NICHE Models The NICHE nursing care models can help hospitals improve their care to better meet the needs of their hospitalized older adult patients. These models have been implemented and tested at hospitals across the country and have been shown to be effective in improving clinical care and outcomes for elders during and following hospital admission. Geriatric Resource Nurse (GRN) Model At NICHE we view the GRN Model as the Foundation for Improving Geriatric Care. The underlying goal, improving the geriatric knowledge and expertise of the bedside nurse, is foundational to implementing system-wide improvement in the care of older adult patients. The Geriatric Resource Nurse (GRN) model is an educational and clinical intervention model that prepares staff nurses as clinical resource person on geriatric issues to other nurses on their unit. GRNs are trained by geriatric advance practice nurses to identify and address specific geriatric syndromes such as falls and confusion, and to implement care strategies that discourage the use of restrictive devices and promote patient mobility. Using pre- and post- test design, 4 NICHE sites employing the GRN model found a statistically significant improvement in nurses perceptions of caring for the acutely ill older adult following implementation of the NICHE/GRN model. 1 All of the original NICHE sites (see NICHE History) chose to implement the GRN model and over the last decade the GRN model has remained as the most frequently implemented NICHE model. Thus the GRN model is often the first step in developing and implementing other systemic geriatric initiatives, including an ACE unit (described below), geriatric case management, transitional care, and geriatric protocol dissemination. The following are reasons to implement the GRN model: 1. Provide excellent bedside nursing to older adults hospitalized older adults 2. Develop a corps of nurses armed with the clinical competencies to meet the needs of older adult, and serve as resources to other staff. 1 Fulmer T, Mezey M, Bottrell M, et al. Nurses Improving Care for Healthsystem Elders (NICHE): nursing outcomes and benchmarks for evidenced-based practice. Geriatr Nurs. 2002;23(3):121 127.
3. Stimulate interest in gerontologic care. 4. Develop incentives and improve morale for nurses caring for the older adult. 5. Provide a mechanism for professional growth of nurses. 6. Enhance the nurse-patient relationship and patient satisfaction. 7. Promote the effectiveness of the interdisciplinary team. 8. Increase implementation of evidence-based clinical practice. 9. Provide optimal utilization of hospital services. 10. Facilitate safe and effective discharges. 11. Promote continuity of care between the hospital and other settings. The GRN model has been implemented in many specialty areas, including diverse areas such as critical care, dialysis, and the neurosurgical unit. Gerontologic nursing needs to fine tune theoretical and clinical knowledge content to provide GRNs with the focused educational preparation and training, as well as practice tools to provide expert care in these specialty areas. Involvement in specialty organizations provides GRNs the opportunity to shape conference and journal content to reflect the needs of older adult patients. The Hartford Institute s Geriatric Competence of Specialty Nurses initiative which supports specialty nurses associations as vehicles for assuring the geriatric competence of specialty nurses. See www.consultgerirn.org for further information. An Acute Care of the Elderly Medical-Surgical Unit (ACE Unit) The ACE model was formally developed at University Hospitals of Cleveland in conjunction with the Frances Payne Bolton School of Nursing at Case Western Reserve University. A 29-bed medical- surgical specialty unit was renovated and dedicated as an Acute Care of the Elderly (ACE) unit to prevent functional decline in this targeted group of patients. Consistent with the original concept, The ACE model reallocates unused or underutilized hospital beds to create a specific unit targeted to improving clinical outcomes in older adult patients. The ACE unit combines flexible nurse staffing and a renovated physical environment to deal with the problem of functional decline. The model
promotes collaborative team building and developing nurse-initiated clinical protocols of care. The geriatric medical director and clinical nurse specialist provide clinical leadership. The also fosters hospital-wide improvement of nurses geriatric knowledge by serving as a resource center for care of older adult patients. The NICHE approach to the ACE Model focuses on the role of nursing in improving care for hospitalized elders. Specifically, our approach highlights the role of the geriatric advanced practice nurse and the GRN. We believe all nurses working on an ACE unit should receive GRN-level education. Whether or not you decide to implement the ACE model in your hospital, there are certain of the ACE concepts that can be disseminated throughout the hospital to make the environment more elder friendly. These include: geriatric training