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Service Delivery Innovation Profile

Hospital-Based Program Proactively Identifies, Addresses Delirium Risk Factors in Elderly, Leading to Less Cognitive/Functional Decline and Lower Nursing Home Costs


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Snapshot

Summary

The Hospital Elder Life Program (or HELP) seeks to reduce functional and cognitive decline in older persons during and after hospitalization. All patients aged 70 years and older are screened at admission for the presence of six risk factors for delirium, after which an interdisciplinary team and trained volunteers implement targeted interventions designed to reduce identified risks. Team members also coordinate with local agencies that serve the elderly and follow up with patients to ease the transition home. The program significantly reduced the rate of cognitive and functional decline by reducing the likelihood of delirium1 and has been found to be cost-effective,2 with reductions of more than 15 percent in the cost of long-term nursing home care.3 Results from other settings confirm these findings.

Evidence Rating (What is this?)

Moderate: The evidence across several studies primarily consists of matched-group comparisons of key metrics (including incidence and severity of delirium, inpatient costs, and nursing home costs) in patients enrolled in HELP to a similar group of patients receiving usual care.
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Developing Organizations

Yale University School of Medicine
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Use By Other Organizations

As of August 2012, over 800 hospitals have downloaded HELP materials. There are over 100 HELP sites within the United States and internationally, including sites in Canada, Australia, the United Kingdom, Singapore, the Netherlands, and Taiwan. The United Kingdom is conducting a National Health System-sponsored pilot testing HELP for national dissemination. Four additional sites use the program for research purposes.Planning and patient recruitment began in 1993; the initial clinical trial ran from 1995 to 1998.begin pp

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Delirium, defined as an acute decline in cognitive functioning and attention, commonly occurs in the elderly as a complication of hospitalization, and often leads to increased morbidity, mortality, and costs.3
  • A common problem: Between 14 and 56 percent of older hospitalized persons suffer from delirium, which means that roughly 2.4 million hospitalized individuals (representing 17.5 million hospital days) are affected by delirium each year in the United States.3
  • Leading to higher mortality, morbidity, and costs: Delirium often initiates a cascade of events that culminate in functional decline, increased caregiver burden, and increased morbidity and mortality.2 For example, a meta-analysis found that elderly patients with delirium had longer hospital stays, higher mortality rates, and higher rates of institutional care than did an unmatched control group.4 Expenditures for delirium have been estimated at between $16,303 to $64,421 per patient, which translates to $38 billion to $152 billion per year (in 2005 dollars). Delirium also raises "downstream" costs, as it increases the need for institutionalization (e.g., nursing home placement), rehabilitation, and home care.3

What They Did

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Description of the Innovative Activity

