New initiative provides best practices for elderly
New initiative provides best practices for elderly
Benchmarking, indicators, guidelines for geriatrics
Baby boomers: They changed everything they’ve touched. And in 10 to 30 years, their massive influx into the health care system will catch most facilities unaware unless those facilities begin now to reorient their geriatric care with a system of structured benchmarking, best practices, and clinical outcomes indicators, says Terry Fulmer, PhD, RN, FAAN, a professor of nursing at New York University and co-principal investigator of a project called Nurses Improving Care to the Hospitalized Elderly (NICHE).
"Today’s elders consume a tremendous amount of acute health care resources, and tomorrow’s will consume even more," she says. For example, patients who are 65 and older make up about half of hospital admissions and two-thirds of all hospital days. Yet few hospitals have specific programs to meet the care of their elderly patients, and many nurses have little exposure to principles of geriatric nursing, Fulmer says. "As a result, frail elders often experience preventable complications of hospitalizations such as falls or adverse drug reactions that can increase morbidity and mortality." Common geriatric syndromes such as incontinence and pressure ulcers also contribute to longer lengths of stay, increasing costs for both providers and patients.
So how can you help your health care system position itself to meet the needs of acutely ill elders? In addition to best practice models and research-based protocols, the NICHE project includes a unique benchmarking tool called the Geriatric Institutional Assessment Profile (GIAP), says Melissa Bottrell, MPH, project director.
This 69-question survey is designed to assess the following about your hospital’s staff (see sample questions, above):
• attitudes regarding care of the elderly;
• knowledge of institutional guidelines for care of the elderly;
• knowledge of best practices of four common geriatric syndromes;
• perceived institutional barriers to "best practice" for care of elders.
"The GIAP exposes barriers to providing good geriatric care, describes possible staff problems, and provides information about the capacity and quality of the institution," Bottrell says.
By comparing data with similar community, regional, and academic medical centers, institutions can use their profile to benchmark for strategic planning, designing new services or redesigning current ones, and professional development, she says. She gives this typical comparison, using a sample regional medical center:
• A regional medical center may have good knowledge of the specifics of preventing pressure ulcers, compared with other regional centers as well as all NICHE hospitals generally.
• Staff may have better overall core knowledge of the four geriatric syndromes and better awareness of best practice principles in geriatric nursing than other regional medical centers, but much less than combined average for all NICHE hospitals.
"Thus, this profile would show that the hospital may provide excellent care in one specific area pressure sore prevention but the ability to deal with the entire range of geriatric care is limited," Bottrell explains.
Hospitals have used the benchmarking data in various ways. "Some use it to provide a baseline of staff strengths and weakness against which to judge subsequent CQI [continuous quality improvement] efforts," she says. "Others use the data to help overcome resistance to change by providing objective evidence of deficiencies in knowledge and the critical need to improve outcomes for elders. Still others offer it to present to JCAHO surveyors as evidence of improvement. Finally, it’s a strong negotiating tool for contracts with insurers."
Bottrell suggests benchmarking professionals begin assessing their institutions’ ability to provide geriatric care by asking questions and researching national and local demographics:
1. What proportion of our patient load is 65 and older? Is that proportion projected to increase in the next five years?
2. What proportion of our total patient care costs is spent for patients 65 and older?
3. How many master’s-prepared geriatric nurses do you have, or how many nurses have had special training in geriatric care?
The following demographics gleaned from The Merck Manual of Geriatrics (by Merck & Co. Inc. in Whitehouse Station, NJ) also may help you develop plans for best practice benchmarking:
• In 1990, one in eight Americans were 65 and older, a gain of 22% from 1980.
• They represent 13% of the population, but account for nearly one-third of all health care spending, 40% of all doctor visits, and nearly one-third of all prescription drug sales.
• The leading causes of hospitalization are heart disease, cancer, and stroke.
• More than 25% of total Medicare expenditures for a given year go to enrollees who were in their last year of life.
• In 10 years, the number of 65- to 85-year-olds will increase by 73% to 57 million.
• In 10 years, when the first of the baby boomers turn 65, one in five Americans will be 65 and older. The 85-plus population will grow 33% to 8 million.
• In 1900, 75% of our population died before age 65. Today, 70% die after 65.
• The average person over 65 has multiple chronic conditions. Here are the most prevalent: arthritis, hypertension, heart disease, hearing loss, influenza, injuries, orthopedic impairment, catar-acts, chronic sinusitis, depression, cancer, diabetes, visual impairment, and urinary incontinence.
• One million or more Americans over 65 live in California, Texas, Florida, Illinois, Ohio, Michigan, Pennsylvania, and New York. In these states, 500,000 to 999,999 people are over 65: Georgia, Alabama, Tennessee, Missouri, North Carolina, Virginia, Delaware, Massachusetts, Wisconsin, Minnesota, and Washington.
For more details, contact: Melissa Bottrell, MPH, project director, New York University, Division of Nursing, Room 429, 50 West 4th St., New York, NY 10012. Telephone: (212) 998-5371. E-mail: bottrell@ is2.nyu.edu.
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