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
Abstract
BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization. OBJECTIVE: To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: A total of 1531 community‐dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997. INTERVENTION: ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient‐centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness. MEASUREMENTS: The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction. RESULTS: Self‐reported measures of function did not differ at discharge between the intervention and usual care groups by intention‐to‐treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05). CONCLUSIONS: ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.
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Studies in bed-ridden hospitalized elders have demonstrated a clear negative relationship between bed rest and functional capacity.
“Although some performance measures (e.g., 5-min walk, 50-ft walk, 5-step test, functional reach, and floor transfer), may not be sensitive enough to detect change in a small cohort of study volunteers following short periods of bed rest [22], studies in bed-ridden hospitalized elders have demonstrated a clear negative relationship [4,23,24].”
From Protecting muscle mass and function in older adults during bed rest (2010) · cites this paper as [24]
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“Heart disease, n (%) 72 (57) 69 (54) Infectious disease, n (%) 20 (16) 25 (20) Gastrointestinal disease, n (%) 22 (17) 15 (12) Cerebrovascular disease, n (%) 38 (30) 28 (22) Endocrine disease, n (%) 24 (19) 21 (17) Airway disease, n (%) 17 (13) 12 (9) Cancer, n (%) 12 (9) 10 (8) Psychiatric disorder,* n (%) 48 (38) 9…”
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“Frail geriatric populations requiring hospitalization have also benefited from a programmatic approach to inpatient care (32) and rehabilitation postdischarge.”
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Kosse, N. M., Dutmer, A. L., Dasenbrock, L., Bauer, J. M., & Lamoth, C. J. C. (2013) · BMC Geriatrics · doi:10.1186/1471-2318-13-107 · Cited by 156 · see citing works
“Sager MA, Franke T, Inouye SK, Landefeld CS, Morgan TM, Rudberg MA, Sebens H, Winograd CH: Functional outcomes of acute medical illness and hospitalization in older persons.”
BackgroundInfluentialFox, M. T., Persaud, M., Maimets, I., Brooks, D., O’Brien, K. K., & Tregunno, D. (2013) · BMC Geriatrics · doi:10.1186/1471-2318-13-70 · Cited by 147 · see citing works
“Early discharge planning was defined by interventions during the acute phase of illness or injury to facilitate transition of care back to the community [14].”
BackgroundSalonen, H., Lahtinen, M., Lappalainen, S. K., Nevala, N., Knibbs, L. D., Morawska, L., & Reijula, K. E. (2013) · Intelligent Buildings International · doi:10.1080/17508975.2013.764838 · Cited by 146 · see citing works
“…Grant 1993; Horton 1997; Harris 2000), ease of walking, a probable reduction in falls and resultant injuries, a feeling of safety (Willmott 1986; Counsell et al. 2000; Harris 2000; Joseph 2006b), improved personal comfort (psychological and thermal comfort) (Weinhold 1988; Radke 1997), longer…”
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“Several community hospitals in Norway are comparable with community hospitals in England [7,8] and general practitioners hospitals in Holland [23] where some studies have explored their appropriateness [11,12,22-25].”
BackgroundHospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial
Levine, D. M., Ouchi, K., Blanchfield, B. B., Diamond, K. G. A., Licurse, A. M., Pu, C. T., & Schnipper, J. L. (2018) · Journal of General Internal Medicine · doi:10.1007/s11606-018-4307-z · Cited by 140 · see citing works
“21 Picker questionnaire (0–15), median (IQR) 15 (4) 13 (4) 0.”
Sands, L. P., Yaffe, K. S., Covinsky, K. E., Chren, M., Counsell, S. R., Palmer, R. M., Fortinsky, R. H., & Landefeld, C. S. (2003) · The Journals of Gerontology Series A · doi:10.1093/gerona/58.1.m37 · Cited by 137 · see citing works
“A prior study that was restricted to patients from Akron City Hospital also confirmed that the intervention did not affect ADL, IADL, and mobility outcomes through 3 months after discharge (18).”
MethodSelf-citationGregorevic, K. J., Hubbard, R. E., Katz, B., & Lim, W. K. (2016) · BMC Geriatrics · doi:10.1186/s12877-016-0292-4 · Cited by 139 · see citing works
“A new need for residential care has also been used as a marker of functional decline [25].”
