FEATURE ARTICLE
Current Evidence Regarding
Models of Acute Care
for Hospitalized Geriatric Patients
This article examines the current evidence on
models of acute care for hospitalized older
people. The 3 models examined were Acute
Care for Elders (ACE), Hospitalized Elder Life
Program (HELP), and Nurses Improving Care
for Health-System Elders (NICHE). Thirteen
research reports examining these models of
care were assembled from online search en-
gines and used for this integrative literature
review. Preliminary evidence suggests that
all 3 programs may be effective at improving
outcomes for hospitalized older people. How-
ever, more rigorous research is needed to de-
termine which programs are most effective at
improving clinical geriatric outcomes in dif-
ferent settings. Recommendations for addi-
tional research, use of the models in clinical
nursing practice, and nursing implications of
the models. (Geriatr Nurs 2010;31:331-347)
Introduction and Purpose
eriatric patients, those aged 65 years and
G older, make up the majority of all acutely
hospitalized patients.1 Even as geriatric
patients are prevalent in the hospital system,
their outcomes are generally poorer compared
with younger patients.1 Additionally, patients
aged $80 are reported to be the least satisfied
with their hospital care out of all age groups.2
Multiple models have been created in the past 2
decades that try to improve care and outcomes
for geriatric patients.3 Models to guide care of ge-
riatric patients are valuable resources to optimize
care and promote the well-being of these patients
in acute hospital settings.4
It is important to note that the models of care
that have been created do not all focus on the
same aspects of care. Some models have been de-
veloped to guide care solely in the in-patient hospi-
tal setting. Examples of these in-patient models
include the Acute Care for Elders (ACE) program,
Hospitalized Elder Life Program (HELP), and
Geriatric Nursing, Volume 31, Number 5
Julia S. Steele, BSN, RN
Nurses Improving Care for Health-System Elders
(NICHE). Other models guide care across settings,
such as transitional care models. Examples of
transitional care models include the Transitional
Care Model led by Mary D. Naylor, PhD, RN,
and the Care Transitions Model led by Dr. Eric
Coleman and supported by the John A. Hartford
Foundation.5,6
The goal of this study was to focus on models
that guide acute inpatient care for geriatric pa-
tients. This topic was further narrowed to the 3
most prevalent programs found in clinical practice
and the literature. These models are the ACE pro-
gram, HELP, and NICHE. All 3 programs focus on
improving care for acute-care hospitalized geriat-
ric patients by preventing functional and cognitive
decline and reducing iatrogenic complications.
This article reviews available evidence from
the ACE, HELP, and NICHE models. An integra-
tive literature review of research on all 3 pro-
grams is presented and conclusions are drawn
to direct implications for nursing practice and
future research.
Background and Significance
People aged over 65 years currently make up
12.5% of the overall U.S. population;7 however
they comprise a far greater percentage of hospital
inpatients.8 The proportion of the U.S. population
aged 65 and older is expected to rise over time.7
By 2030, nearly 1 in 5 residents will be aged 65 or
older; by 2050, the geriatric age group is expected
to double its population from 2008 (from 38.7 to
88.5 million people).6 The percentage of older
adults who are admitted to the hospital is greater
than their proportion of the general U.S. popula-
tion.8 According to the National Center for Health
Statistic’s National Hospital Discharge Survey, pa-
tients aged 65 years and older made up 38% of all
hospital discharges and used 46% of all inpatient
days in 2001.8 Given the large and growing preva-
lence of the older adult inpatient, it is undoubtedly
beneficial for models to be used in hospital care
that tailor care to the geriatric patient.
331
 Multiple variables interact to create unique
needs experienced by older adults during hospi-
talization for acute and critical illness. Normal
changes that occur with aging include a ‘‘decline
in muscle strength and aerobic capacity, vaso-
motor instability, baroreceptor instability, re-
duced total body water, reduced bone density,
reduced ventilation, reduced sensation, altered
thirst, taste, smell, and dentition, and fragile
skin.’’3 These changes can result in altered
function, which influences homeostasis and
functional reserve. Older patients also often
have multiple chronic medical conditions as
well. Arthritis, hypertension, heart disease, can-
cer, and diabetes are among the most com-
mon.9 These chronic conditions often require
acute care to manage exacerbations.4 Other
common chronic conditions associated with ag-
ing include hearing impairment, vision impair-
ment, and orthopedic impairments; these
conditions can complicate acute illnesses.9 All
of these factors increase risk of iatrogenic
illness and complications in a hospital setting,
and slow recovery and rehabilitation. Special-
ized models of care may help avoid complica-
tions and promote well-being for older
patients when normal age-related changes,
chronic conditions, and acute medical or surgi-
cal conditions intersect.
Traditional hospital design and models of care
focus purely on treatment of disease, rather than
on the distinct needs of older patients.3,10 For
example, hospitals have polished floors that can
become slippery, rooms that become cluttered
with devices and supplies, and mazes of hallways
often poorly mapped and signed, all of which can
lead older people to become confused or fearful
of walking.11 Hospitalized patients spend an aver-
age of 20 hours per day in bed and only 43 min-
utes per day standing or walking, regardless of
their level of independence upon admission.12
This increased bed rest can lead to a decrease
in muscle mass, strength, orthostatic tolerance,
and plasma volume.12 Psychoactive drugs may
be given to promote sleep or relaxation, even
though these drugs can have the opposite
effects on older patients.13 Psychoactive drugs
also increase the risk of falls and the develop-
ment of delirium.13
As a result of such factors, deconditioning rap-
idly occurs in older adults when hospitalized.10,14
Deconditioning describes the physiological
changes, such as decreased muscle mass, that
332
result from aging and/or immobility and contrib-
utes to overall weakness.10 This phenomenon oc-
curs for some as early as the second day of
hospitalization.14 Many patients never regain pre-
admission functional status after deconditioning
occurs.15 As a result, these individuals require
greater assistance after discharge and may be
unable to return home.
The costs of care are much higher for geriatric
patients than for their younger counter-
parts.1,4,16,17 These costs are related to a higher
acuity, longer lengths of stay, more complica-
tions, more documented adverse health events,
and the use of larger amounts of health care
supplies and resources.1,4,16
Search Methods
A search was conducted to obtain all available
primary research reports on the ACE, HELP, and
NICHE models. Four search engines were used:
Cumulative Index to Nursing and Allied Health
Literature (CINAHL), Medline, PubMed, and
Google Scholar. The following search terms
were used: ACE model, ACE units, ACE unit,
acute care for elders, ACE program, HELP pro-
gram, hospitalized elder life program, HELP
AND elder, HELP AND geriatric, NICHE, nurses
improving health system elders, NICHE pro-
gram, NICHE geriatric, and NICHE elder.
Searchers were not limited by time to ensure
the best access to available literature, although
they were limited to reports in the English lan-
guage. Only research reports were included in
the review. In total, 13 articles met inclusion
criteria and are reviewed here.
Literature Review
This review examines 13 reports, categorized
according to the program on which they report.
Six reports look at the ACE program, 5 reports
address the HELP program, while the remaining
2 articles report the NICHE program data. All
studies considered a geriatric patient to be aged
70 or older. Multiple factors were considered in
the review. These factors are reviewed in the
Table of Evidence (Appendix A).
ACE Program
The ACE unit model was developed by Lande-
feld, Palmer, and Kresevic and colleagues in 1995
Geriatric Nursing, Volume 31, Number 5
at the University Hospitals of Cleveland.18,19 The
ACE program follows a model of holistic care, in-
cluding the social and environmental context,
rather than solely focusing on medical diagnoses.20
The ACE program implements changes in 4 areas:
creating a specially designed environment, provid-
ing patient-centered care, multidisciplinary team
discharge planning, and enhanced review of medi-
cal care.18,20-22 These changes were designed to im-
prove geriatric care and outcomes.
ACE units have an environment designed to
meet the unique needs of the geriatric patient.
Environmental features include carpeting in pa-
tient rooms and hallway and handrails in the hall-
ways to support independent ambulation; large
clocks and calendars in patient rooms to assist ori-
entation; elevated toilet seats; large lever-style
door handles; and a parlor room for group meals,
activities, and visiting with guests.20,22 These envi-
ronmental characteristics are intended to meet
needs of older patients, i.e., promoting activities
of daily living (ADLs) performance without
assistance.
ACE patient-centered care incorporates multiple
practices. Patient-centered care includes daily as-
sessment of physical, cognitive, and psychosocial
function, as well as protocols to improve immobil-
ity, dependence in dressing and bathing, inconti-
nence, malnutrition, skin care, falls, depression,
and delirium.20-23 Patient-centered care also in-
cludes rounds by a multidisciplinary care team in-
cluding a physician, a clinical nurse specialist,
a physical therapist or an occupational therapist,
a social worker, a dietitian, a pharmacist, a case
manager, an RN discharge planner, and a primary
nurse.20-23 Patient-centered care implemented by
a multidisciplinary team is designed to increase
care of elderly patients in all specialty areas.
Discharge planning is also interdisciplinary18,20
and focuses on returning the patient to their
home with optimal outcomes.20 Each day during
rounds, care is directed to assist the patient in re-
turning to the home as soon as possible, rather
than a skilled nursing facility or nursing home.
Medical care is reviewed ‘‘to prevent complica-
tions secondary to medicines and procedures.’’20
Discharge planning, as well as the other aspects
of the ACE program, is designed to promote ho-
listic care and recovery for older patients. The
ability of the ACE program to meet its goals are
examined in multiple studies.
Six articles report on investigation into the
ACE program. Four of these report data from
Geriatric Nursing, Volume 31, Number 5
randomized control trials (RCTs),19-21,24 and 2
report hospital surveys.18,25 Sample sizes and
methodology varied widely among studies.
Three RCTs looked at the same sample of 651 pa-
tients,19,20,24 and the remaining RCT looked at
a separate sample of 1531 patients.21 Methodol-
ogy for all 4 RCTs is comparable; all studies
used performance of ADLs as their primary indi-
cator.19-21,24 None of these 4 reports were
blinded to participants or data collectors, al-
though this was not feasible given the design of
the studies.
The performance of ADLs under the ACE pro-
gram was addressed in 3 RCTs.19-21 Counsell
and colleagues21 reported that there was not a sta-
tistically significant difference in ADL perfor-
mance from baseline to discharge between the
ACE intervention group and control group. Land-
efeld and colleagues19 and Covinsky and col-
leagues,20 using the same data set, reported that
patients from the ACE intervention unit were
‘‘more likely to improve and less likely to decline
in ADL performance’’21 between admission and
discharge. There is a positive trend toward ADL
improvement under the ACE program. Whereas
Counsell and colleagues21 reported that differ-
ences in ADL performance were not statistically
significant, Landefeld and colleagues19 and Cov-
insky and colleagues20 reported that differences
in ADL performance were statistically significant.
This difference in statistical significance may be
due to sample sizes. Counsell and colleagues21
had a much larger sample size than Landefeld
and colleagues19 and Covinsky and colleagues.20
Their sample demographics and method of data
collection were similar.
Three reports studied costs of implementing
the ACE program. Counsell and colleagues21 re-
ported that there was not a significant difference
in the cost of care for ACE or usual care patients.
Covinsky and colleagues20,24 reported that it was
more expensive to care for patients in the ACE
program while patients are hospitalized; how-
ever, the patients in the ACE program had a
shorter length of stay (see Appendix A).19,20,24
As a result, there was not a statistically signifi-
cant difference in the cost of caring for a patient
on the ACE unit or a usual care unit.20,24 There
was also not a statistically significant difference
in total cost of care for a patient on an ACE unit
or a usual care unit (see Appendix A).20,24 There-
fore, all studies examining cost appear to have an
consensus that the ACE unit is not more
333
expensive than the usual method of care and may
indeed be cheaper than the usual method of
care.20,21,24
Counsell and colleagues,21 Covinsky and col-
leagues,20 and Covinsky and colleagues24 found
that ACE patients were less likely to be dis-
charged to a nursing home or other long-term
care facility. Counsel and colleagues21 followed
patients for 12 months after discharge and found
that they were less likely to be discharged to
a nursing home or to spend time in a nursing
home in the 12 months following discharge. Cov-
insky and colleagues20,24 found that patients from
the ACE unit were less likely to spend any time in
a nursing home or long-term care facility in the
