivalent lengths of stay and hospital charges; and decreased falls, 30‐day readmissions, and restraint use.

METHODS

Intervention

The Hospitalist‐ACE unit implemented an interdisciplinary team approach to identify and address geriatric syndromes in patients aged 70 and over. The Hospitalist‐ACE model of care consisted of clinical care provided by a hospitalist attending with additional training in geriatric medicine, administration of standardized geriatric screens assessing function, cognition, and mood, 15 minute daily (MondayFriday) interdisciplinary rounds focusing on recognition and management of geriatric syndromes and early discharge planning, and a standardized educational curriculum for medical residents and medical students addressing hazards of hospitalization.

The Hospitalist‐ACE service was a unique rotation within the Hospitalist Training Track of the Internal Medicine Residency that was developed with the support of the University of Colorado Hospital and the Internal Medicine Residency Training Program, and input from the Geriatrics Division at the University of Colorado Denver. The director received additional training from the Donald W. Reynolds FoundationUCLA Faculty Development to Advance Geriatric Education Mini‐Fellowship for hospitalist faculty. The mission of the service was to excel at educating the next generation of hospitalists while providing a model for excellence of care for hospitalized elderly patients. Important stakeholders were identified, and a leadership teamincluding representatives from nursing, physical and occupational therapy, pharmacy, social work, case management, and later, volunteer servicescreated the model daily interdisciplinary rounds. As geographic concentration was essential for the viability of interdisciplinary rounds, one unit (12 West) within the hospital was designated as the preferred location for patients admitted to the Hospitalist‐ACE service.

The Hospitalist‐ACE unit team consisted of one attending hospitalist, one resident, one intern, and medical students. The attending was one of five hospitalists, with additional training in geriatric medicine, who rotated attending responsibilities on the service. One of the hospitalists was board certified in geriatric medicine. Each of the other four hospitalists attended the Reynolds FoundationUCLA mini‐fellowship in geriatric medicine. Hospitalist‐ACE attendings rotated on a variety of other hospitalist services throughout the academic year, including the usual care services.

The brief standardized geriatric assessment consisted of six validated instruments, and was completed by house staff or medical students on admission, following instruction by the attending physician. The complete assessment tool is shown in Figure 1. The cognitive items included the Mini‐Cog,15 a two‐item depression screen,16 and the Confusion Assessment Method.17 The functional items included the Vulnerable Elders Survey (VES‐13),18 the Timed Get Up and Go test,19 and a two‐question falls screen.20 The elements of the assessment tool were selected by the Hospitalist‐ACE attendings for brevity and the potential to inform clinical management. To standardize the clinical and educational approach, the Hospitalist‐ACE attendings regularly discussed appropriate orders recommended in response to each positive screen, but no templated order sets were used during the study period.

Figure 1

Interdisciplinary rounds were attended by Hospitalist‐ACE physicians, nurses, case managers, social workers, physical or occupational therapists, pharmacists, and volunteers. Rounds were led by the attending or medical resident.

The educational curriculum encompassed 13 modules created by the attending faculty that cover delirium, falls, dementia, pressure ulcers, physiology of aging, movement disorders, medication safety, end of life care, advance directives, care transitions, financing of health care for the elderly, and ethical conundrums in the care of the elderly. A full table of contents appears in online Appendix 1. Additionally, portions of the curriculum have been published online.21, 22 Topic selection was guided by the Accreditation Council for Graduate Medical Education (ACGME) core geriatrics topics determined most relevant for the inpatient setting. Formal instruction of 3045 minutes duration occurred three to four days a week and was presented in addition to routine internal medicine educational conferences. Attendings coordinated teaching to ensure that each trainee was exposed to all of the content during the course of their four‐week rotation.

In contrast to the Hospitalist‐ACE service, usual care on the control general medical services consisted of either a hospitalist, a general internist, or an internal medicine subspecialist attending physician, with one medical resident, one intern, and medical students admitting every fourth day. The general medical teams attended daily discharge planning rounds with a discharge planner and social worker focused exclusively on discharge planning. The content of teaching rounds on the general medical services was largely left to the discretion of the attending physician.

This program evaluation of the Hospitalist‐ACE service was granted a waiver of consent and Health Insurance Portability and Accountability Act (HIPAA) by the Colorado Multiple Institutional Review Board.

