A mobile version of the Acute Care for Elderly inpatient care model reduced the rate of adverse events and shortened hospital stays, but it didn’t reduce 30-day readmission rates or improve patients’ functional status more than standard care did, according to a single-center cohort study.
The Mobile Acute Care for the Elderly (MACE) program at Mount Sinai Medical Center, New York, thus appears to promote better outcomes in some key areas "for this vulnerable older adult population," said Dr. William W. Hung of the department of geriatrics and palliative medicine at Mount Sinai and his associates in a study published online April 22 in JAMA Internal Medicine (2013 April 22 [doi:10.1001/jamainternmed.2013.478]).
However, compared with usual care, the MACE program did not improve patients’ functional status, reduce 30-day readmission rates, decrease visits to the emergency department within 30 days of hospital discharge, or decrease rates of discharge to a skilled nursing facility, the investigators noted.
Introduced in the 1990s, the Acute Care for Elderly unit is "widely accepted as a prototype model to provide inpatient care for older adults," the study authors noted. The model includes a designated hospital unit with a specially designed environment, interdisciplinary caregivers including geriatricians, and particular attention to discharge planning and the avoidance of adverse events.
However, such units "have not been widely disseminated across institutions, particularly because of barriers to initial setup, including costs, staffing, and space needs," the investigators added.
The MACE model delivers care without requiring a dedicated, physical ACE unit.
This mobile approach allows an interdisciplinary team of geriatricians, social workers, and clinical nurse specialists to care for elderly patients admitted to any unit in the hospital. As with the ACE model, the MACE model focuses on reducing the risks of hospitalization, improving coordination with outpatient practice, and discharge planning.
Dr. Hung and his colleagues conducted a 3-year prospective cohort study to determine whether MACE was associated with improved outcomes. They assessed 173 patients aged 75 years and older who received MACE service when they were admitted to the medical center, and 173 control subjects admitted to the general inpatient medical service during the same period.
The two groups were matched for age, primary diagnosis, and ability to ambulate independently. The mean age of both groups was approximately 85 years; approximately 76% of patients were women, 56% were white, and 35% were Medicaid beneficiaries. Fewer than one-third of both groups were able to ambulate independently.
The primary outcome measure was readmission within 30 days of hospital discharge. On that measure, there was no significant difference between the two groups: 15.4% of the patients in the MACE service required readmission, as did 22.4% of the usual-care group, the researchers said.
Similarly, combined rates of readmission plus emergency department visits within 30 days did not differ significantly, at 20.8% for the MACE service and 25.6% for usual care.
Functional status at 30 days also did not differ. Mean scores were similar between the MACE patients and the usual-care patients on two separate measures of the ability to perform basic activities of daily living.
Similarly, overall health status at 30 days, as measured using the Patient Reported Outcomes Measurement Information Systems (PROMIS) 10-item instrument, was not significantly different between the two study groups.
However, the rate of in-hospital adverse events such as falls, bed sores, the need for restraints, and catheter-associated urinary tract infections was significantly lower in the MACE group (9.5%) than in the usual-care group (17.0%).
The adjusted mean length of stay was 0.8 days shorter for the MACE group than for the usual-care group. But discharge destination was similar between the two groups, with 24.9% of the MACE group and 22.5% of the usual-care group requiring discharge to a skilled nursing facility.
Patients in the MACE service were much more likely to report that their caregivers discussed post-discharge care with them (92.2%), compared with those in the usual-care group (67.6%).
Patient satisfaction with care was greater with the MACE service than with usual care on one instrument, the three-item Care Transition Measure. But it was no different on another instrument, the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS).
The study may have been subject to selection bias, the investigators noted, because the patients in the MACE service were also receiving their primary care at a geriatric-based practice rather than in a general practice. Also, the investigator who reviewed the medical records for adverse events was not blinded to the patients’ group assignment.
Given the constraints that limit hospitals’ adoption of the ACE unit model, the MACE model "may be a viable alternative, because it can be seamlessly integrated in a hospital’s work flow without the requirement for a dedicated unit," the investigators concluded.