first 90 days after discharge. This finding was sta-
tistically significant.
Interestingly, only 1 article, by Counsell and
colleagues,21 reviewed other outcomes of the
ACE program, such as patient and health care
satisfaction with the program, use of restrains,
and use of interdisciplinary team members.
Patients, family members, nurses, and doctors
all reported increased satisfaction with the ACE
program compared with usual care.21 This study
also found that there were other benefits to the
ACE program of care. Patients were less likely
to be physically restrained than patients in a usual
care unit.21 Depression was also recognized more
often by physicians and earlier in the patient’s
stay.21 The effects of depression recognition
were not addressed in this study; however, it
can be presumed that treatment and recognition
of depression early on can improve physical as
well as emotional well-being. Interdisciplinary
team members were utilized more in the ACE
unit compared with the usual care unit. For ex-
ample, physical therapy consults were obtained
sooner and more often and social work was con-
sulted more often.21 These findings suggest that
ACE improves multiple aspects of patient care
and well-being.
Of the 2 surveys reviewed, 1 queried 82 hospi-
tals with geriatric divisions for the presence of
an ACE unit. Only 16 hospitals reported having
an ACE unit.18 In the other survey, 18 hospitals
with ACE units were surveyed to describe their
ACE units (see Appendix A).25 Most hospitals
that implemented ACE were urban or university
hospitals. Importantly, hospital revenue was sig-
nificantly associated with having an ACE unit;
hospitals with higher revenues more often
have ACE units.18 These survey findings
334
describe the types and quantity of hospitals
with ACE units.
HELP Program
The ACE program requires specially designed
and constructed units. In 1999, the Hospitalized
Elder Life Program (HELP) was introduced;
HELP can be implemented in any preexisting
hospital environment. The HELP program was
developed by Inouye at Yale University School
of Medicine and was first described in the New
England Journal of Medicine.26 Implementation
of the HELP program at other hospitals outside of
Yale began in 2001.27 HELP is a program that is
designed ‘‘to maintain physical and cognitive
function throughout the hospitalization; to maxi-
mize independence at discharge; to assist with
the transition from hospital to home; and to
prevent unplanned remissions.’’16 The program
is composed of multiple interventions that are ap-
plied based on individual need.16
In HELP, older patients are screened for 6 risk
factors of functional decline and delirium: cogni-
tive orientation and impairment, sleep deprivation,
immobility, vision impairment, hearing impair-
ment, and dehydration.16,28 For patients deemed
at risk for functional decline or delirium based
on these risk factors, protocols are put in place
to prevent decline. Protocols include a daily visitor
program, therapeutic activities program, early
mobilization program, nonpharmacologic sleep
protocol, hearing and vision protocol, geriatric
interdisciplinary care, and links with community
services.27 ‘‘While the intervention protocol are
standardized, the menu of assigned interventions
is individualized for each patient’’ based on their in-
dividual risk factors at screening and regular reas-
sessments.16 An individual patient can be involved
in anywhere from 0 to all 6 protocols to avoid func-
tional decline.
The HELP program uses an interdisciplinary
team of volunteers and professionals. Volunteers
must undergo a rigorous hospital training program;
untrained volunteers, such as family members,
are not considered to be a part of the intervention.
Methods of volunteer recruitment are left to the
discretion of the individual hospital. Trained
volunteers can implement many aspects of the
HELP model.16,27,28 Volunteers are used to assist
with the ambulation of patients, offering warm
milk and massages before bed, and providing so-
cialization.16,27,28 Other members of the HELP
Geriatric Nursing, Volume 31, Number 5
team include an elder life nurse specialist, elder life
specialist, geriatrician, program director, and inter-
disciplinary support staff as needed (including
a chaplain, pharmacist, dietician, rehabilitation
therapists, discharge planner, social worker, and
psychiatric liaison nurse).27 Each member of the
team works to decrease risk factors for each
patient.
Five articles report aspects of research on the
HELP program. Two studies surveyed HELP
sites;28,29 1 study was a descriptive study,16 and
1 was a prospective matching clinical trial.26
One study followed a pre- and posttest design
of a HELP implementation.30 Sample sizes were
large, ranging from 852 patients in 1 study26 to
4763 patients in the largest study.30 Methods var-
ied widely (see Appendix A). Bradley and col-
leagues29 and Inouye and colleagues28 used
survey-style self-reporting by HELP administra-
tors. Inouye and colleagues16 and Rubin and col-
leagues30 enrolled all qualified patients to HELP
within a given time period. Inouye and col-
leagues26 used a prospective patient-matching
style for their clinical trial.
Inouye and colleagues26 and Rubin and col-
leagues30 reviewed the effectiveness of the HELP
program by looking at how HELP influenced risk
factors and delirium. In these studies, the HELP
program met its main goal of maintaining physical
and cognitive function in geriatric patients. HELP
resulted in a lower incidence of delirium, a lower
number of total days with delirium, and a lower
number of episodes of delirium. HELP also had
a positive effect on the presence of risk factors in
patients. When HELP patients were reassessed af-
ter 5 days of hospitalization or at discharge (which-
ever occurred first), they were found to have less
cognitive impairment, less sleep deprivation and
less use of sedative drugs, less immobility, more vi-
sion and hearing corrected patients, and less dehy-
dration.26 These findings showed positive trends;
however, only the findings for cognitive impair-
ment and sleep deprivation and use of sedative
drugs were statistically significant.26
Bradley and colleagues29 and Inouye and col-
leagues28 looked at various hospitals implement-
ing HELP to look at perceived benefits of HELP,
structures necessary for successful implementa-
tion, and challenges of implementation (see
Appendix A). Subjective reported benefits of the
HELP program included decreased incidence of
delirium, decreased use of restrains, improved
quality of care, and improved patient outcomes.
Geriatric Nursing, Volume 31, Number 5
Hospitals reported that their clinical staff had
a better understanding of geriatric care and that
HELP acted as an educational resource.29,30
HELP improved nursing education and increased
nursing retention.28 An increase in communica-
tion among the interdisciplinary team was also re-
ported.29 The program was perceived to be
cost-effective for multiple hospitals.28,29 The HELP
program assisted in improved geriatric care, staff
education and retention, and cost-effectiveness.
Bradley and colleagues29 and Inouye and col-
leagues28 also examined factors that led to the
success of the HELP program. Factors that
were deemed essential to the success of the
HELP program in various hospitals included the
work of dedicated clinician leaders to champion
the cause and internal support from multiple de-
partments.28,29 Allowing flexibility to adapt the
HELP program to meet the individual needs of
the hospital was also necessary to the success
of HELP in different hospital settings.28,29 Adap-
tations included changing some forms to de-
crease repetitive documentation, decreasing the
frequency of some interventions, allowing flexi-
bility for the intensity of the interventions.28,29
Quality assurance procedures (such as staff
meetings, patient satisfaction surveys, and moni-
toring the performance of volunteers) were not
always implemented.28,29 There were no reports
examining whether adaptations affected the fi-
delity of the HELP program.
The most commonly cited concerns by hospital
employees when implementing a HELP program
were obtaining adequate staffing, funding, and
volunteers.16,29 Patient adherence to the program
was also a common concern. Patients did not
always adhere to all or any parts of the HELP pro-
gram.16 Reasons for patient nonadherence in-
cluded a lack of volunteer or staff to implement
the interventions, patient refusal of the interven-
tion, medical contraindication, and patient un-
availability (such as when the patient was off
the floor for procedures).16
Bradley and colleagues29 (2005) and Inouye
and colleagues16,28 examined patient, family,
and nurse satisfaction in HELP. All results re-
ported patient and family satisfaction with
HELP at greater than 90% by self-report in sur-
veys. Nurses and nursing aids also reported
greater satisfaction with the HELP program
than the usual care methods.30
Inouye and colleagues28 and Bradley and
colleagues29 examined cost-effectiveness of
335
HELP in survey studies. Bradley and colleagues
reported that 2 hospitals conducted their own
financial analyses and found HELP to be cost-
effective. Inouye and colleagues surveyed 13
HELP sites; 10 of those sites reported that they
found HELP to be cost-effective for their hospi-
tals. All studies examining cost-effectiveness
were based on self-report, which may have an
impact on the validity of the results.
NICHE Program
Unlike ACE and HELP, the NICHE program is not
a specific set of rules or interventions that must be
applied to patients but rather acts as a guide for
nursing practice for participating hospitals.31 The
NICHE program is a nursing resource program de-
veloped in 1992 by the Hartford Institute for
Geriatric Nursing at New York University.31,32 The
goal of NICHE is to ‘‘achieve systematic nursing
change that will benefit hospitalized older pa-
tients’’32 through the implementation of ‘‘principles
and tools to stimulate a change in the culture of
healthcare facilities to achieve patient-centered
care for older adults.’’27 By educating nurses and
changing practices, NICHE developers aim to
improve patient outcomes.
NICHE provides a wide variety of resources
that hospitals may use to educate nursing
staff on the care of geriatric patients. Resources
provided to the nursing staff include models of
nursing care, research-based clinical practice
protocols, action plan worksheets to guide im-
proved care,31,32 and review guides to assist
nurses in preparation for gerontological nursing
certification.31-33 NICHE also provides resources
to assess nursing knowledge of geriatric care.
These assessment tools include the Geriatric In-
stitutional Assessment Profile (GIAP) to survey
nursing staff and to test nursing knowledge.31-33
In addition, there are resources to keep nurses
up-to-date with current evidence-based care for
geriatric patients, such as a national listserv,
a members-only Web site, and research-based
clinical practice protocols.31-33
NICHE relies on use of 1 of 2 nursing care
models to support integration of knowledge.
One model is the Geriatric Resource Nurse
(GRN) model. Nurses receive specialized training
in geriatric nurses.31-33 The specially trained
nurses serve as a resource for all nurses on the
floor. When questions arise in care of an elderly
patient, the GRN can provide guidance to support
336
care. The other model is the Acute Care for
Elders (ACE) Unit.31-33 The ACE model can be
applied as part of the NICHE program. Both
the GRN model and ACE model can be imple-
mented together or separately, depending on
the preferences of the hospital. However, a hospi-
tal is not required to use the NICHE program if an
ACE unit is in place. ACE is reviewed separately
here because many hospitals implement ACE
programs without following other NICHE recom-
mendations. Only 2 NICHE research reports were
identified for review.
Boltz and colleagues31 used the GIAP in a pre-
and post-test cross-sectional survey of registered
nurses in 8 acute-care hospitals in urban areas.
The geriatric nursing practice environment,
including institutional values regarding older
adults and resource availability, was significantly
improved after NICHE implementation. Institu-
tional values regarding respect for the rights of
older adults, inclusion of older adults in
decision-making regarding care was significantly
improved. The actual quality of geriatric care
according to nurses in the survey was also signif-
icantly improved (see Appendix A). Quality of
care was defined as ‘‘geriatric-specific, evidence-
specific, individualized care that promotes in-
formed decision making and is continuous across
settings.’’31 Boltz and colleagues found that geriat-
ric care, nursing environment, and values regard-
ing geriatric care were improved.
Mezey and colleagues33 also conducted a survey
of hospitals that implemented NICHE to determine
what aspects of the NICHE program were adopted.
One-hundred thirty-seven hospitals implementing
NICHE in 2002 were surveyed, and 103 hospitals
responded. The majority of hospitals reported us-
ing the GRN model, best practice protocols, the
NICHE listserv, and hospital benchmarking proto-
cols. Hospitals were likely to use more than one
NICHE tool. The most popular programs were
the GIAP survey and GRN model. NICHE was
most commonly used to reduce and monitor falls,
restrains, and pressure ulcers.
Discussion
ACE Program
The ACE program is well defined, and all stud-
ies have reported identical implementation of the
program. These reports on the ACE program
show positive outcomes in multiple areas. ACE
Geriatric Nursing, Volume 31, Number 5
care results in a positive trend in ADL perfor-
mance improvement.20,21 Patients on ACE units
have a shorter length of stay than those on other
units.19,20,24 Patients spend less time in nursing
homes or long-term care facilities in the 3-12
months following discharge from an ACE
unit.20,24,26 Additionally, patients on ACE units
spend less time in physical or physical re-
straints,26 and depression is recognized and
treated more often than on other units.26 These
findings suggest that the ACE program is an effec-
