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Address correspondence to Marthe E. Ribbink, MD, Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, D3-335, PO Box 22600, 1100 DD Amsterdam, the Netherlands.
Amsterdam University Medical Center, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
RE-FIT Barcelona research group, Parc Sanitari Pere Virgili and Vall d'Hebron Institute of Research (VHIR), Barcelona, SpainDepartment of Medicine, Univeristat Autonoma de Barcelona, Barcelona, Spain
Amsterdam University Medical Center, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
RE-FIT Barcelona research group, Parc Sanitari Pere Virgili and Vall d'Hebron Institute of Research (VHIR), Barcelona, SpainDepartment of Medicine, Univeristat Autonoma de Barcelona, Barcelona, Spain
Amsterdam University Medical Center, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The NetherlandsACHIEVE – Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
RE-FIT Barcelona research group, Parc Sanitari Pere Virgili and Vall d'Hebron Institute of Research (VHIR), Barcelona, SpainDepartment of Medicine, Univeristat Autonoma de Barcelona, Barcelona, Spain
Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs.
Design
Exploratory cohort study.
Setting and participants
Subacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics.
Measures
We compared setting, characteristics, and outcomes between patients admitted to the 2 units.
Results
Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH).
Conclusions and Implications
These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.
European Commission The 2012 Ageing Report: Economic and budgetary projections for the EU27 Member States (2010-2060). Prepared with the Economic Policy Committee (AWG), European Economy 2.
Older hospitalized adults with multiple chronic conditions and/or frailty are predisposed to poorer outcomes compared to patients who do not have these conditions,
With increased demand for care, increasing costs, and poor outcomes after hospital admission, several models of care that aim to avoid admission to a general acute hospital have been developed.
However, these models may assume that patients have an informal caregiver and cannot always provide acute or unplanned care.
Another model of care is admission to an acute geriatric unit in intermediate care as alternative to admission to a general hospital. Intermediate care was recently defined in an international Delphi study as care that represents a broad range of time-limited services that aim to ensure continuity and quality of care; promote recovery; restore independence and confidence; or prevent a decline in the functional ability at the interface between hospital, home, long-term care (nursing homes), primary care, and community services.
In our model of acute geriatric units in intermediate care, acute medical care and early rehabilitation are provided for patients with exacerbations of chronic conditions or “minor” acute events, for example, an infection in patients with complex social or functional problems. The care is delivered at a unit within an intermediate care facility and is led by a geriatrician.
Geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate-care hospitalization.
We present this model of care in context with other models of care for geriatric patients in Figure 1, which shows how acute geriatric units may fill a gap in care for adults with multiple chronic conditions
European collaborative and interprofessional capability framework for prevention and management of frailty—A consensus process supported by the Joint Action for Frailty Prevention (ADVANTAGE) and the European Geriatric Medicine Society (EuGMS).
Fig. 1Patient trajectory and care settings during an acute medical crisis. Figure depicts the patient trajectory during an acute medical crisis, the settings in which care can be provided, and the specialized units for (older) adults in acute and post-acute care. ACE units are situated in a general hospital and provide care during the acute phase, when there is diagnostic uncertainty or patients may require admission to an intensive care unit.
The acute geriatric units that we describe in intermediate care can provide acute care when there is no diagnostic uncertainty in patients who have exacerbations of chronic conditions or “minor” acute events. HaH care can be provided during both acute and post-acute phases.
After hospitalization in either a general hospital or at an acute geriatric unit, patients can receive care in a geriatric rehabilitation unit, which is similar to post-acute care in a community hospital in the United Kingdom.
The specific example of acute geriatric units that we will discuss in this article was pioneered in 2012 at an intermediate care facility, Parc Sanitari Pere Virgili in Barcelona, Spain.
Here, a specific ward, the Subacute Care Unit (SCU), provides acute and subacute care to older adults. Previous studies of this unit have shown its potential as an alternative to conventional hospitalization in selected older patients.
Geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate-care hospitalization.
Recently, this model of care was successfully scaled up to provide acute care to older adults affected by COVID-19 and thereby reduce the caseload of general hospitals.
Investigating the effectiveness of care delivery at an acute geriatric community hospital for older adults in The Netherlands: A protocol for a prospective controlled observational study.
These 2 units, the SCU and the AGCH, both offer an age-friendly environment, where a comprehensive geriatric assessment (CGA) is used to direct care and provide early rehabilitation.
Investigating the effectiveness of care delivery at an acute geriatric community hospital for older adults in The Netherlands: A protocol for a prospective controlled observational study.
