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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER    |   |   |   |   |
|                                                          |   |   |   |   |
| ### *Annual Report: Fiscal Year [2007]{.underline}*      |   |   |   |   |
|                                                          |   |   |   |   |
| ######## Part II: Accomplishments                        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **1. GRECC NAME/LOCATION**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **GRECC Name:** VA Greater Los Angeles Healthcare    |   |   |   |   |
|     System                                               |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location** *(facility, VISN)*: Los Angeles, VISN   |   |   |   |   |
|     22                                                   |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **Name:** Thomas T. Yoshikawa, MD                    |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Position:** Director, GRECC                        |   |   |   |   |
|                                                          |   |   |   |   |
| c.  **Phone, e-mail:** (310) 268-4110                    |   |   |   |   |
|     <Thomas.Yoshikawa@va.gov>                            |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **3. GRECC FOCUS AREA(S)**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **GRECC Focus Area**                                     | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | R |   |   |   |
|                                                          | e |   |   |   |
|                                                          | s |   |   |   |
|                                                          | e |   |   |   |
|                                                          | a |   |   |   |
|                                                          | r |   |   |   |
|                                                          | c |   |   |   |
|                                                          | h |   |   |   |
|                                                          | T |   |   |   |
|                                                          | y |   |   |   |
|                                                          | p |   |   |   |
|                                                          | e |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
|                                                          | > | > | > | > |
|                                                          |   |   |   |   |
|                                                          | * | * | * | * |
|                                                          | * | * | * | * |
|                                                          | B | A | H | R |
|                                                          | a | p | e | e |
|                                                          | s | p | a | h |
|                                                          | i | l | l | a |
|                                                          | c | i | t | b |
|                                                          | > | e | h | i |
|                                                          |   | d | > | l |
|                                                          | B | > |   | i |
|                                                          | i |   | S | t |
|                                                          | o | C | e | a |
|                                                          | m | l | r | t |
|                                                          | e | i | v | i |
|                                                          | d | n | i | o |
|                                                          | i | i | c | n |
|                                                          | c | c | e | * |
|                                                          | a | a | s | * |
|                                                          | l | l | * |   |
|                                                          | * | * | * |   |
|                                                          | * | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| -   Endocrinology of aging, molecular biology of bone    | * |   |   |   |
|     and brain, Alzheimer's disease, cellular & molecular | * |   |   |   |
|     basis of osteoporosis, osteoarthritis and            | X |   |   |   |
|     immunosenescence                                     | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| -   Osteoporosis, immunology/infectious diseases, falls  |   | * |   |   |
|     and instability, long-term care, exercise, sleep,    |   | * |   |   |
|     Alzheimer's disease                                  |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| -   Evaluation of clinical programs, minority elderly    |   |   | * |   |
|     health care utilization, geriatric assessment,       |   |   | * |   |
|     cost-effective geriatric care, quality of care       |   |   | X |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| -   Geriatric rehabilitation                             |   |   |   | * |
|                                                          |   |   |   | * |
|                                                          |   |   |   | X |
|                                                          |   |   |   | * |
|                                                          |   |   |   | * |
+----------------------------------------------------------+---+---+---+---+

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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Report Year***: list **the**       |
|     **most important ways** in which the GRECC has had specific       |
|     impact on **host VAMC's** research, staff education, program      |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VAMC) during the Report Year. **Please     |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   GRECC clinicians provided 6-hours of didactic education for the   |
|     annual GLA medical staff meeting. GRECC educators continued to    |
|     provide extensive teaching activity to GLA through 3 day-long     |
|     conferences, 6 medicine grand rounds, clinical teaching in        |
|     ambulatory, inpatient and long term care settings. A total of 298 |
|     GLA clinical staff received 1324 hours of education from GRECC.   |
|     GRECC educators served on GLA committees for CME, GMEC,           |
|     fellowship and conference planning.                               |
|                                                                       |
| -   GRECC researchers had a total of 38 active research projects      |
|     totaling \$26,960,989.00 in grant awards for which GLA received   |
|     indirect funding.                                                 |