of nurses and all other direct care providers, a physical environment that addresses age-related changes, and interprofessional teams. Other Approaches that Complement NICHE Models The following interventions (or modifications thereof) are often implemented in tandem with the GRN model and /or the ACE model: The Geriatric Syndrome Management Model was developed at the University of Chicago Hospitals and provides for consultation and education by a Gerontological Nurse Specialist (GNS) to improve nurses accuracy and speed in detecting and managing common geriatric syndromes such as falls, urinary incontinence, and sleep disturbance in hospitalized older patients. Strategies used to address a syndrome include receiving initial and repeated direct instruction on all NICHE units and on every shift. Pre-printed assessment forms and a large poster that summarize all instrumental components of the approach are commonly placed in a prominent position in each nursing station. This model uses a target condition to open the way for improving geriatric care comprehensively. The Hospital Elder Life Program (HELP), created by Sharon K. Inouye, M.D., M.P.H. at Yale University School of Medicine, is an innovative approach to improving the hospital care for older
patients. The multicomponent intervention strategy employs targeted interdisciplinary geriatric assessment with an innovative volunteer model to provide personal, supportive attention to vulnerable older patients. Quality Cost Model of Transitional Care was developed by Dr. Mary Naylor at the University of Pennsylvania School of Nursing. It contains a discharge planning protocol developed specifically for the hospitalized elderly and implemented by Gerontological Nurse Specialist (geriatric nurse practitioners and clinical specialists). The assumption is made that Gerontological Nurse Specialists (GNS) has advanced knowledge and skill in caring for high-risk elderly and their caregivers; therefore, the GNS provides care under a general protocol and adapts this protocol to the specific needs of the elderly. The GNS assesses patients soon after admission and at least every 48 hours during the course of the patient s hospital stay. Initially, the GNS was accessible to patients and family members by telephone seven days a week and worked with unit staff to customize care. Recently the GNS has followed patients at home to coordinate a plan of care in the critical period postdischarge. By coordinating care of multiple health care providers involved in discharge planning, the GNS becomes the one consistent person to whom patients and families can turn to during and soon after hospitalization. Evaluating the effectiveness of this model as compared to the hospital s general discharge planning procedures indicates that this intervention has lengthened improved outcomes and significantly lengthened the time between re-hospitalizations for subjects in the experimental group. This brief description of NICHE models was adapted from the following sections of the comprehensive NICHE Planning and Implementation Guide: LaReau, R. & Lyons, D. (2007). Developing and expanding the geriatric nursing knowledge base: A guide for NICHE sites. In M. Boltz (Ed.), NICHE Planning and Implementation Guide: A Program for Nurses and Other Staff Working in Acute Care and Affiliated Environments. New York: Hartford Institute for Geriatric Nursing, 39 pages.
Boltz, M., Capezuti, E., Mezey, M., & Fulmer, T. (2007). Choosing a geriatric nursing model: A guide for NICHE sites. In M. Boltz (Ed.), NICHE Planning and Implementation Guide: A Program for Nurses and Other Staff Working in Acute Care and Affiliated Environments. New York: Hartford Institute for Geriatric Nursing, 16 pages. Fulmer, T., Boltz, M., Mezey, & Capezuti, E., (2007). The Geriatric Resource Nurse Model: A guide for NICHE sites. In M. Boltz (Ed.), NICHE Planning and Implementation Guide: A Program for Nurses and Other Staff Working in Acute Care and Affiliated Environments. New York: Hartford Institute for Geriatric Nursing, 33 pages. Wexler, S. (2007). The Acute Care for the Elderly (ACE) Model: A guide for NICHE sites. In M. Boltz (Ed.), NICHE Planning and Implementation Guide: A Program for Nurses and Other Staff Working in Acute Care and Affiliated Environments. New York: Hartford Institute for Geriatric Nursing, 15 pages. Other References The Geriatric Resource Nurse (GRN) Model Fulmer, T. (2001). The geriatric resource nurse: A model of caring for older patients. American Journal of Nursing, 102:62. Fulmer, T. (1991). The geriatric nurse specialist role: A new model. Nursing Management, 22, 91 93. Fulmer, T. (1991). Grow your own experts in hospital elder care. Geriatric Nursing, 12, 64 66. Fulmer, T. & Wallace, M. (2000). Fulmer SPICES: An overall assessment tool of older adults. Geriatric Nursing, 21:147. Inouye, S. K., Acampora, D., Miller, R., Fulmer, T., Hurst, L., & Cooney, L. M. (1993). The Yale geriatric care program: A model of care to prevent functional decline in hospitalized elderly patients. Journal of the American Geriatrics Society, 41, 1345 1352.