RESULTS

Two hundred seventeen patients met the study entry criteria (Table 2): 122 were admitted to the Hospitalist‐ACE service, and 95 were admitted to usual care on the general medical services. The average age of the study patients was 80.5 years, 55.3% were female. Twenty‐eight percent of subjects were admitted for pulmonary diagnoses. The two groups of patients were similar with respect to age, gender, and distribution of primary diagnoses. The Hospitalist‐ACE patients had a mean MS‐DRG weight of 1.15, which was slightly higher than that of usual care patients at 1.05 (P = 0.06). Typically, 70% of Hospitalist‐ACE patients are admitted to the designated ACE medical unit (12 West).

DISCUSSION

We report the implementation and evaluation of a medical service tailored to the care of the acutely ill older patient that draws from elements of the hospitalist model and the ACE unit model.7, 14, 24 For this Hospitalist‐ACE service, we developed a specialized hospitalist workforce, assembled a brief geriatric assessment tailored to the inpatient setting, instituted an interdisciplinary rounding model, and created a novel inpatient geriatrics curriculum.

During the study period, we improved performance of important processes of care for hospitalized elders, including recognition of abnormal cognitive and functional status; maintained comparable resource use; and implemented a novel, inpatient‐focused geriatric medicine educational experience. We were unable to demonstrate an impact on key clinical outcomes such as falls, physical restraint use, and readmissions. Nonetheless, there is evidence that the performance of selected processes of care is associated with improved three‐year survival status in the community‐dwelling vulnerable older patient, and may also be associated with a mortality benefit in the hospitalized vulnerable older patient.25, 26 Therefore, methods to improve the performance of these processes of care may be of clinical importance.

The finding of increased use of DNAR orders in the face of equivalent documentation of code status is of interest and generates hypotheses for further study. It is possible that the educational experience and use of geriatric assessment provides a more complete context for the code status discussion (one that incorporates the patient's social, physical, and cognitive function). However, we do not know if the patients on the ACE service had improved concordance between their code status and their goals of care.

We believe that there was no difference in key clinical outcomes between Hospitalist‐ACE and control patients because the population in this study was relatively low acuity and, therefore, the occurrence of falls and the use of physical restraints were quite low in the study population. In particular, the readmission rate was much lower than is typical for the Medicare population at our hospital, making it challenging to draw conclusions about the impact of the intervention on readmissions, however, we cannot rule out the possibility that our early discharge planning did not address the determinants of readmission for this population.

The ACE unit paradigmcharacterized by 1) closed, modified hospital units; 2) staffing by geriatricians and nurses with geriatrics training; 3) employing geriatric nursing care protocolsrequires significant resources and is not feasible for all settings.6 There is a need for alternative models of comprehensive care for hospitalized elders that require fewer resources in the form of dedicated units and specialist personnel, and can be more responsive to institutional needs. For example, in a 2005 report, one institution reported the creation of a geriatric medicine service that utilized a geriatrician and hospitalist co‐attending model.14 More recently, a large geriatrics program replaced its inpatient geriatrics unit with a mobile inpatient geriatrics service staffed by an attending geriatricianhospitalist, a geriatrics fellow, and a nurse practitioner.27 While these innovative models have eliminated the dedicated unit, they rely on board certified geriatricians, a group in short supply nationally.28 Hospitalists are a rapidly growing provider group that, with appropriate training and building on the work of geriatricians, is poised to provide leadership in acute geriatric care.29, 30

In contrast to the comprehensive inpatient geriatric care models described above, the Hospitalist‐ACE service uses a specialized hospitalist workforce and is not dependent on continuous staffing by geriatricians. Although geographic concentration is important for the success of interdisciplinary rounds, the Hospitalist‐ACE service does not require a closed or modified unit. The nursing staff caring for Hospitalist‐ACE patients have generalist nursing training and, at the time of the study, did not utilize geriatric‐care protocols. Our results need to be interpreted in the light of these differences from the ACE unit model which is a significantly more intensive intervention than the Hospitalist‐ACE service. In addition, the current practice environment is quite different from the mid‐1990s when ACE units were developed and studied. Development and maintenance of models of comprehensive inpatient geriatric care require demonstration of both value as well as return on investment. The alignment of financial and regulatory incentives for programs that provide comprehensive care to complex patients, such as those anticipated by the Affordable Care Act, may encourage the growth of such models.