tive model of care for elderly patients with im-
proved outcomes compared with caring for
geriatric patients on other units.
Although positive trends in patient care on
ACE units have been shown, there are some lim-
itations to the research. The current evidence is
greatly limited by the use of 1 data set for multiple
reports. All 4 of the RCTs took place in Ohio,
where ACE was first developed.19-24 Three of
the 4 reports relied on the same data set
collected at the University Hospitals of Cleveland
from November 1990 through March 1992.19,20,24
This limits the generalizability of the studies to
examine the effectiveness of ACE outside of
this geographic area and this time period. The
available literature is less diverse when different
analyses of the same data are used, instead of rep-
licating the ACE unit in different time periods or
environments. Also, the limitations of the data
collection are carried into all 3 studies. For exam-
ple, the ACE unit had dedicated nursing and
housekeeping staff, but the attending and resi-
dent physicians cared for by the ACE unit inter-
vention group as well as the usual care control
group; this creates the potential for contamina-
tion of the control group. Currently, the available
data on ACE units is limited by the use of the
same data for multiple reports.
More diversity in studies is needed to improve
the generalizability of research on the ACE pro-
gram. Issues concerning external validity and
contamination of intervention groups also limit
the current data. To increase diversity in ACE
research, studies need to be conducted outside
of Ohio and on different populations of patients.
Rigorous studies should be conducted, especially
prospective case-control studies with large sam-
ple sizes. This will increase the generalizability
of ACE studies and create a stronger case for
their effectiveness and implementation.
No studies assess the implementation of the
ACE model in diverse hospital settings. Currently,
Geriatric Nursing, Volume 31, Number 5
ACE units are most prevalent in urban or univer-
sity 18,25 and in hospitals with greater revenue.18
There are no data to suggest why ACE units are
most prevalent in these areas. Examination of
the implementation process and interim out-
comes outside of urban, university hospitals is
important to support the utility of the model
throughout the United States.
Perhaps the largest drawback of the ACE
program is the necessity of a devoted unit with
specialized features to care for patients. Given
the skyrocketing prevalence of older adults in in-
patient units, there may not be sufficient capital
to create ACE units to treat all older adult pa-
tients. It may be necessary to pick and choose
which patients and conditions warrant admission
to the ACE unit. Unfortunately, the principles of
ACE require environmental changes to the unit,
which limits the ability of the ACE principles to
be applied in non-ACE units.
HELP Program
Available evidence on the HELP program sug-
gests that the program improves some clinical
outcomes for older patients. Data show that
patients in the HELP program have decreased
incidence of delirium, cognitive impairment,
sleep deprivation and use of sedatives, immobil-
ity, and dehydration.26,30 Beyond clinical effec-
tiveness, there is apparent satisfaction with the
model reported by patients, family members,
and nurses.28,29 However, this does not include
the satisfaction of those who refused to complete
surveys. Overall, these findings suggest that HELP
may be an effective program that is well received
by laypersons as well as clinical staff.
The available research on the HELP program is
generally high quality. There are multiple rigor-
ous studies with large sample sizes, which reflect
an ability to detect differences in outcomes. Stud-
ies examine not only clinical outcomes but also
satisfaction and implementation of the HELP pro-
gram. Although there is a good base of evidence
to support the HELP program, the evidence
should be expanded.
Blinding data collectors can enhance construct
validity. External validity can also be increased
through the implementation of more RCTs.
Topics should be expanded to include long-term
patient outcomes, cost-effectiveness, staffing,
funding, and adherence to the HELP model.
Cost-effectiveness and funding particularly
337
require future examination. It has not been shown
that hospitals can all afford a HELP coordinator
fully implement the HELP protocol. The expansion
of research to include these topics can increase the
strength of the clinical outcomes of HELP. It also
can assist hospitals to understand the necessary
staffing and funding to implement HELP. Future
research can strengthen HELP’s evidence and
assist in the implementation of HELP.
NICHE Program
Current evidence for the NICHE program is
limited to 2 studies. Other reviews have been pub-
lished on the NICHE program, but they do not
meet the requirements of a scientific research pa-
per; instead, they are reviews of how individual
hospitals felt about implementing NICHE.
This research suggests that the NICHE pro-
gram is effective at improving geriatric nursing
knowledge, institutional values of geriatric care,
and the use of evidence-based practice in geriat-
ric care.33 The reports available support the goals
of NICHE to promote nursing culture. It is impor-
tant to look beyond the promotion of nursing cul-
ture when evaluating NICHE. Research needs to
evaluate how the implementation of NICHE af-
fects patient outcomes, such as functional status,
ADL performance, and overall well-being.
Research on NICHE should be widely ex-
panded. RCTs and prospective case control trials
are needed to support the effectiveness of the
NICHE program. There is no research available
that examines objective patient clinical outcomes,
cost of implementation, or satisfaction with the
NICHE program. Research on patient outcomes
includes length of stay, performance of ADLs,
functional decline during hospitalization, and dis-
charge location. Research on patient outcomes,
patient and clinical staff satisfaction, and cost of
implementation can help to determine whether
NICHE improves patient care and is valued by
health care team members. It is important to deter-
mine whether NICHE improves patient outcomes
and can be effectively implemented in a wide
range of acute care areas before it is recommen-
ded for use for the general hospital population.
Implications for Research, Practice,
and Education
Given the large population of acutely ill geriatric
patients spending time in the hospital and the large
338
amount of hospital resources that these patients
use, it is of great importance that acute geriatric
care becomes a focus of nursing research and
education. ACE, HELP, and NICHE are 3 well-
developed models of acute care for older hospital-
ized patients. There has been initial research on all
3 programs that suggest that they may be effective
at improving patient outcomes. Further research is
needed to elaborate on the benefits of each pro-
gram for patients, health care providers, and hospi-
tals. It is imperative that the nursing profession
focus research on the ACE, HELP, and NICHE
models. Geriatric patient outcomes reflect deeply
on the nursing care that is provided to older pa-
tients. If nursing is to continue to improve care of
geriatric patients, models must be used to guide
care. These models require strong evidence that
supports their efficacy.
Nurses at every level of care and administra-
tion must be aware of the effects of models of
geriatric care on nursing practice. In all adult
settings, nurses will care for geriatric patients
at some point in their career. It is imperative to
stay abreast of the developments in caring for
elderly patients. The 3 models currently in use
and discussed in this article (ACE, HELP, and
NICHE) all have unique aspects, and initial re-
search suggests that they are effective at improv-
ing patient outcomes. Therefore, hospitals need
to assess all 3 models and the evidence associ-
ated with them and choose which best fits their
needs as a hospital. Hospitals should introduce
a model of care for geriatric patients and closely
track outcomes. Outcomes that should be
tracked include patient clinical outcomes, use
of the interdisciplinary team, satisfaction, staff
education, and cost-effectiveness. Nurses can
then make changes as needed to tailor the model
to their needs. Nurses and hospitals can also con-
tribute to the available research on the models.
Nurses will find that use of a geriatric model of
care can decrease patient length of stay, cost of
care, and inpatient complications; it can also in-
crease patient satisfaction, nurse satisfaction,
and positive patient outcomes. Use of ACE,
HELP, or NICHE is imperative to improve hospi-
tal care of older patients.
References
1. Russo CA, Elixhauser A. Hospitalizations in the elderly
population, 2003 (Statistical Brief No. 6). Agency for
Healthcare Research and Quality. Available at www.
Geriatric Nursing, Volume 31, Number 5
 hcup-us.ahrq.gov/reports/statbriefs/sb6.pdf. 2006. Cited
November 6, 2009.
2. Press Ganey Associates. Hospital Pulse Report 2009:
Patient perspectives on American health care. Available
at www.pressganey.com/galleries/ED_Pulse_2009_
files/2009_ED_Pulse_Report.pdf. Cited on February 28,
2010.
3. Reuben DB. Making hospitals better places for sick older
persons. J Am Geriatr Soc 2000;48:1697-706.
4. Hickman L, Newton P, Halcomb EJ, et al. Best practice
interventions to improve the management of older
people in acute care settings: a literature review. J Adv
Nurs 2007;60:113-20.
5. Naylor M. Transitional care for older adults: a cost-
effective model. Leonard Davis Institute Issue Brief 2004;
9:1-4.
6. Coleman E. Care transitions model. John A. Hartford
Foundation. Available at www.jhartfound.org/
ar2007html/model1_care_transitions.html. Cited on
February 27, 2010.
7. Houser A, Fox-Grange W, Gibson M. Across the states:
profile of long term care and independent living. 8th ed.
American Association of Retired People; 2009. Available at,
www.aarp.org/acrossthestates. Cited September 13, 2009.
8. Hall MG, DeFrances CJ. 2001 national hospital discharge
survey. Advance Data From Vital and Health Statistics
2003;332.
9. Novielli KD, Arenson CA. Overview of geriatrics. Clin
Podiatr Med Surg 2003;20:373-81.
10. Graf C. Functional decline in hospitalized older adults.
Am J Nurs 2006;106:58-67.
11. Creditor MC. Hazards of hospitalization of the elderly.
Ann Int Med 1993;118:219-23.
12. Brown C, Redden D, Flood K, et al. The underrecognized
epidemic of low mobility during hospitalization of older
adults. J Am Geriatr Soc 2009;57:1660-5.
13. Boustain M, Munger S, Beck R, et al. A gero-informatics tool
to enhance the care of hospitalized older adults
with cognitive impairment. Clin Interven Aging 2007;2:247-53.
14. Hirsch CH, Sommers L, Olsen A, et al. The natural history
of functional morbidity in hospitalized older patients.
J Am Geriatr Soc 1990;38:1296-303.
15. Sager MA, Franke T, Inouye SK, et al. Functional
outcomes of acute medical illness and hospitalization in
older persons. Arch Int Med 1996;156:645-52.
16. 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;48:1697-706.
17. Hall MG, DeFrances CJ. 2001 national hospital discharge
survey. Advance Data From Vital and Health Statistics
2003;332.
18. Jayadevappa R, Bloom BS, Raziano DB, et al.
Dissemination and characteristics of acute care for
elders (ACE) units in the United States. Int J Technol
Assess Health Care 2003;19:220-7.
19. Landefeld CS, Palmer RM, Kressevic DM, et al. A
randomized trial of care in a hospital medical unit
especially designed to improve the functional outcomes
of acutely ill older patients. New Engl J Med 1995;322:
1338-4.
Geriatric Nursing, Volume 31, Number 5
20. Covinsky KE, Palmer RM, Kresevic DM, et al. Improving
functional outcomes in older patients: lessons from an
acute care for elders unit. Joint Commiss J Qual Improve
1998;24:63-76.
21. Counsell SR, Holder CM, Liebenauer LL, et al. Effects of
a multicomponent intervention on functional outcomes
and process of care in hospitalized older patients:
a randomized control trial of acute care for elders (ACE)
in a community hospital. J Am Geriatr Soc 2000;48:
1572-81.
22. Palmer RM, Counsell SR, Landefeld SC. Acute care for
elders: practical considerations for optimizing health
outcomes. Dis Manage Health Outcomes 2003;11:
507-17.
23. Benedict L, Robinson K, Holder C. Clinical nurse
specialist practice within the acute care for elders
interdisciplinary team model. Clin Nurse Specialist 2006;
20:248-52.
24. Covinsky KE, King JT, Quinn LM, et al. Do acute care for
elder units increase hospital costs? A cost analysis using
the hospital perspective. J Am Geriatr Soc 1997;45:
729-34.
25. Siegler EL, Glick D, Lee J. Optimal staffing for acute care
of the elderly (ACE) units. Geriatr Nurs 2003;23:152-5.
26. Inouye SK, Bogardus ST, Charpenter PA, et al. A
multicomponent intervention to prevent delirium in
hospitalized older patients. New Engl J Med 1999;340:
669-76.
27. Inouye SK. The hospital elder life program. Available at
http://elderlife.med.yale.edu/public/public-main.php.
2007. Cited October 23, 2009.
28. Inouye SK, Baker DI, Fugal P, et al. Dissemination of
the hospital elder life program: implementation,
adaption, and successes. J Am Geriatr Soc 2006;54:
1492-9.
29. 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:
1455-61.
30. 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:
969-74.
31. Boltz M, Capezuti E, Bowar-Ferres S, et al. Changes in the
geriatric care environment associated with NICHE
(Nurses Improving Care for Health System Elders).
Geriatr Nurs 2008;29:176-85.
32. About NICHE. Hartford Institute for Geriatric Nursing.
2008. Available at www.nicheprogram.org/about. Cited
November 6, 2009.
33. Mezey M, Kobayashi M, Grossman S. Nurses improving
care to health system elders (NICHE). J Nurs Admin
2004;34:451-7.
JULIA S. STEELE, BSN, RN, University of Pennsylvania,
School of Nursing, Arlington, VA.
0197-4572/$ - see front matter
Ó 2010 Mosby, Inc. All rights reserved.
doi:10.1016/j.gerinurse.2010.03.003
339
 Appendix A.
340

