Kent takes '4-M' approach to elderly care

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The hospital is a place you go to get stuck in bed until you get better and it’s time to go home.

That’s not the way Dr. Ana Tuya Fulton thinks of health care or Kent Hospital. And that certainly is not what’s happening in the newest 10-bed unit at Kent.

Indeed, patients have beds at the Acute Care for Elders (ACE) unit, which had a soft opening in January followed by an official opening last month. Since then, about 80 patients have transitioned through the unit.

So far, Kent patients have been identified as candidates for the unit. It doesn’t promise to stay that way for long. Fulton reports she is starting to see referrals from primary care physicians as the word gets out.

Patients in the unit don’t spend all their time in bed. They don’t eat meals in bed, but rather are assisted to eat at a chair. With help, they walk the unit corridor as part of their exercise regimen. They also undergo tests as part of the “4-M” model of care – mobility, mentation, medication and what matters as developed by the Institute for HealthCare Improvement .

Fulton is passionate about the unit, which she has been thinking about and planning for nearly five years. She knows of no other hospital unit like it in the state.

During a visit Monday, she described how patients are seen by the geriatric medicine team for a geriatric assessment, including cognitive and function screening to identify needs and goals upon admission. She also talked about the Monday through Friday care rounds led by a geriatrician and/or geriatric nurse practitioner.

The goal of the unit, she said in a statement, is “to ensure that older adults receive access to the best care with assurance of the greatest level of patient safety and quality…and to optimize hospital treatment and recovery, as well as to work with patients to define what their care goals are so that all care is patient-centered, with a focus on quality of life and maintaining independence.”

Fulton said she was prompted to look at alternative means of elderly care by the community Kent serves. She found Warwick has a high number of assisted living facilities and nursing homes and an “aging in place” population.

There is a need here.

The center targets patients who are 75 years old and older with the objective of having them return to the lifestyle to which they were accustomed.

A brochure describing the program says the team works “to ensure that you go home with everything you need and there are no delays; your discharge planning is initiated from the day of your admission.” The team is in communication with family members and the patient’s caregivers during hospital admission and following the discharge.

The ACE unit looks no different than most wings of Kent with rooms off a corridor. One of the rooms has been converted into a team room, where team members can do patient reports and meet to talk over the needs of patients and map out a care plan. The room also provides a place where team members can meet patients and their families to understand what they would like as outcomes. Some signage distinguishes the unit, and there’s a bulletin board with the four M’s.

Under mobility, patients are reminded of the importance of being mobile but told to be safe by seeking assistance from a family member, friend, volunteer or caregiver.

As for mentation, the ACE team makes a point of the importance of knowing a patient’s risk of delirium, which can result from the confusion due to their illness. Patients are given tests to assess their cognitive ability. Fulton points out that seemingly inconsequential things, such as a patient not having their proper glasses or their hearing aid, can contribute to or even be the cause of delirium.

Medication is also on the list of M’s. The team conducts a detailed medication review to avoid inappropriate medications and discuss with the patient and their caregivers how to simplify medications.

“What matters” as described in the ACE brochure is defined as understanding a patient’s goals for the hospitalization and health care through discussion between health care teams, patients and their families.

Fulton said the care provided is covered by health insurance for the patient. As for Care New England, she said the unit represents an initial investment, but she believes the care provided will result in reduced hospitalizations and in savings to insurers and improved outcomes to patients.

The ACE team is made up of:

Ana Tuya Fulton, MD, FACP, AGSF, is executive chief of geriatrics and palliative care at Care New England and medical director of Integra Community Care Network LLC. Fulton is a graduate of the George Washington University School of Medicine and completed a residency in internal medicine, chief residency, and geriatric medicine fellowship at Brown University. An associate professor of medicine and associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, Fulton received a Geriatric Academic Career Award from the Health Resources and Services Administration (HRSA). Fulton’s major focus of clinical and academic work is on improving end-of-life and transitional care for persons with cognitive impairments. Fulton is the Care New England site director and co-project director for the Rhode Island Geriatric Workforce Enhancement Project (RI-GWEP).

Michael G. Ross, DO, is a geriatrician and director of inpatient services at Kent Hospital. A graduate of the University of New England College of Osteopathic Medicine, Ross completed the New Hampshire Dartmouth Family Medicine Residency Program and the Maine Dartmouth Geriatric Medicine Fellowship. Specializing in geriatric and family medicine, Ross has specific clinical interest in medication management, falls prevention, and the treatment of delirium.

Julio Defillo Draiby, MD, is trained to provide comprehensive medical care for elderly and aging patients. As patients age, they may experience an increased susceptibility to illness and injury. In some cases, illnesses or injuries in seniors may overlap to create complicated diagnostic and treatment processes. Defillo Draiby is trained to diagnose, treat and manage these and any related medical situations in seniors. He currently serves as an advisor to Healthcentric Advisors, helping to optimize the management of geriatric patients through the Centers for Medicare & Medicaid Services.

Mary Beth Welesko, MS, APRN-CNP, FNP-BC, GNP-BC, ACHPN, WCC, is a family nurse practitioner and gerontological nurse practitioner who provides medical care to geriatric patients across the continuum of health care settings. A graduate of Providence College, Rhode Island College School of Nursing, and the Family Nurse Practitioner Program at the University of Rhode Island, Mary Beth is also a teaching associate at The Warren Alpert Medical School of Brown University. She has also earned advanced certification in hospice and palliative care nursing and wound care, and is a member of the Hospice and Palliative Care Nurses Association and the Nurse Practitioner Association of Rhode Island.

Leyda Urugutia-Cante, BSW, is a social worker with Integra Community Care Network and Kent Hospital. A graduate of Rhode Island College with a degree in social work, Leyda is also a certified nursing assistant and a medical assistant. Leyda has worked as an advocate for patients and their families and is fluent in both English and Spanish.

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