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J Am Geriatr Soc. Author manuscript; available in PMC 2023 Oct 1.
Published in final edited form as:
J Am Geriatr Soc. 2022 Oct; 70(10): 3012–3020.
Published online 2022 Jun 6. doi:10.1111/jgs.17892
PMCID: PMC9588489
NIHMSID: NIHMS1808959
PMID: 35666631
Stephanie E. Rogers, MD, MS, MPH,a Kellie L. Flood, MD,b Qiao Yu Kuang, MPH,a James D. Harrison, MPH PhD,c Michael L. Malone, MD,d Julia Cremer, MD,a and Robert M. Palmer, MD, MDHe
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The publisher's final edited version of this article is available at J Am Geriatr Soc
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- Supplementary Materials
Abstract
Background:
The clinical benefits of Acute Care for Elders (ACE) units have been established for over 25 years. However, how widely disseminated ACE units are in the United States and the degree of fidelity to the key elements of this model of care are unknown. Our objective was to identify all existing ACE units in the United States and to obtain detailed information about variations in implementation.
Methods:
The strategy to identify current ACE units began with online searches and snowball sampling using contacts from professional societies and workgroups. Next, a request for information regarding the existence of ACE units was sent to the remaining US hospitals listed in a national hospital database. An online survey was sent to identified ACE unit contacts to capture information on implementation characteristics and the five key elements of ACE units.
Results:
There were 3692 hospitals in the database with responses from 2055 (56%) hospitals reporting the presence or absence of an ACE unit. We identified 68 hospitals (3.3%) with an existing or previous ACE unit. Of these 68 hospitals, 50 (75%) completed the survey and reported that 43 ACE units were currently open and 7 had been closed. Of the 43 currently open ACE units, most are affiliated with an academic hospital and there is variable implementation of each of the five key ACE elements (from 70–98%).
Conclusions:
Among the 50 hospitals to complete the survey, 43 current ACE units were identified, with variable fidelity to the key elements. Estimates of prevalence of ACE units and fidelity to key elements are limited by non-responses to the national survey request by nearly half of hospitals.
Keywords: Acute Care for Elders units, ACE units, Geriatrics Models of Care, Hospitalized Older Adults, Age-Friendly Health Systems
Introduction:
The Acute Care for Elders (ACE) unit is an evidence-based model of care designed to reduce incidence of functional decline for older adults during hospitalizations.1,2 Two randomized-controlled trials demonstrate significantly greater independence in performance of activities of daily living (ADLs) in patients aged 70 or above who are admitted to the ACE unit compared to similar patients admitted to usual care.1,3 In addition, patients on ACE units compared to usual care, are more likely to have shorter length of hospital stay and reduced costs.4,5 Given that hospitalizations for older adults are increasing,6 ACE units or the implementation of its key elements have the potential to improve quality and safety of care for older hospitalized adults. Five key elements of an ACE unit include:7
Patient-centered care assessment conducted by an interdisciplinary team (IDT) with protocols to assess, restore or maintain physical functioning: activities of daily living (ADLs), mobility, continence, nutrition, skin integrity, mood, sleep and or cognition.
Medical care review to optimize medication management, assure patient safety and medical standards of care.
A specialized prepared environment (environmental modifications to facilitate patients’ physical and cognitive functioning).
Early mobilization/physical therapy with the advice or consultation of physical and/or occupational therapists in the daily team meetings that focuses on preventing functional decline or restoring the patient’s independence in performance of ADLs and mobility.
See AlsoAcute Care for Elders (ACE) Tracker and e-Geriatrician: Methods to Disseminate ACE Concepts to Hospitals with No Geriatricians on StaffMastering Acute Care Charting: 2023 UpdatesImproving Hospital Care for Older Adults through Acute Care for Elders (ACE Units): Kellie Flood and Stephanie RogersEarly planning by the IDT for discharge to home (activities to facilitate return to the community).
Little is known about the extent of dissemination of ACE units in the United States, and their fidelity to the five key elements, including variations in the structure of clinical operations, staffing, patient population, and implementation challenges. Given that different health systems have unique environments, the ACE unit model may be implemented in a variety of ways that align with the goals, resources, and characteristics of each institution. Information about the variety of ways the ACE unit model is implemented could be helpful to health systems that are planning to create, or sustain, an ACE unit. This cross-sectional descriptive study aims to identify all known ACE units in the United States and describe the variations in their implementation of the five key elements of an ACE unit.