Lee, V. K., & Burnett, E. (1998). A case report: Special needs of hospitalized elders. Geriatric Nursing, 19:185-91. Lee, V. K. & Fletcher, K.R. (2002). Sustaining the geriatric resource nurse model at the University of Virginia. Geriatric Nursing, 23 (3), 128-132. Lee, V., Fletcher, K., Westley, C., & Fankhauser, K.A. (2004). Competent to care: Strategies to assist staff in caring for elders. Medical Surgical Nursing, 13 (5), 281-288. Lopez, M., Delmore, B., Young, K., Golden, P., Bier, J., & Fulmer, Y. (2002). Implementing a Geriatric Resource Model. Journal of Nursing Administration, 32 (11), 577-585 Mezey, M., Kobayashi, M., Grossman, S., Firpo, A., Fulmer, T., & Mitty, E. (2004). Nurses Improving Care to HealthSystem Elders (NICHE): Implementation of best practice models. Journal of Nursing Administration, 34 (10), 451-457. Pfaff, J. (2002). The Geriatric Resource Nurse Model: A culture change. Geriatric Nursing, 23 (3), 140. The Acute Care of the Elderly Model (ACE Unit) Asplund, K., et al. (2000). Geriatric-based versus general wards for older acute medical patient: A randomized comparison of outcomes and use of resources. Journal of the American Geriatric Society, 48:1381-8. Barrick. O., et al. (1999). Impacting quality: Assessment of a hospitalbased geriatric acute care unit. Am J Med Qual, 14:133-7. Counsell, S. R., et al. (2000). Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of acute care elders (ACE) in a community hospital. Journal of American Geriatric Society, 48:1572-81. Covinsky, K. E., Palmer, R. M., Kresevic, D. M., Kahana, E., Counsell, S. R., Fortinsky, R. H., et al. (1998). Improving functional outcomes in older
patients: Lessons from an acute care for elders unit. Joint Commission Journal of Quality Improvement, 24(2): 63-76. Landefeld, C. S., Palmer, R. M., Kresevic, D. M., Fortinsky, R., & Kowal, J. (1995). A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. New England Journal of Medicine, 32, 1338 1344. Palmer, R. M., et al. (1998). Clinical intervention trials: The ACE unit. Clinical Geriatric Medicine, 14:831-49 Palmer, R. M., Landefeld, C. S., Kresevic, D., & Kowal, J. (1994). A medical unit for the acute care of the elderly. Journal of the American Geriatrics Society, 42, 545 552 Discharge Planning and Home Follow-up Model Naylor, M. D., (1990) Comprehensive discharge planning for hospitalized elderly: A pilot Study. Nursing Research, B9, 156-161. Naylor, M. D., Brooten, D., et al. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association, 281: 613-20. Naylor, M.D., Brooten, D., Campbell, R., Jacobsen, B.S., Mezey, M., Pauly, M.V., et al., (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association, 281(7), 613-620. Naylor, D., Brooten, D., Campbell, R., Maislin, G., McCauley, K.M., & Schwartz, J.S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52, 675-684. Naylor, M.D., Stephens, C., Bowles, K.H., & Bixby, M.B. (2005). Cognitively impaired older adults: From hospital to home. American Journal of Nursing, 105 (2), 52-61.
Naylor, M. D., & Prior, P. R. (2001). Transitions between acute and longterm care. In: Katz, P. R., Kane, R. L., Mezey, M.D. Emerging systems in longterm care. Spring Series: Adv Long term Care, 4: 1-22. Interdisciplinary Case Management Cohen, E., L., & Cesta, T. G. (1993). Nursing case management: From concept to evaluation. Mosby Yearbook, Inc: St. Lous, Missouri. Lopez, M., Delmore, B., Young, K., Golden, P., Bier, J., & Fulmer, Y. (2002). Implementing a Geriatric Resource Model. Journal of Nursing Administration, 32 (11), 577-585.