BY: GAY LANDSTROM, M.S., RN, NEA-BC, and DONNA GRAY, MSN, RN, NEA-BC
Serving the unique care needs of our elder population is an ethical imperative for Catholic health systems. As Catholic health care providers, we define ourselves as champions of the vulnerable and as the sources of just and compassionate responses to our communities' needs. Still, and far too often, Catholic health care providers give greater focus to ethical issues at the beginning of life. In Trinity Health, we believe that senior care, end-of-life care and palliative care services should be among hallmarks of faith-based care — especially at this unique time in the nation's history when the population of seniors is growing exponentially.
Today, seniors represent a large and rapidly growing community demographic and a large percentage of those served by U.S. hospitals. The U.S. Department of Health and Human Services' Agency on Aging reports that persons 65 years or older numbered 39.6 million in 2009 (the latest year for which data is available), representing about 13 percent of the U.S. population or about 1 in every 8 Americans. By 2030, the agency expects there will be more than 72 million older persons, or nearly 20 percent of the population.
In some regions where Trinity Health operates ministries, the older population represents an even larger segment, making this group's special health care needs particularly salient. Our mission, the nation's statistics on aging and our experience all make it clear that changing the way we care for senior citizens is a matter of urgency.
What's more, consider the new health care landscape: Beginning October 1, 2012, hospitals will be denied Medicare reimbursement for care when seniors return within 30 days with the same diagnosis. The policy is intended to help save government money and improve care by encouraging hospitals to deliver better, more patient-focused care and to pay more attention to patients after discharge. It is also intended to help hospitals better encourage their patients' compliance with doctors' orders.
To meet these challenges and to deliver even more beneficial care, we believe that hospitals should take a close look at gaining and sustaining support of the Nurses Improving Care for Healthsystem Elders program, known as NICHE. The program helps nurses, hospitals and whole systems make the changes that best serve this important patient segment.
We know that hospitals face critical priorities: dealing with health reform requirements, declining reimbursements and general budget concerns. Those, along with challenges like ageism, fear of change and lack of time for training can make NICHE accreditation seem too large a project to tackle. Our experience, though, is that the challenges can often be overcome and that the required cultural, operational and clinical changes required are worth every effort.
By encouraging — not requiring — the hospitals throughout its 10-state system to participate in the NICHE program, and by sharing and building upon NICHE best practices and elder-care success stories throughout the system, Trinity Health hospitals are doing better by a population that so frequently is plagued with poverty, frailty, chronic illness, ageism and limited access to geriatric expertise. We have found NICHE learnings, assessments and processes to be completely in line with what we should be doing for all patients — taking accountability and coordinating their care.
WHERE IT STARTS
NICHE is a program of the Hartford Institute for Geriatric Nursing at New York University College of Nursing. It provides principles, policies, education and tools that stimulate and support important changes in a health care facility's — or system's — culture in the way it provides health care for seniors. The training is designed to enhance nursing knowledge and skills for treating common geriatric illnesses and to help hospitals achieve shorter lengths of stay, increased time between patient readmissions, reduced readmission rates and reduced costs, according to NICHE program materials and the www.nicheprogram.org web site. Not only will it help providers meet Medicare reimbursement requirements in the future, NICHE training also promises to help caregivers, clinicians and entire health care systems deliver patient-centered, relationship- and evidence-based, high-quality care.
The NICHE program already is an important part of Trinity Health's efforts to better serve our patients, to reduce readmissions and to transform. We have encouraged NICHE designation across our ministry, and, at this time, six of our 49 hospitals have achieved it, and six more are engaged in the process. A number of others are evaluating their readiness to embark on the journey that ends with designation as a NICHE facility, and we look forward to reporting higher NICHE numbers in the future. It will mean we are delivering better, safer and more effective care to our ever-increasing number of senior patients.
Here's an example of how NICHE training can cascade from an overall philosophy to a very specific use with a very gratifying outcome: At the Lacks Cancer Center at Saint Mary's, Grand Rapids, Mich., NICHE-trained staff focus on creating a supportive environment that mitigates many issues, including dementia, that their senior patients face inside and outside the hospital setting. One such issue involves something everyone knows firsthand — the stress of waiting. Staff at the cancer center put together a therapeutic activity closet full of items and pastimes ranging from puzzles, games and PVC pipe that can be assembled into patterns and shapes (useful for psychosocial, cognitive, motor, vision and sensory benefits) to sound machines, sewing boards and more. The closet serves as a resource for patients and their families and friends as they wait between treatments, wait for assessments and conversations with doctors and nurses, and while they hope. Items from the closet help families pass the time, as well as help patients calm their fears and anxieties by taking comfort from the sense of purpose they can experience as they work on a puzzle or craft.
But the resources in the closet can be called into use as important tools, as well. Our associates saw a powerful example one night when they admitted a frail, 80-year-old woman with mental status changes. Agitated and very confused, she had a history of dementia and lived at home with her visibly exhausted daughter. Staff told the daughter to go home and rest, assuring her that her mother was in good hands. The daughter did leave the campus, but more than a little skeptically. Based on past experience, she had no doubt she would be called in during the night to assist with her mother.
