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| ### *GRECC Annual Report: Fiscal Year [2005]{.underline}*             |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| This GRECC Annual Report covers [October 1, 2004-September 30,        |
| 2005]{.underline}: **the "Report Year"**.                             |
|                                                                       |
| This GRECC Annual Report reflects status and accomplishments of       |
| [**GRECC Core Staff \***only]{.underline}.                            |
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| **\*[GRECC Core Staff ]{.underline}**is limited to either **Primary   |
| Core**, **Affiliate Core**, or **Research Core**:                     |
|                                                                       |
| -   **Primary Core =** positions authorized by the original GRECC     |
|     allocation plus any addition in ceiling from VA Central Office    |
|     specifically designated for GRECC.                                |
|                                                                       |
| -   **Affiliated Core** = Staff who work full- or part-time in        |
|     [direct support]{.underline} of the GRECC's research, education   |
|     or clinical activity.                                             |
|                                                                       |
|     -   May be either "contributed" by the VA Medical Center or       |
|                                                                       |
|     -   May have been acquired through centralized                    |
|         enhancements/awards for programs\                             |
|         (e.g., Home-Based Primary Care, Geriatric Evaluation and      |
|         Management Program, etc.)                                     |
|                                                                       |
|     -   To be considered Affiliated Core, staff must be               |
|         organizationally aligned under the GRECC or specifically      |
|         identified by the Medical Center as **"GRECC-affiliated       |
|         staff."**                                                     |
|                                                                       |
| -   **Research Core** = Full-or part-time staff who devote 51% or     |
|     more of their total time to GRECC research and whose salaries are |
|     supported by research funds (either VA or non-VA). Includes all   |
|     GRECC staff whose salaries are paid from research funds, e.g.:    |
|                                                                       |
|     -   Associate Investigator                                        |
|                                                                       |
|     -   Assistant Research Scientist                                  |
|                                                                       |
|     -   Senior Research Career Scientist                              |
|                                                                       |
|     -   Research Career Scientist                                     |
|                                                                       |
|     -   Advanced Research Career Scientist.                           |
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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** VA Pittsburgh Healthcare System                   |
|                                                                       |
| b.  **Location** *(facility, VISN)*: Highland Drive Division, VISN 4  |
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| **2. CONTACT PERSON (if there are questions about this report)**      |
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| a.  **Name:** Juanita Chapman                                         |
|                                                                       |
| b.  **Position:** Administrative Officer                              |
|                                                                       |
| c.  **Phone, e-mail:** (412) 365-5756, juanita.chapman@med.va.gov     |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| GRECCs are required to conduct research in a basic biomedical area,   |
| an applied clinical area, and either a health services or             |
| rehabilitation topic. The number of specific research foci in each    |
| perspective should be limited to two or fewer.                        |
|                                                                       |
| Please enter a succinct phrase that best characterizes the focus      |
| area(s) recognized for your GRECC in the first two and either the     |
| third or fourth (or both) category below:                             |
|                                                                       |
| a.  **Basic Biomedical**: Stroke, Neuronal Cell Death, Gene Therapy   |
|                                                                       |
| b.  **Applied Clinical**: Depression in the Elderly, Communication    |
|     Research, Polypharmacy, End of Life                               |
|                                                                       |
| c.  **Health Services**: Barriers of delivery of care to the elderly, |
|     Stroke related quality of life measures                           |
|                                                                       |
| d.  **Rehabilitation**: Aphasia rehabilitation                        |
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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         |
|     positive impact on the host VAMC\--i.e., how the GRECC has "made  |
|     a difference" locally. **Please limit your response to five ways  |
|     or fewer.** Please be as succinct as possible but specify the     |
|     GRECC contribution, what the impact was and whom it benefited,    |
|     where it occurred, and why it was important. **Please limit the   |
