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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2004]{.underline}*                   |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| **NOTE:** The **GRECC Annual Report** reflects status and             |
| accomplishments of **[GRECC Core Staff]{.underline}** (as defined     |
| below) [only]{.underline}. Report year is from [October 1 through     |
| September 30]{.underline}. [This Accomplishments report should be no  |
| more than a [total of ten pages]{.underline}.]{.mark}                 |
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| **GRECC Core Staff** includes **Primary Core**, **Affiliated Core,**  |
| and **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 acquired through     |
| centralized enhancements/awards for programs such as 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:** Tennessee Valley GRECC for Prevention,            |
|     Therapeutics and Quality Improvement                              |
|                                                                       |
| b.  **Location** *(facility, VISN)*: Tennessee Valley Healthcare      |
|     System; VISN 9: Mid-South Veterans Healthcare Network             |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Robert Dittus, MD, MPH                                  |
|                                                                       |
| b.  **Position:** GRECC Director                                      |
|                                                                       |
| c.  **Phone, e-mail:** 615-340-2364; robert.dittus@med.va.gov         |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **NOTE:** Each problem area should ideally be approached from the     |
| basic biomedical, clinical [and]{.underline} health services research |
| perspectives, as well as from the rehabilitation research perspective |
| where that expertise exists. The number of problem areas should be    |
| limited to one or two. If the focus of research is different for      |
| basic biomedical, clinical, health services and/or rehabilitation     |
| research, there should be no more than a [total]{.underline} of 4     |
| major areas of investigation. [Changes to GRECC focus area(s) must be |
| approved by VACO (114).]{.mark}                                       |
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| a.  **Basic Biomedical**: Prevention; Drug Utilization                |
|                                                                       |
| b.  **Applied Clinical**: Prevention; Drug Utilization; Quality       |
|     Improvement and Patient Safety                                    |
|                                                                       |
| c.  **Health Services**: Prevention; Drug Utilization; Quality        |
|     Improvement and Patient Safety                                    |
|                                                                       |
| d.  **Rehabilitation**: Prevention; Quality Improvement and Patient   |
|     Safety                                                            |
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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Current Year** *([list up to       |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific impact on host VAMC research, staff education, program   |
|     evaluation, or clinical care improvements for elderly veterans;   |
|     [up to five lines each]{.mark})*:                                 |
|                                                                       |
| -   Dr. Marie Griffin received the Tennessee Valley VA Clinical       |
|     Research Center of Excellence award that will help support junior |
|     faculty at the host VA and help build the infrastructure for      |
|     clinical research at the VA. The objective of our CRCoE is to     |
|     augment the current growing Tennessee Valley VA training and      |
|     research infrastructure by developing a robust faculty            |
|     development program. This program will help the VA overcome the   |
|     major "translational blocks" that prevent the fruits of basic     |
|     biomedical knowledge from achieving their full potential as       |
|     instruments of improved health. The three major goals of this     |
|     program are 1) the recruitment of outstanding junior clinical     |
|     research faculty, 2) the retention of these faculty in the VA     |
|     system by providing an atmosphere that fosters productive         |
|     research and individual development, and 3) producing a body of   |
|     research that has a direct impact on the health of veterans.      |
|                                                                       |
| -   The GRECC has tremendous impact on education at the Host VAMC     |
|     through its interdisciplinary geriatrics-training program. The    |
|     program provides over 250 man-months of training in geriatrics    |
|     annually for trainees who represent eight health professions.     |
|     Adult learning theory and problem-based learning provide the      |
|     conceptual framework for the curriculum. Over 80 trainees have    |
|     completed the program. In addition, GRECC Faculty have            |
|     collaborated with Vanderbilt University, Meharry Geriatric        |
|     Education Center, Mountain Home VA, and regional professional     |
|     societies to train hundreds of health professionals through       |
|     lectures, conferences, training modules, rounds, and visiting     |
|     professorships.                                                   |
|                                                                       |
| -   Dr. Kallianpur has studied the effects of genetic mutations in    |
|     iron metabolism and oxidant stress on several disease states and  |
|     disease complications affecting older veterans, including         |
|     degenerative arthritis, anti-retroviral therapy-related nerve     |
|     damage in HIV/AIDS, development of breast cancer, Alzheimer-type  |
|     dementia, prediction and prevention of acute organ damage         |
|     associated with cancer treatment, and chronic hepatitis C. These  |
|     projects have impact on research in areas that directly affect    |
|     older veterans, both male and female by advancing knowledge about |
|     how iron (dietary or supplemental) superimposed on genetic        |
|     mutations that alter iron metabolism may change the course of     |
|     common, chronic conditions in this population of Veterans. These  |
|     projects will also focus on risk factors of these diseases and    |
|     also potentially lead to interventions for high risk patients.    |
|                                                                       |
| -   Dr. John Newman is the supervisor of a new Lung Nodules Nurse     |
|     Practitioner. This was Dr. Newman's own brainchild and emerged as |
|     a wonderful solution to the burgeoning number of Veterans with    |
|     lung nodules. These nodules often represent early forms of lung   |
|     cancer, and time evaluation and management will offer the best    |
|     opportunity for cure. Dr. Newman and this program in conjunction  |
|     with the inter-disciplinary Chest Conference held every Wednesday |
