“There are nearly 5,000 acute care hospitals in America, but only about 200 of them have HELP programs. Yet most of them should.”
By Sandra Gordon for ASA
Fred Rubin, MD, Chief of Medicine at University of Pittsburgh Medical Center (UPMC) Shadyside, discusses best practices for implementing a Hospital Elder Life Program (HELP) to decrease the risk of post-operative delirium.
UPMC Shadyside Hospital has been helping to reduce the incidence of delirium in hospitalized patients over age 70 since 2002 through its Hospital Elder Life Program (HELP). “We’re the biggest HELP program in the world, serving around 7,000 patients per year,” says Fred Rubin, MD, Chief of Medicine at UPMC Shadyside.
Developed by Sharon Inouye, MD, MPH, director of the Aging Brain Center at the Hinda and Arthur Marcus Institute for Aging Research in Boston, the HELP program is now under the ownership of the American Geriatrics Society and has a new name: AGS CoCare®: HELP.
“HELP is a proven intervention that reduces the harmful outcomes of delirium. It shortens length of stay for hospitalized patients, reduces the cost of care, reduces the death rate for people who become delirious, reduces hospital readmissions and falls in the hospital, and the need for transfers to a long-term care facility,” Rubin says. “It reduces the burden on the nursing staff. Patients who are not delirious are easier to take care of.”
Those benefits translate to savings. “Our ROI is greater than 10 to 1 for every dollar spent,” Rubin says. “But that’s not a sufficient reason to do this. We save people’s lives. That’s why every hospital should have HELP.”
A robust pipeline of 100 trained HELP volunteers from local Pittsburgh colleges and universities implement the UPMC Shadyside’s HELP program, which involves keeping patients’ minds engaged during their hospital stay. The volunteers, typically students in pre-health professions, such as pre-PA and pre-nursing students, spend daily quality time interacting with patients while watching for signs of delirium. Patients are supplied with toys, magnifying glasses, hearing amplifiers, Scrabble, crossword puzzles, exercise squeeze balls, and copies of the daily newspaper and magazines.
“One of the interventions is actually just chatting,” Rubin says. “We have techniques for how to chat with patients. People love to reminisce about when they were teens and in their 20s, and the music that was popular when they were young, such as Bob Dylan, the Beatles, and the Rolling Stones,” Rubin says. Volunteers also make sure patients’ water bottles are filled, help them feed themselves, and walk with them in the hallways.
HELP interventions are not difficult to understand, but they are difficult to maintain and implement every day. For example, to make sure patients with hearing loss have amplifiers, you need to make sure the batteries in the amplifiers aren’t dead and that volunteers are screening patients for hearing loss, Rubin says.
Since March 2020, Shadyside’s HELP volunteer program has been on hold. But trained staff have been implementing the HELP protocol and will continue until COVID resolves. “Before COVID, we were serving over 7000 patients per year with our HELP program. Right now, we’re serving 4000. That’s still a lot,” Rubin says.
To staff a HELP program on one service line, UPMC Shadyside’s HELP program requires a nurse practitioner, a fulltime volunteer coordinator, known as an Elder Life Specialist, 10% of a geriatric physician, and a program administrator. “The real costs are in the salaries of the employees,” Rubin says. The program, which started on one nursing unit, is now on 11.
Making a Business Case for HELP
If you’re interested in implementing a HELP program to help reduce the risk of post-operative delirium, Rubin recommends starting with one service line and taking these key steps:
- Team up with another physician champion. “HELP gets incorporated on the floors, which is foreign territory to the anesthesiologist,” Rubin says. For that reason, Rubin recommends anesthesiologists interested in starting a HELP program partner with a physician champion, preferably someone with elderly patients, such as the chief of surgery, the chief of orthopedics, or the chief of neurology. Their visibility can help spread the word about HELP and underscore the importance of reducing the risk of post-operative delirium.
- Identify stakeholders to further the cause. “When I started HELP, I did at least a year of prework, which included rounding up stakeholders,” says Rubin, who was the physician champion at UPMC Shadyside. “I created a central planning committee of physicians who had an interest in delirium, which included the chief of neurology, the chief of psychiatry, the chief of physical medicine and rehabilitation, the director of nursing, the head to rehab services, the chaplain, the hospital librarian, mostly anybody who was receptive to a better way to take care of older people in the hospital,” Rubin says.
- Gather data. Before implementing HELP, Rubin had a one-year grant. “I didn’t want to do a research project replicating other research projects and then be done and t move on. I wanted to change practice,” Rubin says. That meant the HELP program had to ultimately be funded by the hospital’s general ledger. “I met with administration and said, ‘What metrics do you want me to measure that will convince you that you should pay for this going forward?’” Rubin says. “They said ‘quality of patient care,’ but also costs. So, I tracked financial metrics carefully. I partnered with our hospital fiscal department. They were willing to pull the data on patients who were in HELP compared to comparable patients not in HELP. They were willing to assign a fiscal analyst to crunch the numbers and look at the differences. “When I presented that data to our hospital administrators, it was very credible because it was their people,” Rubin says.
A key piece of data to track is hospital length of stay, he says.
Overall, “most cases of post-operative delirium occur on day two or three. There is an opportunity for prevention. This multi-component intervention called HELP is the best tool out there,” Rubin says. “It’s evidence based and supported in multiple studies. HELP works and every hospital should do it.”
For more information on developing a HELP program, visit https://www.americangeriatrics.org/programs/ags-cocarer-help.
Mark your calendars. The AGS virtual annual scientific meeting will host a HELP pre-conference on May 12, 2021.
For more information on scaling and sustaining a HELP program, Rubin recommends this 2011 study in the Journal of the American Geriatrics Society.
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