Methods:
Study design, participants, and oversight
We conducted a cross-sectional study that involved surveying clinicians, nurses and healthcare administrators from ACE units in the United States. This study was approved by the University of California San Francisco Institutional Review Board (#19–29802).
Sampling strategy
To identify potential survey respondents from ACE units in the United States we employed the following systematic processes: we initially used purposeful sampling and contacted individuals known to the study team through personal knowledge, professional contacts, and professional workgroups (including the American Geriatrics Society’s Acute Care Special Interest Group with 112 professional members).8 Then, using snowball sampling methods,9 these individuals were asked to send the names and contact details of other known potential ACE unit leaders in a repeating pattern until known ACE units were saturated. We then used the Definitive Healthcare Database (https://www.definitivehc.com/data-products/hospital-view), which offers the most comprehensive and up-to-date data on United States hospitals, to identify the names of remaining hospitals that lacked a potential survey contact. For each hospital, we used publicly available information (e.g., hospital websites and/or phone numbers) to identify the contact details of up to three geriatricians, internists, or other geriatrics specialists who were contacted by email. These providers were chosen on the assumption that they would know if there was an ACE unit at their hospital and, if so, be able to complete the survey or identify a contact who could. Non-responders to our initial email request received three reminder e-mails or phone calls within a six-month range (at variable intervals due to COVID-19 surges). There were no exclusion criteria for invitation or participation of hospitals.
Survey development
A study-specific survey was developed, consistent with academic research guidelines,10 to assess the research question of the prevalence and structure of ACE units. Survey questions were informed by reviewing literature on ACE units5,7,11–16 in consultation with a multidisciplinary team of geriatricians, nurses, researchers, and implementation scientists. Five experts, consisting of geriatricians and nurse specialists who work on ACE units, pre-tested the piloted survey, and provided informal feedback for improvement. The final survey instrument (Supplemental Material S1) captured information on ACE unit characteristics (years of operation, number of beds, number of patients cared for, admission criteria, staffing, and use of routine assessments or protocols). The survey instrument included fixed choice, multiple choice, and open-ended responses. Surveys were disseminated to all identified contacts during a 6-month period between December 2020 and June 2021 using the online platform Qualtrics (Provo, UT). Three reminders were sent to non-responders via email in two-week intervals. Three survey respondents’ names were drawn randomly to receive a $100 Amazon® gift card to incentivize responses. Survey responder names were kept anonymous to the entire research team except for one research assistant (author QYK).
Analysis
We used descriptive statistics to summarize quantitative data. Responses to open-ended questions were analyzed using content analysis.17 Two reviewers (QYK and JDH) independently performed open coding to identify and categorize data. Reviewers met to confirm coding categories and any discrepancies were resolved using negotiated consensus.18 Survey responses for reliability and validity were not assessed.
Results:
Number and types of ACE units:
Of the 3,692 hospitals in the database, contacts from 2055 (56%) hospitals responded and 1637 (44%) did not respond. More responses were from urban sites compared to rural sites (75% versus 25%), but there was no difference between responders and non-responders to the survey invitation related to the mean number of staffed beds. We identified 68 hospitals (3.3%) with an existing or previous ACE unit, with completed surveys from 50 of the 68 (75%) ACE unit contacts. We found that 7 (14%) of these ACE units have closed, while 43 (86%) of ACE units remain operational (Figure 1). Survey respondents were ACE unit medical directors (27), ACE unit clinicians (6), ACE unit nurse managers (3), Geriatrics chiefs (3), or another person associated with the ACE unit (4).
Figure 1.