To help older patients remain independent during and after hospitalization, the Hospital Elder Life Program (HELP) team screens all older patients for six risk factors for delirium. For those with one or more risk factors, an interdisciplinary team implements specific interventions to reduce the risk of cognitive and functional decline. Team members also coordinate with area agencies that serve the elderly and follow up with discharged patients to identify and address problems that might arise during the transition home. Key elements are described below:
  • Screening and enrollment: Patients aged 70 years and older admitted to the hospital are screened to determine eligibility for program services. Patients qualify if they can communicate verbally or in writing, do not meet any of the exclusion criteria (e.g., being in a coma or on mechanical ventilation, displaying combative or dangerous behavior), and have one or more of the following risk factors for cognitive and functional decline: cognitive impairment (as determined by cognitive testing), any mobility or activity of daily living (ADL) impairment, dehydration, vision impairment, or hearing impairment.
  • Tailored interventions via interdisciplinary team: An interdisciplinary team consisting of a geriatric nurse specialist, a trained elder life specialist, and trained volunteers implement tailored interventions to reduce the identified risks. Potential interventions include the following:
    • Daily visitor and orientation: Program staff and volunteers place the names of care team members and a schedule on the patient's white board each day. Someone visits at least once a day to communicate with and reorient the patient to his or her surroundings. Patients with low cognitive testing or orientation scores may be visited up to three times a day.
    • Sleep deprivation prevention: Patients identified as being sleep deprived (through daily tests) receive assistance, including a warm drink at bedtime, tapes of relaxing music, and/or a back massage. Volunteers often take the lead in providing these services. In addition, the unit employs noise-reduction strategies, such as silent pill crushers, vibrating beepers, and a policy requiring quiet in hallways. Patients may also receive adjustments to their schedules so as to facilitate sleep, such as rescheduling medication administration.
    • Promoting mobility: All HELP patients are ambulated whenever possible, with the goal of three times daily. Patients on bed rest orders are encouraged to engage in range-of-motion exercises. Volunteers often take the lead in providing these services, along with the elder life specialist who oversees the daily operations of the program. In addition, staff minimize use of immobilizing equipment, such as bladder catheters or physical restraints.
    • Visual aids: Patients with less than 20/70 visual acuity on a near-vision test receive visual aids (e.g., glasses or magnifying lenses) and adaptive equipment (e.g., large illuminated telephone keypads, large-print books, and fluorescent tape on their call bell). Team members reinforce use of these aids on a daily basis.
    • Hearing support: Any patient who hears 6 or fewer of 12 whispers on the whisper test has his or her earwax removed. These individuals also receive portable amplifying devices and are taught special communication techniques, with reinforcement on a daily basis.
    • Avoiding dehydration: A geriatric nurse specialist screens all patients at baseline and periodically throughout admission to identify those with a blood urea nitrogen creatinine (BUN/Cr) score of 18 or higher. Those at risk of dehydration are encouraged to intake fluids orally.
    • Fall prevention: A geriatric nurse specialist screens all patients to assess risk of falling and, as necessary, implements and monitors a fall prevention plan.
  • Twice-a-week interdisciplinary rounds: Each week, an interdisciplinary team conducts two rounds on each HELP patient. The team reviews and discusses the patient's condition, sets goals, and recommends and tracks interventions to reach those goals.
  • Geriatrician and interdisciplinary team consultations: A geriatrician consults with attending physicians as needed, while the interdisciplinary team consults with nursing and unit staff as necessary.
  • Community linkages and telephone followup to ease transition home: The geriatric nurse specialist or elder life specialist makes referrals to, and communicates with, community agencies that offer services to optimize the transition home. Using a standard form, a team member contacts the patient's next stop to make sure that all relevant information has been communicated and understood. A team member also calls all patients within 7 days of discharge to check on the transition and address any remaining issues or concerns, such as having food and medications and making and having transportation to a followup medical appointment. The team attempts to resolve identified problems; for example, the team may conduct "emergency" grocery shopping or arrange for transportation or for delivery of prescription drugs to the patient's home. (HELP has an agreement with a local pharmacy to provide this latter service).

Context of the Innovation

Yale New Haven Hospital, an 966-bed urban teaching hospital in New Haven, CT, offers a full range of acute care services for the local community; the hospital also serves as a regional referral center for patients throughout New England and other parts of the country. The hospital has 200 medical beds, many of which are filled by elderly patients. The impetus for HELP came from Sharon K. Inouye, MD, MPH, who came to the hospital in the early 1980s as an attending physician. Dr. Inouye repeatedly saw elderly patients become confused and delirious, which started a downward spiral that often led to death and/or the need for institutionalization. After observing this problem in six patients (three of whom died), Dr. Inouye began to realize that medications were not being adjusted to account for the patient's age and the potential impact on physical and mental health status. Over time, Dr. Inouye (who later became trained as a geriatrician) began conceptualizing other aspects of the problem, including sleep deprivation, hydration issues, and immobility. Beginning in 1993, Dr. Inouye began planning the program, forming a workgroup to develop the interventions and enrolling patients in a trial that ran from 1995 to 1998.

Did It Work?

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Results

At Yale New Haven Hospital, HELP significantly reduced the likelihood of delirium and the rate of cognitive and functional decline, proved to be cost-neutral in the inpatient setting, and reduced nursing home costs. Results from other settings confirm these findings.

Results From Yale University School of Medicine
  • Less delirium: In a matched-group comparison of 852 patients, delirium developed in 9.9 percent of those participating in HELP, compared with 15 percent of those receiving usual care. Those receiving program services also experienced fewer days with delirium (105 vs. 161) and delirium episodes (62 vs. 90).5
  • Less cognitive and functional decline: Only 8 percent of program participants experienced a decline of two or more points on the Mini-Mental Status Examination, while only 14 percent experienced a similar rate of decline on the ADL score. Comparable figures in the usual care group were 26 and 33 percent, respectively.5
  • Roughly cost neutral in hospital, but reduced downstream costs: Excluding program costs, HELP reduced inpatient costs among those individuals considered to be at intermediate risk of developing delirium. Including program expenses, overall inpatient costs for this group remained roughly the same. Overall costs (including program expenses) for patients at high risk of developing delirium increased as a result of the program.2 A matched comparison of 801 patients (400 enrolled in HELP and 401 receiving usual care) found that HELP enrollees had 15.7 percent lower nursing home costs.3
Similar Results From Other Settings
  • University of Pittsburgh Medical Center: A review of 4,763 patients found that HELP reduced the risk of delirium (from 40.8 percent to 26.4 percent), reduced costs by $560,000 on one 40-bed nursing unit (primarily due to lower length of stay), and led to high levels of nurse and patient satisfaction.6
  • Prince of Wales Hospital: A review of 37 patients found that HELP reduced delirium incidence and severity and generated cost savings by reducing use of nursing assistants on the unit.7