Staff took time to carefully assess the patient's behavior, and their NICHE training helped them devise a course of appropriate and needed patient-centered care. To help calm this agitated patient, her nurse turned to the resource closet; she brought out a baby doll and offered it to the patient to watch over and care for. The woman held the baby doll as if it were her own, very real child and was immediately soothed. When the daughter returned in the morning, she was relieved and impressed to find her mother's agitation significantly lessened. She reported she had never seen her mother so relaxed. Staff sent the baby doll home with the patient at discharge — she, too, had been provided with a tool.
Today, individualized therapeutic activities for patients are a staple at Lacks, and this patient's story is only one of many wonderful and moving successes. Staff at the center has been greatly impressed by the impact these kinds of items and activities have made both in patients' care and in the staff's ability to deliver that care. In large part, we owe thanks to NICHE.
At St. Mary Mercy Hospital, in Livonia, Mich., NICHE training fit into a journey already under way. The hospital's primary patient population is, on average, 10 years older than the population a typical acute-care hospital serves. Recognizing the importance of specialized senior care, St. Mary Mercy opened Michigan's first Senior Emergency Center in 2010 as part of Trinity Health's national Senior ER initiative.
Patient-centered Senior ERs offer a care model that better meets the medical needs and preferences of older adults, and it does so in a setting that offers more physical comforts than in a traditional emergency department. Caregivers do not view visits to a Senior ER as a single, isolated incident. Rather, the process goes much deeper — Senior ER patients receive a wider variety of screenings, a thorough assessment and attentive follow-up care. It all adds up to a comprehensive program that considers seniors' overall health and whole person — body, mind and spirit.
At St. Mary Mercy, undertaking the NICHE program followed the establishment of the Senior ER. In fact, NICHE assessments helped inform some of the Senior ER work and, in doing so, shone a spotlight on NICHE's many other benefits. Hospital administrators, already buoyed by an overwhelmingly positive response to the Senior ER, found themselves setting a new goal: to make the entire hospital as focused on the elderly as a children's hospital is focused on the young.
That meant NICHE protocols would need to expand beyond the Senior ER unit.
In our experience at St. Mary Mercy, we learned that people often have an unintended blindness about the needs of an aging population. Once something like a Senior ER stimulates awareness, the blindness is lifted. Caregivers can see how more precise attention to aging-related issues improves care.
So, as they became accustomed to NICHE and saw the results, St. Mary Mercy caregivers felt strongly that the NICHE program's highly focused interventions — which include follow-up contact with patients and linking them to key resources like home health services — could help patients beyond the walls of the Senior ER. NICHE training began for all hospital RNs, unit by unit. Each RN had a mandatory time line for completing the NICHE training modules and for attending a four-hour class, and unlicensed assistive staff attended a class to learn key NICHE concepts. Making this change on a total unit basis — rather than person by person — supported the culture change needed to ensure all of St. Mary Mercy's senior patients would receive consistent, very similar interventions and attention.
As staff of each unit completed their training, changes began to occur. Focus of care shifted from simply addressing the immediate, acute issue to returning the patient to the highest level of health he or she could attain. Special attention went to maintaining patients' physical activity levels to combat the loss of strength and mobility many elders experience because of hospitalization.
The hospital created the Care Transitions program, inspired by NICHE; it represents significant changes in practice for patients transitioning to long-term care settings — improving information about them and how it is shared upon transition from one caregiver to another.
Though the NICHE program was created specifically for the needs of the elderly, its learnings have inspired changes in care for all patients. After all, what patient wouldn't prefer attention to skin care, increased mobility, fewer falls, education materials that are easier to read and understand? And improvements in coordination of care patients receive at home and in other health care settings benefit everyone involved.
WHY IT WORKS
NICHE helps caregivers change the quality of their relationships with their patients. Our experience has revealed that nurses find relationship-based care more effective and more rewarding — that it is as good for them as it is for the patient. Subject-matter expert Marie Manthey, author and the founder of Minneapolis-based consultant Creative Health Care Management Inc., speaking at the 2011 Trinity Health Nursing Conference, said that many nurses feel they provide care in a world where many hospitals have refocused their attention away from their patients and onto financial goals, task lists and business, in general. She reminded us that this is counter to the fact that we are supposed to be benevolent organizations that put patient needs above all else.
Like Manthey, Trinity Health leadership believes in pursuing excellence through implementation of best practices and patient-centered and relationship-based care. Leaders have encouraged all hospitals in the system to become NICHE-certified when they are ready to undertake the program.
Some hospitals were eager to take the steps immediately, building on their participation in Trinity Health's Senior ER initiative. Like St. Mary Mercy, these hospitals were very well-positioned from a philosophical perspective. Their staff and leaders already were aware of what could be done to improve the care and experience of seniors in the ER, so it made sense to them to start improving that care and experience elsewhere in the hospital as well.