Table of Evidence
Quality of
Study
Sample, Intervention, (Sackett’s Strengths and
Reference Design Purpose Setting Variables Results Method) Limitations
ACE
Counsell SR, RCT ‘‘To test the hypothesis Community - Intervention: P \ .05 II (large, - Large sample size.
Holder CM, Pre- and that a multi-component teaching ACE unit. - There was no difference in independent ADLs randomized - The usual care and ACE
Liebenauer Post- design intervention, called hospital - Compared with: from baseline to discharge (P 5 .33) or from RCT but with care groups did not show
21
LL, et al. Acute Care for Elders (Akron City usual care units. admission to d/c (P 5 .67). No significant uncertain any statistically significant
(ACE), will improve Hospital). - Main outcome: difference in the mean number of independent results). differences.
functional outcomes 1531 change in the ADLs at d/c (P 5 .29). ADL decline from baseline to - High satisfaction with
and the process of community- number of ADLs d/c was less frequent for intervention pts, but not the ACE unit by
care in hospitalized dwelling pts from 2 weeks statistically significant (P 5 .051). physicians, nurses,
older pts.’’ age 70+ before - The intervention group had less ADL decline from patients, and caregivers.
admitted for admission baseline through the 12 month f/u after d/c - No [ in hospital LOS or
an acute (baseline) to (P 5 .037). costs.
medical discharge. - Changes in self-reported mobility from baseline - No clearcut
illness - Secondary and admission to d/c were also similar between improvement in ADLs at
between outcomes: groups (P 5 .29, P 5 .10). d/c.
11/1994-5/ resource use, - Intervention pts had better Physical Performance - ‘‘On the intervention
1997. implementation and Mobility Exam scores at d/c (P 5 .022). unit, nursing care plans
Intervention of orders to - ‘‘Fewer intervention than usual care pts were implemented more
unit n 5 767. promote function, experienced the composite outcome of either ADL often, bed-rest orders
Usual care planning for pt decline from baseline or nursing home placement were stopped and activity
unit n 5 764. discharge to at d/c (P 5 .027). This difference persisted between was advanced sooner,
home, and groups during the year following hospitalization.’’ physical therapy was
review of (P 5 .022). consulted earlier and in
medical care - No difference in LOS (P 5 .26), hospital costs more pts, and physical
to prevent (P 5 .36), or proportion of pts readmitted within 1 restraints were used less
iatrogenic month of d/c (P 5 .14). often and applied for
illness. - ‘‘Nursing care plans to promote independent shorter periods of time.’’
Geriatric Nursing, Volume 31, Number 5