ACE Units Identified and Surveyed
ACE (Acute Care for Elders)
Demographics and characteristics of ACE units:
The majority of the 43 currently open ACE units are in an urban area (42, 98%) with 19 (44%) located in the northeast, 9 (21%) in the south, 8 (19%) in the Midwest, and 6 (16%) in the western regions of the United States. Table 1 shows affiliation status, yearly patient volume and average daily patient census of these ACE units. About half (21) of the ACE units have opened in the past 10 years (years 2012–2021). Thirty-six (84%) existing ACE programs reported also having Nurses Improving Care for Healthsystem Elders (NICHE) engagement in their hospital and 30 (70%) programs reported being involved in the National Age-Friendly Health System initiative.19,20
Table 1:
Characteristics of Open ACE Units at the Time of Survey (n=43)
| n (%) | |
|---|---|
| Affiliation | |
| Academic medical center | 29 (67) |
| Community hospital | 8 (19) |
| Integrated health system | 3 (7) |
| Public or safety net hospital | 3 (7) |
| Volume >1000 patients annually | 12 (37) |
| Average daily census | 18 (range 5–39) |
| Use of Age-based inclusion/admission criteria | 32 |
| ≥ 50 years | 1 (3) |
| ≥ 65 years | 23 (72) |
| ≥ 70 years | 4 (13) |
| ≥ 72 years | 1 (3) |
| ≥ 75 years | 3 (9) |
| Use of Other inclusion/admission criteria | |
| Cognitive or functional ability | 13 (38) |
| Community dwelling | 10 (29) |
| Frailty status | 5 (12) |
| Certain medical diagnosis | 3 (9) |
| Exclusion criteria | |
| Admitted from long-term care | 5 (12) |
| End of life or on comfort care protocols | 5 (12) |
| Patient is total care or has a low rehabilitation Potential | 7 (16) |
| Severe dementia | 4 (9) |
| Primary psychiatric issue | 3 (7) |
| Excluding a specific admitting team | 3 (7) |
| Funding sources (partial or full sources) | |
| Hospital or Health System | 36 (84%) |
| Billing Reimbursem*nts | 12 (28%) |
| Philanthropy | 3 (7%) |
| Grants | 1 (2%) |
Open in a separate window
Three main themes emerged when the survey asked responders how the ACE unit fits into the overall context of care for older patients in their hospital. The most common theme was that the ACE unit is the place in the hospital to pilot clinical workflows or other inpatient models of care for older adults that could be used on other units. Secondly, in many hospitals, it is also the primary location for geriatrics interdisciplinary education, research, and quality improvement projects. Finally, many hospitals used the geriatrics-trained ACE staff and ACE key elements to help other units or departments become “Age-Friendly” (for example, an Emergency Department that gained Geriatrics certification).
Patient characteristics:
Most ACE units select patients using an inclusion criterion (34, 79%). Age was the most common inclusion criterion used at almost all units (32, 94%). Table 1 shows the age cut off distributions as well inclusion criteria used to admit patients to the ACE units. Some (17, 40%) ACE units included an exclusion criterion (Table 1).
Funding and staffing:
Funding sources for surveyed ACE units are shown in Table 1. Most ACE units are staffed by hospitalists (19, 44%); some use geriatricians (10, 23%) and the rest use a mix of both (14, 33%) (Figure 2). Each ACE unit has an average of 1.5 full-time equivalent (FTE) providers (whether physician or advanced-care provider (APP) for their ACE program (range 0.1– 4+). Nearly half of the ACE units use advanced-care providers as part of this total FTE (most using 1.0 FTE for an APP and 0.5 FTE for a physician). Given the average daily census for units is 18, we calculate that this approximates 0.08 provider FTE is provided daily per patient. ACE units reported the average staff to patient ratios for the following interdisciplinary roles in their units: Registered nurse: patient 5:1 (range 3–8:1), physical therapist: patient 18:1 (range 0–39:1), occupational therapist: patient 18:1 (range 0–40:1), case manager: patient 19:1 (range 0–35:1), social worker: patient 21:1 (range 0–40:1).
Figure 2.
Percent of Surveyed ACE Units that have each Interdisciplinary Team Member Type at ACE Rounds
ACE (Acute Care for Elders)
**Includes patient aids, Geriatrics Clinical Nurse Specialists, music or art therapists, recreational therapist or restorative aid, medical director, palliative care providers or nurses, charge nurses, community partners, hospital flow personnel, or learners.
Operations:
ACE units have a mean average of 25 beds on the unit (range 6–44). In a quarter of these units (11, 26%), all beds on the unit are designated for ACE patients. In 25 of the surveyed ACE units (58%), the beds designated for ACE patients is a changing number based on hospital need. Most ACE units (35, 81%) have ACE IDT rounds 5 days a week; 4 ACE units (9%) have them 7 days a week; and 4 ACE units round the following number of days a week: three days (1, 2%), two days (1, 2%), one day a week (1, 2%), and no IDT rounds (1, 2%). For the 42 units (98%) that hold IDT rounds, a variety of team members are present (Figure 2). Most IDT rounds take place with team members in a rounding room (35, 83%), but depending on the day this location or structure can change even within a single hospital. Other ways of completing IDT rounds at times include at the bedside of the patient (5, 12%), virtual meeting (pre-COVID-19) (4, 10%), phone meeting (3, 7%), via a template or form that each team member completes on their own (3, 7%), or outside patient rooms (2, 5%).