These data represent findings from a six‐month evaluation of a novel inpatient service in the middle of its first year. There are several limitations related to our study design. First, the results of this small study at a single academic medical center may be of limited generalizability to other settings. Second, the program was evaluated only three months after its inception; we did not capture further improvements in methods, training, and outcomes expected as the program matured. Third, most of the Hospitalist‐ACE service attendings and residents rotate on the UCH general medical services throughout the year. Consequently, we were unable to eliminate the possibility of contamination of the control group, and we were unable to blind the physicians to the study. Fourth, the study population had a relatively low severity of illnessthe average MS‐DRG weight was near 1and low rates of important adverse events such falls and restraint use. This may have occurred because we excluded patients transferred from the ICUs and other services. It is possible that the Hospitalist‐ACE intervention might have demonstrated a larger benefit in a sicker population that would have presented greater opportunities for reductions in length of stay, costs, and adverse events. Fifth, given the retrospective nature of the data collection, we were not able to prospectively assess the incidence of important geriatric outcomes such as delirium and functional decline, nor can we make conclusions about changes in function during the hospitalization.

While the outcome measures we used are conceptually similar to several measures developed by RAND's Assessing Care of Vulnerable Elders (ACOVE) project, this study did not explicitly rely on those constructs.31 To do so would have required prospective screening by clinical staff independent from the care team for vulnerability that was beyond the scope of this project. In addition, the ACOVE measures of interest for functional and cognitive decline are limited to documentation of cognitive or functional assessments in the medical record. The ACE service's adoption of a brief standardized geriatric assessment was almost certain to meet that documentation requirement. While documentation is important, it is not clear that documentation, in and of itself, improves outcomes. Therefore, we expanded upon the ACOVE constructs to include the need for the additional evidence of a treatment plan when abnormal physical or cognitive function was documented. These constructs are important process of care for vulnerable elders. While we demonstrated improvements in several of these important processes of care for elderly patients, we are unable to draw conclusions about the impact of these differences in care on important clinical outcomes such as development of delirium, long‐term institutionalization, or mortality.

CONCLUSIONS

The risks of hospitalization for older persons are numerous, and present challenges and opportunities for inpatient physicians. As the hospitalized population agesmirroring national demographic trends and trends in use of acute care hospitalsthe challenge of avoiding harm in the older hospitalized patient will intensify. Innovations in care to improve the experience and outcomes of hospitalization for older patients are needed in the face of limited geriatrics‐trained workforce and few discretionary funds for unit redesign. The Hospitalist‐ACE service is a promising strategy for hospitalist programs with sufficient numbers of older patients and hospitalists with interest in improving clinical care for older adults. It provides a model for hospitalists to employ geriatrics principles targeted at reducing harm to their most vulnerable patients. Hospitalist‐run geriatric care models offer great promise for improving the care of acutely ill elderly patients. Future investigation should focus on demonstrating the impact of such care on important clinical outcomes between admission and discharge; on model refinement and adaptation, such as determining what components of comprehensive geriatric care are essential to success; and on how complementary interventions, such as the use of templated orders for the hospitalized elderly, impact outcomes. Additional research is needed, with a focus on demonstrating value with regard to an array of outcomes including cost, readmissions, and preventable harms of care.

For the frail older patient, hospitalization marks a period of high risk of poor outcomes and adverse events including functional decline, delirium, pressure ulcers, adverse drug events, nosocomial infections, and falls.1, 2 Physician recognition of elderly patients at risk for adverse outcomes is poor, making it difficult to intervene to prevent them.3, 4 Among frail, elderly inpatients at an urban academic medical center, doctors documented cognitive assessments in only 5% of patients. Functional assessments are appropriately documented in 40%80% of inpatients.3, 5

The Acute Care for Elders (ACE) unit is one of several models of comprehensive inpatient geriatric care that have been developed by geriatrician researchers to address the adverse events and functional decline that often accompany hospitalization.6 The ACE unit model generally incorporates: 1) a modified hospital environment, 2) early assessment and intensive management to minimize the adverse effects of hospital care, 3) early discharge planning, 4) patient centered care protocols, and 5) a consistent nursing staff.7 Two randomized, controlled trials have shown the ACE unit model to be successful in reducing functional decline among frail older inpatients during and after hospitalization.7, 8 While meta‐analyses data also suggests the ACE unit model reduces functional decline and future institutionalization, significant impact on other outcomes is not proven.9, 10

Several barriers have prevented the successful dissemination of the ACE unit model. The chief limitations are the upfront resources required to create and maintain a modified, dedicated unit, as well as the lack of a geriatrics trained workforce.7, 1113 The rapid growth of hospital medicine presents opportunities for innovation in the care of older patients. Still, a 2006 census demonstrated that few hospitalist groups had identified geriatric care as a priority.14

