BY JENNIFER PETTIS, MS, RN
America is aging, and older adults comprise a more racially and ethnically diverse group than ever. In fact, there were 52.4 million adults over the age of 65 in 2018, an increase of nearly 14 million individuals in just 10 years. This segment of the popula-tion is expected to grow to nearly 95 million by 2060.1 The changing population composition, combined with the movement toward value-based care, has resulted in an urgent need for health care providers to implement systems of care that effectively honor the wishes of older adults and their families.2, 3
To address the urgent need to change the design and delivery of care for older adults, The John A. Hartford Foundation and the Institute for Health Improvement, with their partners, the American Hospital Association and the Catholic Health Association, launched the Age-Friendly Health Systems initiative in 2017. The vision for age-friendly care focuses on the 4M model — What Matters, Medication, Mentation and Mobility — as an indispensable set of evidence-based care approaches that support the dignity and self-determination of each older adult.
Ensuring that nurses are well prepared to recognize and meet the unique needs of older adults is a critical step in any organization's process of becoming age-friendly. Nurses must be prepared to provide evidence-based care to older adults and be ready to lead teams to implement the changes needed to improve the overall quality, safety and value of care. Nurses Improving Care for Healthsystems Elders (NICHE) can enable nurses to do just that. NICHE, a program of the NYU Rory Meyers College of Nursing, is one of the original geriatric care models that focuses on the important contributions of nurses to influence the health outcomes of older adults.
NICHE is an organizational membership program that aims to improve the care of older adults across the health care continuum.4 The NICHE practice model supports exemplary nursing care by employing four major levers: the Geriatric Resource Nurse (GRN) role; practice standardization and clinical guideline use; coordinated care transitions; and a population-focused environment of care.
The Geriatric Resource Nurse role is foundational to NICHE in that it positions frontline nurses as experts in geriatric nursing care. Nurses in this role serve as peer mentors, change agents and leaders in person-centered interdisciplinary care planning aimed at ensuring excellent care for older adults.5 The Geriatric Patient Care Associate (GPCA) and Geriatric Certified Nursing Assistant (GCNA) roles empower unlicensed nursing personnel in a similar fashion to the GRN. These staff, who often spend the most time with older adults in acute as well as long-term and post-acute care settings, serve as the eyes and ears of the team and are often the first to detect subtle changes in an older adult's status. Ensuring they are well versed in the most current, evidence-based practices to identify and act on such changes enables the entire care team to better meet the needs of older adults.
Second, practice standardization is achieved through nurse-initiated evidence-based clinical guidelines tailored to the needs of older adults. Members of the NICHE program gain access to evidence-based resources, tools and education housed in the NICHE Knowledge Center, an online learning management system. The eight-week NICHE Leadership Training Program introduces new members to the NICHE nursing practice model, in which clinical leaders identify opportunities to improve care of older adults by implementing evidence-based nursing interventions into daily clinical practice.6
Third, recognizing the importance of well-coordinated transitions of care, the NICHE program positions nurses to lead patients and families to prepare for transitions. For example, NICHE nurses learn best practices regarding caregiver readiness and other important nursing considerations when preparing an older adult for discharge from an inpatient care setting. The NICHE "Need to Knows" patient education tools and pocket cards support the consistent use of evidence-based practices, including teach-back strategies to prepare older adults and their families for a successful care transitions.
The fourth component of the NICHE model is centered on providing older adults with a population-focused care environment, set forth in the Acute Care of the Elderly (ACE) unit model. Acute Care of the Elderly units employ strategies focused on enhancing older adults' function and autonomy through robust use of adaptive equipment to overcome sensory, functional or mobility limitations. They also use simple strategies to promote orientation such as large-print calendars, clocks and whiteboards. Table 1 exemplifies how the NICHE program supports the Age-Friendly Health Systems initiative.
Currently, there are approximately 500 NICHE-member hospitals and post-acute care organizations in the U.S., Canada and Singapore.
NICHE's positive impacts on patient, staff and organizational outcomes are well documented.7 For example, evidence shows that implementing NICHE resulted in decreases in restraint use and hospital-acquired urinary incontinence as well as increases in nurse satisfaction caring for older adults and a marked improvement in the overall nursing practice culture.8 Similarly, other NICHE members have reported clinical and organizational outcomes associated with NICHE including reduced falls, improved patient satisfaction, decreased use of inappropriate medication, improved cultural competence, improved detection and management of delirium, decreased lengths of stays and associated costs, and reductions in avoidable staff turnover.9 As Terry Fulmer, PhD, RN, noted during a recent IHI National Nursing Home Huddle, NICHE is the backbone of Age-Friendly Health Systems, and its long-standing success makes it an obvious choice for organizations seeking to provide the best possible care to older adults.
JENNIFER PETTIS is acting director, programs for NICHE.
- Administration for Community Living, "2019 Profile of Older Americans," May 2020, .
- Terry Fulmer, Kedar S. Mate and Amy Berman, "The Age-Friendly Health System Imperative," Journal of the American Geriatric Society 66, no. 1 (2018), doi: 10.1111/jgs.15076.
- Institute for Healthcare Improvement, "Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults," 2019, http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx
- Terry Fulmer et al., Nurses Improving Care for Healthsystem Elders, (New York: Springer, 2020).
- Linda Bub et al., "The NICHE Program to Prepare the Workforce to Address the Needs of Older Patients," in Geriatrics Models of Care, eds. Michael Malone et al. (New York: Springer, 2015).
- Nurses Improving Care for Healthsystems Elders, NYU Rory Meyers College of Nursing, 2020, .
- Allison Squires et al., "A Scoping Review of the Evidence About the Nurses Improving Care for Healthsystem Elders (NICHE) Program," The Gerontologist, (Nov. 4, 2019), https://doi.org/10.1093/geront/gnz150.
- Jann Pfaff, "The Geriatric Resource Nurse Model: A Culture Change," Geriatric Nursing 23, no. 3 (May-June 2002): 140-44.
- Bub et al., "The NICHE Program to Prepare."