The John A.

Hartford Foundation

Redesigning Hospital Care to Prevent

Functional Decline in Older Adults:
The ACE Unit Innovation
Systematic Preparations and When acutely ill elderly patients have an illness that requires hospitalization, they
frequently lose some physical function. Elements of hospitalization, including
“ACE” Units Shorten Stays,
iatrogenic illnesses, bedrest and immobility can contribute to a poor result, leading
Link Hospital Care to Outcomes to prolonged hospital stays, nursing home placement, and death. Too often, this
for Elderly Patients decline is accepted as an inevitable outcome of hospitalization.
The Acute Care for Elders (ACE) model—a general medical unit that provides
typical medical services plus geriatric interventions—addresses functional decline
Hospitals with ACE Units often find the units
by redesigning hospital care. It employs an interdisciplinary team that provides
become models of care for other specialty
care based on proven, effective practices. It prepares the hospital environment
units, and preferred sites for patients
in Medicare risk plans, among others. to “fit the patient,” encouraging patient mobility and creating a home-like feel.
Community and teaching hospitals have Medical and nursing review is employed to prevent complications from medicines
successfully created interdisciplinary Acute and procedures. ACE units have been shown to improve physical function among
Care for Elders (ACE) units when they have elderly patients, while producing cost savings or remaining budget neutral.
followed these time-tested steps, usually
taking up to two years:
■
Agree on the need for an ACE unit by The JAHF Contribution
presenting the idea to key decision makers
as a “win/win/win” proposition for patients,
providers, insurers, and the health system.
■
Build the ACE unit through strong
physician and nurse leadership and an To help hospitals find ways to more effectively
interdisciplinary team approach to planning treat older patients, in 1989 the John A. Hartford
and development. Foundation made grants totaling more than
■
Commence operations of the unit while $2.68 million to six hospitals as part of its Hospital
paying special attention to medical staff Outcomes Program for Elders (HOPE), which
issues and promotional opportunities.
included a three-year effort to develop and evaluate
■
Document implementation of the unit to the first ACE unit. The results of a clinical trial
ensure that changes in the process of care
of the unit were published in the New England
take place as planned.
Journal of Medicine in 1995. The ACE model has
Evaluate the ACE unit for its benefits to
been replicated at academic medical centers and
■

patients, providers, and the health system.

community hospitals throughout the United
Feedback evaluative information to health
States, and the cost-effectiveness and benefits of
■

system administrators and medical staff

leadership to gain ongoing support for the ACE Units for general medicine, orthopedics,
ACE unit. stroke, cardiovascular illness, and other conditions
have been widely published.
The John A. Hartford Foundation
“We won agreement by
making a presentation
about the ACE model to
every department in the
hospital.”
Testing a Model to Reduce Functional Decline in the Hospital
When older patients are treated in the hospital, they often lose some of their ability
to care for themselves, even while they are told “you can be discharged, your disease
is better.” Elements of hospitalization, including the processes of care and the physical
environment, can contribute to this poor result. Loss of physical function for elders
can lead to prolonged hospital stays, nursing home placement, and death.
In 1989, doctors and nurses at the University Hospitals of Cleveland (UHC) developed
an intervention that redesigned hospital care for elders. They created a new hospital
unit specifically designed to incorporate home-like features and help patients be as
active as possible and involved in their care and the workings of the facility. The result
was the Acute Care for Elders (ACE) unit, which integrated geriatric assessment into
the medical and nursing care of older patients using an interdisciplinary team.
The ACE unit team, jointly led by the medical director and nurse manager, developed
guidelines for optimal medical care for older patients, and collected them into a care
manual. The hospital modified the physical environment of the unit to encourage
patient mobility and self-care and to create a more home-like feel. When the unit
began operations, it commenced daily rounds by the entire interdisciplinary team.
During rounds, the team reviewed the status of each patient and the therapeutic goals
for the hospitalization and length of stay. Rounds included a
focus on preventing functional decline and developing a plan
of care for going home from the hospital and home care needs.
Intensive medical care review was employed to prevent
complications due to medicines and procedures.
Nearly five months after UHC created the ACE unit, a clinical
trial evaluated the unit’s effectiveness. It found that patients in
the ACE unit had better functional outcomes than patients
receiving usual care, and fewer ACE patients were discharged to
long-term care institutions. Costs of care for both units were
comparable. In subsequent studies, costs of care for ACE unit
patients were less than those for patients receiving usual care.
Since the original grant to UHC, the ACE model has been
replicated at many academic medical centers and community
hospitals throughout the United States. The model has also
been applied to special populations, such as patients in
stroke and cardiology units. ACE units have also been found,
anecdotally, to influence providers’ care and treatments for
non-ACE patients, as well, resulting in better care across
the hospital.
2