Evidence Rating (What is this?)

Moderate: The evidence across several studies primarily consists of matched-group comparisons of key metrics (including incidence and severity of delirium, inpatient costs, and nursing home costs) in patients enrolled in HELP to a similar group of patients receiving usual care.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Securing funding: Dr. Inouye applied for and received funding from local and national organizations to support the initial program. Other programs have used hospital or donated funds.
  • Introducing program to staff: A nurse specialist, geriatrician, and nurse practitioner held formal didactic sessions, engaged in one-on-one sessions, and provided resource materials to educate nurses and physicians about the program and issues in acute care of the elderly. Yale experienced significant resistance to the program initially, with physicians and nurses being uncomfortable with the idea of using volunteers to interact with patients. Over time, however, this resistance faded as clinicians saw the benefits of the program. Both nurses and physicians now serve as strong program advocates, often requesting that their patients be enrolled.
  • Forming community advisory board: At Yale, this board included representatives from 14 community agencies that serve older people (e.g., senior housing, adult day care, area agency on aging, volunteer agencies, cooperative ministries). This group initially met on a quarterly basis and now meets twice a year to provide input on the program and develop strategies for improving community linkages, expanding interaction with community agencies, and assisting patients with the transition home. This group's input led to the development of the discharge communication form.
  • Gaining support for expansion: By sharing information on the success of the initial trial with administrators, program leaders gained approval to expand the program to the hospital's three medical units, each of which has 30 to 35 beds. (Members of the community advisory board proved critical to securing this approval by orchestrating a letter-writing campaign from community agencies, patients, and referring physicians.) The program has also been adopted by several other units at the hospital.

Information provided by program developers in August 2010 indicates that sites interested in adopting HELP should also consider the following development steps:

  • Downloading program materials: HELP manuals and tools are available to interested sites free of charge, with no need to sign a contract. See the Tools and Other Resources section for more details.
  • Establishing business case: Interested sites need to develop the business case to demonstrate the program's potential to generate clinical benefits and reduce costs. This business case can help to secure program funding, gain administrative support, and identify key performance measures necessary for sustainability. A planning committee with representatives from both clinical and administrative departments (including quality improvement and finance) can assist in development of a business case tailored to the hospital's unique characteristics.
  • Developing program model: Achieving success similar to that seen at Yale and other settings likely requires implementation of all available interventions. However, adopting sites might consider phasing them in over time, and/or making minor adaptations to fit unique circumstances.

Resources Used and Skills Needed

  • Staffing: According to information provided in August 2010, the HELP Business Tools Manual and spreadsheet allows would-be adopters to estimate staffing requirements; hospitals can input either the number of patients to be served (with the tool providing required staffing) or available resources (with the tool estimating the number of patients that can be served). For example, the recommended staff to serve 300 to 450 patients a year consists of 1.6 to 1.7 full-time equivalents,1 including a full-time elder life specialist, a half-time geriatric nurse specialist, a geriatrician (who devotes 10 percent of his or her time), a program director (usually a nurse specialist or geriatrician who also devotes 10 percent of his/her time), at least 21 volunteers (each performing one shift a week), and other interdisciplinary staff serving in consultative roles. At Yale, several different individuals have served as the elder life specialist, including a family therapist, a volunteer coordinator, and a certified therapeutics specialist. This individual does not have to have clinical training, but should have strong communication skills and ideally some experience in geriatrics.
  • Costs: Total program operating costs over a 6-month period on a 40-bed nursing unit at the University of Pittsburgh Medical Center were $63,650, including both personnel and supplies.6 Estimated startup costs on one or two 35-bed units are $3,000, including equipment (mostly computers and software) and supplies (e.g., dry erase boards, audio cassette players, headsets, large print reading materials).1
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Funding Sources

