FORT WAYNE, Ind.–Shirley Davis walks three miles a day to stay fit and active. But a few days ago, the 79-year-old tripped over a table leg in her Fort Wayne home. The injury required hospitalization.
It’s a fact of life that as we age, we are more prone to falls and other health issues that require physician and hospital visits.
Older adults are hospitalized at three times the rate as the general population, according to the U.S. Department of Health and Human Services. Care for individuals 65 and older accounts for 63 percent of all health care spending, and hospital costs comprise the largest segment of those expenditures.
By 2030, one in five of us will be among the 65-plus demographic, HHS data show, and by 2035, the United Nations Population Division estimates one in five people on the planet will be in that age group. They are so many in numbers and are living so much longer that “older adult” has further been divided into young old, old and oldest of the old.
However this population is defined, it is mandating changes in health care delivery, with a growing number of nurses taking the lead in implementing evidence-based practices that improve patient care, reduce costs and meet the psychosocial needs of older adults.
Nurses Improving Care
Fortunately for Davis, the Dupont Hospital emergency room nurse who cared for her was especially in tune to her needs. Gina Wirick, a nurse for 25 years, had just completed intensive training to become a geriatric resource nurse, or GRN. The designation is a component of an international initiative called NICHE, or Nurses Improving Care for Healthsystem Elders.
Wirick is one of 11 Dupont Hospital nurses who are now GRNs, and Dupont is one of only six Indiana hospitals to date to attain a NICHE designation by implementing research-supported NICHE practices. The NICHE mission is to provide “principles and tools to stimulate a change in the culture of health-care facilities to achieve patient-centered care for older adults.”
“The Geriatric Resource Nurse model is foundational to the NICHE program,” said Barbara Bricoli, executive director of NICHE, which is based at New York University School of Nursing. “If you train a nurse at the bedside to be a geriatric expert, they will serve as a resource to the other staff on the unit.”
Dupont ER nurse Theresa Shull is the hospital’s NICHE program coordinator. NICHE implementation is an ongoing process that started 10 months ago, Shull said, noting much of the initial focus has been on the ER, looking at every aspect of care and the environment that older adults encounter.
Nurses completed the NICHE Geriatric Institutional Assessment Profile (GIAP), which measured their skills, attitudes and knowledge of older adults. The assessment revealed strengths and areas of need, such as additional training in dementia and potentially dangerous pressure ulcers. The hospital is taking advantage of expertise within other community entities and using NICHE curriculum to improve GIAP benchmark scores. As education continues, staff is re-assessed.
Through Patients’ Eyes
The NICHE model is more than book knowledge and collegial instruction. Patient and family input is pivotal. At Dupont Hospital, focus groups of older adults are randomly chosen from individuals who have attended Senior Circle activities.
Senior Circle is a national organization focused on health, wellness and socialization for the 50-plus age group. Dupont is part of Lutheran Health Network, which sponsors the local Senior Circle chapter.
Senior Circle input is already visible. For Dupont’s first 12 years of existence, a wide painted blue line was the signature color to follow when driving on campus toward the ER. Focus group members pointed out all other emergency signage is red; the blue color was a bit confusing. Drive the campus today, and you will see a wide red line on the road leading to the ER.
Focus group feedback also spurred changes in how the hospital’s valet parking services are explained. People questioned the security of handing over their car keys to the valets; they wondered if the service was free or if they should tip. Some had forgone the service because of such concerns.
The clinical focus of NICHE includes nurse education on preventing hospital-acquired infections, falls and other preventable conditions and adverse events. The curriculum includes ways to improve patients’ transition from hospital to home or a long-term care setting. NICHE also provides specialized training for pharmacy staff.
With hospital reimbursement rates negatively impacted by readmission of Medicare patients within 30 days of discharge, ensuring patients and their families understand discharge instructions and medications is crucial to hospitals’ bottom line.
“Two years ago, we opened up NICHE to skilled nursing facilities and a few home-health agencies,” Bricoli said. NICHE now offers the geriatric patient care associate course for nursing assistants and an intro to gerontology for all hospital staff. Currently, 500 hospitals and 80 long-term-care facilities have NICHE designation.
Focus on Patients and Families
Although aggregate data collection for comparing clinical outcomes of NICHE-designated hospitals to non-NICHE ones is in early stages, Bricoli said individual hospital data reveal higher patient satisfaction and improved clinical outcomes in certain areas within units following NICHE implementation.
NICHE researchers hope to glean more outcome data by looking at federal patient perspective surveys, which hospitals must now give to patients.
Among Fort Wayne’s five hospitals, Dupont consistently has been at or near the top for number of babies delivered annually. But Wirick said, in her three years working in the ER, she has seen a dramatic increase in older patients. The NICHE principles are both needed and effective, she said, because the focus is “not only on caring for patients, but for their families, too.”
Shull said her two-year vision for NICHE at Dupont is “for every unit to have that GRN champion to propel those quality practices for the patients.”
Tonya Teegarden, Dupont’s emergency department manager, said, “It’s about identifying the barriers and bridging the gaps.”