|                                                                       |
| -   GRECC clinicians supported 14 inpatient internal medicine and     |
|     geriatric acute, sub-acute and long-term care clinical programs   |
|     and outpatient clinics at GLA, providing primary care, attending  |
|     coverage and teaching.  A total of 14 Primary Core GRECC staff    |
|     contributing 6.42 FTEE or 13,354 hours/year of clinical care time |
|     (\$837,740/year in salary) towards providing direct patient care  |
|     at GLAHS. Additional major clinical care delivery is provided by  |
|     GRECC clinical trainees.                                          |
|                                                                       |
| -   GRECC professional staff has contributed to 17 different host     |
|     committees during FY07. The committee activities have involved    |
|     GLA and affiliated training programs, medicine grand rounds,      |
|     nursing home oversight committees, medical executive committees,  |
|     tele-health care coordination committee, VA/California nursing    |
|     home steering committee, and GLA/UCLA Dean's committee. GLA       |
|     continues to rely on GRECC for administrative activities,         |
|     including supporting the department of Medicine.                  |
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| b.  [**GRECC Impact on VISN in the Report Year:** *list **the**       |
|     **most important ways** in which the GRECC has had specific       |
|     impact on the **host** **VISN's** research, staff education,      |
|     program evaluation, or clinical care improvements for elderly     |
|     veterans (i.e., how the GRECC has "made a difference" in these    |
|     areas within the entire host VISN) during the rating period.      |
|     **Please limit your response to [5 or fewer]{.underline} "ways";  |
|     and please limit your description of each of the five "ways" to   |
|     [five lines or fewer]{.underline}***]{.mark}***.***               |
|                                                                       |
| -   GRECC core faculty served on VISN 22 clinical (GEC Executive      |
|     Committee) and Education Committees including chairmanship of the |
|     GEC Committee of the Clinical Practices Council.                  |
|                                                                       |
| []{.mark}                                                             |
|                                                                       |
| -   GRECC provided accredited education in medicine, nursing and      |
|     social work to VISN 22 facilities' staff through annual           |
|     conferences (FY07: palliative care and hospice, real estate,      |
|     fraud and elder abuse), satellite programs (series of 5 topics in |
|     geriatrics) and monthly audio-conferences. A total of 333         |
|     clinical staff from Loma Linda, Long Beach, Las Vegas and San     |
|     Diego healthcare systems received a total of 1590 hours of        |
|     education directly from GRECC faculty.                            |
|                                                                       |
| -   GRECC supported the VISN 22 palliative care initiative with the   |
|     creation and distribution of geriatric pain management pocket     |
|     references. The lead of the VISN palliative care initiative is a  |
|     member of the GRECC's annual hospital and palliative care         |
|     conference planning committee.                                    |
|                                                                       |
| -   The Elders at Risk program is a 17-year consortium of VA and      |
|     community groups working with frail elders, has partnered with    |
|     the Los Angeles City Attorney's Office and hosts popular monthly  |
|     didactic/case conferences.  This partnership has improved the     |
|     quality of life of older adults and increased the knowledge of    |
|     geriatric clinical syndromes and resources for providers of elder |
|     care.                                                             |
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| c.  [**GRECC Trend-Setting Innovations since October 1,               |
|     [2002]{.underline}**: *list **the** **most significant** GRECC    |
|     research, education or clinical innovations in the past five      |
|     years. For each item, provide date or date range, GRECC core      |
|     staff responsible, and a description. **Please limit your         |
|     response to 5 or fewer innovations; and please limit each of the  |
|     five innovation descriptions to five lines or fewer. ***]{.mark}  |
|                                                                       |
| []{.mark}                                                             |
|                                                                       |
| -   **The Alzheimer laboratory at the GLA GRECC** has published the   |
|     original and follow-up work on multiple mechanisms whereby        |
|     curcumin can block Alzheimer\'s pathogenesis, not just by binding |
|     it and clearing it from the brain (*J Biol Chem. 2005 Feb 18; 280 |
|     (7):5892-901*), but also by stimulation of inflammatory clearance |
|     reduction in adverse chronic inflammation and inhibition of lipid |
|     peroxidation *(Neurobiology of Aging. 22: (6) Nov-Dec 2001. pp    |
|     991-1003; J. Neuroscience 21:8370-8377)*. This has led to         |
|     initiation of a clinical trial with curcumin.                     |
|                                                                       |
| -   **The Alzheimer laboratory at the GLA GRECC** published  the      |
|     original work on Alzheimer\'s mutations interacting with          |
|     dietary omega-3 fatty acid depletion  to accelerate synaptic and  |
|     memory loss; *(Neuron. 42:633-45.2004; J. Neurosci 25:3032-40,    |
|     2005; Eur J. Neuroscience 2005, Aug, 22(3):617-26).*  This has    |
|     led to the Alzheimer National Consortium initiating a prevention  |
|     trial with dietary docosahexaenoic acid.                          |
|                                                                       |
| -   **Sally A. Frautschy, PhD** and colleagues have been              |
|     investigating role of GSK 3beta and pERK hyperactivation in       |
|     Alzheimer\'s disease and models.  The regulation of these         |
|     enzymes, which are essential for neuron function, are disrupted   |
|     by beta amyloid oligomers (*J Neurochem. 2007 Aug 30; \[Epub      |
|     ahead of print\]*). Dr. Frautschy has also been exploring         |
|     formulations where curcumin can be absorbed by GI tract without   |
|     glucuronidation and stability problems.                           |