Structure and elements of ACE units:
We asked respondents if each of the five key elements exist in their ACE unit and if so, to provide more details for each. We found that only 17 (40%) of surveyed ACE units have all 5 key elements, 12 (28%) have 4 elements, 10 (24%) have 3 elements, 3 (7%) have 2 elements, and 1 ACE unit (2%) has only 1 key element. The percent of surveyed ACE units with each ACE key element is shown in Figure 3 along with the top three ways this element is utilized.
Figure 3.
Percent of Surveyed ACE Units with each ACE Key Component (and Top 3 Examples Utilized)
ACE (Acute Care for Elders)
ADL (Activities of Daily Living)
D/C (Discharge)
IADL (Instrumental Activities of Daily Living)
Meds (Medications)
Recs (Recommendations)
Rehab (Rehabilitation)
PT/OT (Physical Therapy/Occupational Therapy)
Perceived challenges to ACE unit sustainability:
Of the 50 hospitals with an ACE unit who completed the survey, we learned that 7 ACE units had closed. The average length of time these units were open for varied: Three (43%) were open for longer than 6 years, three (43%) were open from 4–6 years, and one (14%) was open for 1–3 years. Respondents thought the strongest factors behind the closing of the ACE unit were lost commitment from hospital administration (2, 29%), the ACE service was not reliably used (2, 29%), the loss of physical space for other services (1, 14%), strategic changes in hospital priorities (1, 14%), and ACE elements were expanded to the entire hospital (1, 14%). Additional factors that impacted the sustainability of ACE units reported anecdotally by respondents can be categorized into the following: 1) Turnover in leadership: when hospital leaders who are ACE advocates or ACE unit leaders leave or change positions, enthusiasm wanes; 2) Lack of data: the challenge to provide hospital leadership with data to demonstrate benefits on quality measures or return on investment of the ACE unit; and 3) Replacement of the ACE unit by expansion of revenue-generating services (e. g., transplant).
Discussion:
We identified only 43 open ACE units in the United States and of these 67% reported incorporating at least four of the five original core elements of the ACE unit model of care.2,7 The majority are in urban settings (98%), in academic health systems (67%), with almost half located in the northeastern region of the US, and are usually funded by the hospital or health system (84%). These ACE units care for an average of 18 older adults a day (range 5–29) with an average nurse to patient staffing ratio of 5:1. Many are affiliated with NICHE (84%) and Age-Friendly Health System programs (70%) in their hospitals.
To our knowledge this is the first study to systematically assess the prevalence of ACE units in the United States and to describe the variations that currently exist in the implementation and operations. The only previous study surveying known ACE units included only those affiliated with US medical schools.13 In this study, out of the 100 medical schools surveyed, there were 16 ACE units. Many of the findings of this study were similar to ours: the majority were in urban settings (75%) and in academic hospitals (63%), with the majority located in the northeast region of the United States (63%). Those ACE units had a similar average daily census (range 10–20) and similar nurse: patient staffing ratios (6:1). This study did not assess the fidelity to key elements of ACE units.
The strengths of our study include the rigorous and systematic effort to identify and contact stakeholders at every US hospital in the database that included community, academic, and Veterans Affairs (VA) hospitals to determine actual prevalence of ACE units in the United States. We used professional contacts and society, online searches, and multiple attempted contacts with Geriatrics or Internal Medicine professionals at every hospital in the database. For those contacts from ACE units who responded to our survey, we have been able to capture valuable information on ACE unit structures and operational characteristics, including the use of routine geriatric assessments or protocols, from medical professionals closely associated with the operations of each ACE unit.
