NICHE Nurses Improving Care for Healthsystem Elders HARTFORD INSTITUTE FOR GERIATRIC NURSING NEW...

NICHE • Nurses Improving Care for Healthsystem EldersHARTFORD INSTITUTE FOR GERIATRIC NURSING • NEW YORK UNIVERSITY COLLEGE OF NURSING



Our Objectives • Discuss the implications of the aging

population for our hospital

• Discuss the opportunities and resources offered by the NICHE program


NICHE Nurses Improving Care for Healthsystem Elders

• NICHE is a program of the Hartford Institute at the New York University College of Nursing

• NICHE is the only national geriatric nursing program that addresses the needs of hospitalized older adults

• Currently there are approximately 300 hospitals in more than 40 states as well as Canada with NICHE designation and this number is expanding


Why a program focused on older adults?


Utilization of Healthcare Services

While adults aged 65 years & older represent

only 12% of the U.S. population, they account for:– 26% of all physician office visits– 35% of all hospital stays– 34% of prescriptions– 90% of nursing home use

• In 2003, $329 billion or 44% of national hospital bill

Reference: Hing, E., Cherry, D.K., Woodwell, B.A. (2006). National Ambulatory Medical Care Survey: 2004 Summary. Advance data from vital and health statistics; no 374. Hyattsville, MD: National Center for Health Statistics.Merrill, C.T. & Elixhauser, A. (2005). Hospitalization in the U.S., 2002: HCUP fact book No. 6. Rockville, MD: AHRQ.Jones, A. (2002) The National Nursing Home Survey: 1999 Summary. Hysattsville, MD: National Center for Health Statistics.Families USA. (2000). Cost overdose: Growth in drug spending for the elderly, 1992-2010. Washington, DC: Families USA.Russo, C.A. & Elixhauser. (2006). Hospitalizations in the elderly population, 2003. Rockville, MD: Agency for Healthcare Research and Quality. HCUP Statistical Brief No. 6.


Implications of an Aging Society• Older adults utilize 48% of the nation’s total

health care resources

• Number of Americans age 65 and older will reach 70 million by 2030 20% of the population

• Approximately 50% of hospitalized patients are age 65 and over

Reference: DeFrances, C.J., Lucas,C.A., Buie, V.C., & Golosinskiy, A. (2008). 2006 National Hospital Discharge Survey. National Health Statistics Reports, 5, 1-20.


_____% of_____________ (our hospital)

inpatient admissions are 65 years and older

Older Adults Are Hospitals’ CORE Consumers


Acute Care Services

All ages Ages

65-74 yrs

Ages

75 + yrs

# of physician office visits per 100 persons 329 647 768

# of injury-related visits per 100 persons 37 60 74

# of hospital outpatient visits per 100 persons 31 41 38

# of ED visits per 100 persons 40 37 60

# of days of hospital care per 100 persons 55 140 259

Average hospital length of stay 4.8 days 5.3 days 5.7 days

Health Services Utilization by Age Group, 2005

Data is for non-institutionalized persons. Data for injury-related visits is for 2004.

Reference: Adapted from Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce (p. 46). Washington, DC: The National Academies Press.



• U.S. Census Bureau reports 1/4 of all inpatient hospital days were used by adults 75 years and older

• Fastest growing segment of the population is those 85 years and older

• In the next 30 years, those 85 years and older will double in number to 8.5 million

Reference: U.S. Dept. of Health and Human Services, Centers for Disease Control. Trends in Health and Aging. Retrieved October 31, 2008, from http://www.cdc.gov/nchs/hdi.htm



___% of_____________ (our hospital)

inpatient admissions are 85 years and older


Older adults have:

• Longer lengths of stay (7.8 days vs. 5.4 days)• Higher rates of re-admission within 30 days• Higher rates of functional decline and medical errors

Reference: U.S. Dept. of Health and Human Services, Centers for Disease Control. Trends in Health and Aging. Retrieved October 31, 2008 from http://www.cdc.gov/nchs/hdi.htm

The Quality Imperative: Improve Clinical and Fiscal Outcomes!


Improving Care for Hospitalized Older Adults is Good Business

• Optimal care requires appropriate skills– Aging demographics– Geriatric skill gap– High cost of inaction

• Older adult patients are everywhere– Need for flexibility– Ongoing training

and coaching roles– Cost effective “train

the trainer” virtual services


Improving Care for Hospitalized Older Adults is Good Business

• Proactive & skilled nursing care avoids costly problems– “Never” events– Complications that increase LOS and costs

• Patients and families satisfaction– Better functional status at discharge– Smoother transitions

• Improved nurse satisfaction & efficiency, less turnover

• Improved MD satisfaction and improved efficiency


NICHE Program• Goal

– Achieve systematic nursing change that will benefit hospitalized older adults

• Vision– Provide geriatric sensitive and exemplary care to all

hospitalized older adults 65 years and over

• Mission– Import principles and tools to stimulate change in the

culture of healthcare facilities to achieve patient-centered care for older adults


What is the focus of NICHE?

