Becoming Age WISE The Need for a Better

Becoming Age. WISE: The Need for a Better Way Susan M. Lee, Ph. D, RN & The Age. WISE Pilot Project Team Massachusetts General Hospital August 2012 1

Geropalliative Care Geropalliative care is a philosophy of care which recognizes that older adults are not a homogeneous group. Older Adult: 65 through 100+ years! 2

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The World is Aging Source: United Nations Population Division, World Population Prospects: The 2004 Revision (New York: United Nations, 2005). Republished in Kaneda, T. (2006). A Critical Window for Policymaking on Population Aging in Developing Countries. http: //www. prb. org/Articles/2006/ACritical. Windowfor. Policymakingon. Population. Agingin. Developing. Countries. aspx 4

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The Dartmouth Atlas Project reports that older adults are receiving more aggressive end-of-life care (days in ICU and many specialty consultations) despite the fact that most older adults prefer not to receive such care at end-of-life. 8

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• Nearly 80% of Americans wish to die at home although less than 25% actually do. Among US adults age 65 and above, about 50% die in hospitals, often following stays in intensive care and after life-prolonging treatments. (Last Acts, 2002) • The disparity between what older adults want and receive strikes nurses at their core. 11

• The nurse plays a critical role in making the hospital experience better and safer for each older adult. • In the past 10 years, an abundance of new knowledge and evidence for practice has been generated in geriatrics and palliative care. • Age. WISE brings new knowledge to the bedside—just in time. 12

• Age. WISE expands upon the conventional “disease model” of geriatrics to a functional, emotional, and social perspective of aging, which palliative care is an integral component. • But, Age. WISE also focuses on developing the nurse and taking practice to new levels. 13

• Age. WISE also expands the scope of hospitalbased continuing education from informative learning to transformative learning. • Through transformative learning, changes occur first in the nurse who then changes his/her practice based upon new awareness and perspectives. 14

Definition • The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for otherapies. • Palliative care is both a philosophy of care and an organized, highly structured system for delivering care. National Consensus Project 15

Definition • Palliative care expands traditional diseasemodel medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, helping with decision making, and providing opportunities for personal growth. • As such, it can be delivered concurrently with life-prolonging care or as the main focus of care. 16

Trajectory Model of Palliative Care Curative Death Palliative Bereavement 17

Geropalliative Care • Encompasses the traditional notion of palliative care which is to alleviate suffering and enhance quality of life, within the context of curative care or palliative care, or both. • Departs from traditional notions of palliative care in that it is not dependent on the presence of life-limiting disease but may be a useful framework for the care of older adults, by virtue of their frailty or extreme old age, in the last five years of life. 18

Implications • Narrower window of opportunity to respond to changes in condition due to homeostenosis. • Increased vulnerability and greater risk for iatrogenesis, which necessitate: – – – – Meticulous assessment Excellent communication Multidisciplinary team approach Family and caregiver-centered care Protection from all anticipated harm Persuasive advocacy Pain and symptom management Advance directives • Goals of treatment must be clear, documented, and revisited on a regular basis. 19

Geropalliative Care • Associated with unique, age-related phenomena: high risk for ineffective pain management, agerelated changes in pharmacokinetics, unpredictable trajectories of illness, geriatric syndromes, chronic co-morbid conditions, shrinking social networks, insurance limitations, care across multiple settings, and communication challenges • Age-related phenomena require specific assessment and interventions in order to achieve the best outcomes for older adults and their families. 20

Lynn and Adamson, 2003. RAND Health (Used with permission. Lee. 2009) 21 Available online at http: //www. rand. org/pubs/white_papers/2005/WP 137. pdf

Age. WISE Genesis: RN Residency: Transitioning to Geriatrics and Palliative Care (2007 -2010) RN Residency was supported by funds from the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under D 11 HP 08359. 22

Age. WISE Genesis: RN Residency Goals • Build geropalliative capacity in the nursing workforce • Retain nurses in the work force • Improve the care to older adults and their families. 23

Age. WISE Genesis: RN Residency was fundamentally unique. • Unlike most nurse residency programs that aim to socialize novice nurses into their 1 st professional positions, this residency filled a critical knowledge-practice gap, bringing knowledge in geriatrics and palliative care to the bedside. • Learning “that sticks” 24

Age. WISE Genesis: RN Residency Major message of RN Residency: • The critical role that nurses play in shaping the care environment for older adults: nutrition, early mobility, safety, effective communication, and frequent human interaction, so that function is preserved, and healing can occur. • Major focus is aligning care with the preferences and values of older adults. 25