MethodBuurman, B. M., Munster, B. C. V., Korevaar, J. C., de Haan, R. J., & de Rooij, S. E. (2010) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2010.07.005 · Cited by 134 · see citing works
“11 Landefeld [10] 1995 Medical 651 80 Katz ADL Admission Discharge Patient or proxy 12 Inouye [25] 1998 Medical 727 79 Katz ADL Premorbid Discharge Professional 13 Counsell [9] 2000 Medical 1,531 80 Katz ADL Premorbid Discharge Patient or proxy”
BackgroundThe effect of health care working conditions on patient safety.
Hickam, D. H., Severance, S. M., Feldstein, A. C., Ray, L. U., Gorman, P., Schuldheis, S., Hersh, W., Krages, K. P., & Helfand, M. (2003) · PubMed Central · Cited by 127 · see citing works
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Acute Care for Elders Components of Acute Geriatric Unit Care: Systematic Descriptive Review
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Healthcare professionals’ views on patient-centered care in hospitals
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“As patient satisfaction, resulting from PCC, has been shown to be associated with treatment compliance, such efforts may then contribute to better health outcomes, reduced readmissions and consultations, and, consequently, reduced healthcare costs [32–36].”
BackgroundAvelino‐Silva, T. J., Farfel, J. M., Curiati, J. A. É., Amaral, J. R., Campora, F., & Filho, W. J. (2014) · BMC Geriatrics · doi:10.1186/1471-2318-14-129 · Cited by 117 · see citing works
“are essential to return patients to independence [53,54].”
BackgroundSystematic Review of Interdisciplinary Interventions in Nursing Homes
Nazir, A., Unroe, K. T., Tegeler, M., Khan, B. A., Azar, J., & Boustani, M. A. (2013) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2013.02.005 · Cited by 116 · see citing works
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Self-citationOrganizational Interventions to Improve Health Outcomes of Older Persons
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Sensory environment on health-related outcomes of hospital patients
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Impact of a Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults
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Prediction of Recovery, Dependence or Death in Elders Who Become Disabled During Hospitalization
Barnes, D. E., Mehta, K. M., Boscardin, W. J., Fortinsky, R. H., Palmer, R. M., Kirby, K. A., & Landefeld, C. S. (2012) · Journal of General Internal Medicine · doi:10.1007/s11606-012-2226-y · Cited by 99 · see citing works
Self-citationThe Acute Care for Elders Unit Model of Care
Palmer, R. M. (2018) · Geriatrics · doi:10.3390/geriatrics3030059 · Cited by 100 · see citing works
“Eligible patients were identified in the emergency department and 1531 patients were enrolled in the study [41].”
BackgroundSelf-citationThe Geriatric Floating Interdisciplinary Transition Team
Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E. K., Boult, C., Eubank, K. J., & Durso, S. C. (2010) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2009.02682.x · Cited by 97 · see citing works
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“Five of them did not show any increase in costs (9, 48, 49, 56), while three concluded that the intervention was cost effective (45, 54, 56).”
InfluentialIncontinence in the Frail Elderly
Fonda, D., Ce, D., Harari, D., Ouslander, J., Palmer, M. H., & Roe, B. H. (2005) · Edge Hill University Research Information Repository (Edge Hill University) · Cited by 94 · see citing works
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Nursing staff perceptions of physical function in hospitalized older adults
Boltz, M. P., Capezuti, E., & Shabbat, N. (2010) · Applied Nursing Research · doi:10.1016/j.apnr.2010.01.001 · Cited by 93 · see citing works
Going home better not worse: Older adults' views on physical function during hospitalization
Boltz, M. P., Capezuti, E., Shabbat, N., & Hall, K. (2010) · International Journal of Nursing Practice · doi:10.1111/j.1440-172x.2010.01855.x · Cited by 91 · see citing works
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From Research to Reality: Minimizing the Effects of Hospitalization on Older Adults
Admi, H., Shadmi, E., Baruch, H., & Zisberg, A. (2015) · Rambam Maimonides Medical Journal · doi:10.5041/rmmj.10201 · Cited by 92 · see citing works
Hassett, L. M., van den Berg, M., Lindley, R. I., Crotty, M., McCluskey, A., van der Ploeg, H. P., Smith, S., Schurr, K., Killington, M., Bongers, B., et al. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-012074 · Cited by 90 · see citing works
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Effect of strength training on muscle function in elderly hospitalized patients
Suetta, C., Magnusson, S. P., Beyer, N., & Kjær, M. (2007) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/j.1600-0838.2007.00712.x · Cited by 87 · see citing works
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“The other explains improvements in usual care as the main cause for the lack of significant results.(27) It is also possible that usual care was contaminated by the intervention in the majority of studies, which may have influenced the ability to show positive effects.”