Both units provide care to patients directly admitted from emergency departments (EDs) or from home through specific primary care pathways (only SCU).
Acute care for older adults in bed-based units led by a geriatrician and implemented outside a general hospital is not common and has not yet been compared between European countries. We think the model that was implemented since 2012 (SCU) is like the model that was newly introduced (AGCH). By comparing and sharing these existing practices, this approach could be implemented in other European countries. Therefore, we will describe and compare these 2 existing models of care that have been implemented in Spain (SCU) and in the Netherlands (AGCH).
We will answer 2 questions: (1) What patients are amendable to transfer to these 2 units? (We will do this by evaluating the baseline characteristics of patients who have been transferred to these units.) and (2) What are the outcomes at discharge, regarding return to a general acute hospital, length of stay (LOS), mortality during admission, and return to original living situation?
Methods
Design, Setting, and Staffing
In both settings, we gathered data from existing prospective cohort studies.
Investigating the effectiveness of care delivery at an acute geriatric community hospital for older adults in The Netherlands: A protocol for a prospective controlled observational study.
The SCU is a 40-bed unit, which serves the northern part of Barcelona (reference population 900,000). It is located within a 350-bed intermediate care facility, Parc Sanitari Pere Virgili, including wards for geriatric rehabilitation, palliative care, and long-term nursing beds as well as outpatient and home care resources. Patients are mainly admitted from the nearby university hospitals Vall d’Hebron and Hospital Clinic de Barcelona (1.5 and 4.5 km from the SCU, respectively) or directly from primary care. Staff at the referring hospitals and primary care centers are trained to select patients for admission to the SCU. Table 1 lists all daytime staff that work exclusively at the SCU located within the intermediate care facility. During evening, nighttime, and weekends, the intermediate care facility has a geriatrician on duty who attends to medical emergencies and provides clinical support to the SCU. The geriatrician may attend the SCU in person 1 to 5 times per evening and night.
The AGCH is a 23-bed unit, which serves an urban area in Amsterdam with approximately 150,000 inhabitants.
It is located in a 123-bed skilled nursing facility, Eben Haëzer from care organization Cordaan providing geriatric rehabilitation, palliative care, and long-term care. Patients are directly and primarily admitted from the EDs of 2 nearby locations of the Amsterdam University Medical Centers. At the first location, the Academic Medical Center, specialized nurse practitioners and/or the attending geriatrician select(s) patients at the ED for admission to the AGCH. At the second location, the Vrije Universiteit Medical Center, staff from the department of internal medicine was trained to select patients for transfer and request transfer through the attending geriatrician at the AGCH. Staff from the AGCH operate from the skilled nursing facility. The geriatricians work both at the AGCH as in the university hospital Academic Medical Center location. During the evening, nighttime, and weekends, a geriatrician is on duty and will be present at the university hospital or on call at home. On average, the attending geriatrician may receive 3 to 5 phone calls per evening and night and may need to come to the AGCH once per week to perform acute medical interventions.
Moreover, both units may adapt beds and/or staffing when the demand from ED of general acute hospitals increases during the winter vs in summer when bed occupation is usually lower.
Admission Criteria
Admission criteria for transfer to both units were:
1.
acute medical problems in older patients that require hospitalization (eg, acute events such as a pneumonia, exacerbation of chronic conditions such as heart failure, or minor acute events in very frail patients);
2.
hemodynamic stability (on assessment at the ED);
3.
no need for complex diagnostic testing (such as CT or MRI scans during admission);
4.
expecting to return to previous living situation in 10–14 days; and
5.
only for AGCH: geriatric conditions (see Table 1; eg, delirium, cognitive impairment, falls, functional impairment).
is performed on admission as a basis for an individualized interdisciplinary care plan. For the AGCH, the CGA is partially conducted at the ED by a nurse practitioner and is completed by a nurse practitioner at the AGCH. The care plan includes the prevention or management of complications of hospitalization in older adults such as immobilization, delirium, or falls.
Geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate-care hospitalization.
is established, including both short-term goals during admission (maximum desirable intensity of care, transfer to acute care, resuscitation) and conversations related to long-term goals. Another focus of both units is discharge planning.
A transitional care program is available for selected patients at the SCU. In this program, an advance practice nurse will prepare the discharge by connecting to local home care agencies and informing the patient and family with regard to medication and primary care services. In addition, the electronic health care record is shared in Catalonia between hospital and primary care, which facilitates the transmission of clinical information.
At both units, personal handovers by telephone or email are used to inform primary care providers that the patient is being discharged and to assist in (re)starting primary care services.