“We engaged all the different
disciplines in creating the
clinical guidelines so they
would feel a part of what
we were building.”
“The team worked one-
on-one with nurses and
physicians about optimal
care, making respectful
suggestions. That’s where
a lot of the learning
happened.”
“ACE saves money from
decreased lengths of stay
and patient costs. The
ACE unit must be able to
demonstrate its financial
and clinical benefits.”
Studies have shown that patient and nursing satisfaction is generally higher in ACE
units than on traditional hospital floors. In many cases, ACE units produce cost
savings. In others, they remain budget neutral, with initial development costs offset
by shorter lengths of stay and reduced patient costs. The units have also been shown
to make more efficient use of scarce hospital staff, concentrating staff efforts on
patients who need more care.
The ACE model has been widely acknowledged as a tool to improve care quality
and prevent functional decline among elders in the hospital. But because it requires
a change in hospital design and culture, it takes commitment from all levels of
leadership and perseverance to make the model succeed. As Carolyn Holder, geriatrics
coordinator for post-acute senior services and head of ACE training at Summa Health
System in Akron, Ohio, said, “It isn’t rocket science. But you must have all of the
elements in place to make an ACE unit successful.”
Required Elements for a Successful ACE Unit
Agree
The first stage requires gaining consensus that an ACE unit should be established.
This is the most challenging step and the most important. Identify the key decision
makers at all hospital levels, including physicians, nurses, administrators, therapists,
and more. This stage must constantly be revisited, keeping everyone informed of the
progress of the ACE unit and reminding all interested parties about ACE goals and
concepts of care. Complete endorsement of an ACE unit may not come until medical
staff and hospital administration see the full benefits of the program.
Build
At this stage, a geriatrician medical director and a gerontological clinical nurse
specialist should be chosen to lead the unit. Together, they should be involved in each
step of the unit’s development and should meet regularly with administrative staff.
They should identify individuals from each of the professional departments that will
participate and engage them in planning for the ACE unit and creating the clinical
guidelines. At this stage, the team should identify a general medical unit for
conversion and determine patient admission criteria. Changes to the facility can span
minor alterations (placement of clocks and calendars in patient rooms to facilitate
awareness and installation of handrails) to more substantive modifications, such as a
therapy room and a communal room for dining and socialization.
Commence
Initiate the ACE unit program at this stage while paying special attention to medical
staff issues and opportunities to promote the value of the ACE unit. Delineate
responsibility among team members. Find a time when the team can meet each day
to conduct rounds. Keep the rounds brief and focus on patients most at risk for
functional decline and institutionalization.
3
The John A. Hartford Foundation

“The team members
developed the
documentation tools,
so they owned them.
That’s how we got such
high compliance.”
“It’s very important to
keep talking about the
successes and to be open
to making changes based
on others’ suggestions.”
Document
It is critical to document that the desired changes are actually occurring. Document
the team’s assessment of patient functional status, anticipated length of stay, and
discharge plan with a simple checklist. Record the preventive and restorative measures
that the team has suggested and employed. Make sure that copies of the clinical
guidelines are available for all staff on the unit.
Evaluate
Focus on identifying the benefits experienced by patients, providers, and the health
care system. Evaluate the areas of greatest concern to hospital administrators and
staff, including length of stay, satisfaction, use of restraints, sitter use, and falls
prevention.
Feedback
Provide feedback to the administrators and medical staff leadership to update them
on the progress of the unit. In doing so, gain their continuing support for the
program. In this way, feedback is continually used as a means to secure agreement
among key decision makers in the hospital for the ACE unit and possible expansion
to other units and specialties.

For More Information

A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of
acutely ill older patients. New England Journal of Medicine, 1995, 332(20): 1338-1344.
Landefeld, C.S., Palmer, R.M., Kresevic, D.M., Fortinsky, R., and Kowal, J.
“Acute care for elders unit: Practical considerations for optimizing health outcomes.“
Palmer, R.M., Counsell, S.R., and Landefeld, S.C.
Disease Management & Health Outcomes, 2003; 11(8): 507-517.
The Acute Care for Elders (ACE) manual: Meeting the challenge of providing quality and cost-effective hospital
care to older adults
Counsell, S.R., Holder, C., Liebenauer, L.L., Allen, K.R., Palmer, R.M., Kresevic, D., and Landefeld, S.C.
Summa Health System, 1998.
This manual provides detailed instructions on how to create an ACE unit. It also contains clinical tools, including
sample patient care protocols. To purchase, call Carolyn Holder, MSN, RN, CS at (330) 375-7784.
email: holderc@summa-health.org.
This pamphet is available at the Web site of the John A. Hartford Foundation
at www.jhartfound.org/IDEAS/ACEunits.

THE JOHN A. HARTFORD FOUNDATION 55 EAST 59TH STREET, NEW YORK, NY 10022 212 832-7788