1. NICHE • Nurses Improving Care for Healthsystem Elders
HARTFORD INSTITUTE FOR GERIATRIC NURSING • NEW YORK UNIVERSITY COLLEGE OF NURSING 1

2. Our Objectives
Discuss the implications of the aging population for our hospital
Discuss the opportunities and resources offered by the NICHE program

3. 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 3 3

4. Why a program focused on older adults?4 4

5. 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, Washington, DC: Families USA.
Russo, C.A. & Elixhauser. (2006). Hospitalizations in the elderly population, Rockville, MD: Agency for Healthcare Research and Quality. HCUP Statistical Brief No. 6. 5

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 % 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) National Hospital Discharge Survey. National Health Statistics Reports, 5, 1-20. 6

7. Older Adults Are Hospitals’ CORE Consumers
_____% of_____________ (our hospital)‏
inpatient admissions are 65 years and older
Insert a picture of your hospital here. 7 7

8. Health Services Utilization by Age Group, 2005
Acute Care Services
All ages
Ages
65-74 yrs
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
# 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
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. 8

9. Older Adults Are Hospitals’ CORE Consumers
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

10. Older Adults Are Hospitals’ CORE Consumers
___% of_____________ (our hospital)
inpatient admissions are 85 years and older

11. The Quality Imperative: Improve Clinical and Fiscal Outcomes!
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
Insert a picture of your hospital on this slide. 11 11

12. 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 12

13. 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 13

14. NICHE Program Goal Vision Mission
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 14 14

15. What is the focus of NICHE?
NICHE focuses on programs and protocols that are predominantly under the control of
nursing practice. 15 15

16. In other words…
areas where nursing interventions have a substantive and positive impact on patient care 16 16

17. 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 17 17

18. 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 18 18

19. What are the objectives of the NICHE program?19 19

20. 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 20 20

21. 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 21 21

22. 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 22 22

23. 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 23 23

24. 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 24 24

25. NICHE Program Goal #6: Increase collegial networks
Form partnerships with other hospitals through an exchange of information and shared resources
Form academic alliances 25 25

26. Characteristics of Sustainability
Goals #1& 2 focus on improving outcomes that are durable and cumulative for care of hospitalized Older Adults.
Goal #3 Promote staff effectiveness and satisfaction focuses on increasing knowledge and competency around the care of Older Adults. “Home grown experts” develop into stable expert staff which improves job satisfaction and interdisciplinary collaboration.
Goal #4 Establish leadership as a provider of care to Older Adults
New value is critical to survival in today’s healthcare environment. With the NICHE program, member hospitals will set an example of exemplary care for the older adult within their community. It is also an opportunity to be proactive with community partners in geriatric sensitive care.
Goal #5 Provide fiscally responsible care
Through increasing staff competence and improvement in sensitive outcomes, hospitals’ shift their momentum to develop new collaboratives, new opportunities, diversitfication, and marketing.
Goal #6 Increase collegial networks
Proactive Leadership builds stable support through formation of partnerships and academic alliances. 26

27. 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)‏ 27 27

28. 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 28 28

29. 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 29 29

30. 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 30 30

31. 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 31 31

32. What resources does the NICHE Program offer?32 32

33. NICHE Program www.nicheprogram.org
This 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 33 33

34. NICHE Program Resources for “Members Only”
NICHE Planning & Implementation Guide
Geriatric Institutional Assessment Profile (GIAP)
NICHE Training and Education Programs
Online Connect Webinars
NICHE Clinical Practice Protocols
NICHE Organizational Strategies
NICHE Clinical Improvement Models
NICHE Listserv and Discussion Boards
Unlimited contact hours
All tools and resources will be accessed through NICHE’s new Knowledge Center 34 34

35. 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 35

36. 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 36 36

37. Using GIAP: A Case Study
Site: a community hospital
Sample: 235 surveys were returned for
analysis 37 37

38. Staff Perceptions: Appropriate Use of Treatments
% Reporting Appropriate Use
Staff Perceptions: Appropriate Use of Treatments 20 40 60 80
100
Mechanical
Restraints
Incontinence
Pads
Urinary
Catheters
Tube
Feedings
Sleeping
Medication
Pain
Adaptive
Devices
Adult
Diapers
Pressure
Mattresses
Ulcer
Treatment 38 38

39. Staff Perceptions: Obstacles to Care of
% Reporting Interference
Staff Perceptions: Obstacles to Care of
Older Adults 20 40 60 80
100
Staff
Shortages/
Time
Constraints
Economic
Pressure
Communication
Problems
Exclusion of
from Decisions
Confusion
about Who is
the Decision
Maker
Lack of
Specialized
Services
Equipment
Nurses from
Decisions
Inadequate
Knowledge
Policies
Inter-
disciplinary
Conflicts 39 39

40. Perceptions: Staff Disturbed by Behavior
Uncooperative
% Reporting Interference
Perceptions: Staff Disturbed by Behavior
of Older Adults 20 40 60 80
100
Confused/ Agitated
Argumentative
Demanding
Wander During the Day
Up During the Night
Seek Reassurance 40 40

41. Comparative Results: Staff Knowledge
Pressure Ulcer Management
Mean Score
Comparative Results: Staff Knowledge
vs. Attitudes
Best Possible Scores
Neither Good
Nor Bad
Poor Scores 1 2 3 4 5 6 7 8 9 10
Knowledge
Attitude
Sleep Management
Incontinence Management
Restraint Management 41 41

42. 3. Training and Education Programs
Introduction to Gerontology: Interdisciplinary Curriculum
Geriatric Patient Care Associate (GPCA) Core Curriculum
Geriatric Resource Nurse (GRN) Core Curriculum 42 42

43. 4. Online Connect Webinars
Examples:
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 43 43

44. 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 44 44

45. NICHE Protocols NICHE 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 45 45

46. 6. Organizational Strategies
Examples:
Certification Toolkit
Business Case: Cost Savings Estimate Tool 46 46

47. 7. Clinical Improvement Models
Examples:
Overview
Restraint Reduction
Pressure Ulcer Prevention Program
Reducing Fall-Related Injuries 47 47

48. 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 48

49. 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 49

50. Hartford Institute for Geriatric Nursing
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) 50 50

51. 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” 51 51

52. 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

53. Thank you! For more information, please go to www.nicheprogram.org
© 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. 53