NICHE focuses on programs and protocols that are predominantly

under the control of

nursing practice.


In other words…areas where nursing interventions have a

substantive and positive impact on patient care


Nurses Positioned to Play a Central Role

• Nurses are the primary caregivers for older patients in hospitals

• Nurses are generally not fully prepared to care for older patients

• Nursing models can improve older patients’ care and decrease hospital costs

• Nursing can be the focal point for stimulating interdisciplinary care


Hospitals participating in NICHE report…

• Enhanced nursing knowledge and skills regarding treatment of common geriatric syndromes

• Greater patient satisfaction• Decreased length of stay for older adult patients• Reduction in costs associated with hospital care

for the older adult• Enhanced Magnet initiatives• Improved compliance with regulations and

industry standards


What are the objectives of the NICHE program?


NICHE Program Goal #1: Improve patient outcomes

• Decrease iatrogenic complications– Facility acquired pressure ulcers– Falls and fall related injuries– Catheter associated urinary tract infections– Medication errors– Functional decline

• Decrease length of stay for older adults on general medical units


NICHE Program Goal #2: Improve the patient experience

• Promote environmental design that enhances function and comfort

• Increase staff sensitivity to the needs of older adults


NICHE Program Goal #3: Promote staff effectiveness and

satisfaction• Increase knowledge and competence around

care of older adults• Promote role development “home grown

experts”• Maximize retention of nurses and enrich job

satisfaction• Maximize interdisciplinary collaboration


NICHE Program Goal #4: Establish leadership as a

provider of care to older adults

• Set an example of exemplary care for the older adult within your community

• Be proactive with community partners in geriatric sensitive care


NICHE Program Goal #5: Provide fiscally responsible care

• Increase competence of existing staff

• Demonstrate improvement in sensitive outcomes: – length of stay– Medicare cost per day– high risk (Pay for Performance) clinical

outcomes


NICHE Program Goal #6: Increase collegial networks

• Form partnerships with other hospitals through an exchange of information and shared resources

• Form academic alliances


Characteristics of Sustainability


NICHE Nursing Care Models

NICHE models of care have been shown to

be effective in improving care and outcomes

for older adult patients

• Geriatric Resource Nurse Model (GRN)• Acute Care of the Elderly Unit (ACE Unit)


Geriatric Resource Nurse (GRN) Model

• Began in Boston– Early 1980’s at Beth Israel

• Unit based experts using existing resources

• Expanded at Yale New Haven Hospital

• Rationale - those who voluntarily chose to participate in the effort would provide better care to older adults

• Central to the role - geriatric education, competency evaluation, and mentoring


Rewards Related to the GRN Model• Clinical ladder• Novice expert feeling• Respect within role• Deeper expertise - content specialists in more

circumscribed areas• Parsimonious use of resources

Outcomes described by NICHE sites• improved clinical outcomes• increased staff skill• increased satisfaction


Acute Care of the Elderly (ACE) Unit

Key Elements• Prepared physical environment• Use of evidence-based protocols• Patient centered care• Family involvement• Medical care review• Education of staff


ACE Outcomes• Nurse sensitive

patient outcomes– Falls– Pressure ulcers– Restraint use– UTI– Catheter use

• Hospital outcomes– Length of stay– Case mix– Cost per case– Readmission within

30 days


What resources does the NICHE Program offer?


NICHE Program www.nicheprogram.orgThis website provides online access to:

• The NICHE journey, how to get started• Online Leadership Training Program information• Annual Conference information• NICHE Knowledge Center (online tools and resources)• Individual NICHE hospital websites• NICHE Certification Toolkit

All visitors to this website have access regardless of membership status


NICHE ProgramResources for “Members Only”

1. NICHE Planning & Implementation Guide2. Geriatric Institutional Assessment Profile (GIAP) 3. NICHE Training and Education Programs4. Online Connect Webinars5. NICHE Clinical Practice Protocols6. NICHE Organizational Strategies7. NICHE Clinical Improvement Models8. NICHE Listserv and Discussion Boards9. Unlimited contact hours

All tools and resources will be accessed through NICHE’s new Knowledge Center


1. Planning & Implementation Guide

Essential set of tools for start-up • Creating a vision • Internal evaluation • Establishing a business case and action plan • Staff development strategies • Embedding evidence-based protocols • ACE and GRN models guidebook


2. Geriatric Institutional Assessment Profile (GIAP)

• Assesses– staff knowledge and attitudes towards older adults– institutional barriers and supports for quality

geriatric care

• Provides – benchmarking data based on hospital size and

teaching status

• Sensitizes – staff to geriatric issues


Using GIAP: A Case Study

Site: a community hospital

Sample: 235 surveys were returned for analysis


% Reporting Appropriate Use

Staff Perceptions: Appropriate Use of Staff Perceptions: Appropriate Use of TreatmentsTreatments

