HEALTHSTREAM LIVING LABS IN ACTION A CONVERSATION WITH: Mitchel T. Heflin MD, MHS Associate Professor of Medicine, Duke University School of Medicine Eleanor McConnell PhD, RN, GCNS-BC Associate Professor, Duke University School of Nursing Loretta Matters MSN, RN Associate Director, Center of Excellence for Geriatric Nursing Excellence Duke University School of Nursing Eleanor McConnell PhD, RN, GCNS-BC and Mitchel T. Heflin MD, MHS. Unavailable for Photo: Loretta Matters MSN, RN How do you define Frail Elder and the need to improve care quality for the growing frail elder population across the continuum of care? In general, older adults have a more difficult time recovering from illness or other health stressors like surgery. This is, in part, related to higher rates of medical problems and medications. It is also due to less tangible factors like memory loss, weakness, and fatigue a collage of problems we might refer to as frailty. Imagine an 85-year-old woman in the hospital for repair of a hip fracture. While we would hope that she would recover from surgery promptly and resume her prior routine, issues like confusion, poor nutrition, and immobility can threaten a successful recovery, prolong hospital stays, and increase the need for institutional care after discharge. Further, the complexity of the healthcare system and limited experience and training on the part of healthcare teams about care of frail older adults present additional risks.
Can you share some statistics about aging and the size of the frail population? The older adult population in the US is growing steadily such that by 2030, there will be nearly 70 million adults over age 65. The fastest growing portion of that population will be those over 85, for whom frailty is a more common condition. This has important implications for all health professionals. While we imagine an active and contented late life for many of our older patients, we know that aging comes with a greater burden of illness and potential loss of ability and independence. This can result in a growing need for ongoing healthcare and significant challenges to recovery from acute illness. What is the importance of the quality of care and the care continuum for a frail population? Frail elders constitute a disproportionate percentage of those hospitalized. While older adults make up 12-13% of the population, they constitute as much as 40% of those hospitalized. Recent data suggests that we have become better at caring for them in the hospital (at least as much as this is measured by length of stay). However as folks age, they are much less likely to return home after hospitalization to live independently and much more likely to need institutional care. The percentage requiring skilled care post-hospitalization grows by about 50% with each decade of age after 65, such that nearly 50% of those over 85 are routinely discharged to skilled care for rehab or long term care. What is the relationship between readmissions and the frail elder population? Frail elders comprise a significant proportion of hospital readmissions, which are expensive and now have an impact on Medicare/Medicaid reimbursements. Prevention of readmissions for older adults requires recognition of common problems and pitfalls in providing healthcare across settings. For example, greater awareness of the presence of acute confusion, also known as delirium, and the fact that it persists after discharge is important for understanding an older patient s healthcare needs. Also, careful reconciliation of medications and recognition and removal of high risk drugs can help avoid unnecessary complications and can keep people from returning to the emergency department (ED) or hospital. Effective transitions also require careful communication between inter-professional team members across all settings, accounting for medical conditions, medications, monitoring, and follow-up visits. A structured approach to managing these transitions for older adults can improve care and the care experience for these patients and their families.
Tell us a little bit about the new certificate program how does it work, what are the topic areas involved, care settings, etc.? Changing this trajectory, or at least caring for people effectively across this period of time, requires not just attending to the admitting diagnosis but to the variety of factors that constitute high quality care for older adults. We have chosen five initial focus areas based on our assessment of the evidence and feedback from teams of professionals who care for frail elders. Increased expertise in these areas would prepare clinicians to impact frailty-related adverse outcomes among older adults across the care continuum. These topic areas include: Delirium, an acute impairment in cognition, which is common among hospitalized elders, and can have far-reaching effects on safety and care outcomes Poor nutrition, an important factor in the development of frailty and a barrier to recovery High risk medications, increase the incidence of adverse events recognition and removal can reduce complications and improve outcomes Transitions of care, a set of robust evidence-based strategies, can improve care delivery between settings and reduce readmissions in high risk older adults Goals of Care, established to help clinicians account for patient prognosis, priorities and preferences in medical decision making in late life. Can you describe the differing ways in which frontline staff, prescribers, and allied staff are currently equipped to face these challenges? What new skills do they need? Members of the care team often are trained to perform a set of tasks or duties that apply narrowly to their functions in caring for a person with a single disorder. Yet care for older adults requires understanding of how multiple diseases interact with each other, and with aging. Failing to understand these complexities can create gaps in care, leading to delayed diagnosis of problems, and setting the stage for transitions that are especially risky for the frail elder population. Failing to appreciate the importance of team care can likewise lead to delayed care or unresolved care needs. To address the care needs of older adults across the care spectrum, we have characterized the nature of the problems and desired staff performance from an interprofessional perspective. What makes your program unique? We have identified both core competencies that we expect of all healthcare staff, as well as role-specific competencies. For example, in the area of medications ALL professionals should understand that geriatric syndromes such as malnutrition, falls, cognitive disturbance, and urinary incontinence may result from an adverse drug effect. Prescribers, however, need to have more in-depth knowledge of how to avoid high risk drugs and how to prescribe therapeutic alternatives. Likewise, medication reconciliation, which is already mandated by the Joint Commission, takes on added importance (and complexity) in elders who are also likely to be cared for by multiple providers. In addition to role-specific differences in content, we have designed the modules to take into account both common and distinct
