A GEM Approach: Outside the VA

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A GEM ApproachOutside the VA

• Eileen H. Callahan MD
• Medical Director ACE Unit
• Brookdale Department of Adult and Geriatric
  Medicine
• AGS-May 11, 2005

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Why is this important?
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Who is in the hospital?

• Elderly account for a disproportionate percentage
  of inpatient hospital care
• 13 in the US
• 38 in the hospital
• 45 of hospital days of care

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Average LOS (days)
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Functional decline

• 31 of elderly patients lose one or more ADLs in
  hospital at discharge
• 40 of elderly patients declined in IADL function
  at 3 months after discharge
• Negative consequences death, longer length of
  stay, institutionalization, rehospitalization,
  increased comorbidities

Hirsch CH, JAGS 1990 Sager MA, Arch Int Med
1996 Creditor M, Arch Int Med 1993
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What is needed?
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From the Geriatricians view

• Decrease hazards of hospitalization
• Work with a team
• Do good by the patient

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From the patient/familys view

• Get good comprehensive care by those who can
  provide it (a team)
• Feel satisfied with hospital stay
• Go home

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From the hospital view

• Length of stay
• Satisfied staff
• Satisfied patients/families

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Options

• GEMU (Geriatric Evaluation and Management Unit)
• IGCS (Inpatient Geriatric Consult Service)
• ACE (Acute Care for the Elderly)
• HELP (Hospital Elder Life Program)

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GEMUNon-VA Hospital

• Does it exist? None published
• Is it similar to discharging a patient from an
  acute care hospital to a Sub-acute
  Rehabilitation Unit in a nursing home?
• Interdisciplinary team care
• Rehabilitation focus
• No Comprehensive Geriatric Assessment
• Physiatrist providing care

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Options

• GEMU (Geriatric Evaluation and Management Unit)
• IGCS (Inpatient Geriatric Consult Service)
• ACE (Acute Care for the Elderly)
• HELP (Hospital Elder Life Program)

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Inpatient Geriatric Consult Service (IGCS)

• A multidisciplinary team that assesses,
  discusses, and recommends a treatment plan that
  is patient centered
• Composition of team often differs, but in general
• Geriatrician is involved
• Daily nursing care usually not specialized
• Recommendations often not implemented!

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IGCSMeta analysis and Systematic Reviews

• Comprehensive meta-analysis of 28 international
  studies of CGA in various clinical settings
• Of 8 studies of IGCS, the only positive effect
  was seen for improved cognitive function at 6
  months

Stuck AE et al. Lancet 1993 Ellis G, Langhorne P.
British Med Bull 2005
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IGCSMeta analysis and Systematic Reviews (cont.)

• Overall, no improvements in mortality,function,
  living location, or hospital readmission at 12
  months
• Programs with control over medical
  recommendations and ambulatory follow-up have
  more effects on function and survival

Stuck AE et al. Lancet 1993 Ellis G, Langhorne P.
British Med Bull 2005
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Options

• GEMU (Geriatric Evaluation and Management Unit)
• IGCS (Inpatient Geriatric Consult Service)
• ACE (Acute Care for the Elderly)
• HELP (Hospital Elder Life Program)

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Acute Care for Elders Units (ACE)

• Prepared environment
• Multidimensional assessment linked to
  non-pharmacologic prescriptions
• Medical care review
• Interdisciplinary team rounds and comprehensive
  discharge planning

Palmer RM et al. JAGS 1994
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Functional Trajectory
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ACE Unit-Processes of Care

• More Nursing care plans to promote independence
• Earlier discharge planning
• Earlier and more frequent SW consult
• Less days at bed rest
• Less restraints
• Patients, caregivers, physicians and nurses
  report higher satisfaction with the care in ACE
  Unit

Effects of a Multicomponent Intervention on
Functional Outcomes and Process of Care in
Hospitalized Older Patients A Randomized
Controlled Trial of Acute Care for Elders (ACE)
in a Community Hospital. Counsell SR et. Al. JAGS
2000
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ACE Unit-Clinical outcomes

• More patients discharged with better functional
  status
• Less patients discharged with worse functional
  status
• Fewer patients were discharged to SNF for first
  time
• Overall health status at discharge was better

A Randomized trial of care in a hospital medical
unit especially designed to improve the
functional outcomes of acutely ill older
patients. Landefeld CS et al. NEJM 1995
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ACE Unit-Cost

• Treating patients on the ACE Unit was not more
  costly for the hospital
• Implementation and maintenance costs offset by
  shorter LOS

Do acute care for elders units increase hospital
costs? A cost analysis using the hospital
perspective Covinsky KE et al JAGS 1997
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Dissemination and characteristics of Acute Care
for Elders (ACE) Units in the US

• Survey of all established Geriatric Divisions in
  US Medical Schools, 82 out of 100 responded
• Only 16 (19.5) have established ACE Units
• Larger, urban, more average revenue
• Interdisciplinary team care

Jayadevappa R et al. Int J of Tech Assess in
Health Care 2003
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Options

• GEMU (Geriatric Evaluation and Management Unit)
• IGCS (Inpatient Geriatric Consult Service)
• ACE (Acute Care for the Elderly)
• HELP (Hospital Elder Life Program)

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The Hospital Elder Life Program (HELP) A Model
of care to prevent cognitive and functional
decline in older hospitalized patients

• Model of care designed to prevent functional and
  cognitive decline
• Interdisciplinary Team provided targeted
  interventions for six risk factors

Inouye SK et. Al JAGS 2000
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HELP

• Risk factors
• Cognitive impairment
• Sleep deprivation
• Immobility
• Visual impairment
• Hearing impairment
• Dehydration

• Interventions
• Orientation board
• Non-pharm sleep rx
• Early mobilization
• Visual protocol
• Hearing protocol
• Dehydration protocol

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Results

• Decrease in first episode of delirium (9.9 vs.
  15, p0.02)
• Decrease in total days in delirium
• Decrease in number of episodes of delirium
• Most effective in primary prevention of delirium

Inouye SK et al. NEJM 1999
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MSSM ACE Unit

• 34 bed open unit since 1996
• 98 occupancy
• Only admitting criteria is age over 65
• Strong Interdisciplinary Team
• ½ Teaching beds, ½ covered by GNP
• No IM housestaff geography
• Staff cuts eg. Social work

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Comparisons
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Conclusions

• No reimbursement for GEMU in Non VA Hospitals
• Various models of hospital geriatric care exist,
  some more successful than others
• Local environment/ microsystems
  important-provide comprehensive geriatric
  assessment while treating acute illness without
  prolonging LOS or increasing hospital costs
• Care needs to be disseminated beyond a Unit

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Future directions

• Need to develop a GEM model that provides
  quality care to hospitalized elderly under the
  Medicare Prospective Payment System (PPS)

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Future directions (cont.)

• New clinical programs
• Need to be supported and integrated into existing
  programs
• Prove effective to all stakeholders
• Administration
• Staff
• Patients/families
• Sustainable, change practice, shift
  organizational culture

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Thank You
Eileen H. Callahan MD Medical Director ACE
Unit Brookdale Department of Adult and Geriatric
Medicine AGS-May 11, 2005