However, our study has several limitations. Despite exhaustive efforts to contact the appropriate stakeholders at every hospital, 44% of hospitals did not respond to multiple communication attempts. Thus, it is possible that more ACE units and related programs exist that are not captured in our data. Although we only received confirmed contact from 56% of hospitals in the database, the known presence of 68 currently open or past ACE units in the United States is likely accurate given the scoping survey methodology. The survey was conducted during the winter 2020 surge of the COVID-19 pandemic, which may have prevented some leaders of existing ACE units from responding. In addition, all responses were by self-report of someone affiliated with their ACE unit. Those who responded may not necessarily be the program leader or implementer, possibly limiting the accuracy of their responses. Reliability and validity of survey responses was not feasible as there was no external objective method for assessing them. Finally, we do not know why there are so few ACE units in the United States as we did not assess barriers to implementation in hospitals where an ACE unit did not exist.
Our finding of a low presence of ACE units in US hospitals (3.3%) is interesting given the large number of studies documenting their positive impact on quality and cost indicators.1–5,12,14–16 Barriers to dissemination of ACE units might include, among others, a lack of a geriatrician or other champion to serve as program leader, lack of a geriatric trained workforce, perceived lack of financial benefit, and demand for hospital beds for other patient populations.13,21,22 These barriers mirror the anecdotes reported by respondents in this study to explain the closure of their local ACE unit.
However, on a positive note, about half of current ACE units have opened in the past decade despite the barriers to dissemination of ACE units; and national initiatives that support best practices for older adults in hospital health systems are complementing elements of ACE. Examples of national organizations leading these efforts include, among others, Nurses Improving Care for Healthsystem Elders (NICHE), Age-Friendly Health Systems initiatives, the American Geriatrics Society’s Co-Care Programs for the Hospital Elder Life Program (HELP) and Orthopedics co-management, American College of Surgery’s Geriatric Surgery Verification Program, and the Geriatric Emergency Department (ED) Accreditation Program.19,20,23–25 The 4 M’s framework (Mentation, Mobilization, Medications and what Matters), provides an opportunity to deliver high-quality care to older adults in all settings.26,27 Each of these 4M’s is mirrored in an ACE unit’s key elements.28,29 The 4M’s in the acute hospital setting is implemented by the interdisciplinary team in the specialized environment of an ACE unit.28,29 Despite the lack of ACE unit dissemination in US hospitals currently, there are growing opportunities for hospitals to design systems using key elements of ACE to improve care of all hospitalized older adults.
Key points
Currently, there are 43 known Acute Care for Elders (ACE) units in the United States.
67% of current ACE units report having at least four of the five original key elements of the ACE unit model of care.
Why does this paper matter?
This study is the first to use rigorous criteria to define and measure the prevalence of ACE units in hospitals the United States. Despite extensive research, with effectiveness established by randomized-controlled trials, dissemination of ACE units is currently limited to 43 hospitals.
Supplementary Material
supinfo
Supplementary Material S1. ACE survey
Click here to view.(360K, pdf)
Acknowledgements:
We thank Alanna Bush, Anika Kumar, Martha Lecklinski, Sara Suhl, and especially Karen Yuan for their work contacting hospitals to find ACE units. We are grateful to Kathleen Stark (moc.liamg@krats.r.neelhtak) who designed figures 2 and and33 and to Dr. William (James) Deardorff for his thoughtful suggestions. Ms. Kuang and Drs. Rogers, Flood, Harrison, Malone, Cremer, and Palmer had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure:
Qiao Yu Kuang was funded as a research assistant through the John A. Hartford foundation for purposes of doing this study. James Harrison is supported by the National Institute of Aging of the National Institutes of Health under Award Number K01AG073533 and the National Center for Advancing Translational Sciences of the NIH under Award Number KL2TR001870. Michael Malone owns stock in Abbott Labs and AbbVie. Dr. Flood is a consultant for the University of North Texas Health Science Center at Fort Worth Geriatric Practice Leadership Institute and Dr. Rogers is a consultant for Asante Health System’s Age-Friendly Health System in Medford, Oregon.
Sponsor’s Role:
John A. Hartford Foundation funded a research assistant for this project and their program officers were among sources that were asked for their interpretation of the results.
Funding:
John A. Hartford Foundation funded a research assistant for this project. James Harrison is supported in part by the National Institute of Aging of the National Institutes of Health under Award Number K01AG073533 and the National Center for Advancing Translational Sciences of the NIH under Award Number KL2TR001870.
Footnotes
Conflict of Interest: The authors have no conflict of interests.
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