|                                                                       |
| -   **Theodore Hahn, MD and Josea Kramer, PhD** and colleagues        |
|     concluded a successful proposal to the federal and California     |
|     DVAs, and finalized the plans, for a new \$300 million 400-bed    |
|     California State Veterans Home (CSVH) complex that will be        |
|     located on the WLA campus of VA GLAHS. This CSVH will be a unique |
|     academic training model and will also serve as a quality          |
|     improvement and continuing medical education center for the       |
|     entire CSVH system.                                               |
|                                                                       |
| -   Under the leadership of **Nancy Weintraub, MD**, the GRECC        |
|     developed a mentored \"education rotation\" for the geriatric     |
|     medicine fellowship which includes preparing a literature review  |
|     article on a topic in geriatric medicine.  Over the last 4-years, |
|     17-fellows have participated and 13-articles have been published  |
|     in peer reviewed journals.  Two of these articles have been       |
|     selected for special CME publications by American Medical         |
|     Director's Association (AMDA).                                    |
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| **5. RESEARCH**                                                       |
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| [**a. Key Findings Published in the Report Year on projects for which |
| GRECC Core Staff was PI or Co-PI:** *list **five or fewer;** for each |
| item provide GRECC Core Staff name(s), journal reference, and         |
| description of topic/ method/results/clinical significance.           |
| *]{.mark}*[Please limit each response to [5 lines or                  |
| fewer]{.underline}.]{.mark}*                                          |
|                                                                       |
| -   **Samuel Murray, MD & Elsa Brochmann Murray, PhD** and colleagues |
|     are developing improved bone graft substitutes for eventual use   |
|     with an aging patient's own bone marrow stromal or "stem" cells   |
|     by testing the effects of infusing low amounts of a bone growth   |
|     factor (basic fibroblast growth factor) into live rats on the     |
|     ability of stem cells to form new bone.  The infusion of the      |
|     growth factor improved bone formation in ovariectomized           |
|     (post-menopausal) rats. (*Tissue Engineering 13(4): 809-817,      |
|     2007).*                                                           |
|                                                                       |
| -   **Dean Yamaguchi, MD, PhD** and colleagues described that         |
|     multi-potent human mesenchymal stem cells (hMSCs) from bone       |
|     marrow differentiate into bone forming cells can produce          |
|     substances that can stimulate new blood vessel formation, which   |
|     could be important to overall bone repair and healing. (*J Cell   |
|     Biochem. 2007 Jun 21; \[Epub ahead of print\])*.                  |
|                                                                       |
| -   **David Sultzer, MD** and colleagues assessed the effectiveness   |
|     of antipsychotic treatment for psychosis or behavioral problems   |
|     in elderly patients with Alzheimer's disease in a national study. |
|     This is one of the first studies to examine effectiveness under   |
|     usual patient care conditions. The results, that effectiveness of |
|     medication treatment is offset by side effects that may occur,    |
|     will help inform and improve clinical care for those with         |
|     Alzheimer's disease. *(NEJM, 355:1525-1538, 2006)*.               |
|                                                                       |
| -   **Laurence Rubenstein, MD, Cathy Alessi, MD, and Karen Josephson, |
|     MPH** reported findings from a large randomized trial which       |
|     tested an innovative screening, case finding and referral system  |
|     for older veterans who were not previously receiving geriatric    |
|     care, and demonstrated that this system found extensive           |
|     unrecognized geriatric conditions. The program improved           |
|     identification and treatment. Veterans who were depressed and     |
|     functionally impaired at baseline were more likely to show        |
|     improvement in these conditions at 1-year follow-up if they were  |
|     in the intervention group than if they were in the control group  |
|     (*J Am Geriatr Soc 55:166-170, 2007*).                            |
|                                                                       |
| -   **Joshua Chodosh, MD, Theodore Hahn, MD and Laurence Rubenstein,  |
|     MD, MPH** demonstrated that 1) memory impairment (and likely      |
|     dementia) has a 20% prevalence in GLAHS among 75-year and older   |
|     veterans who actively use VA services but do not have a dementia  |
|     diagnosis and 2) concerns about memory were strongly predictive   |
|     of poor memory performance. Questions focused on concern about    |
|     memory may be a useful screener in this population. *(Aging and   |
|     Mental Health. 2007; 11:444-50).*                                 |
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| [**b. Key Findings Published in the Report Year on work in which      |
| GRECC Core Staff served as Co-Investigators to a Non-GRECC PI:**      |
| *list **five or fewer**; for each item provide GRECC Core Staff       |
| name(s), journal reference, and description of                        |
| topic/method/results/clinical significance. Please limit each         |
| response to [5 lines or fewer]{.underline}.*]{.mark}                  |
|                                                                       |
| -   **Samuel Murray, MD & Elsa Brochmann Murray PhD** and colleagues  |
|     developed a statistical model to phase out animal testing of      |
|     demineralized bone matrix products. The results indicate that     |
|     testing the activity of bone graft materials by direct assay      |
|     instead of *in vivo* bioassay will be faster and less expensive   |
|     for laboratory and clinical uses. Alternatives Lab Animals 35:    |
|     405-409, 2007.                                                    |
|                                                                       |
| -   **Cathy Alessi, MD and Karen Josephson, MPH** were                |
|     co-investigators to non-GRECC PI Jill Razani, PhD, in her study   |
|     of the relationship between specific cognitive impairments        |
|     (particularly executive functioning) and dependence in specific   |