Like traditional hospitals, intravenous (IV) medication and fluids can be administered at both units. Daily routine laboratory testing and simple radiography are available (radiography available once a week at the AGCH). The units both aim to admit patients for a limited number of days, a maximum of 10 at the SCU and 14 at the AGCH, to discharge >70% of patients to their original living situation and to discharge less than 15% of patients to another intermediate care unit. We collected these outcomes for both samples.
Preventative Strategies and Adaptations/Environment at the SCU and the AGCH
Lack of social support, reduced physical activity, and sensory overstimulation can contribute to negative outcomes in older admitted patients.
The SCU and AGCH have several adaptations to support the recovery of older patients and reduce the risk of negative outcomes such as delirium. First, at the SCU patients may stay in a room alone or with 1 other patient. The AGCH has large single rooms, where there is space for an extra bed so that informal caregivers can stay overnight. Second, from Monday through Friday patients receive daily specialized rehabilitation therapy from a physiotherapist, and the AGCH also has therapy sessions on Saturday. The SCU has physical therapy room on the same floor, which makes it easier for patients to attend physical therapy sessions. Third, at both units family, friends and informal caregivers may visit patient throughout the day. Finally, to improve sleep quality the SCU has quiet hours (12 pm through 6 am). Also, staff is asked to take special care to reduce noise levels, and these are monitored with an on-site and visible decibel meter. At the AGCH, each room is equipped with a continuous, noncontact heart rate and respiration monitor (EarlySense), which allows measurement of these vital signs without having to disturb the patient during sleep.
We used data from both institutions' routine CGAs. For the SCU, we obtained routine collected data for health care purposes from the electronic health records. In concordance with Spanish law, patients did not sign a specific informed consent other than a general consent, allowing anonymous data use for study purposes. For the AGCH, individual patient or proxy (in case of cognitive impairment) consent was obtained. Each study protocol was approved by local medical Ethics Committees. The data are partly duplicative to earlier publications.
Investigating the effectiveness of care delivery at an acute geriatric community hospital for older adults in The Netherlands: A protocol for a prospective controlled observational study.
) were collected. At the SCU, history of dementia included patients with suspected dementia. At the AGCH, this only included confirmed (by a medical doctor) cases of dementia. Main admission diagnosis was differently defined in the 2 samples. At the SCU, these were defined as respiratory infections, urinary tract infections, cardiovascular diagnosis, and other diagnosis. At the AGCH, there were additional disease categories: other infection, neurologic diagnosis, and gastrointestinal/dehydration/electrolyte disturbance. On admission, the Identification of Seniors at Risk (ISAR) score at the SCU and the Identification of Seniors at Risk–hospitalized Patients (ISAR-HP) score at the AGCH were filled out by clinicians. ISAR scores range from 0 to 6 and ISAR-HP score range from 0 to 5; both are used to predict adverse outcomes after home discharge, with a higher score indicating a higher risk. We used a cut-off of 2 or more points to indicate an increased risk.
at the day of admission was used to assess the presence of delirium. For the SCU, the presence of delirium on admission was assed at the SCU itself. For the AGCH this was assessed at the ED, prior to transfer to the AGCH.
Analysis
Outcomes were presented in frequencies and percentages, means, standard deviations (SDs) and 95% confidence intervals (CIs). For comparing proportions, we used the χ2 test, and when comparing means we used the independent samples t test. To measure Activities of Daily Living, 2 different instruments were used—Barthel vs Katz-ADL index. Therefore, we did not perform comparative statistical analysis for ADL indices. We performed descriptive analysis using SPSS, version 26.00 (IBM SPSS Statistics, IBM Corporation, Armonk, NY).
Results
The detailed clinical sample from SCU included 909 patients collected in January 2015 to March 2016, including readmitted patients. The bed occupancy rate in this period was 47.6%. The sample from AGCH included data collected between February 1, 2019, and October 19, 2019. In this period, there were 278 admissions including 23 readmissions, and 174 patients provided consent for the use of their data. Bed occupancy rate in this period was 52.5%.
Baseline Characteristics
Table 2 provides baseline characteristics of patients admitted to the SCU and AGCH. At the SCU, more patients had been previously hospitalized (45.8% vs 32.8%, P < .001). At the SCU, patients were admitted for respiratory infections (47.4%), urinary tract infections (11.2%), cardiovascular diagnosis (22.9%), and other diagnosis (18.5%). At the AGCH, there were fewer respiratory infections (25.9%), more urinary tract infections (16.7%), and fewer cardiovascular principal diagnoses (8.0%). Respiratory infections also included exacerbations of chronic obstructive pulmonary disease. At both sites, cardiovascular diagnosis concerned mostly exacerbations of heart failure. Charlson comorbidity was similar between the groups, and comorbid dementia was present at 43.8% of patients at the SCU and 19.5% at the AGCH (P < .001). Also, at the SCU, relatively more patients (39.7%) were delirious on admission compared to the AGCH (22.4%) (P < .001).
