ACE Transitional Program

Used to a controlled hospital environment, John Piede, M.D., a first-year resident in Internal Medicine, found visiting elderly patients at home as part of the ACE Transitional Program to be a real eye opener.

“Some patients have as many as twenty pill bottles; their day revolves around taking their meds. Based on age and mental status, they may require help keeping them straight. Seeing how and where patients live showed me that as doctors, we need to understand the whole person to deliver the best care,” Piede says.

The gap between an inpatient hospital stay and the return home can be a trying time for elderly patients. Getting back under the wing of their primary care physician after being hospitalized can take time. Bridging the gap in care and communications was one of the reasons faculty members Hal Atkinson, M.D., and Jamehl L. Demons, M.D., created the ACE Transitional Program as a pilot in 2003 and a formal part of the geriatrics rotation for residents in 2005.

The program is straightforward. Residents, with the support of a multi-disciplinary care team, follow older people from the hospital into their homes or nursing homes during the first ten days after discharge to ensure the hospital plan is implemented. “For many residents, it’s the first time they have visited patients in their homes. These home visits allow residents to see how difficult it can be for elderly patients to follow a physician’s orders without the right resources at home,”  Dr. Atkinson explains. The program, which now sees about 250 patients each year, has two goals. The first is helping a vulnerable population make a safe transition from hospital to home. The second is to teach the next generation of physicians to understand the best way to manage the transition and to know what problems may occur and how to avoid and resolve them.

While faculty and residents see tremendous value in the ACE Transitional Program, patients are pleased too. “Having a doctor visit them in their own home makes patients feel special and cared for; they really appreciate it,” says Dr. Piede.


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Last Updated: 12-12-2013
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