IDENTIFICATION OF NEEDThe “Best Practices in Nursing Care”

suggests the older adult population is at

increased risk of complications when

hospitalized. This vulnerable population

is at a heightened risk for re-hospitalization,

functional decline, and medical errors due

to chronic conditions. During transitions

between settings, the hospitalized older

adult is extremely susceptible to problems

with care fragmentation. The available

evidence suggests that interdisciplinary

team collaboration plays a pivotal role in

ensuring that successful care transitions

occur. Transitional care is one of the most

critical health issues for older adults.

IMPROVING NURSE AND HOSPITALIST CAPACITY TO DELIVER HIGH QUALITY TRANSITIONAL CARE FOR OLDER ADULTS

• Viktoriya Fridman, RN, ANP-BC • Barbara Sommer, RN, MA, CEN, NE-BC • Barbara Donovan, RN • Aphene Fraser, RN, MSA • Danielle Walker, RN • Marcia Nelson, DO, RPh, RN • Tara Easter, RN, GNP-BC •

• Maimonides Medical Center, Brooklyn, New York •

BOTH PROGRAMS • Utilize interdisciplinary teams guided by evidence-based protocols

• Physician-Nurse collaboration across episodes of acute care

NICHE

focuses on quality improvement programs andprotocols whereby nursing interventions have a substantive and

positive impact on care of older hospitalized patients.

• EVIDENCE-BASED NURSING PROTOCOLS• GIAP • GRN

BOOST is a program providing technical support to a quality improvement

teams at hospitals by utilizing resources to improve the hospital discharge process and mitigate discontinuity and fragmentation of care.

• POST-DISCHARGE F/U CALL • DISCHARGE NOTE• POST-DISCHARGE F/U APPOINTMENT

• TEACH-BACK

Better Outcomes for Older adultsthrough Safe Transitions

OBJECTIVE At Maimonides Medical Center the project

was designed to pilot a new, innovative

interdisciplinary geriatric model of care

by blending the NICHE and BOOST care

models simultaneously on two medical

units. This project utilizes a collaborative

care model wherein nurses, physicians,

and the entire interdisciplinary team focus

on improving the care and transitions of

the hospitalized older adult. This is the

first time, nationally, that the models have

been combined together in one hospital.

TEAM SUPPORTEDGOALS• Enhance team collaboration

• Improve geriatric practice knowledge

• Improve nurse competency in providing safe patient care

• Prevention of in-hospital injury and functional decline

• Improve clinical outcomes

• Decrease length of stay

• Enhance patient and family caregiver satisfaction

• Maximize patient/caregiver independence for discharge transition

• Reduce 30 day readmission

• Reduce fragmentation of care

• Decrease total health care cost

EVALUATION• Pre & Post Implementation Unit Data

• NDNQI on clinical outcomes: Pressure ulcer prevalence, Fall & fall injury rate, Restraint use

• GIAP

• 30 day readmission rate

• Length of stay

• Patient Satisfaction Data

CORE COMPONENTS • Leadership buy-in and support

• Evidence-Based Geriatric Nursing Protocols

• “Try This” Best Practices in Nursing Care to Older Adults series

• NICHE Leadership Training Program (LTP)

• Geriatric Institutional Assessment Profile (GIAP)

• NICHE Geriatric Resource Nurse (GRN) Core Curriculum with integrated BOOST elements

• Geriatric Patient Care Technician (GPCT) Core Curriculum

• BOOST Comprehensive Discharge Planning guide

• NICHE Webinar Series

• BOOST Webinar Series/Data Center Training

• NICHE/BOOST Listserv

• Electronic Medical Record

2010 2011

IMPLEMENTATIONS INITIATIVES JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

P Grant Funded Resources allocated ◙ H Pilot Units Units with majority of patients of age 65 and above ◙ A NICHE-BOOST team created Key Personnel Identified, Vision and Mission defined ◙ S NICHE LTP 12 Team Members Participated in 6 weeks LTP ◙ ◙ E BOOST Training 8 Team Members Attended 2 days conference ◙ BOOST Webinar Data Center Training ◙ ◙ 1 GIAP Completed with 100% compliance ◙ Analyze GIAP results Identified gaps in geriatric care & GRN NICHE model identified ◙ Project Presented to: Nursing, Medical, Interdisciplinary & Advisory Board Present project timelines ◙ Training Curriculum

Engaged interdisciplinary teams to participate in nursing training: NP, MD's, Pharmacist, Wound Care Nurse Special-ist, Registered Clinical Nutritionist, Registered Polysomnographist / RN ◙