National Institute on Aging; Commonwealth Fund; Yale-New Haven Hospital; Community Foundation for Greater New Haven; Retirement Research Foundation
Initial funding came from private and community foundation grants, the hospital auxiliary, and private donors. The National Institute on Aging and private foundations funded the initial clinical trial at Yale. Yale New Haven Hospital took over responsibility for funding the program as of January 1, 1998. The Commonwealth Fund, Retirement Research Foundation, and Samuels Foundation initially funded the HELP Dissemination Project.end fs

Tools and Other Resources

According to information provided in August 2010, detailed information and support, including implementation advice and a Site Implementation Tool, is available at http://www.hospitalelderlifeprogram.org. Interested sites can download a variety of materials free of charge without a contract; sites need only acknowledge the copyright in their program. Specific questions or requests for more detailed information can be sent through HELP Google Group (https://groups.google.com/group/elderlife), which offers feedback and support from a network of sites using HELP, or by contacting a HELP Center of Excellence for additional structured, fee-based support.

Several articles have been written that examine the experiences of other hospitals that have implemented HELP, including the following:

  • Bradley EH, Schlesinger M, Webster TR, et al. Translating research into clinical practice: making change happen. J Am Geriatr Soc. 2004;52(11):1875-82. [PubMed]
  • Bradley EH, Webster TR, Baker D, et al. After adoption: sustaining the innovation. A case study of disseminating the hospital elder life program. J Am Geriatr Soc. 2005;53(9):1455-61. [PubMed]
  • Bradley EH, Webster TR, Schlesinger M, et al. The roles of senior management in improving hospital experiences for frail older adults. J Healthc Manag. 2006;51(5):323-37. [PubMed]
  • Caplan GA, Harper EL. Recruitment of volunteers to improve vitality in the elderly: the REVIVE study. Intern Med J. 2007;37:95-100. [PubMed]
  • Inouye SK, Baker DI, Fugal P, et al. Dissemination of the Hospital Elder Life Program: implementation, adaptation, and successes. J Am Geriatr Soc. 2006;54(10):1492-9. [PubMed]
  • Rubin FH, Williams JT, Lescisin DA, et al. Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology. J Am Geriatr Soc. 2006;54(6):969-74. [PubMed]
  • Rubin FH, Neal K, Fenlon K, et al. Sustainability and scalability of the hospital elder life program at a community hospital. J Am Geriatr Soc. 2011;59(2):359-65. [PubMed]
  • SteelFisher GK, Martin LA, Dowal SL, et al. Sustaining clinical programs during difficult economic times: a case series from the Hospital Elder Life Program. J Am Geriatr Soc. 2011; 59(10):1873-1882. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

Reviews of the implementation experiences of other hospitals that have started HELP reveal the following insights about getting started with this innovation8:
  • "Sell" program through tailored messages to different constituents: Hospitals implementing HELP have all faced challenges in gaining internal support for the program. Addressing these challenges requires the development of individualized messages for different constituencies—for example, administration may be most interested in the program's cost-saving or revenue-generating potential, whereas physicians and nurses may focus on the clinical quality benefits. To overcome clinician resistance, consider placing articles in newsletters, making presentations at medical staff and nurse meetings, and sending letters to admitting physicians that describe program benefits.
  • Recruit clinician champions: Both nurses and physicians need to "champion" the program through advocacy, clinical consultation, and coordination of interdisciplinary staff. Champions must have credibility within the hospital, a high personal commitment to HELP and geriatric medicine, linkages to the organizational administrative structure, and knowledge about the organization's culture. Recruiting and retaining these individuals may require some level of support, including funding their time involved in implementing HELP.
  • Collect baseline data: To evaluate the effectiveness of the program, baseline data should be collected for at least 3 months before program implementation, including length of stay, discharge destination, and change in ADL and cognitive testing scores between admission and discharge.
  • Recruit and train volunteers: The elder life specialist takes charge of recruiting and rigorously training volunteers. Volunteers undergo 16 hours of didactic and small group training followed by 16 hours of one-on-one training on hospital units with an experienced trainer or HELP staff member. Subsequently, volunteers undergo quarterly competency checks.
  • Hold regular working group meetings: An interdisciplinary working group that includes the program director/geriatrician, nurse specialist, and elder life specialists should meet twice a month to set program goals and priorities, establish program procedures and guidelines, monitor progress and intervention adherence, address problems, and reach consensus on solutions.
  • Integrate with existing geriatric programs: Some hospitals have other programs designed to enhance geriatric care, and the HELP program should be integrated with these initiatives.
  • Set realistic expectations upfront: Successful implementation requires significant upfront planning and a culture change that can take more than 1 year to fully achieve. Although many hospital administrators demand results in 6 months to 1 year, it is more realistic to expect to see a positive impact in approximately 2 years.