function were more often implemented in the - Follows pts for

intervention group (P \ .001), discharge planning 12 months after d/c.
was documented earlier (P\.001), and social work - IRB approval and
was consulted more frequently (P 5 .012) and informed consent noted.
earlier in the hospital stay (P 5 .05.. Days at bed - Physicians worked with
rest were reduced (P 5 .29), and physical therapy both groups, but nurses
consults were obtained more frequently (P 5 .027) worked in either the ACE
and earlier in the hospitalization (P 5 .03). Physical or usual care unit
restraints were applied less often (P 5 .001) and for (possible contamination
fewer shifts (P 5 .014).’’ Foley urinary catheters by physicians?).
were not used less often (P 5 .83) or for a shorter - Patients and data
length of time (P 5 .58). collectors were not
- Less use of restraints (P 5 .001), no change in blinded to treatment
Foley use (P 5 .83), [ physical recognition of assignment.
depression (P 5 .02). - If patients could not
- Pt satisfaction was greater (P 5 .012), physician report their own health
satisfaction was greater (P \ .001), nurse status, etc., reports were
satisfaction was greater (P \ .001), and caregiver obtained by their
satisfaction was greater (P + .03) for the caregiver proxies.
intervention group. Caregiver and patient
reports may differ.
Geriatric Nursing, Volume 31, Number 5