|     activities of daily living among older people with mild to        |
|     moderate dementia. Appl Neuropsychol 14 (3): 208-214, 2007.       |
|                                                                       |
| -   **Joshua Chodosh, MD, MSHS** was co-PI to non-GRECC-PI, Barbara   |
|     Vickrey, MD, MPH, in the only published dementia quality of care  |
|     (QOC) assessment of 3 health systems (including managed care and  |
|     fee for service). This study establishes important benchmarks     |
|     against which future quality improvement implementation studies   |
|     can be evaluated. J Am Geriatr Soc. 2007; 55:1260-8.              |
|                                                                       |
| -   **Theodore Hahn, MD** and colleagues at UCLA used cell culture    |
|     and molecular techniques to examine the basis for the age-related |
|     decrease in the maturation of normal adult mesenchymal stem cells |
|     (MSCs) into bone-forming osteoblasts that causes osteoporosis in  |
|     older adults. A new class of MSC regulators, called oxysterols,   |
|     was discovered and found to play a major role in this process.    |
|     Further studies in this area should lead to improved treatment of |
|     osteoporosis in older veterans. J Bone Miner Res. 2007: July.     |
|     epub.                                                             |
|                                                                       |
| -   **Greg M. Cole**, **PhD** and colleagues FY07 have been           |
|     investigating and publishing on how insulin signaling defects are |
|     induced by beta-amyloid and how this contribute to not only loss  |
|     of synapses but also to more beta-amyloid accumulation, thus      |
|     presenting a positive feedback mechanisms. They have also been    |
|     investigating how dietary depletion of omega 3 fatty acid         |
|     modifies signal transduction pathways and insulin signaling       |
|     deficits that enhance risk for Alzheimer\'s. Cole, GM and SA      |
|     Frautschy. The role of insulin and neurotrophic factor signaling  |
|     in brain aging and Alzheimer\'s Disease. Experimental Gerontology |
|     42(2007): 10-21.                                                  |
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| **6. EDUCATION**                                                      |
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| **NOTE**: **DO NOT** list trainee and conference data                 |
| here**\--**those data are reported in the GRECC Electronic Database.  |
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| a.  **Innovations in Educational Activities Implemented during the    |
|     Report Year** *(list five or fewer. Please limit each item to [5  |
|     lines or fewer]{.underline} and include clarification of how each |
|     activity is innovative.)*                                         |
|                                                                       |
| -   The **Geriatric Pain Management Pocket Guide Reference** that was |
|     created by the GLA GRECC in 2003 was reviewed and the information |
|     was deemed to be current. The initial distribution did not have   |
|     great impact on VISN 22 facilities so, in conjunction with the    |
|     VISN Geriatrics and Extended Care Committee, the pocket guides    |
|     were distributed to a targeted audience in September, 2007. A     |
|     follow-up survey will be conducted in FY08 to determine the       |
|     impact.                                                           |
|                                                                       |
| -   **Debra Saliba, MD** developed an educational video to train      |
|     nursing home staff on how to approach and interview an older      |
|     adult using the PHQ-9. The video was including in a national      |
|     Satellite Broadcast and Webcast, by the Centers for Medicare &    |
|     Medicaid Services in March, 2007. The broadcast "Improving        |
|     Nursing Home Quality and Payment," is available on line at        |
|     [http://w                                                         |
| ww.cms.internetstreaming.com](http://www.cms.internetstreaming.com/). |
|                                                                       |
| -   As part of **Dr. Saliba's** Minimum Data Set (MDS) 3.0 project,   |
|     training and educational videos were developed to educate nursing |
|     home staff on assessing hearing, cognition, depression, and gait  |
|     and on interviewing residents on preferences for daily care.      |
|     These educational materials were used in trainings at 8 VA        |
|     nursing homes and in 8 states. Over 100 nursing home nurses were  |
|     trained using these materials and CEUs were awarded through the   |
|     VA GLAHS.                                                         |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year** *List five or fewer of the most     |
|     important products. For each item, limit the response to five     |
|     lines summarizing content, target audience, format, and product   |
|     evaluation plan and results. **Include educational products       |
|     developed in previous years ONLY if this is the [first            |
|     year]{.underline} they have been available for distribution.***   |
|                                                                       |
| -   **"Real Estate Fraud of Elderly People: Addressing the Growing    |
|     Crisis"** was distributed as a DVD and CD with conference         |
|     materials to VISN 21 and 22 facilities, including community-based |
|     outpatient clinics, to GRECCS and to other VHA facilities upon    |
|     request at no charge. The main target audiences were social work, |
|     psychiatry, psychology and geriatrics and extended care. A brief  |
|     follow-up survey is planned in FY08.                              |
|                                                                       |
| -   **EES Satellite broadcasts** to all VHA facilities of             |
|     GRECC-organized lectures on [Perioperative Management of the      |
|     Older Patient]{.underline} (April 18-May 15), [Sleep problems in  |
|     the Older Adult]{.underline} (May 16-June 12), [Dementia in the   |
|     Elderly]{.underline} (June 13-July 24), [Current Management of    |
|     Atrial Fibrillation]{.underline} (July 25- August 24) and         |
|     [Controversies in Geriatric Oncology]{.underline} (Sept 5- Oct    |
|     4), target audience all clinical staff. The programs received     |
|     excellent learner evaluations as conducted by the VA Employee     |
|     Education System.                                                 |
|                                                                       |
