(1) Canadian Institute for Health Information, A Focus on Seniors and Aging, 2011; (2) Dhalla et al, Toward Safer Transitions: How Can We Reduce Post-Discharge Adverse Events?, Healthc Q., 2012; (3) http://www.cfhi-fcass.ca/WhatWeDo/ace
ACE Project Coordinator: [email protected] Investigator: [email protected]
● Seniors represent 30% of Emergency Departments (ED) patients in Canada (1). ● Seniors are vulnerable to health system failures and care coordination problems.● Discharge adverse events result in unplanned readmissions and loss of physical,
functional and/or cognitive capacity (2).
● ACE Program at Mount Sinai Hospital (Toronto, Canada) applied strategies which reduced lengths of hospital stay, reduced readmissions, increased patient satisfaction, and saved significant costs.
● Successful dissemination of best practices often remains an exception because human, technical and organizational barriers make context-adaptation difficult.
● Hôtel-Dieu de Lévis Hospital (Lévis, Quebec) is one of the 18 teams across Canada to take part in the ACE Collaborative to support local uptake.
● Adapt ACE program to the local context of a single hospital in Quebec;● Improve care transitions from hospital to home;● Decrease avoidable readmissions (medical units and emergency department).
● Local strategies from ACE program chosen to be implemented:○ Telehealth service;○ Transition coach model;○ Improve communication with community health providers;○ Wiki to facilitate knowledge management and context-adaptation of knowledge.
● Data collection:○ Continuous data collection to capture real-time practice change over 8 months
with 64 patients pre- and 64 post-intervention;○ Inclusion: >50 years; at risk of readmission (modified LACE score);○ Patients data collection at recruitment, 48h and 30 days post-discharge;○ Patient-level outcomes:
■ Functional autonomy (OARS Activities of Daily Living instrument);■ Clinical Frailty Score (CFS);■ Satisfaction with care transition (CTM-3 instrument);■ Quality of life (SF-12 scale);■ Caregiver strain (Caregiver Strain Index);
○ Hospital-level outcomes:■ 30-day post-discharge readmission rate;■ 30-day post-discharge ED visit rate.
Age (years ± SD) 74.4 ± 9.8
Women (%) 39.3
Education (%) Elementary school High school College or university degree
39.335.725.0
OARS (score ± SD) (0-28, independant to very dependant on ADLs/IADLs)
5.8 ± 4.8
CFS (score ± SD) (1-9, very fit to terminally ill)
3.9 ± 1.5
Self-rated health (%) Good to excellent Average Poor to mediocre
3.632.164.3
Figure 1: 30-days readmission rate for >50-years-old patients (29 financial periods from May-2014 to Jul-2016)
Figure 2: ED visit 30-days post-discharge rate for >50-years-old patients (29 financial periods from May-2014 to Jul-2016)
Table 1: Pre-intervention cohort patient characteristics (n=30)
● Growing readmission rate and high ED use among seniors is alarming.● Our context-adapted ACE intervention will be highly relevant to tackle these issues.● However, we still have many issues to deal with:
○ Major health reform that creates large integrated care centers, but that still lacks manpower and information infrastructure to manage change;
○ Overemphasis on confidentiality of information that prevents patients and clinicians from accessing the necessary information to guide timely decision making;
○ Transition coach model needs to be adapted to current lack of human resources;○ Need for more stakeholder buy-in to foster uptake of our local ACE project.