In response to these challenges, the University of Colorado Hospital Medicine Group created a hospitalist‐run inpatient medical service designed for the care of the frail older patient. This Hospitalist‐Acute Care for the Elderly (Hospitalist‐ACE) unit is a hybrid of a general medical service and an inpatient geriatrics unit.7 The goals of the Hospitalist‐ACE service are to provide high quality care tailored to older inpatients, thus minimizing the risks of functional decline and adverse events associate with hospitalization, and to provide a clinical geriatrics teaching experience for Hospitalist Training Track Residents within the Internal Medicine Residency Training Program and medical students at the University of Colorado Denver School of Medicine. The Hospitalist‐ACE unit is staffed with a core group of hospitalist attendings who have, at a minimum, attended an intensive mini‐course in inpatient geriatrics. The service employs interdisciplinary rounds; a brief, standardized geriatric assessment including screens of function, cognition, and mood; a clinical focus on mitigating the hazards of hospitalization, early discharge planning; and a novel geriatric educational curriculum for medicine residents and medical students.

This article will: 1) describe the creation of the Hospitalist‐ACE service at the University of Colorado Hospital; and 2) summarize the evaluation of the Hospitalist‐ACE service in a quasi‐randomized, controlled manner during its first year. We hypothesized that, when compared to patients receiving usual care, patients cared for on the Hospitalist‐ACE service would have increased recognition of abnormal functional status; recognition of abnormal cognitive status and delirium; equivalent lengths of stay and hospital charges; and decreased falls, 30‐day readmissions, and restraint use.

METHODS

Intervention

The Hospitalist‐ACE unit implemented an interdisciplinary team approach to identify and address geriatric syndromes in patients aged 70 and over. The Hospitalist‐ACE model of care consisted of clinical care provided by a hospitalist attending with additional training in geriatric medicine, administration of standardized geriatric screens assessing function, cognition, and mood, 15 minute daily (MondayFriday) interdisciplinary rounds focusing on recognition and management of geriatric syndromes and early discharge planning, and a standardized educational curriculum for medical residents and medical students addressing hazards of hospitalization.

The Hospitalist‐ACE service was a unique rotation within the Hospitalist Training Track of the Internal Medicine Residency that was developed with the support of the University of Colorado Hospital and the Internal Medicine Residency Training Program, and input from the Geriatrics Division at the University of Colorado Denver. The director received additional training from the Donald W. Reynolds FoundationUCLA Faculty Development to Advance Geriatric Education Mini‐Fellowship for hospitalist faculty. The mission of the service was to excel at educating the next generation of hospitalists while providing a model for excellence of care for hospitalized elderly patients. Important stakeholders were identified, and a leadership teamincluding representatives from nursing, physical and occupational therapy, pharmacy, social work, case management, and later, volunteer servicescreated the model daily interdisciplinary rounds. As geographic concentration was essential for the viability of interdisciplinary rounds, one unit (12 West) within the hospital was designated as the preferred location for patients admitted to the Hospitalist‐ACE service.

The Hospitalist‐ACE unit team consisted of one attending hospitalist, one resident, one intern, and medical students. The attending was one of five hospitalists, with additional training in geriatric medicine, who rotated attending responsibilities on the service. One of the hospitalists was board certified in geriatric medicine. Each of the other four hospitalists attended the Reynolds FoundationUCLA mini‐fellowship in geriatric medicine. Hospitalist‐ACE attendings rotated on a variety of other hospitalist services throughout the academic year, including the usual care services.

The brief standardized geriatric assessment consisted of six validated instruments, and was completed by house staff or medical students on admission, following instruction by the attending physician. The complete assessment tool is shown in Figure 1. The cognitive items included the Mini‐Cog,15 a two‐item depression screen,16 and the Confusion Assessment Method.17 The functional items included the Vulnerable Elders Survey (VES‐13),18 the Timed Get Up and Go test,19 and a two‐question falls screen.20 The elements of the assessment tool were selected by the Hospitalist‐ACE attendings for brevity and the potential to inform clinical management. To standardize the clinical and educational approach, the Hospitalist‐ACE attendings regularly discussed appropriate orders recommended in response to each positive screen, but no templated order sets were used during the study period.

Figure 1

Interdisciplinary rounds were attended by Hospitalist‐ACE physicians, nurses, case managers, social workers, physical or occupational therapists, pharmacists, and volunteers. Rounds were led by the attending or medical resident.