| -   **Cathy Alessi, MD** participated in the development of clinical  |
|     practice guidelines on sleep published in the journal Sleep (29:  |
|     1277-1281, 2006; 29:1415-1419, 2006 and 30(4):519-29, 2007) and   |
|     are available on the internet at www.aasmnet.org and are widely   |
|     referred to in the field.                                         |
|                                                                       |
| -   A **Resource Guide for Memory Impaired Adults and Their           |
|     Caregivers** that focuses on Southern California resources was    |
|     developed a**s a** collaborative effort by the Geriatric Social   |
|     Work Education Consortium students at Long Beach, West Los        |
|     Angeles and Sepulveda sites as part of their macro project. The   |
|     guide was distributed to social work, clinical nurse specialists  |
|     and nurse practitioners at these facilities.                      |
|                                                                       |
| -   **Joshua Chodosh, MD** created a peer-reviewed educational model  |
|     for national dissemination, titled, "Dementia. Prevalence,        |
|     Diagnosis, and Management." This Educational Module was one of 12 |
|     designed for a multidisciplinary audience of health professionals |
|     and the one-hour audio/PowerPoint presentation has been           |
|     distributed by U.S Department of Health and Human Services, Heath |
|     Resource and Services Administration, National GEC since August   |
|     2006 and is available at: <https://umconnect.umn.edu/p14094222/>. |
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| **[c. Educational programs offered by your GRECC during the report    |
| year that were evaluated for impact, as described in                  |
| <http://vaww1.va.gov/grecc/docs/2007Measuresinstructions102506.doc>   |
| for Performance Measure 7.]{.mark}**                                  |
|                                                                       |
| -   The national GRECC audio-conference series is a monthly 1-hour    |
|     lecture facilitated by the VA Employee Education System (EES) and |
|     accredited for continuing education in medicine, nursing, social  |
|     work and psychology. The program "Fall Prevention: Research to    |
|     Practice" was presented by Laurence Z. Rubenstein, MD, MPH of the |
|     GLA GRECC with Cynthia Brown, MD of the Birmingham/Atlanta GRECC  |
|     to 127 participants, of whom 99.2% were VAMC other than our host. |
|     Immediately following the presentation, the learner survey        |
|     designed by the EES indicated that the program was well-received  |
|     and the presenters received excellent evaluations by the          |
|     learners. GLA GRECC launched a web-based post-conference survey   |
|     at 6 months to gauge the impact of a 1-time educational program   |
|     on learners. Learners were directed to the URL for this survey    |
|     through SurveyMonkey.com, which stripped identifiers and collated |
|     the results of the anonymous responses. The survey was designed   |
|     in collaboration with Lesa Woodby, PhD, of the Birmingham/Atlanta |
|     GRECC and consisted of 4 demographic questions, 4 questions about |
|     how the learning affected clinical practice and 1 question about  |
|     recommended future topics for this series. The survey had a       |
|     response rate of 22%, representing administrative staff (41.7%),  |
|     nursing (25.0%), associated health professions (12.5%), medicine  |
|     (8.3%) and other disciplines (12.5%). Most (79.2%) worked at a    |
|     medical center, while 16.7% worked at an ambulatory care          |
|     center/CBOC and only 4.2% worked at a nursing home. Nearly half   |
|     the respondents were from VISNs 9, 16 and 20. On a 6-point        |
|     Likert-type scale, which included Not Applicable, the majority    |
|     reported that they were "more confident" or "much more confident" |
|     in achieving each of the program objectives in their clinical     |
|     practices: 1) identify fall risk factors (79%), identify          |
|     appropriate interventions for fall risk factors (72%) and conduct |
|     post-fall assessment per American Geriatrics Society guidelines   |
|     (62%). In an open-ended query to describe one key concept learned |
|     in the program, there were 18 responses that identified specific  |
|     concept learned about assessment (33.3%), risk (22.2%) and        |
|     intervention (5.0%); 27% responded that the question was not      |
|     applicable since they are not clinicians and 2 respondents felt   |
|     that nothing new had been learned. One-quarter of the learners    |
|     had integrated the learning into their clinical practice. When    |
|     asked for more detail about how the learning was applied there    |
|     were four responses indicating successful impact of the program   |
|     at four VHA facilities: 1) Patients are now asked about history   |
|     of falls in the last year and gait or balance problems and an     |
|     assessment protocol is followed, 2) Elements of the presentation  |
|     were integrated into a new nursing fall prevention/management     |
|     policy, 3) Patients are now educated about the use of hip         |
|     protectors and use has increased and 4) Enhanced evaluation by    |
|     the Patient Safety Officer with new, practical considerations.    |
|     The recommended topics for future programs were shared with VACO  |
|     Office of Geriatrics and Extended Care and include pain           |
|     management, heart disease, medication management, stress          |
|     management, wound care, dementia and stroke rehabilitation. We    |
|     conclude that the program had significant impact on learners even |
|     after a 6-month period based on a very conservative analysis of   |
|     self-assessment of confidence to perform the programs earning     |
|     objectives and that at least four VAMCs have integrated the       |
|     learning into clinical practices. Additional education on use of  |
|     clinical guidelines is recommended.                               |
|                                                                       |
| -   The national GRECC audio-conference series is a monthly 1-hour    |
|     lecture facilitated by the VA Employee Education System (EES) and |
|     accredited for continuing education in medicine, nursing, social  |
|     work and psychology. The program "Sleep problems in older         |
|     persons" was presented by Cathy Alessi, MD, of the GLA GRECC with |
|     Steven Barczi, MD, of the Madison GRECC to 40 participants, of    |
|     whom 91.9% were from VAMCs other than our host. Immediately       |
|     following the presentation, the learner survey designed by the    |
