Building senior-friendly care hospitals in the United States: Where are we and where do we need to go?

Transcription

1 Building senior-friendly care hospitals in the United States: Where are we and where do we need to go? IAGG 2013 Seoul, Korea Marie Boltz, PhD, CRNP Elizabeth Capezuti, PhD, RN, FAAN June 24, 2013

2 Acknowledgements Bureau of Health Promotion Department of Health, Executive Yuan, Taiwan Grant UL1 TR from the National Center for the Advancement of Translational Science (NCATS), National Institutes of Health

3 Objectives Describe the context for acute care of older adults in US Discuss NICHE as a national initiative to promote senior-friendly care Describe the NICHE self-evaluation content, process, and results

4 Why do we focus on elders? Those age 65 and above are core consumers: 60% of medical surgical patients 46% of CCU patients 50% of ICU days In Emergency Departments, 26% of trauma admissions In the next 30 years, those 85 years and older will double in number to 8.5 million U.S. Dept. of Health and Human Services, Centers for Disease Control. Trends in Health and Aging.

5 Older adults experience: Higher rates of functional decline Higher rates of medical errors Longer lengths of stay (7.8 days vs. 5.4 days) Higher rates of readmission,within 30 days External Drivers for change Consumer expectations Value-based care environment DeFrances, C.F., Lucas, C.A., Buie, V.C., & Golosinskiy, A. (2008) National Hospital Discharge Survey. Hyattsville, MD. National Center for Health S statistics Reports No. 5. Jencks, S., Williams, M., & Coleman, E.. (2009). Rehospitalizations among Patients in the Medicare Fee-for-Service Program. The New England Journal of Medicine 360 (14), Covinsky et al. (2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 51 (4),

6 Geriatric Acute Care Models ACE (Acute Care for the Elderly) units 1 Hospital Elder Life Program (HELP) 2 Palliative care consultation model 3 Transitional Care Model 4 & Care Transitions Intervention 5 1. Counsell SR, et al. J Am Geriatr Soc. 2000; 48: Inouye SK, et al. J Am Geriatr Soc. 2000; 48: Morrison RS, Meier DE. N Engl J Med. 2004;350 (25): Naylor M, et al. Journal of the American Geriatrics Society 2004; 52: Coleman EA, et al. Archives of Internal Medicine 2006:166;

7 ACE (Acute Care for the Elderly) units interdisciplinary care, geriatric protocols in prepared environments: improved functional outcomes Hospital Elder Life Program (HELP) Lay volunteers orient patients, assist with meals and fluid intake, and promote mobility: decrease the incidence and severity of delirium

8 Transitional Care Model & Care Transitions Intervention Early discharge planning with home follow-up: reduction in number of 30 day readmissions Palliative care consultation model Team approach to symptom management, supported decision-making: improved satisfaction; decreased costs

9 Nurses Improving Care to Healthsystem Elders (NICHE) reported to be foundational to the uptake and sustainability of such models Leff B, et al. Rapid reengineering of acute medical care for Medicare beneficiaries: the Medicare innovations collaborative. Health Affairs 31 (6): , 2012.

10 Nurses Improving Care for Healthsystem Elders Mission support efforts to embed evidence-based geriatric knowledge into practice A program of the Hartford Institute for Geriatric Nursing at NYU College of Nursing technical support center for sites, providing resources via a web-based portal, technical support, and conferences emphasizes the Geriatric Resource Nurse model (peer consultant and change agent at unit level) Evolved through research conducted over the last 21 years More than 450 active member sites

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12 NICHE Measurement Institutional milieu: staff knowledge, attitudes, and perceptions of the care environment for older adults Clinical measures Measures of staffing volume and certification

13 Improved Outcomes and Processes Improved patient outcomes: Decreased incidence & severity of delirium Less reported pain, facilityacquired incontinence, and mobility loss and fall-related injuries and facility-acquired pressure ulcers Decreased incidence of pneumonia and UTI rate Decrease in facility-acquired urinary incontinence Improved interdisciplinary process measures: Reduction in restraint use Increased compliance with protocols Improved documentation and family support Improved clinician competence: Increase in nurse knowledge and attitudes toward care of hospitalized older adults Improved organizational outcomes Decreased length of stay (1 day) Reduction in readmission rates

14 Feedback from sites included: Need for a blueprint to change at a system level Need for process to monitor internal progress toward developing, disseminating, and sustaining a NICHE program. Desire to link dose (number of geriatric resource nurses, protocol use, training, policies..) with outcomes 14

15 Development of the self-evaluation tool Views of clinicians, consumers, and gerontologic researchers identified the components of a geriatric acute care program Boltz, M., Capezuti, E., & Shabbat, N. (2010). Building a Framework for a geriatric acute care model. Leadership in Health Services. 23 (4),