BackgroundFlood, K. L., Carroll, M. B., Le, C. V., & Brown, C. J. (2009) · The American Journal of Geriatric Pharmacotherapy · doi:10.1016/j.amjopharm.2009.05.002 · Cited by 85 · see citing works
Evaluation of the Mobile Acute Care of the Elderly (MACE) Service
Hung, W. W., Ross, J. S., Farber, J., & Siu, A. L. (2013) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2013.478 · Cited by 82 · see citing works
Grimmer, K. A. (2004) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzh071 · Cited by 82 · see citing works
The Aging Muscle in Experimental Bed Rest: A Systematic Review and Meta-Analysis
Girolamo, F. G. D., Fiotti, N., Milanović, Z., Situlin, R., Mearelli, F., Vinci, P., Šimunič, B., Pišot, R., Narici, M. V., & Biolo, G. (2021) · Frontiers in Nutrition · doi:10.3389/fnut.2021.633987 · Cited by 82 · see citing works
Bogardus, S. T., Desai, M. M., Williams, C. S., Leo-Summers, L. S., Acampora, D., & Inouye, S. K. (2003) · The American Journal of Medicine · doi:10.1016/s0002-9343(02)01569-3 · Cited by 80 · see citing works
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Chen, Z., Ding, Z., Chen, C., Sun, Y., Jiang, Y., Liu, F., & Wang, S. (2021) · BMC Geriatrics · doi:10.1186/s12877-021-02319-2 · Cited by 84 · see citing works
“…follow up 12 months; at follow up 24months) Covinsky 1997 [41] √ (90 days after dischargeǂ) √ (Discharge) Caregiver burden: The Robinson Caregiver Strain Index ǁ Asplund 2000 [42] √ (Discharge) Counsell 2000 [43] √ (Discharge) Cohen 2002(unit) [44] √ (Discharge; 12 months after…”
Improving Health Care for Older Persons
Landefeld, C. S. (2003) · Annals of Internal Medicine · doi:10.7326/0003-4819-139-5_part_2-200309021-00008 · Cited by 78 · see citing works
“In a second randomized trial, Counsell and colleagues (18) demonstrated substantial improvements in several processes of care (for example, reductions in restraint use, days to discharge planning, and prescription of high-risk medicines) as well as improvements in satisfaction of 5% for patients and families, 20% for…”
BackgroundSelf-citationMalone, M. L., Vollbrecht, M., Stephenson, J., Burke, L. J., Pagel, P., & Goodwin, J. S. (2010) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2009.02624.x · Cited by 73 · see citing works
“This effort started with a retrospective chart review of the quality of care of older patients on a medical unit.(5) A team of software programmers, geriatricians, nurses, and pharmacists then defined several quality measures of care that formed the basis of a real-time report of the quality of care for older patients.”
BackgroundCapezuti, E., Boltz, M. P., Cline, D. D., Dickson, V. V., Rosenberg, M., Wagner, L. M., Shuluk, J., & Nigolian, C. (2012) · Journal of Clinical Nursing · doi:10.1111/j.1365-2702.2012.04259.x · Cited by 73 · see citing works
“Further, units with specialised care models focused on older adults, such as Acute Care of the Elderly (ACE) units, have demonstrated better outcomes than units that do not have specialised care models (Counsell et al. 2000).”
BackgroundPalleschi, L., Alfieri, W. D., Salani, B., Fimognari, F. L., Marsilii, A., Pierantozzi, A., Cioccio, L. D., & Zuccaro, S. M. (2011) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2010.03239.x · Cited by 71 · see citing works
“Because of its observational nature, this study is not comparable with previous randomized trials that have suggested the superiority of geriatric interventions over those provided in standard medical units.(2,4,6) In this nonrandomized, ‘‘real world’’ observation, the persons admitted to geriatric units were frailer…”
A Clinical Index to Stratify Hospitalized Older Adults According to Risk for New‐Onset Disability
Mehta, K. M., Pierluissi, E., Boscardin, W. J., Kirby, K. A., Walter, L. C., Chren, M., Palmer, R. M., Counsell, S. R., & Landefeld, C. S. (2011) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2011.03409.x · Cited by 72 · see citing works
“The demographic, clinical, and functional characteristics of study participants enrolled were similar to those of people not enrolled.(20) The original prospective studies included 1,632 participants at one site and 1,531 at the second site.”