|     EES indicated that the program was well-received and the          |
|     presenters received excellent evaluations by the learners. GLA    |
|     GRECC launched a web-based post-conference survey at 8 months to  |
|     gauge the impact of a 1-time educational program on learners.     |
|     Learners were directed to the URL for this survey through         |
|     SurveyMonkey.com, which stripped identifiers and collated the     |
|     results of the anonymous responses. The survey consisted of 4     |
|     demographic questions, 4 questions about how the learning         |
|     affected clinical practice and 1 question about recommended       |
|     future topics for this series. The survey had a response rate of  |
|     23%, representing nursing (37.5%), administrative staff (12.5%),  |
|     associated health professions (12.5%), medicine (12.5%) and other |
|     disciplines (25.0%). Most (62.5%) worked at an ambulatory care    |
|     center or CBOC, while 25.0% worked at medical center only 12.5%   |
|     worked at a nursing home. More than one-third of the respondents  |
|     were from our VISN 22 and all respondents were from VISNs 8, 10,  |
|     21, 22 and 23. On a 6-point Likert-type scale, which included Not |
|     Applicable, the majority reported that they were "more confident" |
|     or "much more confident" in achieving each of the program         |
|     objectives in their clinical practices: 1) discuss age-related    |
|     changes that impair sleep (100%), identify strategies and         |
|     questionnaires to assess sleep problems (89%), describe           |
|     pharmacologic and non-pharmacologic sleep interventions (78%) and |
|     refer to a sleep specialist when indicated (67%). In an           |
|     open-ended query to describe how one key concept learned in the   |
|     program was integrated into clinical practice, there were 4       |
|     responses: 1) Education to patient and caregiver about sleep      |
|     physiology, 2) Evaluation of all causes of sleep disturbance, 3)  |
|     Better assessment by asking more questions of patients and 4)     |
|     Improved assessment technique. The recommended topics for future  |
|     programs were shared with VACO Office of Geriatrics and Extended  |
|     Care and include alternative and complementary therapies,         |
|     dementia, hearing disabilities and mental health conditions. We   |
|     concluded that the program had significant impact on learners     |
|     even after an 8-month period based on a very conservative         |
|     analysis of self-assessment of confidence to perform the programs |
|     earning objectives and that at least four VAMCs have integrated   |
|     the learning into clinical practices. Additional education on     |
|     interventions is recommended for a future topic with targeted     |
|     invitations to this audience.                                     |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   GLA GRECC developed a unique 8-hour one-day conference to address |
|     the growing problem of real estate abuse of elders. The           |
|     conference was accredited for continuing education in medicine,   |
|     nursing, social work and law and was attended by 43 staff from    |
|     VISN 22 facilities; 79% were from the GLAHS, our host facility.   |
|     The program was attended by VA social workers (37%), nurses       |
|     (18%), psychologist (15%), other associated health professionals  |
|     (12%) rehabilitation therapists (2%), and administrators (5%). An |
|     additional 112 non-VA individuals attended the conference. Both   |
|     VHA and non-VHA learners were included in the immediate learners' |
|     survey of the conference. On a 5-point Likert-type scale with 5   |
|     being "to a great extent" and 1 being "not at all," evaluations   |
|     were excellent on conference objectives being met (4.51),         |
|     endorsing that the information was useful (4.55) and confirming   |
|     that that the information presented was understood (4.57). In     |
|     addition, the majority felt that the program would have an impact |
|     on their clinical practice in regard to 1) identifying possible   |
|     real estate fraud (4.36), 2) documenting possible real estate     |
|     fraud (4.44), and 3) overall interaction with patients (4.42). To |
|     better understand the clinical impact of this program, a          |
|     post-conference assessment was conducted through e-mail to VA     |
|     participants (n=43) at 1-month asking for identification of key   |
|     concept(s) learned and an action plan to implement key            |
|     concept(s). A follow-up email survey was mailed at 3 months to    |
|     determine how successful learners' were in changing clinical      |
|     practice to accommodate the educational intervention. The 3-month |
|     surveys were personalized to each learner and specified their own |
|     earlier responses as the basis for a response. At 1-month, the    |
|     response rate was 44% and most planned to integrate assessment    |
|     skills, more appropriate referrals to psychiatry, improve work    |
|     with legal system and conduct patient education. At the 3-month   |
|     follow-up, there were 9 respondents (rate = 47%): 78% were able   |
|     to implement plans, 11% had not yet had the clinical opportunity  |
|     to implement plans and 11% recognized that the action plan was    |
|     overly ambitious for implementation. The program impacted a range |
|     of practices and reflected, in part, the learners' roles in the   |
|     episode of care. New or improved practices include for social     |
|     workers and psychologists: 1) capacity evaluation, 2)             |
|     psycho-social assessment, 3) education to patients and to         |
|     colleagues, 4) recommendation and monitoring of fiscal            |
|     conservators and 5) understanding the legal process as it applies |
|     to patients. Despite a response rate below 50% the results        |
|     indicated that the 1-day conference had an impact on focusing VA  |
|     staff on improving care for the most vulnerable older veterans.   |
|     With recognition that real estate fraud is a significant problem  |
|     for older veterans, we concluded that additional programs on this |
|     topic would be valuable in other VISNs as well.                   |
+-----------------------------------------------------------------------+
| **7. CLINICAL DEMONSTRATION PROJECTS**                                |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| [**a. Clinical Demonstration Projects Underway in Report              |
| Year**:]{.mark}                                                       |
|                                                                       |