16 Dimensions Summary of Items Guiding Principles α =.96 k= 2 Mission statement development, dissemination and endorsement by the governing body Organizational Structures α =.76 k= 11 Leadership α=.70 k= 6 Geriatric Staff Competence α =.97 k= 9 The NICHE steering committee composition and activity Processes of interdisciplinary decision-making Geriatric Resource Model (GRN) dissemination ACE (Acute Care of Elders) implementation The NICHE Coordinator role and qualifications Nurse Educator role and qualifications GRN leadership functions Regional leadership role: dissemination and mentorship National leadership role Geriatric education across disciplines Staff development programs integrated into clinical ladder or advancement program. Evaluation of staff capacity to meet the needs of older adults Components were associated with 113 items, or activities associated with program development, implementation, and evaluation. Delphi technique: 49 items were extracted from this list, identified as salient action items Interdisciplinary Resources and Processes α =.98 k=6 Use of interdisciplinary evidence-based guidelines Transitional care processes Established a scoring system to calculate 4 levels of implementation Patient and Family Centered Approaches α =.98 k=6 Patient and family engagement in: * education* decision-making * program development and evaluation Consumer outreach Environment of Care α =.99 k=4 Evaluation and modification of the physical environment Quality metrics α =.74 k=5 Breadth of quality measures Dissemination of findings Utilization of metrics to guide program development

17 NICHE Nurses Improving Care for Healthsystem Elders HARTFORD INSTITUTE FOR GERIATRIC NURSING NEW YORK UNIVERSITY COLLEGE OF NURSING Implementation of self-evaluation process Web-based survey, conducted every 2 years as part of NICHE recommitment Boltz, M., et al. (2013). Implementation of geriatric acute care best practices: Initial results of NICHE sites self-evaluation. Nursing & Health Sciences. 2013

18 Results of First Wave (2012) (N=180) Hospital Characteristics The majority of sites are medium sized (n=70; 39%), teaching hospitals (n=76; 42%) with a comprehensive geriatric assessment program (n=104; 58%) Geriatric Resource Nurse (GRN) Model Number of GRNs Number of units with GRNs Number of nurses certified in geriatrics Acute Care of Elders (ACE) unit 27.2% Hospital Elder Life Program (HELP) 8.3% Better Outcomes for Old Adults through Safe Transitions 11.7% (BOOST) The Care Transitions Program (Coleman model) 12.2% Transitional Care Model (Naylor model) 4.4% 76.1% Mean ± SD (mini-max) 45.0 ± 88.6 (0-80) 4.4 ± 6.1 (0-41) 8.4 ± 22.5 (0-195)

19 Process to ensure accessibility to adaptive and sensory support (51%) Environment on the steering committee agenda (37%) * At least 2 measures as priorities (62%) * Clinical, organizational, staff measures 2 or more units (36%) * Coordinator on clinical practice committee (89%) * NICHE has a national role (34%) * Protocols include patient /family education (52%) * Website for elders/ families (22%) *Steering committee: administration quality, education, clinicians (78%) * patient/family involvement (12%) * Evidence-based guidelines on medical & surgical units (76%) *in critical care and ED (22%) GRN Core curriculum on more than one unit (74%) Gero staff development into clinical ladder (27%)

20 Levels of Implementation early implementation: developing :oversight, leadership, staff development and evaluation (n=29; 16%) progressive level: comprehensive geriatric acute care model, including the GRN model, implemented on one unit (n=101; 56%) senior friendly level: multiple units; assumed regional leadership (n=41; 23%) exemplar level: geriatric initiative throughout and beyond the organization and national leadership role (n=9; 5%)

21 Do hospital characteristics matter? Using chi-square test for independence: hospitals with: ACE unit (p=.021); mobile ACE unit (p=.022) Comprehensive geriatric assessment programs, both inpatient (p=0.029) and outpatient (p=.008) were more likely to be senior friendly implementers as opposed to early or progressive implementers. Bed size (39%; beds), teaching status (42% teaching), and Magnet (40%) status were not associated with level of implementation.

22 Implications NICHE Site Self-evaluation tool may be used to chart a plan toward improving the clinical and organizational culture related to care of older adults, and evaluate progress on an ongoing basis. Implementation can be successful in a variety of settings. Areas that need attention: * patient/family engagement * the environment * critical care/emergency department

23 In process.... Triangulating program self-evaluation with: Clinical outcomes Staff knowledge, attitudes, perceptions of the care environment Patient satisfaction Organizational outcomes: length of stay, readmission rates

24 Thank you!