BackgroundMethodResultInfluentialSelf-citationSaltvedt, I. T., Spigset, O., Ruths, S., Fayers, P. M., Kaasa, S., & Sletvold, O. (2005) · European Journal of Clinical Pharmacology · doi:10.1007/s00228-005-0046-2 · Cited by 73 · see citing works
“[30], the number of inappropriate drugs according to Beers’ criteria was not statistically significantly reduced, probably both because these criteria were not part of daily practice in the GEMU and because there are national differences in prescribing patterns [47].”
BackgroundThe Clinical Care of Frail, Older Adults
Ko, F. (2010) · Clinics in Geriatric Medicine · doi:10.1016/j.cger.2010.08.007 · Cited by 73 · see citing works
Heldmann, P., Werner, C., Belala, N., Bauer, J. M., & Hauer, K. A. (2019) · BMC Geriatrics · doi:10.1186/s12877-019-1201-4 · Cited by 72 · see citing works
“…Control: Usual care eating), Lawton IADL scale (shopping, cooking, performing household chores, using transportation, managing money, managing medication, and using the telephone) MOB: 5-items hierarchical mobility scale ACE: Mortality Counsell 2000 [48] USA n = 1531 Mean age: 80 yrs.”
InfluentialReduction of functional deterioration during hospitalization in an acute geriatric unit
Rodriguez, M. A. Z., Salinas, R., & Baztán, J. J. (2007) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2007.09.008 · Cited by 71 · see citing works
Hazards of Hospitalization: Residence Prior to Admission Predicts Outcomes
Friedman, S. M., Mendelson, D. A., Bingham, K. W., & McCann, R. M. (2008) · The Gerontologist · doi:10.1093/geront/48.4.537 · Cited by 69 · see citing works
“These findings are particularly important, because previous interventions for hospitalized older adults, such as geriatric evaluation units and ACE units (Counsell et al., 2000), have specifically targeted community-dwelling populations.”
BackgroundMabire, C., Dwyer, A. A., Garnier, A., & Pellet, J. (2017) · Journal of Advanced Nursing · doi:10.1111/jan.13475 · Cited by 69 · see citing works
“NDP = Nursing Discharge Planning [Colour figure can be viewed at wileyonlinelibrary.com] United States (n = 5), (Arbaje et al., 2010; Counsell et al., 2000; Dedhia et al., 2009; Koehler et al., 2009; Naylor, Brooten, Campbell, Maislin, & Schwartz, 2004), Australia (n = 3) (Carrington et al., 2013;…”
BackgroundMudge, A., Laracy, S., Richter, K., & Denaro, C. P. (2006) · Internal Medicine Journal · doi:10.1111/j.1445-5994.2006.01135.x · Cited by 68 · see citing works
Reducing Functional Decline in Hospitalized Elderly
Kleinpell, R. M., Fletcher, K., & Jennings, B. M. (2008) · Europe PMC (PubMed Central) · Cited by 66 · see citing works
Matzen, L. E., Jepsen, D. B., Ryg, J., & Masud, T. (2012) · BMC Geriatrics · doi:10.1186/1471-2318-12-32 · Cited by 65 · see citing works
“However, they were representative of a typical case-mix population admitted to an acute geriatric department [13-17].”
BackgroundSands, L. P., Yaffe, K. S., Lui, L., Stewart, A., Eng, C., & Covinsky, K. E. (2002) · The Journals of Gerontology Series A · doi:10.1093/gerona/57.7.m449 · Cited by 66 · see citing works
“Examples include hospital-based interventions designed to improve the functional outcomes for acutely ill older patients (30,31).”