implications for care in different care settings. For example, delirium onset is much more prevalent in the hospital than in other care settings. However, delirium can certainly be first observed in the clinic setting either in the context of new-onset acute illness, or in the context of post-acute care. For this reason, it is important for ALL care settings to have the capacity to recognize and assess delirium, and to develop a setting appropriate response. However, opportunities in clinic and home care to observe behavioral indicators of delirium are much more limited than in hospital or residential LTC settings so heightened awareness among staff is needed, along with setting-specific examples of what they might see and how they might engage family caregivers more effectively. To make sure every member of the care team knows how to diagnose and handle situations, we are going to provide training in best practices that are supported by evidence. The content of the training will be provided at two levels: that which is applicable across the entire team and that which is customized by individual role, as appropriate. How are you going to ensure the program can reach the whole continuum of care spectrum? Using the example of delirium care, there are key differences in when and how delirium affects other aspects of care in the acute care, clinic, home care, and long-term care settings. Delirium onset is most likely in the acute care environment and its early recognition and management is critical. Since delirium symptoms often persist into the post-acute care phase, the emphasis in those settings is on continuing to manage the delirium precipitating factors, and preventing or recognizing relapse in a timely manner. In contrast, in the clinic setting, the key challenge is not overlooking delirium as a presenting feature of acute illness, and educating family about prevention in the case of elective procedures. Why does Duke have the unique expertise to create this program? Duke is home to The Center for the Study of Aging, one of only five original U.S. centers for aging research established by the Surgeon General of the United States in 1955. Duke is the only continuously funded member of the original group, with currently more than 126 Faculty and staff garnering more than $20 million in annual age-related research funding. The Duke Aging Center s faculty include representatives from many disciplines and professions, including those affiliated with both the School of Nursing and the School of Medicine, both of which are top-10 ranked nationally for their expertise in geriatrics. A particular focus of Duke s work is on improving workforce capacity to care for elders. Duke School of Nursing was the first nursing school in the nation to establish a Gerontological master s degree program in the 1960s, and has had a sustained commitment to improving care of older adults. Duke is a National Hartford Center of Gerontological Nursing Excellence (NHCGNE), focused on improving care of older adults by enhancing the expertise of frontline nursing staff and accelerating the implementation of evidence-based care approaches. The Geriatrics Division of the Duke School of Medicine has been producing fellowship-trained geriatricians for over 3 decades. We provide 1-2 years of advanced training in geriatric medicine and place graduates in clinical and academic positions across the country.
HealthStream s Living Labs program gives healthcare leaders the opportunity to innovate in clinical development, quality, risk, technology, education, process, and culture all focused on healthcare workforce development. This program allows participants to share localized solutions and best-practices in other healthcare settings to increase product understanding, determine the feasibility of technology transfer and adoption, as well as assess the size of a potential market opportunity. Healthcare organizations benefit from the Living Labs team s expertise in research, data analytics, publication, and product development. New opportunities that emerge from the innovation process benefit from HealthStream s market position, understanding, and research. Richard Galentino Ed.D. Vice President, Professional Development Pathways & Living Labs, HealthStream How Do Living Labs Work? Building research objectives and launching a pilot around a new initiative is a journey. The Living Labs team works with your organization to conceptualize and validate a potential opportunity through a series of consultations and a formalized research process. Publishing outcomes and sharing data in peer reviewed and trade publications helps us open our model and can accelerate research adoption. Living Labs Program Benefits Living Labs partners are seen as thought leaders in the healthcare industry. Some partners choose to leverage this position and co-invest with HealthStream in a new market opportunity. Program benefits include: Innovative collaboration to address significant business & clinical challenges Experienced research support & project management Thought leadership visibility to healthcare industry Co-development & co-investment; revenue opportunity for the organization The Living Labs team helped us map our Med-Surg competencies into the curriculum of a local nursing school, creating a more confident and skilled applicant pool of nurses for our hospital system. We are expanding to a second regional nursing school this year. Marco Fernandez, Executive Director, Talent Management and Education, Saint Thomas Health Current Living Labs GOAL: Reduce the preparedness gap of new nurses entering the field through a bridged curriculum OUTCOME: Higher retention; more competent and confident new nurses GOAL: Improve quality of care of frail elders across the entire continuum of care OUTCOME: Interprofessional Frail Elder certificate program GOAL: Improve nurse retention and competency through a more effective onboarding program OUTCOME: Hybrid Nurse Residency Program Three Ways to Participate in Living Labs 1. Contributor: You can join the Living Labs community as a contributor and learn from the best practices of others. Quarterly webinars are hosted by HealthStream, updating the Living Labs community with new research findings and programmatic activities. 2. Investigator: Join in the pilot of another institution benefiting from early adoption and agreeing to share their results. 3. Innovator: Co-develop an innovation with the Living Labs team, establish a market position as thought leaders, and have the opportunity to co-invest and profit-share.