Other facilities aren't ready for NICHE just yet. They know, however, that Trinity Health believes the NICHE program innovations help provide better care for elders, and they know the system expects to see the NICHE designations spread. They also hear about the experiences of system hospitals that have been able to make the needed investments to roll out the program and eventually achieve NICHE designation. The unfailingly positive results NICHE makes have been heard, loud and clear, by hospital executive staffs.
WHAT'S THE EFFECT?
We make it clear to all of our ministries that we believe providing special, person-centered care to our nation's growing population of seniors is the right thing to do and, without doubt, smart from the business perspective.
Seniors as a group require more health care services than do younger people. The nation's aging population is a powerful group socially; they are influencing others' opinions as they actively seek options and alternatives for the care of their own parents now and for themselves as they age. Providers that are sensitive to this group's needs will be in a position to grow as the senior population continues to increase.
Joanne Grosh, director of senior services for Saint Joseph Mercy Health System in southeastern Michigan, said Saint Joseph Mercy's experience is a great testimonial to the strength of the program and the importance of its goals. The system's nurses who have gone through NICHE training have told Grosh that they enjoy a unique empowerment. They have taken deep dives into topics including poly-pharmaceutical challenges, multiple chronic conditions and functional and cognitive impairments and, because NICHE is nurse-driven, they feel that the program is extremely effective at helping them enhance quality of care. Many participating nurses have stated, as well, that the program enhances the mission-focus of their work and helps them feel good about their commitment to the highest standards of elder care. It makes them love their jobs again, Grosh says.
Further, specialized geriatric training gives nurses new tools to use in their care of people with a wide range of unique health challenges and experiences. They learn, for example, how to watch for correct positioning of a patient's body to protect joints and bones that may have become more fragile with age. They know to take precautions to safeguard delicate skin and can provide patients with the benefit of improved approaches to other core clinical issues such as falls, restraint use, pain, skin breakdown and wounds, use of advance directives and family involvement in decision-making.
NICHE helps us improve the care we deliver by helping us focus on providing special, person-centered care to our nation's growing population of seniors. Not only is it the right thing to do for systems like Trinity Health; it also helps us know we are living our Catholic mission.
GAY LANDSTROM is senior vice president, patient care services, and chief nursing officer, Trinity Health, Novi, Mich.
DONNA GRAY is vice president, patient care services and chief nursing officer, St. Mary Mercy Hospital, Livonia, Mich.
TRINITY HEALTH
Based in Novi, Mich., Trinity Health operates 49 acute-care hospitals, 432 outpatient facilities, 33 long-term care facilities and numerous home health offices and hospice programs in 10 states. It is the 10th largest health system in the nation and the fourth largest Catholic health system in the country, by total number of hospitals and total bed count, respectively.
CHALLENGES OF CHANGE
For a few early-adopter hospitals, the NICHE journey began before they implemented Senior ERs, but in other hospitals, challenges have halted moves toward NICHE designation before a single step could be taken. As for any major organizational change, a hospital or system really has to be ready. NICHE designation essentially requires a complete transformation of the way a hospital and its staff think about seniors and think about delivering care.
At the organizational level, there can be concerns about the cost of NICHE training and the amount of time it would require, not to mention how to continue unit coverage during the training time line. Then comes some individuals' resistance to investing the time required to train and overcoming a general, predictable sentiment that "this is not new; we have cared for elderly for years. What could we possibly learn that would be different?"
Using St. Mary Mercy as an example, two St. Mary Mercy nursing units have completed 100 percent of the training in a little over one year; the third cohort of about 100 RNs has completed about 70 percent. To date, the hospital has spent about $60,000 on the training.
The training takes time — 20 hours per participant or more — and it is not light learning. At St. Mary Mercy, RN completion of initial NICHE modules is paid (16 hours of pay) and takes place either online, off site or in the hospital's training rooms. When all of these modules are complete, nurses still have to attend a four-hour class. In this class they learn more about the unique needs of the elderly population, experience a virtual dementia exercise, watch a "see me" video, learn about dealing with deliria and dementia, and are trained in how to use a wide variety of screening tools. Participants also learn more about the Trinity Health model of relationship-based care during the class; this helps them see clearly how it fits with their NICHE learnings.
A separate challenge exists after some units achieve their certifications. If a hospital lacks enough geriatricians or geriatric nurse practitioners, it may also lack the support that geriatric-trained nurses need to truly be successful in their NICHE-related efforts. Health care is very multidisciplinary in this area. It takes a whole team to serve the elderly population appropriately due to the complex interplay of their individual physical, cognitive and socioeconomic factors.
Finally, during this time when health care providers are managing through a major transition in health care, seemingly discretionary investments in time and money can be particularly difficult. Depending on a hospital's specific situation, expected reductions in pay and moving from being paid for service to being paid for performance may make investing in a program like NICHE a good choice, but one that can't be readily undertaken.
Copyright © 2012 by the Catholic Health Association of the United States
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