|     description of each bullet item to 5 lines or fewer**)*           |
|                                                                       |
| -   The GRECC Mobile Geriatric Unit improved access to geriatric      |
|     medicine for minorities in five underserved city neighborhoods in |
|     the VAPHS catchment area, and plans to expand its outreach to     |
|     additional sites.                                                 |
|                                                                       |
| -   The GRECC Geriatric Palliative Care Unit at VAPHS Heinz Division  |
|     provided state of the science non-oncological, end of life care   |
|     to 138 frail veterans at VAPHS, and serves as a model for care    |
|     delivery and clinical teaching across multiple disciplines.       |
|                                                                       |
| -   Dr. Andrea Fox, GRECC AD/CC was instrumental in the development   |
|     of the Care Co-ordination/Home Telehealth Program, and for VAPHS' |
|     designation as a VACO approved CC/HT site. The program has        |
|     enrolled and employed Telehealth technology to co-ordinate the    |
|     care of over 70 veterans since its development. Dr. Fox continues |
|     to serve as CC/HT Program's Medical Director.                     |
|                                                                       |
| -   GRECC healthcare providers have played a key role in developing a |
|     proposal to obtain MAGNET certification, an initiative designed   |
|     to improve physician/nurse collaboration at VAPHS. Their          |
|     experience and expertise in multidisciplinary cooperation and     |
|     team building has been an important resource for VAPHS throughout |
|     this process.                                                     |
|                                                                       |
| -   In response to a VAPHS educational needs assessment, GRECC        |
|     clinical and education faculty developed a full-day conference    |
|     curriculum, and provided training to clinicians from a number of  |
|     disciplines on the identification, evaluation, management, and    |
|     counseling of older veterans who are at risk for being unable to  |
|     safely operate motor vehicles.                                    |
|                                                                       |
| -   GRECC Core Investigators have significantly contributed to the    |
|     overall scope and capacity of the VAPHS research program serving  |
|     as PIs or Co-PIs on 26 VA, NIH, and privately funded research     |
|     grants in excess of \$3,500,600 [RDIS verified]{.underline}       |
|     dollars in FY05.                                                  |
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| b.  **GRECC Impact on VISN in Report Year** *\                        |
|     (list the most important ways in which the GRECC has had positive |
|     impact on the host VISN\-- i.e., how the GRECC has "made a        |
|     difference "regionally. **Please limit your response to five ways |
|     or fewer.** Please be as succinct as possible but specify the     |
|     GRECC contribution, what the impact was and whom it benefited,    |
|     where it occurred, and why it was important. **Please limit the   |
|     description of each bullet item to 5 lines or fewer**)*           |
|                                                                       |
| -   GRECC faculty assumed a leadership role in the development of     |
|     VISN 4 Policy regarding access to firearms and driving competency |
|     in geriatric patients. This resulted in creation of pamphlets for |
|     distribution and a project to screen for dementia in primary care |
|     clinics.                                                          |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2000]{.underline}**\                                             |
|     *(list the most significant research, education or clinical       |
|     innovations originating in your GRECC in the past five years.     |
|     Please limit your response to five innovations or fewer. For each |
|     item, succinctly describe the innovation, specify the time frame  |
|     of its earliest impact, whom it benefited, where it occurred, and |
|     why it was important. **Please limit the comments concerning each |
|     innovation to 5 lines or fewer**)*:                               |
|                                                                       |
| -   2003 -- The Pittsburgh GRECC established a non-oncologic          |
|     Geriatric Palliative Care Unit. Emily Jaffe, M.D., GRECC          |
|     Geriatrician leads a unit that was designed in an effort to       |
|     better meet the needs of our older veterans, and emphasizes care  |
|     around the physical, spiritual and emotional quality of life and  |
|     care near the end-of-life. The unit has 40 beds dedicate to       |
|     providing outstanding care to chronically ill and frail older     |
|     adults who are clearly in a terminal decline, but do not have an  |
|     easily predictable clinical course.                               |
|                                                                       |
| -   2000- The Pittsburgh GRECC established a Mobile Geriatrics Unit   |
|     (MGU) which has been a unique model of care providing outreach    |
|     and primary care to older African-American veterans in distressed |
|     neighborhoods in Pittsburgh. It has been recognized locally by an |
|     FEB silver award winner for Teams and nationally through a PBS    |
|     program on care giving. In addition, through academic             |
|     relationships with the VA in New Orleans and Tulane University,   |
|     the concept is now being implemented to care for survivors of     |
|     Hurricane Katrina residing in New Orleans who were previously     |
|     receiving care at Charity Hospital.                               |