Covinsky KE, RCT cost ‘‘To compare the Pts 70 years+, - ACE vs usual - Mean daily hospital costs were slightly higher in I - Treating pts on the ACE
King JT, analysis hospital costs of admitted to care. ACE pts than in usual-care pts ($876 vs $847, unit was not more costly
Quinn LM, caring for medical the general - Outcome P 5 .076). Direct daily costs were $24 per day (ns), but it also was not
et al.24 pts on a specific unit medical variable: higher in ACE pts than usual-care pts; this cheaper.
designed to help older service at resource-based difference was attributable to the fixed direct cost (Technically more
people maintain or University cost of of the interdisciplinary team.’’ expensive, but pts stayed
achieve independence Hospitals caring for pts - ‘‘Mean total cost per hospital admission were for less time).
in self-care activities of Cleveland. (determined by lower in ACE pts’’ ($6608 vs $7240, P 5 .926; ns), - Occurs at the same
with the costs of usual 11/1990-3/ the hospital’s attributable to a shorter LOS. hospital and unit as the
care.’’ 1992; 650 cost accounting - ‘‘ACE pts were less likely to spend time in a nursing Counsell study,21 the
medical system), with home in the 90 days after d/c (P 5 .034).’’ other Covinsky study,20
patients. the cost of the ’’Readmission rates (P 5 .283) and caregiver strain and the Landefeld study19
Intervention intervention (P 5 .280) were similar in the 2 groups.’’ (possibly limits external
n 5 326, usual program validity). The limitations
care n 5 324. estimated and from the data carry over
included in the into all reports. Need to
intervention pts’ examine ACE in other
total hospital cost. hospitals.
- ‘‘Also evaluated - Also looked at post-d/c
3 measures of resource use and
post-d/c resource caregiver burden.
use and caregiver - The 2 groups were not
burden to assess statistically different in
the effects of ACE age, race, or sex.
on other payers - Precision is limited by the
and caregivers.’’ small sample size.
90 days after d/c. - Did not consider the
effects of nursing
satisfaction on cost (if
nursing was more
satisfied, there could be
less turnover, which
decreases hospital costs
of training new nurses
frequently).
- Physicians worked with
both groups, but nurses
worked in either the ACE
or usual care unit
(possible contamination
by physicians?).
(Continued)
341
342

Appendix A
Continued
Quality of
Study
Sample, Intervention, (Sackett’s Strengths and
Reference Design Purpose Setting Variables Results Method) Limitations

Covinsky KE, RCT ‘‘To measure the 651 general - ACE vs. usual P \ .05 II - Same data set as in
Palmer RM, effectiveness of medical pts care. - ‘‘ACE pts were more likely to improve and less Covinsky et al. (1997),24
Kresevic the ACE unit itself.’’ aged 70+. 11/ - Major outcome: likely to decline in overall function, as measured but with less information
DM, et al.20 1990-3/1992. ‘‘change in the by the number of ADLs performed independently about the sample (limited
University ability to between admission and d/c’’ (P 5 .009). external validity.
Hospitals of independently - ‘‘ACE pts were less likely to be d/c to a long-term - Results conflict with
Cleveland perform ADLs care org’’ (P 5 .03). Counsell study.21
*These are the and d/c’’ (bathing, - ‘‘Three months after hospital d/c, ACE pts and - No long-term effects seen;
same data used dressing, usual care pts were similar in their abilities to only follows pts for 3
for the above transferring from perform ADLs’’ (no P value given). months.
24
study, but in bed to chair, - ‘‘The ACE unit intervention resulted in an - Does not consider pt or
this study, the toileting, and additional daily cost of $34 per pt per day. As staff satisfaction.
researchers did eating). a result, the daily cost of caring for pts on the ACE - How can ‘‘effectiveness of
not note the n of - Secondary unit was slightly higher than that for usual care the ACE unit itself’’ be
the intervention outcome: pts’’ (P 5 .08). ‘‘However, the average length of measured?
or usual care resource-based stay was shorter on the ACE unit. As a result, the - Physicians worked with
group. hospital cost. total cost to the hospital of caring for pts on thecae both groups, but nurses
unit was somewhat lower than for those receiving worked in either the ACE
usual care’’ (P 5 .93). ‘‘Although the difference in or usual care unit
total costs . was not statistically significant, these (possible contamination
results do suggest that ACE unit care was not more by physicians?).
costly to the hospital than usual care, in spite of the
investment required for the ACE unit.’’
Jayadevappa R, Survey ‘‘The objective of this ‘‘Survey of all - Survey - Responses received from 82 institutions; 16 had III - Only surveyed established
Bloom BS, paper is to determine established - Prevalence of ACE units. geriatric divisions and
Geriatric Nursing, Volume 31, Number 5

Raziano DB, prevalence and geriatric ACE units in the - 44% of ACE units had telemetry beds. geriatric teaching
et al.18 characteristics of divisions and United States. - Average LOS was 5.2 days. programs; possibility of
acute care for elders geriatric teach - Characteristics - CHF, pneumonia, and respiratory infections were missing hospitals with
(ACE) units and programs of ACE units: most common admitting diagnoses. ACE units (limits internal
hospital characteristics during June- resources, - Average nurse:pt ratio: 1:6. validity?).
associated with the August 2000 structure and - Most ACE units are located in urban hospitals - Responding institutions
presence of an ACE to determine administration, (P 5 553), with an average of 709 hospital beds. were representative of all
unit.’’ the prevalence pt care, (P 5 .010). institutions surveyed.
of ACE units involvement - ‘‘Logistic regression model indicated that hospital - Small number of units
and their of health revenue was the only significant if associated with with ACE programs (only
characteristics.’’ professionals, the presence of an ACE unit. Other independent 16).
and hospital characteristic variables, such as number
demographics. of beds, number of Medicare pts, LOS, and total
- Hospital charges, were not significantly related to having
characteristics an ACE unit.’’
associated with
presence of an
ACE unit: number
of beds, hospital
revenue, number
of Medicare pts,
average LOS, and
hospital location.
Geriatric Nursing, Volume 31, Number 5
Landefeld CS, RCT To examine the 651 pts aged 70+ - ACE
Palmer RM, effectiveness of ACE.
Kressevic
DM, et al.19
* Same data as 2
Siegler EL, Survey ‘‘Because the literature - Survey of key
Glick D, offers little to
Lee J.25 describe the
appropriate staffing
of [ACE] units, we
surveyed ACE units
about their size,
configuration, staffing,
pt selection, training,
and outcomes data.’’
343
- At time of d/c, the intervention pts were classified I - Same data as the other
admitted for - Main outcome as unchanged or better in terms of ADL function Covinsky study,20,24 but
general variable: change more often than usual-care pts (P 5 .009). easier to understand.
medical care from admission - At d/c, the intervention group had a higher level of - Same results, same
at University to d/c in number function in the basic ADLs than they did 2 weeks limitations (only 3 months
Hospitals of of 5 basic ADLs before d/c (P 5 .05). after d/c, does not
Cleveland that the pt could - ‘‘In the intervention group, benefits in number of consider satisfaction).
from 11/1990 perform ADLs were seen for pts less than 80 yo (P 5 .03), - Multiple studies drawing
to 3/1992. ACE independently those who were able to perform independently from the same data- limits
n 5 327, usual (bathing, fewer than 5 basic ADLs 2 weeks before admission external validity.
care n 5 324. dressing, (P 5 .04), and those with APACHE II scores of 0–14 - IRB approval, informed
toileting, (P 5 .02).’’ consent noted.
20,24
other studies. transferring - ‘‘An increase in the number of ADLs performed
from bed to independently form admission to d/c was
chair, and eating). independently associated (P 5 .04) with
- Secondary assignment to the intervention program.’’
outcome - ‘‘Fewer pts assigned to the intervention group
variables: were d/c’d to a long-term care institution’’ than in
differences the usual-care group (P 5 .01).
between ACE - Overall health status at d/c was better for pts
and usual care assigned to the intervention group (P \ .001).
in baseline -‘‘In the intervention group, there was a trend
characteristics, toward greater improvement during
main end points, hospitalization in the pts’ ability to perform
and other instrumental ADLs (P 5 .06) and their ability to
outcomes at walk (P 5 .3).
d/c, hospital - No statistically significant difference in mental-
charges and status at d/c (P 5 .3).
LOS, and - Mean LOS was 1 day shorter for intervention pts
outcomes after (P 5 .04).
d/c (3 months). - No significant difference in total hospital charges
(P 5 .3).
- 3 months after d/c, there was not a significant
difference in the mean number of ADLS that pts
could perform independently (P 5 .3) or overall
health status by self- or proxy-report (P 5 .5).
- Fewer intervention pts lived in long-term care
institutions at any time during the 3 months after
d/c (P 5 .03).
- Similar numbers of intervention and usual-care pts
were readmitted to acute care hospitals during the
3 months after d/c (P 5 .6).
- Survey of - 12 of 18 ACE units were in university hospitals, the IV - This was a survey study.
personnel on admission rest in community hospitals. - Only 18 ACE hospitals
18 ACE units. criteria, - Mean and median number of beds: 2. were included, and only
staffing ratios - 13 units allow private attending physicians to 12 responded (but there
of licensed follow their pts. are not many ACE units to
nursing - Criterion: 11 units said 65+, 4 units said 70+, 11 said survey).
personnel to medical service only.
pts, quality - 6–7.5 RNs are assigned per bed (depends on shift).
measures, - All but 1 unit had assigned social workers, 15 units
and any had an assigned PT, 12 had an assigned OT, 10 had
special attributes. an assigned activity therapist, 7 had speech
language pathologists.
- 13 units had congregate dining facilities, but only
one quarter of pts on average dined outside of
their rooms.
(Continued)
344