RN Residency Findings • • • Job Engagement Empowerment Confidence Communication Skills Specific skills such as mindfulness, listening, authentic presence, and creating a healing environment resonated with RN residents. 26

MGH Age. WISE Team • Susan M. Lee, Ph. D, RN Age. WISE Program Director • Barbara A. Blakeney, MS, RN, FNAP • Lynda K. Brandt, MS, RN-C • Edward E. Coakley, MS, MA, MEd, RN • Constance M. Dahlin, MSN, ANP-BC, FAAN • Marion L. Rideout, MS, ACNP-BC Age. WISE Program Coordinator 27

Age. WISE Pilot Sites 2010 -2012 • Nebraska Methodist Hospital, Omaha, NE • Sanford USD Medical Center, Sioux Falls, SD • NYU Langone Medical Center, New York, NY • St. Joseph’s Regional Medical Center, Paterson, NJ • UH Case Medical Center, Cleveland, OH • URMC Strong Memorial Hospital, Rochester, NY 28

Age. WISE Pilot Sites 2011— 2013 • Abington Memorial Hospital, Abington, PA • Beaumont Hospital - Royal Oak, MI • Dartmouth-Hitchcock Medical Center, Lebanon, NH • Northwest Community Hospital, Arlington Heights, IL • OSF Saint Francis Medical Center, Peoria, IL • Roswell Park Cancer Institute, Buffalo, NY 29

Advisory Board • Ira Byock, MD Director, Palliative Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH • Brenda Cleary, Ph. D, RN, FAAN Ageing Initiatives Administrator, Sigma Theta Tau International, Indianapolis, IN • Constance Dahlin, MSN, ANP-BC, FAAN MGH Cancer Center, Boston, MA • Karen Drenkard, Ph. D, RN, NEA-BC, FAAN Executive Director, American Nurses Credentialing Center, Silver Spring, MD • Terry Fulmer, Ph. D, RN, FAAN Dean, Bouvé College of Health Sciences, Northeastern University, Boston, MA 30

Advisory Board • Jennie Chin Hansen, MS, RN, FAAN CEO, The American Geriatric Society, New York, NY • Karen Hill, DNP, FACHE Editor, Journal of Nursing Administration and VP, Central Baptist Hospital, Lexington, KY • Dorothy A. Jones, Ed. D, RNC, FAAN Professor, Boston College Connell School of Nursing; Director, Yvonne L. Munn Center for Nursing Research, MGH, Boston, MA • Clareen Wiencek, Ph. D, RN, NP Nurse Director, Virginia Commonwealth University, Richmond, VA • Angelo Volandes, MD Assistant Professor, Harvard Medical School and Attending Physician, Massachusetts General Hospital, Boston, MA 31

Age. WISE: Pilot Site Criteria • Advisors suggested that only top-performing hospitals be included in the pilot. • 1 st criterion: Magnet hospital designation • 2 nd criterion: Nurses Improving Care to Healthsystems Elders (NICHE) member hospitals – Demonstrates strong commitment to building geriatric capacity – Permits access to all NICHE curricular materials. 32

Age. WISE: Pilot Site Criteria Demonstrate hospital commitment and capacity to implement two successive 6 -month residencies. At each site, Age. WISE implemented by 6 nurses fulfilling unique roles in the program • Site Director • Site Coordinator • Senior Nurses (2) • Nurse Manager • Site Researcher 33

Age. WISE: Pilot Site Recruitment • Age. WISE pilot announced at meeting of the 30 state teams at the CCNA. • Mailings sent to all hospitals both Magnet designated and NICHE participants. • Invited to submit proposals, including – Curriculum vitae of proposed Age. WISE site team members – Support letter from the chief nursing officer – Brief description of their organization. 34

Age. WISE: Pilot Site Recruitment • In total, approximately 36 hospitals inquired about the program • MGH Age. WISE core team reviewed and scored proposals using an established grading scheme. • Top-ranking sites were selected: 6 for the first cohort (2010 -2012) and 6 for the second cohort (2011 -2013). 35

Age. WISE Model • • Champion Model 10 RNs per unit Culture Change Performance Improvement Projects 36

Age. WISE: Pilot Site Implementation • A variety of interventions are used to sustain the momentum: – Monthly telephone conference calls – Monthly webinars – Newsletters • Core and site teams rotate the responsibility for presenting monthly webinars. • Promotes knowledge sharing regarding best practices, successes and challenges. 37