|                                                                       |
| -   2004- A CRADA was published in the Federal Register (Vol. 69, No. |
|     246, pp. 76977) seeking a commercial partner to license and       |
|     further develop "A Computer Program to Quantify Pharyngeal        |
|     Residue after Swallowing." This technology compares digital       |
|     video-fluorographic images of the neck before and after the       |
|     swallow to quantify the amount of material remaining in the       |
|     pharynx without using radioactive materials. It has wide clinical |
|     application to the assessment and treatment of dysphagia, a       |
|     highly prevalent condition in stroke survivors, and the frail     |
|     elderly. It was developed under VA RR&D Merit Review Project      |
|     Coordination of Breathing & Swallowing in Neurologic and          |
|     Respiratory Disease awarded to Roxann Gross, Ph.D. and Patrick J. |
|     Doyle, Ph.D. Co-PIs.                                              |
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| **5. RESEARCH**                                                       |
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| a.  **Most Noteworthy Findings Published in Report Year by GRECC Core |
|     Staff as PI or CO-PI\                                             |
|     **(Please list five or fewer. For each noteworthy finding,        |
|     include the GRECC Core Staff name(s), journal reference, and a    |
|     JARGON-FREE description of the finding and its clinical or other  |
|     significance. Please limit your description of each noteworthy    |
|     finding to five lines or fewer.)                                  |
|                                                                       |
| -   Cao G, Xiao M, Sun F, Xiao X, Pei W, Li J, Graham SH, Simon RP,   |
|     **Chen J.** Cloning of a novel Apaf-1-interacting protein: a      |
|     potent suppressor of apoptosis and ischemic neuronal cell death.  |
|     *J Neurosci 2004* 24:6189-6201. Dr. Chen and associates           |
|     discovered a novel apoptosis-inhibitory protein (Apaf-1           |
|     interacting protein, AIP) in neural cells. They found that AIP    |
|     inhibits neuronal apoptosis by preventing the formation of        |
|     apoptosome, the protein complex that activates the cell-killing   |
|     caspases. They also found that when AIP is over expressed in      |
|     neurons, it prevents neuronal cell death induced by cerebral      |
|     ischemia or dopaminergic neurotoxins.                             |
|                                                                       |
| -   Jiang Z, Schiedner G, Gilchrist SC, Kochanek S, **Clemens PR**.   |
|     CTLA4Ig delivered by high-capacity adenoviral vector induces      |
|     stable expression of dystrophin in *mdx* mouse muscle. *Gene Ther |
|     2004* Oct;11(19):1453-1461. This study explores a means to        |
|     overcome one of the immunologic hurdles that prevents the         |
|     therapeutic usefulness of gene delivery to skeletal muscle. This  |
|     study demonstrates that simultaneous gene transfer of an          |
|     immunosuppressant protein gene, CTLA4Ig, can significantly lessen |
|     the induction of immunity by the viral vector gene delivery       |
|     vehicle. This strategy has potential applicability for gene       |
|     delivery as treatment for acquired, as well as inherited,         |
|     diseases that affect muscle.                                      |
|                                                                       |
| -   **Doyle, P.J.,** McNeil, M.R., Mikolic, J.M., Prieto, L.R., Hula, |
|     W.D., Lustig, A.P., Ross, K., Wambaugh, J.L., Gonzalez-Rothi,     |
|     L.J., Elman, R.J. "The Burden of Stroke Scale (BOSS) provides     |
|     valid and reliable score estimates of functioning and well-being  |
|     in stroke survivors with and without communication disorders"     |
|     *Journal of Clinical Epidemiology, 2004, 57, 997-1007.* This      |
|     multi-site VHA field trial of 281 community dwelling stroke       |
|     survivors (a) established the internal consistency and            |
|     unidimensionality of the 12 BOSS domains, (b) substantiated the   |
|     hypothesized three factor structure (i.e., physical activity      |
|     limitations, cognitive activity limitations, and psychological    |
|     distress) comprising the measurement construct, and (c)           |
|     demonstrated the ability of cognitive activity limitations and    |
|     psychological distress scales to distinguish communicatively      |
|     impaired (n = 134) from non-communicatively impaired (n =145)     |
|     stroke survivors, and among communicatively impaired stroke       |
|     survivors classified according to severity of communication       |
|     impairment.                                                       |
|                                                                       |
| -   Wu S, Zhou L, Rose M, Xiao X, **Graham SH**. c-FLIP-L recombinant |
|     adeno-associated virus vector infection prevents Fas-mediated but |
|     not nerve growth factor withdrawal-mediated cell death in PC12    |
|     cells. *Brain Res Mol Brain Res* 122:79-87, 2004. Dr. Graham and  |
|     colleagues developed a novel method of inhibiting cell death in   |
|     neurons: an adenovirus vector that expresses cFLIP-L, a protein   |
|     that inhibits cell death caused by activation of the Fas death    |
|     receptor. Fas has been implicated in neuronal death after stroke, |
|     brain trauma and a variety of neurodegenerative diseases. Thus    |
|     development of this vector is a new therapeutic approach to       |
|     stroke and neurodegenerative diseases.                            |
|                                                                       |
| -   **Studenski, S.,** Duncan, P., Perera, S., et al. Daily           |
|     functioning and quality of life in a randomized controlled trial  |