Table 2Baseline Characteristics and Outcomes in Patients From Both Intermediate Care Geriatric Units
Subacute Care Unit (SCU) (n = 909)
Acute Geriatric Community Hospital (AGCH) (n = 174)
Including exacerbation of chronic obstructive pulmonary disease.
431 (47.4)
45 (25.9)
<.001
Urinary tract infection
102 (11.2)
29 (16.7)
.04
Other infection or cellulitis
–
18 (10.3)
—
Cardiovascular
208 (22.9)
14 (8.0)
<.001
Neurological
14 (8.0)
—
Gastrointestinal, dehydration, or electrolyte disturbance
12 (6.9)
—
Other
At AGCH recurrent falls, delirium, medication reconciliation. At the SCU, this includes other diagnoses different to respiratory or urinary tract infections, or cardiovascular diseases.
Range of 0–31, with a higher score indicating more or more severe comorbidity.
mean (SD)
2.77 (1.7)
2.86 (2.1)
.60
Outcomes at discharge
Mean length of stay, mean (SD), target <10/14 days
10 days at the SCU, 14 days at the AGCH.
8.8 (4.4)
9.9 (7.5)
.08
Return to usual living situation, target >70%
692 (76.1)
139 (84.2)
.28
Discharge to other intermediate care unit, target <15%
136 (14.9)
18 (10.3)
.11
Admission to acute hospital, target <5%
22 (2.4)
9 (5.2)
.044
Death during admission
60 (6.6)
9 (5.2)
.48
COPD, chronic obstructive pulmonary disease.
Unless otherwise noted, values are n (%).
∗ Barthel Index range 0–100, Katz Index range 0–6.
† Positive CAM (Confusion Assessment Method) at the SCU or at the ED prior to transfer to the AGCH.
‡ 6 months prior to index admission.
§ Including exacerbation of chronic obstructive pulmonary disease.
|| At AGCH recurrent falls, delirium, medication reconciliation. At the SCU, this includes other diagnoses different to respiratory or urinary tract infections, or cardiovascular diseases.
¶ The SCU includes suspected and confirmed cases of dementia. The AGCH only includes confirmed (by a medical doctor) cases of dementia.
# Range of 0–31, with a higher score indicating more or more severe comorbidity.
Rates of discharge to original living situation (n/ntot), SCU 76.1% (692/909) and AGCH 79.9% (139/174), were similar (P = .28). At the SCU site, 6.6% (60/909) of patients died during admission; this was 5.2% (9/174) at the AGCH (P = .48). A small percentage of patients were readmitted to an acute hospital during admission, 2.4% (22/909) at the SCU and 5.2% (9/173) at the AGCH (P = .044) (Table 2).
Discussion
We found similar models of care between the SCU and the AGCH, with similar admission diagnosis (respiratory and/or urinary infections and heart failure). We also observe relative differences: patients at the SCU were older, with a higher prevalence delirium at admission compared with the AGCH. At the SCU, more patients were living in a nursing home, where geriatric syndromes are more prevalent
and fewer were living independently compared with the AGCH. At discharge, we find similar lengths of stay, return to previous living situation, discharge to another intermediate care unit, and mortality. Importantly, return and admission to general hospital is equal to/lower than 5 percent. Meaning that hospital admission is avoided in most patients.
To place this model of acute geriatric units outside of a general hospital within an international context, we will discuss 4 other models of care for older adults: Acute Care for the Elderly (ACE) units,
ACE units improve hospital outcomes such as LOS and readmissions in frail, older patients. However, acute geriatric units that are situated outside of a general hospital may have advantages over ACE units in specific settings. First, an acute geriatric unit can allow for a more comfortable environment, closer to the community, that can help in the management of care transitions. Second, there also may be an advantage in that an intermediate care facility can combine acute, rehabilitation, and palliative care if indicated. Third, compared with a general acute hospital, the SCU and AGCH do not provide the same range of costly diagnostics and services, reducing the cost per admission.
Other models of care for older adults are admission to NLUs
Compared with our model, these post-acute care units may not fully replace acute hospital admission because they may not always have resources for providing acute hospital treatment (eg, no IV medication or 24/7 acute medical services).