Age. WISE Program • Age. WISE residency continued the tradition of the RN Residency of holding biweekly class days over 6 months. • Age. WISE residents attend 96 hours of classes in the program. • During the pilot, approximately 240 nurse residents will participate in the Age. WISE residency with 36 site team members. 38

Age. WISE Program MGH • Toolkit • Age. WISE Summit in Boston • Train-the-Trainer Model • Two Site Visits • Monthly Telephone Conference Calls • Monthly Webinars • Newsletters • Evaluation • • • Sites Identify Age. WISE Staff Choose 1 to 2 units Recruit 10 nurses Provide 12 class days Use Toolkit as Guide Enlist internal experts to teach Pre/Post Testing Focus Groups Performance Improvement Projects 39

• Toolkit© • The Age. WISE Toolkit Editors • Susan M. Lee, RN, Ph. D • Barbara A. Blakeney, RN, MS • Edward E. Coakley, RN, MS, MA, MEd • Constance M. Dahlin, MS, ANP-BC, FAAN • Marion L. Rideout, MS, ACNP-BC 40

National Consensus Project NQF Framework for Hospice and Palliative Care 1. Structure and Process of Care 2. Physical Aspects of Care 3. Psychological and Psychiatric Aspects of Care 4. Social Aspects of Care 5. Spiritual, Religious and Existential Aspects of Care 6. Cultural Aspects of Care 7. Care of the Imminently Dying Patient 8. Ethical and Legal Aspects of Care 41

Age. WISE I. Advocating for Alignment Communication, Ethics II. Creating a Healing Environment Geriatric Syndromes, Age. WISE Care Rounds III. Alleviating Suffering & Promoting Quality of Life Palliative Care, ELNEC, Optimizing function IV. Managing Transitions Bridging Care, Continuity, Follow-up V. Developing Self Expanding Ways of Knowing/Being/Doing 42

Age. WISE Toolkit Resources • Teaching emphasizes the crucial role nurses play in making the hospital experience better and safer for each older patient and family. • Conceptual work also included in order to explicate the philosophical underpinnings of the emerging specialty of geropalliative care. • Site teams encouraged to reserve about one-third of classroom time for case studies and discussion, which were highly valued by previous residents. 43

Competencies -The AW nurse seeks to discover what is meaningful and important to the older person. -The AW nurse advocates for alignment of the older patient’s preferences and values with the stated goals of treatment as part of nursing’s ethical covenant with persons and society. - The AW nurse approaches the older patient with cultural humility and honors and supports the faith/cultural beliefs of the older patient /family relating to end-of-life, decision -making, and pain and symptom management. - The AW nurse seeks ongoing unfolding of the older patient’s story not only as a means of knowing the other but as a healing gift to the older patient. 44

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Impact Age. WISE • Focuses on the pivotal role of frontline nurses; • Invites nurses to practice at a new level of practice; • Empowers nurses with new competencies; • Provides nurses at the bedside opportunities – to innovate practice changes – to create new care delivery models and policies. 46

• Transformational learning is participantbased, relational, dynamic, and evolving. • The teacher helps the students discover what they can become rather than be “trained. ” • The learning is interactive and engaging and draws upon nurses’ experience so that new knowledge is meaningful. (Newman, 2008) 47

nt De e Pra peni ctic ng e Commitme Resilience w po Em nes t en s m er Conf idenc Aw are Ne Know w ledge e n Trying O n e dg e l ew ow N n K Critical Assessment of Values ss ne Fo rg ive N ow ew le dg e Kn C u mm o C d an ed n s as a re um tion c In r H ec g fo onn in C ean M Re Pr flec ac tio tic n on e tio a nic ty i ac ap Expanding Consciousness (Newman, 1994) 48

What is Age. WISE? • Age. WISE is an approach to the care of older adults who are living with chronic life-limiting disease, acute lifethreatening disease, or extreme old age. The aim of this approach is to insure the highest quality of life by providing care that is meaningful to the older person and his/her family. Age. WISE is “theory-guided, evidencebased, reflective practice” (Watson & Foster, 2003). The five components of Age. WISE: 1) Advocating for Alignment, 2) Creating a Healing Environment, 3) Alleviating Suffering and Promoting Well-being, 4) Managing Transitions, and 5) Nurses Knowing Self. We use Watson’s Caritas Processes from which we derive competencies and interventions that are central to Age. WISE. 49

Next Steps: Age. WISE II • Bring lessons learned from the National Age. WISE Pilot back to MGH for implementation of Age. WISE II with added emphasis on: – Interprofessional collaboration; – Communication skills; – Preventive ethics. 50