|     of therapeutic exercise for subacute stroke survivors *Stroke.*   |
|     2005;36:1764 The ability of therapeutic exercise after stroke to  |
|     improve daily functioning and quality of life remains             |
|     controversial. We examined treatment effects on these outcomes in |
|     a randomized controlled trial of exercise in 100 subacute stroke  |
|     survivors. This rehabilitation exercise program led to more rapid |
|     improvement in aspects of physical, social, and role function     |
|     than usual care in persons with subacute stroke.                  |
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| b.  **Most Noteworthy Findings Published in Report Year -- GRECC Core |
|     Staff as Co-Investigators on Projects with Non-GRECC PI\          |
|     ***(Please list five or fewer. For each noteworthy finding,       |
|     include the GRECC Core Staff name(s), journal reference, and a    |
|     JARGON-FREE description of the finding and its clinical or other  |
|     significance. Please limit your description of each noteworthy    |
|     finding to five lines or fewer)*                                  |
|                                                                       |
| -   McNeil, M.R., Matthews, C.T., Hula, W.D., **Doyle, P.J.,**        |
|     Rubinsky, H.J. Fossett, T.R.D. A dual-task tool for quantifying   |
|     comprehension of aphasic connected speech production.             |
|     *Aphasiology*, *2005,* 19, 473-484. Using a dual-task paradigm,   |
|     this study found a systematic performance cost on visual-motor    |
|     tracking as a functioning of the difficulty of a concurrently     |
|     performed language processing task in a group of non-brain        |
|     injured older adults. However, a reciprocal cost on language      |
|     processing performance as a function of the difficulty of a       |
|     concurrently performed visual motor task was not observed. This   |
|     unidirectional performance cost between linguistic and            |
|     non-linguistic domains of information processing replicates       |
|     previous findings of the investigators and call into question the |
|     application of resource allocation theories of attention to       |
|     language processing.                                              |
|                                                                       |
| -   Jiang J, Borisenko GG, Osipov A, Martin I, Chen R, Shvedova AA,   |
|     Sorokin A, Tyurina YY, Potapovich A, Tyurin VA, **Graham SH,**    |
|     Kagan VE. Arachidonic acid-induced carbon-centered radicals and   |
|     phospholipid peroxidation in cyclo-oxygenase-2-transfected PC12   |
|     cells. *J Neurochem* 90:1036-1049, 2004. This study provides      |
|     novel insight into the mechanism by which cyclooxygenase 2        |
|     (COX2), the enzyme that is the target of nonsteroidal             |
|     antiinflamatory drugs such as Vioxx, may directly injure neurons  |
|     through oxidative stress. These results demonstrate that COX2 can |
|     create carbon centered radicals in and produce oxidative stress   |
|     in neurons                                                        |
|                                                                       |
| -   Duncan, P., Reker, D., Kwon, S., Lai, S., **Studenski, S** .      |
|     Perera, S. Measuring stroke impact with the stroke impact scale:  |
|     telephone versus mail administration in veterans with stroke. Med |
|     Care. 2005;43(5):507-15.\                                         |
|     The purpose of this study was to examine response rate, mode      |
|     effects, and reliability of the Stroke Impact Scale (SIS) in a    |
|     veteran stroke population using mail and telephone modes of       |
|     administration. Four hundred fifty-eight patients with stroke     |
|     were identified, validated, and randomly assigned into 2          |
|     administration groups. No significant cluster effect was          |
|     observed. Response rates for mail and telephone were 45% and 69%, |
|     respectively. Mail non responders were more likely to have had    |
|     severe stokes, cognitive deficits, and be unmarried. Telephone    |
|     mode of survey administration yielded a higher response rate,     |
|     less bias in responder selection, and higher test-retest          |
|     reliability. The cost of telephone administration was 2 times the |
|     cost of mail.                                                     |
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| **6. EDUCATION**                                                      |
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| a.  **Innovations in Educational Activities Implemented During Report |
|     Year**\                                                           |
|     (*Please list up to five. For each, describe the innovation and   |
|     the context in which it was innovative. Please limit your         |
|     description of each innovation to five lines or fewer):*          |
|                                                                       |
| -   GRECC staff developed a multidisciplinary conference curriculum   |
|     for healthcare providers regarding driving safety in older        |
|     veterans. This topic was of particular interest VISN wide and     |
|     nationally given the increasing prevalence of impaired older      |
|     drivers and educational efforts had not previously focused on     |
|     this area.                                                        |
|                                                                       |
| -   Initiation of a project to improve Nurse/Physician collaboration  |
|     throughout the local VAMC. As multidisciplinary cooperation is    |
|     the norm for GRECC staff, this was an innovative opportunity to   |
|     disseminate a collaborative model to improve patient care, to all |
|     staff.                                                            |
