NICHE Practice Model Helps Improve Care of Older Adults
June 1, 2024
By Melinda Young
Nurses Improving Care for Healthsystem Elders (NICHE) is a geriatric care model that targets expert nursing practice at the bedside of older adults. The NICHE model helps organizations meet national quality goals set by the Centers for Medicare & Medicaid Services. It focuses on closing gaps in clinical care by enhancing nursing workforce skills for care of older adult patients.1
“NICHE is an organizational intervention, meaning it begins with nursing but collaborates with other disciplines or spreads the work to other disciplines in terms of improving care for older adults,” says Karen M. Mack, DNP, MBA, APRN, executive director of NICHE at New York University Rory Meyers College of Nursing. “The whole idea is to give individuals dignity and quality of life so they can live their lives to the fullest. Often, the healthcare system is not well designed to do this. I come from a family of nurses, and it takes our full attention as well as our strong advocacy to make sure our loved ones have great care [that does not] worsen their quality of life. That’s the goal.”
The model is growing. It is used in about 5% of U.S. hospitals. There are more than 300 member organizations in the United States, Bermuda, Canada, and Singapore. “We want to see the passion in the nursing workforce and career progression in geriatrics increase,” Mack says. “We have an ever-expanding need for [NICHE] expertise, and not just nationally — but around the world.”
One way to improve care under the NICHE model is to create a NICHE coordinator role responsible for implementing the model. NICHE coordinators are the frontline operational leaders of an organization, Mack says.
NICHE and the vision for developing age-friendly health systems were created by Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation. “The way Dr. Fulmer envisioned the model, a nurse practitioner with geriatric experience or a nurse specialist in geriatrics [or other disciplines] would take the work of NICHE and coordinate it with three main responsibilities,” Mack says.
The responsibilities include leading the program at the organizational level, steering a committee of nurses and specialists, and inviting other disciplines, including quality leaders, therapists, and nutritionists to convene a group that focuses on implementing a nurse practice model.
The model involves implementing the protocols over time and spreads the NICHE philosophy through the hospital, where everyone works on improving patient outcomes. The NICHE coordinator also is responsible for overseeing staff continuing education to keep evidence-based geriatric care and goals on the radar.
One goal involves keeping patients moving while they are in the hospital. “How do you optimize mobility while a patient is in the hospital? For every day an older person spends in bed, it takes three to seven days to get that strength back,” Mack says. “Three days in bed is very significant, and it makes it difficult for the patient to return home. The goal is to get people up and moving as soon as they are able to do so.” Bedrest creates deconditioning, less core strength, and a greater risk of falls.
NICHE also addresses delirium. “There are evidence-based initiatives the hospitals are working on,” Mack notes. “There are geriatric emergency department guidelines and implementation, and nurses present that work.”
NICHE coordinators manage the program, focus on action plans, and ensure the education and competence of frontline clinicians. NICHE coordinators’ training involves a 15-month executive learning program.
The training program is comprehensive. When there is turnover, it is time-consuming to train new staff. “During the pandemic, there was turnover of NICHE coordinators,” Mack says. “So, we also do a boot camp. First, there is a leadership training program for NICHE; second, there is a NICHE boot camp for new people.”
The NICHE coordinator boot camp provides a one-day online orientation to the NICHE coordinator role. The full NICHE leadership training program is online and includes an orientation session, eight 90-minute didactic classes, five 90-minute coaching calls and assignments, and the opportunity to develop and implement a clinical change project using an evidence-based 10-step change model with an assigned NICHE nurse mentor expert.
The NICHE practice model has various components to its framework, including:
• Geriatric resource nurse role. NICHE coordinators cultivate staff nurses in the principles of geriatric nursing practice. They also mentor nurses to become geriatric resource nurses.
Coordinators provide clinical consultation and mentorship to direct care staff, and they work closely with clinical managers. LPN and RN nurses are given additional education on complications and caring for the unique needs of older adults, Mack says. “They work as influencers on the unit and work to improve care projects,” she adds.
There is a role for nonlicensed nursing assistants and technicians as well. “They develop specialized knowledge that is available to patients and families. They’re at the bedside 24/7, 365 days, implementing best research-driven practices and best practices at the bedside through the course of patients’ stay,” Mack explains.
• Textbook of geriatric best practices. NICHE has a textbook containing evidence-based nursing protocols for best practices, and there are more than 20 different protocols based on research. These give specific recommendations for how care is conducted for older adults.
“They include how to prevent falls, pressure ulcers, catheter-associated urinary tract infections, and additional protocols,” Mack says. “They also work around transitions of care and how they move patients.”
Best practices consider all transitions of care, from home to hospital, emergency department, surgery department, and back. “There’s a big focus on making sure medications are adjusted well because they’re complex for older adults,” she adds.
• Physical care. “Are there grab bars at the right location?” Mack asks. “Is there a good use of contrast in the room so it’s easy to navigate for anyone with lower visual acuity or cataracts?”
There also is a team-based care model in which nurses contribute to geriatric care and team-based care on the unit.
The NICHE model focuses on how each patient has their own unique needs, Mack explains. “One piece is medication. It’s key that people bring their medications in a bottle to each location,” she says.
Another focus is on preserving patients’ function. “If you came in walking, the goal is for you to leave walking,” Mack says. “If you can dress yourself, you do that.”
In caring for older adult patients, nurses, care coordinators, and other clinicians need to help patients maintain their strength to help them return to their prior activities of daily living. “It’s key to return them home so they don’t go home weak or debilitated,” Mack says. “If they don’t go back home, they may end up in long-term care.”
When health systems with NICHE programs transition patients to post-acute care, it helps if they can send them to facilities that also have adopted the NICHE model. This can provide a good handoff, Mack notes.
Case managers play a big role in helping patients transition to home therapy services. For example, case managers and hospital nurses can encourage patients to do some things for themselves, such as eat, dress, and walk to the bathroom — if it is safe.
“Often, [hospitals] can create a patient mindset where someone else helps them eat or dress, but we want them to get back to their normal function so they can retain their ability to take care of themselves,” Mack explains. “We can set them up for success by helping them maintain that function.”
REFERENCE
- Mack KM, Gilmartin M. The NICHE coordinator: A key leadership role in the NICHE practice model. Geriatr Nurs 2024;56:340-344.
Nurses Improving Care for Healthsystem Elders (NICHE) is a geriatric care model that targets expert nursing practice at the bedside of older adults. The NICHE model helps organizations meet national quality goals set by the Centers for Medicare & Medicaid Services. It focuses on closing gaps in clinical care by enhancing nursing workforce skills for care of older adult patients.
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