An interdisciplinary team consisting of an attending geriatrician, geriatrics fellow, nurse coordinator and social worker works with elderly patients while they are in the hospital and maintains close contact with their doctors ensuring safe, seamless continuity of care from hospital to home. The MACE team also offers expanded discharge planning services, social support for patients' families, and, when appropriate, end-of-life planning.
The MACE team also functions as an educational training site in geriatric medicine for our medical students, residents, and fellows. Monthly orientation/education sessions for house staff involving the interdisciplinary team include such topics as the role of each interdisciplinary team member, referral mechanisms, team communication, and the overall function and goals of the MACE team. Ongoing education for nursing staff and other interdisciplinary team members on topics related to the acute care of the elderly is also a feature of the MACE team.
Continuing goals include not only maintaining and maximizing patients' functional capacity during the course of hospitalization, but discharging patients to their previous living arrangements when at all feasible.