Appendix A
Continued
Quality of
Study
Sample, Intervention, (Sackett’s Strengths and
Reference Design Purpose Setting Variables Results Method) Limitations
HELP
Bradley EH, Long-itudinal ‘‘To examine key - 13 hospitals ‘‘Staff experiences - Where the HELP unit was used: 7 medicine units, 2 V - This was a qualitative
Webster TR, qual-itative factors that influence implementing sustaining the surgery units, 2 geriatric units, 2 med/surg units. study (interviews).
Baker D, study sustainability in the HELP; 11 in the program, - 3 hospitals dropped HELP by the end of the study. - The interviewees reported
29
et al. diffusion of the United States and including - Participant-reported benefits of help: reduced improved pt outcomes.
Hospital Elder Life 2 outside the challenges incidence of delirium, reduced use of restraints, - It is only subjective data
Program (HELP) as an United States. and strategies greater satisfaction with care by pts and family based on the
example - Occurred from that they members, better understanding of geriatric care interviewees. They may
of an evidence- 11/2000-11/2003 viewed as by clinical staff , and increased communication exaggerate outcomes in
based, multifaceted, (not all hospitals successful in among the clinical team including greater phone interviews (all self-
innovative program were studied for addressing participation by pharmacy and PT. reported). There is no way
to improve care of the same length these - 2 hospitals conduced financial analyses and to determine how far
hospitalized elders.’’ of time). challenges.’’ reported cost-effectiveness. improved the outcomes
- Interviews held ‘‘Participants - ‘‘A critical feature that distinguished the were or whether the
every 6 months were asked to 10 hospitals that sustained the program from the 3 outcomes actually
(interviewees describe current hospitals in which the HELP program was stopped improved at all.
found through experiences with . was the departure and nonreplacement of key - IRB approval was noted.
snowballing); HELP clinical staff members who had been committed to
open-ended implementation, HELP.. Clinician leaders in hospitals that
questions and what difficulties sustained HELP continued to play important
probes. or successes they clinical roles in the program but also persisted as
experienced and strong advocates with senior administration for
why, how the necessary resources to maintain the initial
difficulties were commitment to HELP.’’
addressed, and - ‘‘The hospitals that sustained HELP for at least
Geriatric Nursing, Volume 31, Number 5

what they 12 months were able to ADAPT HELP in ways that

perceived helped enabled continued implementation at their
or hindered the institution.’’ (For example, changing forms and
sustaining of the documentation to reduce redundancies,
program in their decreasing the frequency of interventions d/t
hospital.’’ volunteer constraints, flexibility in the intensity of
interventions).
-‘‘A chronic concern for all HELP programs was
having adequate staff to implement HELP.’’
-‘‘Securing permanent funding for HELP as part of
the hospital’s budget was critical for sustaining the
program over the longer term.’’
Inouye SK, Cross-sectional ‘‘To describe the - 13 HELP sites in - ‘‘75 closed- and - Median time of implementation took 7 months V - Data were self-reports.
Baker DI, survey Hospital Elder Life acute care open-ended (range .5-24 months). - Provides a good
Fugal P, Program [HELP] hospitals. questions - 9 on medical units, 3 on surgical units, 5 on description of HELP
et al.28 across dissemination -7/2005-12/2005 describing details medical/surgical units, 3 on geriatric or ACE units, dissemination,
sites, to detail of the HELP site, 5 on ‘‘other’’ units. adaptations, and
adaptations, and to procedures, - Median full-time HELP staff: .6 full-time advantages.
summarize advantages staffing, equivalents per site; median number of - Participating hospitals
across sites.’’ outcomes volunteers 20. reported improved
 tracked, and - Interdisciplinary consultants regularly participated outcomes.
Geriatric Nursing, Volume 31, Number 5

advantages.’’ in 11 of 13 sites (nutrition, PT, TO, SW, chaplaincy, - The study demonstrates
pharmacy, and care coordination/case that HELP programs are
management). used and appreciated by
- All sites had a HELP program director; all HELP multiple hospitals.
sites reported using trained volunteers. - A challenge to maintain
- Adaptations that occurred: not all programs used program fidelity while
all interventions, not all used quality assurance adapting to local
procedures (e.g., staff meetings, checking circumstances.
volunteer performance, satisfaction surveys for - The small sample size
pts, etc.). limits generalizability.
- Advantages and successes of HELP as reported
across sites: providing an educational resources
(100%), improving hospital outcomes (100%),
providing nursing education and improving
retention (100%), enhancing pt and family
satisfaction with care (92.3%), raising visibility for
geriatrics (92.3%), improving quality of care
(84.6%), providing cost-effective care (76.9%),
improving community relations (76.9%),
contributing to awards or recommendations for
the hospital (76.9%), and distinguishing volunteer
services (53.8%).
- Reported that gaining internal support was critical
to implementing HELP.
Inouye SK, Descriptive ‘‘To describe the - Implementation - Adherence - Overall adherence rate: 89% (complete or partial V - Provides insight into
Bogardus Hospital Elder Life of HELP at Yale - Quality adherence). reasons for
ST, Baker DI, Program, a new New Haven assurance - Major reasons for nonadherence: lack of nonadherence (which can
et al.16 model of care Hospital for procedures and availability of staff or volunteers (32%), pt refusal be helpful in looking at
designed to all qualified performance of intervention (26%), medical contraindication how often the program
prevent functional pts age 70+. reviews. (22%), and pt unavailability (13%). would be utilized, any
and cognitive - 1507 pts in 1716 - Anonymous pt and/or family surveys: more than changes that would be
decline of older hospital 90% satisfaction. necessary to make it more
persons during admissions from - 8% of admissions declined by 2 or more points on utilized); insight into
hospitalization.’’ 3/1995-8/1999. the MMSE. satisfaction; suggestive of
- 14% of pts declined by 2 or more points on effectiveness in retaining
ADL score. mental status and ADLs.
- Median LOS: 7 days (range 1–163 days). - Large sample size.
- High rates of adherence to
interventions.
- Assesses satisfaction.
Inouye SK, Controlled ‘‘Our aims were to - Pts 70+ at Yale - Primary - Lower incidence of delirium in intervention group III - Used strong methods,
Bogardus clinical trial compare the New Haven outcome: (P 5 .02). strict guidelines for
ST, (prospective effectiveness of Hospital from delirium. -Lower total number of days with delirium in inclusion/exclusion in
Charpenter individual a multi-component 3/25/1995-3/18/ - Adherence intervention group (P 5 .02). study.
PA, et al.26 matching strategy for reducing 1998. - Effect on - Lower total number of episodes of delirium in - Provides evidence that
instead of the risk of delirium - 852 pts matched targeted risk intervention group (P 5 .03). HELP may be effective in
randomization). with that of a usual as 426 pairs of pts factors. - Overall adherence to intervention (complete and meeting its goals.
plan of care for receiving the partial adherence): 89%. - Includes detailed tracking
hospitalized older study intervention - Change in risk factors at reassessment on Day 5 or of adherence.
pts, to determine the and usual care. d/c: cognitive impairment (P 5 .04), sleep - Random assignment was
level of adherence to deprivation—use of sedative drugs for sleep not possible.
the intervention during stay (P 5 .001), immobility (P 5 .06), vision - Hospital staff carried some
protocol, and to impairment—early vision correction (P 5 .27), interventions over to the
measure the effect hearing impairment (P 5 .10), dehydration usual-care group
345