|                                                                       |
| -   A unique geriatric curriculum component was created for third     |
|     year medical students completing their Community Ambulatory       |
|     Medicine rotation. It involves the use of "standardized patient"  |
|     actors working with students in small groups to teach concepts in |
|     geriatric preventive medicine, falls, and cognitive decline.      |
|                                                                       |
| -   Teaching rotations for geriatric medicine fellows and internal    |
|     medicine residents began on the Geriatric Palliative care unit.   |
|     This unit provides palliative care to older veterans with         |
|     non-oncologic endstage illness and provides a site for focused    |
|     instruction in palliative care practices in an often unrecognized |
|     area for internists.                                              |
|                                                                       |
| -   GRECC staff completed a project on gun ownership among            |
|     cognitively impaired veterans seen by HBPC. The results of the    |
|     investigation led to an award winning poster presentation at the  |
|     AGS meeting in May 2005. This provided an important venue to      |
|     disseminate information about this crucial issue nationwide.      |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year**\                                    |
|     *(Please list your most important products. Please limit to five. |
|     Your description of each item should succinctly summarize the     |
|     content, target audience, format, and product evaluation results  |
|     if any. You may include products developed in prior years ONLY IF |
|     THIS IS THE FIRST YEAR they have been available for distribution. |
|     Please limit each description to five lines or fewer)*:           |
|                                                                       |
| -   A pamphlet detailing the issues of gun ownership and driving      |
|     safety in older veterans was designed and distributed throughout  |
|     VISN 4. It was based on work completed by GRECC staff in the      |
|     previous year.                                                    |
|                                                                       |
| -   A new curriculum syllabus was developed for the multidisciplinary |
|     training program that includes core conferences and case          |
|     presentations presented to multidisciplinary trainees by          |
|     multidisciplinary educators in a team teaching format. It has     |
|     been distributed to all learners in the GRECC training program    |
|     this year.                                                        |
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| **7. CLINICAL INNOVATIONS**                                           |
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| **NEW DEFINITION:** A "Clinical Innovation" is an untested,           |
| GRECC-initiated clinical effort that ideally is related to one of the |
| GRECC's research foci. A Clinical Innovation may be a wholly original |
| clinical program or an original aspect of or variation on an          |
| established program. A Clinical Innovation must incorporate an        |
| evaluation plan for assessing the innovation's efficacy so that, if   |
| the innovation is demonstrated to be an improvement over an existing  |
| approach to care, there is a basis on which it can be exported for    |
| implementation elsewhere.                                             |
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| a.  **Clinical Innovations Underway in Report Year**\                 |
|     *(list all Clinical Innovations underway during the report year.  |
|     For each, indicate whether the innovation is [N]{.underline}ew or |
|     [O]{.underline}ngoing in the report year. Please describe each    |
|     innovation in five lines or fewer)*:                              |
|                                                                       |
| -   [N]{.underline} The GRECC AD/CC participated in development and   |
|     implementation of the Care Coordination / Home Telehealth program |
|     focusing on hypertension, CHF, diabetes, and COPD and serves as   |
|     its Medical Director. We have successfully recruited staff,       |
|     patients to initiate the program. This will be a future site for  |
|     GRECC clinical demonstration projects and a venue for training.   |
|                                                                       |
| -   [N]{.underline} The GRECC AD/CC has become the Medical Director   |
|     for the Contract Nursing Home Program. This has resulted in the   |
|     expansion of the number of nursing home sites available and       |
|     involvement of community nursing home medical directors in the    |
|     site visits. This will be a future site for GRECC clinical        |
|     demonstration projects and a venue for training. Thus, our GRECC  |
|     has a leadership role in all aspects of Community Based Care      |
|     Service Line as it relates to geriatrics and long term care.      |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   [N]{.underline} GRECC core staff participated in the creation of  |
|     a CPRS screening tool for gun possession and has helped develop   |
|     best practices for managing this issue in cognitive impaired or   |
|     depressed elderly patients. These tools are now being piloted in  |
|     Home Based Primary Care.                                          |
|                                                                       |
| -   [O]{.underline} The GRECC has a fully established non-oncological |
|     Geriatric Palliative Care Unit. The Geriatric Palliative Unit has |
|     transformed the long term care culture at our Heinz campus to     |
|     provide a unique environment where the elderly veteran's goals of |