Interdisciplinary Teams Engagement Nutrition, Pharmacy, Rehabilitation ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ GRN training implementation 16 out 45 RN’s from two pilot unit completed GRN training ◙ Teach Back Methodology Embedment Nursing and medical staff teach back methodology training by utilizing BOOST DVD ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ Discharge Note

Patient friendly discharge note to improve flow of information between hospital and outpatient physicians by utilizing BOOST toolkit ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙

Promote and Publicize NICHE-BOOST project Promote two pilot units as NICHE-BOOST designated facility internal and external audiences ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ P Project Pre-Implementation Data Evaluation NICHE-BOOST data analyzed ◙ ◙ ◙ ◙ ◙ ◙ ◙ H Project Goes Live NICHE-BOOST initiatives & Adapt System Protocols 1st A Medical Staff Engagement Physician Champions lead teaching rounds, reinforce teach back, CAM, Discharge Note and other project initiatives ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ S Scheduling F/U Appointments Prior Discharge At time of discharge patient has F/U appointment with PMD within 7 days ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ E Post Discharge F/U Calls APN call's patient's within 72 hours post discharge ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙

Medication Reconciliation & Fill Prescriptions Program Medications reconciled by pharmacist & filled at hospital pharmacy prior to discharge. Medications teaching instruc-tions delivered by clinical pharmacist ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙

2 Delirium Protocol Imbedded CAM screening tool in to Electronic Medical Record, Developed and will sustain "Delirium Nursing Proto-col" ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙ ◙

Post-Implementation Project Evaluation NICHE-BOOST data analyzed ◙ ◙ ◙ ◙ ◙ ◙ Develop Geriatric Patient Care Technician Curriculum (GPCT) Key Personnel: APN, GRN's ◙ GPCT Training

Develop GPCT Class schedule and implement ongoing coaching by a GRN or APN. Will implement after GRN's role on the unit will be sustained ◙ ◙ ◙ ◙

Train all nursing staff Implement initial educational initiative - 16 hour education program for all unit nurses ◙ ◙ Model Dissemination Sustain NICHE-BOOST model & move to the next phase of the project ◙ FUTURE GOAL- NEW GERIATRIC MODEL of CARE on ALL NURSING

PROMOTION NICHE-BOOST AWARENESS TARGETS:

• Advisory Board

• Nursing & Medical Leadership

• Medical residents

• Nursing Staff

• Voluntary Physicians

• Interdisciplinary Teams

METHODS:

• Power-Point Presentations

• Grand Rounds with Dr. Mark V. Williams (BOOST Principal Investigator)

• Publicized on MMC intranet

• NICHE designation posters & brochures

CONCLUSION The NICHE-BOOST model promotes

team collaboration to improve the

quality of transitional care for older

adults. By having a vision of the same

goal, nurses and hospitalists can

enhance safe hospitalization, cohesive

transitional care, and optimal

organizational performance. Integrating

these two care models helps mitigate

the effects of discontinuity and bridges

the gap between hospital & home for

patients with complex or multiple

health problems.

REFERENCESBixby, M. B., & Naylor, M. D. (2009). The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults. Try This: Best Practices in Nursing Care to Older Adults. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_26.pdfBurke, M., Boal, J., & Mitchell, R. (2004). Communicating for better care: improving nurse-physician communication. American Journal of Nursing, 104 (12), 40-48. Retrieved from http://ovidsp.tx.ovid.com/sp-3.3.1a/ovidweb.cgiCapezuti, E., & Brush, B. L. (2009). Implementing Geriatric Care Models: What Are We Waiting For? Geriatric Nursing, 30(3), 204-206.

McGaw, J., Conner, D. A., Delate, T. M., Chester, E. A., & Barnes, C. A. (2007). A Multidisciplinary Approach to Transition Care: A Patient Safety Innovation Study. Permanente Journal, 11 (4), 4-9. Retrieved from http://xnet.kp.org/permanentejournal/Fall07/transition_care.pdfSnow, V., Beck, D., Budnitz, T., Miller, D. C., Potter, J., Wears, R.L.,...Williams, M. V. (2009, August). Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. Journal of Hospital Medicine 4 (6). doi: 10.1002/jhm.510

INTERDISCIPLINARYCORE TEAM• NURSING: NICHE-BOOST Coordinator, CNO, Nursing Leadership, Unit’s Nurse Mangers, Staff Nurses

• HOSPITALISTS: Physician Champions

• CASE MANAGEMENT: CM Leadership, Unit CM, Clinical SW, SW Assistant

• PI: Quality Analyst, Data expert

• PHARMACY

• NUTRITION

• REHABILITATION: PT, OT, ST

FUTURE GOAL – NEW GERIATRIC MODEL of CARE on ALL NURSING UNITS