Purpose:

With an increased number of seniors, coupled with advances in medicine, healthcare systems are faced with older, sicker patients who are at high risk for functional decline. As the complexity of care increases, the care delivery systems will need to adapt.

Significance:

As complex care increases for hospitalized elders, the clinical specialist is essential for the ongoing development of nursing practice and the care standards in conjunction within an interdisciplinary team model known as the Acute Care for Elders (ACE).

Design/Background/Rationale:

The ACE model is supported by research and has been proven effective in the care of the hospitalized older adult. Central to the model is the role of nursing, specifically the leadership of the CNS. The model has now been coupled with the care of chronic disease management, such as with heart failure, stroke, and pneumonia.

Methods/Description:

The CNS plans, implements, and evaluates health programs, as well as reviews and formulates healthcare policies specific to a targeted population using evidence-based practice (EBP). With the CNS as leader of the interdisciplinary team, primarily nurse-driven, the team develops a comprehensive care and discharge plan, implemented across a care continuum.

Findings/Outcomes:

The team delivers cost-effective, coordinated care that promotes process improvement, with the result being practice alignment to current standards of care.

Conclusions:

By effectively facilitating the expertise and collaboration skills of the ACE team members, coupled with the use of research and education, the CNS role positively influences the care/management outcomes for high-risk, elderly patient populations within an acute care unit and throughout the care continuum.