The educational curriculum encompassed 13 modules created by the attending faculty that cover delirium, falls, dementia, pressure ulcers, physiology of aging, movement disorders, medication safety, end of life care, advance directives, care transitions, financing of health care for the elderly, and ethical conundrums in the care of the elderly. A full table of contents appears in online Appendix 1. Additionally, portions of the curriculum have been published online.21, 22 Topic selection was guided by the Accreditation Council for Graduate Medical Education (ACGME) core geriatrics topics determined most relevant for the inpatient setting. Formal instruction of 3045 minutes duration occurred three to four days a week and was presented in addition to routine internal medicine educational conferences. Attendings coordinated teaching to ensure that each trainee was exposed to all of the content during the course of their four‐week rotation.

In contrast to the Hospitalist‐ACE service, usual care on the control general medical services consisted of either a hospitalist, a general internist, or an internal medicine subspecialist attending physician, with one medical resident, one intern, and medical students admitting every fourth day. The general medical teams attended daily discharge planning rounds with a discharge planner and social worker focused exclusively on discharge planning. The content of teaching rounds on the general medical services was largely left to the discretion of the attending physician.

This program evaluation of the Hospitalist‐ACE service was granted a waiver of consent and Health Insurance Portability and Accountability Act (HIPAA) by the Colorado Multiple Institutional Review Board.

RESULTS

Two hundred seventeen patients met the study entry criteria (Table 2): 122 were admitted to the Hospitalist‐ACE service, and 95 were admitted to usual care on the general medical services. The average age of the study patients was 80.5 years, 55.3% were female. Twenty‐eight percent of subjects were admitted for pulmonary diagnoses. The two groups of patients were similar with respect to age, gender, and distribution of primary diagnoses. The Hospitalist‐ACE patients had a mean MS‐DRG weight of 1.15, which was slightly higher than that of usual care patients at 1.05 (P = 0.06). Typically, 70% of Hospitalist‐ACE patients are admitted to the designated ACE medical unit (12 West).

DISCUSSION

We report the implementation and evaluation of a medical service tailored to the care of the acutely ill older patient that draws from elements of the hospitalist model and the ACE unit model.7, 14, 24 For this Hospitalist‐ACE service, we developed a specialized hospitalist workforce, assembled a brief geriatric assessment tailored to the inpatient setting, instituted an interdisciplinary rounding model, and created a novel inpatient geriatrics curriculum.

During the study period, we improved performance of important processes of care for hospitalized elders, including recognition of abnormal cognitive and functional status; maintained comparable resource use; and implemented a novel, inpatient‐focused geriatric medicine educational experience. We were unable to demonstrate an impact on key clinical outcomes such as falls, physical restraint use, and readmissions. Nonetheless, there is evidence that the performance of selected processes of care is associated with improved three‐year survival status in the community‐dwelling vulnerable older patient, and may also be associated with a mortality benefit in the hospitalized vulnerable older patient.25, 26 Therefore, methods to improve the performance of these processes of care may be of clinical importance.

The finding of increased use of DNAR orders in the face of equivalent documentation of code status is of interest and generates hypotheses for further study. It is possible that the educational experience and use of geriatric assessment provides a more complete context for the code status discussion (one that incorporates the patient's social, physical, and cognitive function). However, we do not know if the patients on the ACE service had improved concordance between their code status and their goals of care.

We believe that there was no difference in key clinical outcomes between Hospitalist‐ACE and control patients because the population in this study was relatively low acuity and, therefore, the occurrence of falls and the use of physical restraints were quite low in the study population. In particular, the readmission rate was much lower than is typical for the Medicare population at our hospital, making it challenging to draw conclusions about the impact of the intervention on readmissions, however, we cannot rule out the possibility that our early discharge planning did not address the determinants of readmission for this population.

The ACE unit paradigmcharacterized by 1) closed, modified hospital units; 2) staffing by geriatricians and nurses with geriatrics training; 3) employing geriatric nursing care protocolsrequires significant resources and is not feasible for all settings.6 There is a need for alternative models of comprehensive care for hospitalized elders that require fewer resources in the form of dedicated units and specialist personnel, and can be more responsive to institutional needs. For example, in a 2005 report, one institution reported the creation of a geriatric medicine service that utilized a geriatrician and hospitalist co‐attending model.14 More recently, a large geriatrics program replaced its inpatient geriatrics unit with a mobile inpatient geriatrics service staffed by an attending geriatricianhospitalist, a geriatrics fellow, and a nurse practitioner.27 While these innovative models have eliminated the dedicated unit, they rely on board certified geriatricians, a group in short supply nationally.28 Hospitalists are a rapidly growing provider group that, with appropriate training and building on the work of geriatricians, is poised to provide leadership in acute geriatric care.29, 30

