(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] Principal 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 39.3 35.7 25.0 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 3.6 32.1 64.3 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.