BackgroundSelf-citationTrajectories of Community Mobility Recovery After Hospitalization in Older Adults
Loyd, C., Beasley, T. M., Miltner, R. S., Clark, D. E., King, B., & Brown, C. J. (2018) · Journal of the American Geriatrics Society · doi:10.1111/jgs.15397 · Cited by 63 · see citing works
Interventions for reducing hospital-associated deconditioning: A systematic review and meta-analysis
Smith, T. O., Sreekanta, A., Walkeden, S., Penhale, B., & Hanson, S. (2020) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2020.104176 · Cited by 65 · see citing works
O’Shaughnessy, Í., Robinson, K., O’Connor, M., Conneely, M., Ryan, D., Steed, F., Carey, L., Leahy, A. M., Shanahan, E., Quinn, C., et al. (2022) · Age and Ageing · doi:10.1093/ageing/afac081 · Cited by 63 · see citing works
“Six trials reported on the primary outcome of functional decline, five at 3 months [31, 38–41] and three at 6 months [32, 38, 41].”
InfluentialAcute Care for the Elderly: A Literature Review
Ahmed, N. N., & Pearce, S. (2010) · Population Health Management · doi:10.1089/pop.2009.0058 · Cited by 63 · see citing works
“15 Of the 2 descriptive studies, surveys demonstrated improved provider satisfaction rates for nurses and physicians in the intervention group versus usual care.”
InfluentialMinimizing the use of restrictive devices in dementia patients at risk for falling
Capezuti, E. (2004) · Nursing Clinics of North America · doi:10.1016/j.cnur.2004.02.015 · Cited by 59 · see citing works
Boustani, M. A., Campbell, N. L., Khan, B. A., Abernathy, G., Zawahiri, M., Campbell, T. A., Tricker, J. L., Hui, S. L., Buckley, J. D., Perkins, A. J., et al. (2012) · Journal of General Internal Medicine · doi:10.1007/s11606-012-1994-8 · Cited by 61 · see citing works
Ekdahl, A., Sjöstrand, F., Ehrenberg, A., Oredsson, S., Stavenow, L., Wisten, A., Wårdh, I., & Ivanoff, S. D. (2015) · European Geriatric Medicine · doi:10.1016/j.eurger.2015.10.007 · Cited by 60 · see citing works
Interprofessional collaboration and patient-reported outcomes in inpatient care: a systematic review
Kaiser, L., Conrad, S., Neugebauer, E. A. M., Pietsch, B., & Pieper, D. (2022) · Systematic Reviews · doi:10.1186/s13643-022-02027-x · Cited by 73 · see citing works
“One study only [15] provides information about p-values but no ES estimates.”
BackgroundMethodInfluential
- Authors
- Counsell, S. R., Holder, C. M., Liebenauer, L. L., Palmer, R. M., Fortinsky, R. H., Kresevic, D. M., Quinn, L. M., Allen, K. R., Covinsky, K. E., & Landefeld, C. S.
- Affiliations
- Summa Health System (US)
- Cleveland Clinic (US)
- UConn Health (US)
- University Hospitals of Cleveland (US)
- Case Western Reserve University (US)
- San Francisco VA Medical Center (US)
- Corresponding author
- Counsell, Steven R.
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2000-12
- Volume
- 48
- Issue
- 12
- Pages
- 1572-1581
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- OpenAlex
- W2063673978
- Cited by
- 406
- References
- 42
- Citations by year
- 2026: 2 · 2025: 11 · 2024: 8 · 2023: 4 · 2022: 29 · 2021: 33 · 2020: 18 · 2019: 16 · 2018: 16 · 2017: 21 · 2016: 22 · 2015: 18 · 2014: 18 · 2013: 18 · 2012: 29
- FWCI
- 5.51
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute on Aging (AG-10418, P60AG010418)
- Topics
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- acute care for elders, hospitalized older adults, functional decline, activities of daily living, nursing care plan, rehabilitation, nursing home admission, patient-centered care, hospital environment design, restraint, physiotherapy, iatrogenic disease, patient satisfaction, community-dwelling older adults, discharge planning
- MeSH terms
- Activities of Daily Living, Acute Disease, Aged, Aged, 80 and over, Female, Geriatrics, Health Facility Environment, Hospitals, Community, Hospitals, Teaching, Humans, Male, Ohio, Outcome and Process Assessment, Health Care, Patient Care Planning, Patient Discharge, Program Evaluation, Geriatric Assessment, Hospitals, Private, Patient Satisfaction, Total Quality Management, Patient-Centered Care
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