However there is a large variation in practice. Most community hospitals are focused on rehabilitation and may be nurse-led vs led by a physician. They may also have a longer LOS (range 11–58 days) compared with the model of care that we descibe.
Moreover, in community hospitals in the United Kingdom, most patients are discharged from wards of general acute hospitals and are not referred from the ED, unlike our model of care.
Another bed-based model of care is where an HaH team comes in to a nursing home or community hospital to provide, for example, treatment with IV medication.
More commonly in the HaH model, hospital-level care is provided at the home of an older patient. The outcomes (eg, mortality or readmission) of admission to HaHs are similar to an acute general hospital.
In contrast, in our sample many older persons were living in a nursing home (SCU) or independently by themselves (AGCH), without a spouse or family member who could act as an informal caregiver. Therefore, the social support of patients attended in SCU or AGCH could be lower, and this can contribute to the clinical and functional complexity. These patients may need more intensive monitoring or treatment than can be provided by an HaH team.
Limitations of this study include data collection in 2 settings and at 2 different time points, which may reduce comparability of data. Therefore, the statistical testing should be interpreted with caution. However, our descriptive patient data demonstrate that these 2 units serve a similar population with similar outcomes.
Speculating on benefits of acute geriatric units, we suggest that they are adapted to the needs of older patients with frailty. At both units, patients receive specialized geriatric rehabilitation that may help to prevent functional decline and sustain functional capacity at an early stage. Furthermore, the environment is adapted to improve night rest, prevent delirium, and boost recovery. These adaptations may not have been feasible in the setting of a general hospital, as the growth of hospital budgets has been restricted in recent years, length of hospital stay is decreasing, and hospitals are primarily focused on providing acute specialist care, which may not be the primary focus of care for frail older adults.
In rural areas or island communities, this model could be implemented if there is no general acute hospital within the proximity of the patient's home. Another benefit is that this model of care can be scaled up within a facility; the SCU was scaled up and used to deliver acute care to older adults affected by COVID-19.
Telemedicine could also be implemented within this model of care for example by inviting consulting specialists and primary care providers to partake in multidisciplinary consultations.
European collaborative and interprofessional capability framework for prevention and management of frailty—A consensus process supported by the Joint Action for Frailty Prevention (ADVANTAGE) and the European Geriatric Medicine Society (EuGMS).
Our descriptive data show that, though in 2 different settings, these acute geriatric units are quite similar and can provide an alternative to general hospital. Our results encourage the comparison with other European care models that aim to provide acute care outside of a general hospital. Further research could focus on performing multicenter studies, evaluating cost-effectiveness, and comparison to hospital-based units.
Acknowledgments
We would like to thank the Amsterdam Public Health- Aging and Later Life research line for providing funding for a work visit of the first author (M.R.) to the Research group on Aging, Frailty and care Transitions (Re-fit) at Parc Sanitari Pere Virgili in Barcelona. The authors thank all (care) professionals from Parc Sanitari Pere Virgili, the Amsterdam University Medical Centers, and Cordaan who work at the SCU and AGCH. We would also like to thank the members of the AGCH study group; these are the clinicians who work at the Geriatrics Department of the Amsterdam University Medical Centers and who have supported the data collection at the AGCH.
References
European Commission
The 2012 Ageing Report: Economic and budgetary projections for the EU27 Member States (2010-2060). Prepared with the Economic Policy Committee (AWG), European Economy 2.
Geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate-care hospitalization.
European collaborative and interprofessional capability framework for prevention and management of frailty—A consensus process supported by the Joint Action for Frailty Prevention (ADVANTAGE) and the European Geriatric Medicine Society (EuGMS).
Investigating the effectiveness of care delivery at an acute geriatric community hospital for older adults in The Netherlands: A protocol for a prospective controlled observational study.
Funding sources: The research conducted at the Subacute Care Unit (Parc Sanitari Pere Virgili) did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The Acute Geriatric Community Hospital (AGCH, Amsterdam University Medical Centers) research receives funding though ZonMw, the Netherlands Organization for Health Research and Development, project number 808393598041. Moreover, the care provided at the AGCH is provided in a partnership between Cordaan, a community and home care organization and the Amsterdam University Medical Center, location Academic Medical Center. The AGCH is financially supported by Zilveren Kruis, a health insurance company.
The AGCH study group include R. Franssen, W. J. Frenkel, M. J. Henstra, M. A. van Maanen, I. Oudejans, J. L. Parlevliet, E. P. van Poelgeest, M. N. Resodikromo, K. J. Kaland, N. van der Velde, M. E. Visser, and H. C. Willems.
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