Sustaining This Innovation

Reviews of the implementation experiences of other hospitals that have started HELP reveal the following insights about sustaining this innovation9:
  • Monitor, track, and share program outcomes: Given the challenge and costs associated with gathering and analyzing data, some hospitals look for inexpensive ways to track program outcomes. However, such tracking is critical to maintaining program momentum, as sharing positive results can help to maintain internal support for the program. Results should be summarized in language that is relevant and credible to the target audience. The HELP Business Tools provide interactive spreadsheets and a customizable presentation to help present the economic value of HELP in the hospital.
  • Seek permanent funding: Most hospitals that have implemented HELP began with temporary grant or research funding. Permanent funding, however, is critical to sustaining the program. Securing internal funding will be more likely if positive outcomes can be documented, especially cost savings and/or revenue enhancements.

Use By Other Organizations

As of August 2012, over 800 hospitals have downloaded HELP materials. There are over 100 HELP sites within the United States and internationally, including sites in Canada, Australia, the United Kingdom, Singapore, the Netherlands, and Taiwan. The United Kingdom is conducting a National Health System-sponsored pilot testing HELP for national dissemination. Four additional sites use the program for research purposes.

More Information

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Contact the Innovator

Sharon K. Inouye, MD, MPH
Professor of Medicine, Beth Israel Deaconess Medical Center
Harvard Medical School
Milton and Shirley F. Levy Family Chair
Director, Aging Brain Center
Institute for Aging Research
Hebrew SeniorLife
1200 Centre Street
Boston, MA 02131
Phone: (617) 971-5390
Fax: (617) 971-5309
E-mail: agingbraincenter@hsl.harvard.edu

Innovator Disclosures

Dr. Inouye has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Inouye SK, Bogardus St, Baker DI, et al. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc. 2000;48(12):1697-1706. [PubMed]

Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-76. [PubMed]

Leslie DL, Zhang Y, Bogardus ST, et al. Consequences of preventing delirium in hospitalized older adults on nursing home costs. J Am Geriatr Soc. 2005;53(3):405-9. [PubMed]

Rizzo JA, Bogardus ST, Leo-Summers L, et al. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Med Care. 2001;39(7):740-52. [PubMed]

Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls and unintended consequences. N Engl J Med. 2009;360(23):2390-3. [PubMed]

Footnotes

1 Inouye SK, Bogardus ST, Baker DI, et al. The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc. 2000;48(12):1697-1706. [PubMed]
2 Rizzo JA, Bogardus ST, Leo-Summers L, et al. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Med Care. 2001;39(7):740-52. [PubMed]
3 Leslie DL, Zhang Y, Bogardus ST, et al. Consequences of preventing delirium in hospitalized older adults on nursing home costs. J Am Geriatr Soc. 2005;53(3):405-9. [PubMed]
4 Leslie DL, Marcantonio ER, Zhang Y, et al. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168(1):27-32. [PubMed]
5 Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-76. [PubMed]
6 Rubin FH, Williams JT, Lescisin DA, et al. Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology. J Am Geriatr Soc. 2006;54(6):969-74. [PubMed]
7 Caplan GA, Harper EL. Recruitment of volunteers to improve vitality in the elderly: the REVIVE study. Intern Med J. 2007;37:95-100. [PubMed]
8 Bradley EH, Schlesinger M, Webster TR, et al. Translating research into clinical practice: making change happen. J Am Geriatr Soc. 2004;52(11):1875-82. [PubMed]
9 Bradley EH, Webster TR, Baker D, et al. After adoption: sustaining the innovation. A case study of disseminating the hospital elder life program. J Am Geriatr Soc. 2005;53(9):1455-61. [PubMed]
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Original publication: September 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 18, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
The seeds of the Hospital Elder Life Program (HELP)—the goal of which is to reduce the likelihood of functional and cognitive decline in older persons during and after hospitalization—were sown when a young physician with a passion to improve hospital care was moved by the plight of her most vulnerable...

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