| -   **Caregiver Psychoeducation & Support: Improving Outcomes in      |
|     Alzheimer's Disease -** A 12-month, internet-based education and  |
|     support intervention for caregivers of house-bound veterans with  |
|     Alzheimer's Disease will improve patient outcomes through         |
|     caregiver instruction on effective management of problematic      |
|     behaviors and will also reduce caregiver depression and burden in |
|     this setting. (N)                                                 |
|                                                                       |
| -   **Center for Adult Rehabilitation & Education (CARE)-             |
|     Psychoeducational therapy in ADHC -** Psychoeducational therapy   |
|     modalities in the CARE unit change yearly, with the latest        |
|     interventions, a 4-week caregiver support workshop with tools to  |
|     offer as end products to the veterans' caregivers, advance        |
|     directive forms, a caregiver resource guide and handouts created  |
|     by VA GRECC SW interns, and a music therapy group that resulted   |
|     in a CD (no copyright) that the veterans developed with the GRECC |
|     GSWEC interns. (O)                                                |
|                                                                       |
| -   **Geriatric Medication Review Clinic -** A self-referred program  |
|     to improve quality of pharmaceutical care and medication          |
|     adherence of community-dwelling veterans via a one-time visit to  |
|     reconcile medication list and assess medication regimens with     |
|     established guidelines (Beer's criteria, pharmaceuticals quality  |
|     Care for Vulnerable Older Patients). Both medication knowledge    |
|     and self-efficacy are assessed after participation in the visit,  |
|     and potential savings determined. Project is approved by IRB. (O) |
|                                                                       |
| -   **Home Telerehabilitation for Deconditioned Older Adults -** This |
|     is a 2-year pilot project, known as TEL-REHAB to assess if it is  |
|     possible to develop and safely monitor a home exercise program    |
|     using a text messaging device for older deconditioned patients    |
|     discharged from the hospital. Project has IRB approval. (N)       |
|                                                                       |
| -   **Improving Depression Screening in Frail Older Minority Veterans |
|     -** Compare the diagnostic accuracy of the Geriatric Depression   |
|     Scale (developed on Caucasians, less sensitivity in Hispanic and  |
|     African Americans) with the PHQ-9 (new instrument with validity   |
|     in Hispanic and African American in younger & inpatient           |
|     rehabilitation) in comparison with a clinical interview for       |
|     depression by a clinical psychologist. Project is assessing       |
|     improved clinical care. (N)                                       |
|                                                                       |
| -   **Minimum Data Set (MDS) 3.0 -** The project revised and tested   |
|     improvements to the standardized resident assessments that used   |
|     interviews for cognitive impairment, mood, preferences and        |
|     pain. The project moved into a larger national sample of VA and   |
|     community nursing homes.  (O)                                     |
|                                                                       |
| -   **Nonpharmacological Interventions on Sleep in Post-acute         |
|     Rehabilitation -** To test a multi-component, nonpharmacological  |
|     intervention to improve sleep/wake patterns, functional recovery  |
|     and quality of life among older veterans undergoing post-acute    |
|     rehabilitation. The intervention combines: 1) structured sleep    |
|     assessment, 2) patient education in key elements of cognitive     |
|     behavioral strategies to improve sleep, and 3) environmental      |
|     interventions on factors which likely contribute to abnormal      |
|     sleep/wake patterns in the post-acute rehabilitation setting. (O) |
|                                                                       |
| -   **The Respite Evaluation Clinic** - This clinic was developed to  |
|     evaluate candidates for respite admission to ensure that the      |
|     veteran will be safe and appropriate for the inpatient respite    |
|     program.  The Respite Evaluation Clinic is run by a physician     |
|     assistant and GRECC social worker.  It also affords an            |
|     opportunity to educate the veteran's family about the respite     |
|     stay. (O)                                                         |
|                                                                       |
| -   **Safety Risk Profile of Self-Neglect and Decisional Capacity to  |
|     Return Home -** A specific protocol using standardized assessment |
|     of self-care requisites was used to define a Safety Risk Profile  |
|     that can be consolidated into a single progress note. Specific    |
|     safety concerns and recommendations are communicated to patient   |
|     and families, and if decisional capacity is impaired than a       |
|     focused case management approach is needed. (N)                   |
|                                                                       |
| -   **Sleep disturbance among older people in assisted living         |
|     facilities -** To determine whether sleep disturbance is common   |
|     among older people in assisted living facilities and whether it   |
|     is associated with functional status impairment. IRB approved.    |
|     (N)                                                               |
|                                                                       |
| [b. **Evaluation of Clinical Demonstration Projects: **]{.mark}       |
|                                                                       |
| -   **Caregiver Psychoeducation & Support: Improving Outcomes in      |
|     Alzheimer's Disease** pending, project has IRB approval, flyers   |
|     distributed in clinic -- (N)                                      |
|                                                                       |
| -   **Center for Adult Rehabilitation & Education (CARE) -            |
|     Psychoeducational therapy in ADHC** - The surveys completed by    |
|     the caregivers indicated a significant increase in comfort level  |
|     and knowledge of the disease process and available resources. (O) |
|                                                                       |
| -   **Geriatric Medication Review Clinic** - 87 patients have         |
|     inquired about the MRC project, 46 have completed the visit + one |
