Models of Care

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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 older adults 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 the clinical resource person on geriatric issues to other nurses on their unit. GRNs are trained by geriatric advanced 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, four 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 hospitalized older adults.
  2. Develop a corps of nurses armed with the clinical competencies to meet the needs of the older adult, and serve as a resource to other staff.
  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 critical care, oncology, and emergency departments. This requires "fine tuning" clinical knowledge to provide GRNs with 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 supports specialty nurses associations as vehicles for assuring the geriatric competence of specialty nurses.

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 NICHE ACE model designates a specific unit or a section of a unit in order to deliver interventions known to improve the clinical outcomes of older adult patients. Key elements of an ACE unit include environmental adaptations for older patients (e.g., flooring to decrease visual glare and noise, enhanced lighting, clocks and calendars in patient rooms, communal area for activities and meals), staff with special expertise in geriatrics, and an interdisciplinary team focused on preventing geriatric syndromes.

The ACE model promotes collaborative team building and nurse-initiated clinical protocols of care. The geriatric medical director and geriatric advanced practice nurse provide clinical leadership. The ACE model 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 older adults. Specifically, we highlight the role of the geriatric advanced practice nurse and the geriatric resource nurse (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 some ACE concepts that can be disseminated throughout the hospital to make the environment more senior friendly. These include: geriatric training of nurses and all other direct care providers, a physical environment that addresses age-related changes, and interprofessional teams.

 

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.