In contrast to the comprehensive inpatient geriatric care models described above, the Hospitalist‐ACE service uses a specialized hospitalist workforce and is not dependent on continuous staffing by geriatricians. Although geographic concentration is important for the success of interdisciplinary rounds, the Hospitalist‐ACE service does not require a closed or modified unit. The nursing staff caring for Hospitalist‐ACE patients have generalist nursing training and, at the time of the study, did not utilize geriatric‐care protocols. Our results need to be interpreted in the light of these differences from the ACE unit model which is a significantly more intensive intervention than the Hospitalist‐ACE service. In addition, the current practice environment is quite different from the mid‐1990s when ACE units were developed and studied. Development and maintenance of models of comprehensive inpatient geriatric care require demonstration of both value as well as return on investment. The alignment of financial and regulatory incentives for programs that provide comprehensive care to complex patients, such as those anticipated by the Affordable Care Act, may encourage the growth of such models.

These data represent findings from a six‐month evaluation of a novel inpatient service in the middle of its first year. There are several limitations related to our study design. First, the results of this small study at a single academic medical center may be of limited generalizability to other settings. Second, the program was evaluated only three months after its inception; we did not capture further improvements in methods, training, and outcomes expected as the program matured. Third, most of the Hospitalist‐ACE service attendings and residents rotate on the UCH general medical services throughout the year. Consequently, we were unable to eliminate the possibility of contamination of the control group, and we were unable to blind the physicians to the study. Fourth, the study population had a relatively low severity of illnessthe average MS‐DRG weight was near 1and low rates of important adverse events such falls and restraint use. This may have occurred because we excluded patients transferred from the ICUs and other services. It is possible that the Hospitalist‐ACE intervention might have demonstrated a larger benefit in a sicker population that would have presented greater opportunities for reductions in length of stay, costs, and adverse events. Fifth, given the retrospective nature of the data collection, we were not able to prospectively assess the incidence of important geriatric outcomes such as delirium and functional decline, nor can we make conclusions about changes in function during the hospitalization.

While the outcome measures we used are conceptually similar to several measures developed by RAND's Assessing Care of Vulnerable Elders (ACOVE) project, this study did not explicitly rely on those constructs.31 To do so would have required prospective screening by clinical staff independent from the care team for vulnerability that was beyond the scope of this project. In addition, the ACOVE measures of interest for functional and cognitive decline are limited to documentation of cognitive or functional assessments in the medical record. The ACE service's adoption of a brief standardized geriatric assessment was almost certain to meet that documentation requirement. While documentation is important, it is not clear that documentation, in and of itself, improves outcomes. Therefore, we expanded upon the ACOVE constructs to include the need for the additional evidence of a treatment plan when abnormal physical or cognitive function was documented. These constructs are important process of care for vulnerable elders. While we demonstrated improvements in several of these important processes of care for elderly patients, we are unable to draw conclusions about the impact of these differences in care on important clinical outcomes such as development of delirium, long‐term institutionalization, or mortality.

CONCLUSIONS

The risks of hospitalization for older persons are numerous, and present challenges and opportunities for inpatient physicians. As the hospitalized population agesmirroring national demographic trends and trends in use of acute care hospitalsthe challenge of avoiding harm in the older hospitalized patient will intensify. Innovations in care to improve the experience and outcomes of hospitalization for older patients are needed in the face of limited geriatrics‐trained workforce and few discretionary funds for unit redesign. The Hospitalist‐ACE service is a promising strategy for hospitalist programs with sufficient numbers of older patients and hospitalists with interest in improving clinical care for older adults. It provides a model for hospitalists to employ geriatrics principles targeted at reducing harm to their most vulnerable patients. Hospitalist‐run geriatric care models offer great promise for improving the care of acutely ill elderly patients. Future investigation should focus on demonstrating the impact of such care on important clinical outcomes between admission and discharge; on model refinement and adaptation, such as determining what components of comprehensive geriatric care are essential to success; and on how complementary interventions, such as the use of templated orders for the hospitalized elderly, impact outcomes. Additional research is needed, with a focus on demonstrating value with regard to an array of outcomes including cost, readmissions, and preventable harms of care.