|     care are met and respected. The entire program is held together   |
|     by an education component that spans the entire continuum from    |
|     beginning trainees to CME, and has been designed to educate       |
|     providers in a wide variety of disciplines to incorporate the     |
|     elements of geriatrics into their care of older patients.         |
|                                                                       |
| -   [O]{.underline} GRECC core staff developed and implement          |
|     nurse-driven warfarin management, a modification to an existing   |
|     model of care, the outpatient anticoagulation clinic              |
|     (pharmacist-run). Staff nurses in Home Based Primary Care using a |
|     protocol and portable lab equipment adjust warfarin doses during  |
|     their home visits to veterans who require this therapy.           |
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| b.  **Evaluation Results of Clinical Innovations listed in the        |
|     preceding box\                                                    |
|     ***(for each clinical innovation listed in 7-a above, summarize   |
|     evaluation outcome(s) identified in the report year, in five      |
|     lines or fewer. Please specify "no evaluation results" for any    |
|     innovation for which that is the case)*                           |
|                                                                       |
| -   The Care Coordination / Home Telehealth program is a new program  |
|     that has not yet been formally evaluated except that site         |
|     visitors from central office determined that the program has been |
|     successfully implemented.                                         |
|                                                                       |
| -   The GRECC participation in the Contract Nursing Home Program is a |
|     new activity. New quality indicators are being developed.         |
|                                                                       |
| -   A QI project studied the incidence of firearm possession among    |
|     homebound veterans. 30% of homebound veterans had firearms, with  |
|     33% being unsecured, 37% stored with bullets and only 37% locked  |
|     in a cabinet. 10% of those with cognitive impairment had firearms |
|     that were not secured.                                            |
|                                                                       |
| -   The geriatric palliative care program has been evaluated by       |
|     comparing patient and family satisfaction with care in the unit   |
|     versus conventional long term care units. The results             |
|     demonstrated a higher level of satisfaction in those families of  |
|     patients receiving geriatrics palliative care than in the usual   |
|     nursing care units. These results were Presented at the Annual    |
|     Meeting of the AGS in 2004.                                       |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Nurse-driven warfarin management has been measured since its      |
|     inception to the present in quarterly reports of the same quality |
|     indicators used by the outpatient anticoagulation clinic.         |
|     Findings demonstrate that the model of care is feasible,          |
|     practical, is cost effective, and has equal efficacy.             |
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| c.  **Clinical Innovation Exported in Report Year**\                  |
|     *(Please list up to five examples. In three lines or less for     |
|     each example, name or describe the innovation, identify the name  |
|     of the VA or non-VA facility to which it was exported, and the    |
|     method of export)*:                                               |
|                                                                       |
| -   Due to the AD/CC's outreach efforts, Coatesville HBPC has         |
|     developed a home based primary care model where the physician     |
|     makes home visits to augment nurse home visits. This model of     |
|     care was developed by the Pittsburgh GRECC AD/CC in the           |
|     Pittsburgh HBPC program.                                          |
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| **8. CONSULTATION AND OUTREACH**                                      |
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| **DEFINITIONS:**                                                      |
|                                                                       |
| **"Consultation"** for this section of the report has occurred when   |
| GRECC staff has materially assisted in the development of a non-GRECC |
| research, education or clinical program **[within the host            |
| VAMC.]{.underline}**                                                  |
|                                                                       |
| **"Outreach"** for this section of the report has occurred when GRECC |
| staff has materially assisted in the development of a non-GRECC       |
| research, education or clinical program **[at a facility other than   |
| the host VAMC.]{.underline}**                                         |
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| **Note:**                                                             |
|                                                                       |
| **for the 2005 Annual Report,**                                       |
|                                                                       |
| **Consultation and Outreach activity**                                |
|                                                                       |
| **will NOT be reported here.**                                        |
|                                                                       |
| **It will be reported via the Electronic Annual report Data Base.**   |
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