|     month post-survey. Recruitment efforts tried to date include      |
|     flyers posted & left on patient waiting areas, intermittent       |
|     recruitment table in waiting area, participation in the first     |
|     ever VA GLAHS Research Fair. The flyers have been the most        |
|     effective method. The project was presented at the American       |
|     Geriatrics Society Annual Meeting. (O)                            |
|                                                                       |
| -   **Home Telerehabilitation for Deconditioned Older Adults --** The |
|     evaluation of the project is underway. **(N)**                    |
|                                                                       |
| -   **Improving Depression Screening in Frail Older Minority Veterans |
|     -** The goal is to conduct 40 clinical interviews for depression, |
|     score additional 30 GDS & PHQ-9 and provide follow-up as needed.  |
|     This is also a Goal Sharing project to improve clinical care. The |
|     project is an unfunded but IRB-approved project with anticipated  |
|     data entry, statistical analysis, and submission of the results   |
|     for publication anticipated. (N)                                  |
|                                                                       |
| -   **Minimum Data Set (MDS) 3.0 -** The project revised and tested   |
|     improvements to the standardized resident assessments that used   |
|     interviews for cognitive impairment, mood, preferences and        |
|     pain. The project moved into a larger national sample of VA and   |
|     community nursing homes.  (O)                                     |
|                                                                       |
| -   **Nonpharmacological Interventions on Sleep in Post-acute         |
|     Rehabilitation -** Outcomes being measured include objective and  |
|     subjective measures of sleep disturbance and measures of          |
|     functional recovery and quality of life. IRB approved. (O)        |
|                                                                       |
| -   **The Respite Evaluation Clinic**. - Numbers of patients and      |
|     outcomes are being compiled. (O)                                  |
|                                                                       |
| -   **Safety Risk Profile of Self-Neglect and Decisional Capacity to  |
|     Return Home -** Lessons learned- Medicolegal concerns of some     |
|     staff on documentation of safety risks, despite assurance by VA   |
|     legal counsel, limited implementation and analysis. Also,         |
|     difficult to discharge patients with prolonged length of stay on  |
|     the GEM Unit occurred. It is important to establish               |
|     outpatient-based, active case management protocols to ensure      |
|     close follow up with adequate staffing before implementing a      |
|     widespread screening of Safety Risk Profile. Project submitted    |
|     for publication. (N)                                              |
|                                                                       |
| -   **Sleep disturbance among older people in assisted living         |
|     facilities -** The project has enrolled 72 adults (aged ≥ 65      |
|     years) from 12 assisted living facilities in the Los Angeles      |
|     area. Measures included demographics, mental status testing,      |
|     screening for depressive symptoms, self-reported general health   |
|     and functional status, and self-report measures of sleep and      |
|     objective estimate of sleep/wake patterns by wrist actigraphy.    |
|     (N)                                                               |
|                                                                       |
| a.  [**New Clinical Models developed at your GRECC that were exported |
|     in the Report Year***:*]{.mark}                                   |
|                                                                       |
| []{.mark}                                                             |
|                                                                       |
| None were exported in FY07.                                           |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| [**a. Current Year Activity Outcomes** *(**list up to five            |
| examples**, up to two lines each; summarize specific outcomes         |
| realized from current year **consultation**, e.g., "Host VAMC         |
| instituted a Falls Clinic after consultation from GRECC staff;" or    |
| **outreach**, e.g., [X]{.underline} VAMC instituted a Falls Clinic    |
| after GRECC outreach via series of videoconferences)**:***]{.mark}    |
|                                                                       |
| -   GLA Nursing Research Outcomes Council developed criteria for      |
|     Facts Sheets to be used to educate bedside nurses on specific     |
|     evidence based practice after consultation with GRECC.            |
|                                                                       |
| -   After consultation with GRECC, Dental service implemented a       |
|     formal structure for dental technicians to present issues to      |
|     upper management reducing turnover and absenteeism.               |
|                                                                       |
| -   VISN 22 Palliative Care Executive Committee revitalized VISN 22   |
|     VAMC palliative care programs and 5-year strategic plan with      |
|     participation of GRECC.                                           |
|                                                                       |
| -   VA GLA Care Coordination Home Telehealth (CCHT) committee         |
|     developed and implemented home rehabilitation medical compliance  |
|     and functional monitoring programs with participation of GRECC.   |
|                                                                       |
| -   VACO Office of Geriatrics and Extended Care developed a           |
|     consensus-based set of quality indicators for outpatient and      |
|     inpatient data collection regarding falls.                        |
+-----------------------------------------------------------------------+
| b.  [**Previous Years' Activities Outcomes**]{.mark}                  |
|                                                                       |
| []{.mark}                                                             |
|                                                                       |
| -   Provided experience to GLA and California Department of Veterans  |
|     Affairs to develop and locate State Veterans Home on the grounds  |
|     of the GLA. Ground breaking occurred in FY07.                     |
+-----------------------------------------------------------------------+