of the intervention on (P 5 .40), total number of risk factors (P 5 .02). Not (contamination of results).
the targeted risk all statistically significant but all showed ‘‘positive
factors.’’ trends.’’
(Continued)
 Appendix A
346

Continued
Quality of
Study
Sample, Intervention, (Sackett’s Strengths and
Reference Design Purpose Setting Variables Results Method) Limitations
Rubin FH, Pretest–posttest ‘‘To evaluate 4763 pts aged - Incidence of - Delirium decreased from baseline-intervention IV - The study used a proxy
Williams JT, quality- a replication 70+ admitted delirium (P \ .002). measure instead of
Lescisin DA, improvement of the Hospital Elder to 1 nursing (measured - Total LOS for pts who developed delirium measuring rates of
30
et al. study. Life Program (HELP), unit over 3.5 via proxy decreased. by .3 days (P 5 .32). delirium directly.
a quality-improvement years measure). - Nurses and nurses aides reported reported - ‘‘Some modifications in
model, in a community (University - Financial satisfaction; pts reported satisfaction. the original protocols
hospital without of Pittsburgh outcomes. were necessary (eg
a research Medical - Nursing and exercise protocol was
infrastructure, using Center pt satisfaction. omitted).’’
administrative data.’’ Presbyterian
Shadyside).
NICHE
Boltz M, Pre-post cross- ‘‘To examine the 8 urban, not-for- - Used the GIAP - Geriatric nurse practice environment V - 9 years between pre- and
Capezuti E, sectional; influence of NICHE in profit, acute- to measure (institutional values toward posttest is a threat to
Bowar- a secondary a national sample of care hospitals; results. Looked at: older adults and staff, internal validity.
Ferres S, analysis of data member hospitals on RN acute-care geriatric nurse capacity for collaboration, and resource - There was limited external
31
et al. collected by the select geriatric nurses in direct practice availability), P \ .0001. validity (did not look at for-
NICHE program. outcomes.’’ care positions; environment, - Institutional values (RN perceptions of respect for profit hospitals or
pre-NICHE, institutional the rights for older adults, involvement of older hospitals in rural areas).
n 5 821; and values adults and families in decision making, support of - Study did not consider the
post-NICHE, regarding nurse autonomy and personal growth), P \ .0001. intensity, consistency, and
n 5 942. older adults - Capacity for collaboration (RN perceptions of other duration of NICHE
and staff, capacity disciplines’ knowledge of geriatric care, use of implementation.
for collaboration, geriatric protocols, and degree of conflict), - ‘‘Significant improvement
resource P 5 .13. in the scores measuring
availability, - Resource availability (RN perceptions of access to nurse perceptions of both
Geriatric Nursing, Volume 31, Number 5

geriatric human and material resources specific to care of the geriatric nursing
nursing older adults and management support of practice environment and
knowledge, communication with pts and families), P 5 .11. quality of geriatric care.’’
and quality - Geriatric nursing knowledge (knowledge of the - ‘‘The findings suggest that
of geriatric assessment and nursing management of 4 these sites demonstrated
nursing care/ common geriatric syndromes: pressure ulcers, a trend toward
aging-sensitive incontinence, restraint use, and sleep improvements associated
care delivery. disturbance), P 5 .1462. with the stated goal of
(Descriptions of - Quality of geriatric care (geriatric-specific, NICHE, which is to provide
variables on pp. evidence-specific, individualized care that organizational tools to
179-80). promotes informed decision making and is modify the nurse practice
continuous across settings), P 5 .0004. environment to make it
more geriatric-
responsive.’’
Mezey M, Survey ‘‘To determine 103 active Categories in - GIAP: 48 (76%) hospitals implemented the GIAP; V - Limited generalizability (it
Kobayashi perceptions of the NICHE the survey: 29 (46%) rated the GIAP excellent or very good, 5% only assessed active
M, NICHE program, hospitals. - hospital rated it fair. NICHE hospitals, not
Grossman the adoption of - 85 usable characteristics - GRN model: implemented in 42 (63%) hospitals; hospitals that never fully
S.33 NICHE models and surveys were - coordinator 69% rated it as excellent or very good. implemented or
protocols, and the returned (83% demographics - Geriatric Syndrome Management Model was used discontinued NICHE).
 educational response rate). and by 14 (21%) hospitals.
Geriatric Nursing, Volume 31, Number 5

outcomes, policy - 2002 responsibilities - ACE Model was fully implemented by 12 (18%).
changes, and - utilization - No hospitals reported using Comprehensive D/C
benchmarks r/t care and perception Planning/ Quality Cost Model of Transitional Care.
of older pts established of usefulness of - 34 (51%) hospitals reported using at least 1 of the
by the participating the GIAP protocols Geriatric Nursing Protocols for Best
NICHE models.’’ - nursing models Practice. Of those that used the protocols, 19 (56%)
and other had implemented at least one protocol as a policy/
components of practice standards, most frequently for falls (n 5
the NICHE tool 10), restraints (n 5 9), and pressure ulcers (n 5 5).
kit - Try This: 33 (49%) implemented, 16 incorporated
- Development a Try This as a policy or standard of practice. Most
of nursing common were the Katz ADL Scale and the MMSE.
standards of - Partners for Dissemination of best Nursing
geriatric practice Practice and Certification in Gero Nursing: 29
- Benchmarking (34%) used the materials.
activities - NICHE listserv: 79% used the listserv, and 17 used
it daily; 91% of coordinators rated the listserv as
excellent or very good.
- Gerontological Nursing Certification: 30 (35%)
reported using the Hartford Institute review course
on the Web site, 56% reimburse nurses to become
certified in gero nursing; 25 (31%) prepare RNs to
sit for the exam—16 offer review classes at the
hospital, 12 offer hospital-reimbursement for
review classes, 11 provide the Hartford Institute
materials, 14 did not know how RNs prepare for
the exam.
- Benchmarking: 39% of the 79 hospitals that
answered this questions said they used hospital-
wide benchmarking. 4 hospitals tracked 3+
benchmarks. The most frequent benchmarks were
falls (n 5 22), restraint use (n 5 11), and pressure (n
5 9). Other benchmarks were LOS, pain
management, and incontinence.

ADL 5 activities of daily living; CHF 5 congestive heart failure; d/c 5 discharge; f/u 5 follow-up; GIAP 5 Geriatric Institutional Assessment Profile; GRN 5 Geriatric Resource
Nurse; IRB 5 internal review board; LOS 5 length of stay; MMSE 5 Mini-Mental State Exam; pts 5 patients; RCT 5 randomized clinical trial.
347