0

20

40

60

80

100

Mechanical Restraints

Incontinence Pads

Urinary Catheters

Tube Feedings

Sleeping Medication

Pain Medication

Adaptive Devices

Adult Diapers

Pressure Mattresses

Ulcer Treatment


0

% Reporting Interference

Staff Perceptions: Obstacles to Care of Staff Perceptions: Obstacles to Care of Older AdultsOlder Adults

20

40

60

80

100

Staff Shortages/

Time Constraints

Economic Pressure

Communication Problems

Exclusion of Older Adults

from Decisions

Confusion about Who is the Decision

Maker

Lack of Specialized

Services

Lack of Equipment

Exclusion of Nurses from

Decisions

Inadequate Knowledge

Inadequate Policies

Inter- disciplinary

Conflicts


Uncooperative

% Reporting Interference

Perceptions: Staff Disturbed by Behavior Perceptions: Staff Disturbed by Behavior of Older Adultsof Older Adults

0

20

40

60

80

100

Confused/ Agitated

Argumentative Demanding Wander During the Day

Up During the Night

Seek Reassurance


Pressure Ulcer Management

Mean Score

Comparative Results: Staff Knowledge Comparative Results: Staff Knowledge vs. Attitudesvs. Attitudes

Best Possible Scores

Neither Good Nor Bad

Poor Scores

0123456789

10

Knowledge Attitude

Sleep Management

Incontinence Management

Restraint Management


3. Training and Education Programs

• Introduction to Gerontology: Interdisciplinary Curriculum

• Geriatric Patient Care Associate (GPCA) Core Curriculum

• Geriatric Resource Nurse (GRN) Core Curriculum


4. Online Connect WebinarsExamples: • Linking Quality and Cost

– The Business Case for NICHE– Retooling Performance Improvement Systems

• Accelerating the Advance of Best Practice

– Pressure Ulcers– Falls– Catheter Associated Urinary Tract Infections– Restraints

• Improving the Geriatric Care Environment including the physical environment and nursing practice environment


5. Clinical Practice Protocols

• Research based • Focused on common geriatric syndromes• Accessible and usable by bedside nurses• Redesigned to meet hospital’s needs• Used to embed knowledge


NICHE ProtocolsNICHE protocols are based

on content in E. Capezuti, D.

Zwicker, M. Mezey, T.

Fulmer, D. Gray-Miceli, and

M. Kluger (2008) (Eds.),

Evidence-Based Geriatric

Nursing Protocols for Best

Practice (3rd ed.). New York:

Springer Publishing Co.

To order Geriatric Nursing Protocols for Best Practice go to http://www.springerpub.com/prod.aspx?prod_id=11033


6. Organizational Strategies

Examples:

• Certification Toolkit• Business Case: Cost Savings Estimate

Tool


7. Clinical Improvement Models

Examples:

• Overview

• Restraint Reduction

• Pressure Ulcer Prevention Program

• Reducing Fall-Related Injuries


8. NICHE Discussion Boards and Listserv

• Ongoing dialogue with NICHE hospitals nationwide

• Contact with NICHE/Hartford Institute for Geriatric Nursing

• Daily opportunity for collaboration, problem solving, and sharing


9. Unlimited Contact Hours

• NICHE Training and Education Programs and Webinars include continuing education credit at not cost

• Unlimited contact hours for all personnel• Track your team’s progress


Hartford Institute for Geriatric Nursing

www.hartfordign.org• Try This Assessment Series

• Try This Dementia Series

• Try This for the PDA

• How To Try This Series

• A New Look at the Old American Journal of Nursing

• ConsultGeriRN.org

• Gerontological Nurse Certification Review Course

• The Geriatrics and the Advanced Practice Curriculum

• REASN (Resourcefully Enhancing Aging in Specialty Practice)


Getting Started • Gather Stakeholders • Identify needs derived from:

• staff development measures• clinical outcomes• financial outcomes• budget considerations• satisfaction surveys• other strategic initiatives/plans• passion of the “gerontologized”


How to become a NICHE designated hospital

• Attend Leadership Training Program (LTP)

– Who should attend the LTP? (minimum of 3 people responsible for initial steering of initiative)

• Nurse Clinical Leader

• Clinical Educator

• Quality Manager or Administrator

• Recommended additions to steer initiative: direct care staff, and other disciplines (medical, rehab, social work, pharmacy etc.)

• How is the LTP delivered?

– 6 week online program delivery

• Participate in several scheduled live webinars

• Engage in online group activities

– Facilitated by NICHE faculty & experts from experienced NICHE sites

– Earn 38 contact hours

– Development of Action Plan upon program completion – Reviewed & discussed with NICHE staff and faculty


© 2010 NICHE All rights reserved. The information contained in this module is provided for informational purposes only. The content has been developed by NICHE participants and the NICHE staff of the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing and is protected by copyright under the laws of the United States and foreign laws. Under no circumstances may these material be reproduced for sale or profit. Any use of content not expressly permitted may violate copyright, trademark, and other laws.

Thank you!

For more information, please go to www.nicheprogram.org

NICHE Nurses Improving Care for Healthsystem Elders HARTFORD INSTITUTE FOR GERIATRIC NURSING NEW...

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