|     are dramatically improving the accuracy and thoroughness of       |
|     follow-up for our Veterans for this life-threatening problem.     |
|                                                                       |
| -   Dr. Kathleen Figaro studied racial disparities in flu vaccine     |
|     receipt locally in Davidson County Tennessee. This study showed   |
|     that blacks over 65 were less likely to be vaccinated than other  |
|     elderly. The presence of several comorbidities including diabetes |
|     and asthma did not attenuate this disparity. This work could help |
|     us avoid such disparities within our own local VA system and      |
|     eventually in other Vas throughout our VISN and beyond. This work |
|     was published in Figaro, M. K., Belue, R. Prevalence of Influenza |
|     Vaccination in a High-risk Population: Impact of Age and Race. J. |
|     Ambulatory Care Manage 2004;28:24-29.                             |
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| b.  **GRECC Impact on VISN in Current Year** *([list up to            |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific VISN-wide impact on research, education/training,        |
|     program evaluation, or clinical care improvements for elderly     |
|     veterans; [up to five lines each]{.mark}.* NOTE: GRECCs are       |
|     intended and expected to serve as a [regional]{.underline}, and   |
|     not merely local resource*)*:                                     |
|                                                                       |
| -   The GRECC held its first Aging Symposium, "Improving the Care of  |
|     Critically Ill Elderly", on November 7, 2003 in Nashville, TN.    |
|     This was a daylong interdisciplinary professional development CE  |
|     program with attendance of \~100 healthcare professionals from    |
|     throughout VISN 9. The conference served as an excellent forum    |
|     for us to translate research findings from two of our research    |
|     foci, quality and pharmaco-epidemiology, into the educational and |
|     clinical arenas.                                                  |
|                                                                       |
| -   The GRECC Associate Director for Education and Evaluation, as     |
|     Course Director, held the inaugural session of the 24-month VISN  |
|     9 Palliative Care Consultation Teams (PCCTs) Comprehensive        |
|     Training Program in Nashville on June 23-24, 2004. Seven lead     |
|     teams of at least four disciplines each represented the seven     |
|     VAMCs in VISN 9 at this train-the-trainer workshop where they     |
|     began VA PCCTs program development for their facilities.          |
|                                                                       |
| -   GRECC faculty lead the Geriatrics and Extended Care (GEC)         |
|     Committee of the VISN 9 Health Systems Committee advising         |
|     leadership on GEC matters. This year featured promoting uniform   |
|     standards and policies for the VISN, education of Long Term Care  |
|     Staff concerning Minimum Data Set Quality Indicators, and         |
|     directing expansion of non-institutional care, including the      |
|     recently funded \$1M telephone care system.                       |
|                                                                       |
| -   Dr. Jensen and his research group have been collaborating with    |
|     colleagues at the Little Rock GRECC (Dr Allman) in the testing of |
|     our new obesity screening questionnaire. This approach is         |
|     facilitating regional cross-validation with the Pennsylvania      |
|     population that we have studied.                                  |
|                                                                       |
| -   Our GRECC sponsored the second Aging Symposium: Quality Care in   |
|     Long Term Care, with a state-wide attendance of healthcare        |
|     professionals.                                                    |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [1999]{.underline}** *([list up to five]{.mark} most significant  |
|     GRECC research, education or clinical innovations in past five    |
|     years; for each item, provide date, GRECC staff responsible, and  |
|     [up to five line]{.mark} description)*:                           |
|                                                                       |
| -   Investigators Ely and Dittus disseminated delirium monitoring     |
|     materials throughout VISN 9 (and throughout the GRECCs            |
|     nationally). These investigators developed methods for monitoring |
|     delirium that have been adopted throughout many ICUs around the   |
|     world. In VA hospitals nationally, this work has been the subject |
|     of ongoing practice improvement teleconferences held in relation  |
|     to delirium as a quality indicator. Through this work, delirium   |
|     has been identified as predictor of mortality that ought to be    |
|     tracked in all VA patients in the ICU. On June 2 and 3, 2004,     |
|     Sharon Gordon PsyD conducted training at the Lexington VA on the  |
|     use of the RASS and CAM-ICU. This was a collaborative effort      |
|     among Pharmacy, Nursing and IRM to improve identification of      |
|     delirium in the ICU. She also served as a mentor to a Nurse       |
|     Manger working toward her Master's Degree in Nursing.  Her        |
|     project was to implement the RASS and CAM-ICU at the Nashville VA |
|     and Dr. Gordon helped her develop and implement her plan.         |
|                                                                       |
| -   GRECC Faculty are collaborating with TVHCS long term care         |
|     personnel in developing demonstration models for quality          |
|     indicators: falls, incontinence, patient-on-patient abuse, and    |
|     pain management, and resident physical activity (9/04).           |
|                                                                       |
| -   Dr. Richmond in collaboration with John Wikswo developed          |
|     microfluid devices to follow cell motility under conditions that  |
|     mimic movement of cells through the blood stream. This work was   |
|     submitted for publication in the Biophysics Journal. The impact   |
|     of this work has lead to two patent filings, two new clinical     |
|     trials to test new drugs for treatment of cancer, publication of  |
|     several important papers, and presentations at a number of        |
|     national and international meetings.                              |
|                                                                       |
| -   Dr. Jensen and his research group have been systematically        |
|     developing and validating a new 14-item obesity screening         |
|     questionnaire to identify individuals at risk for healthcare      |
|     resource use and functional decline. This tool can have practical |
|     application in improving healthcare throughout the VA System.     |
|                                                                       |
| -   Investigators Roumie and Speroff: The treatment and control of    |
|     high blood pressure is an important goal of VISN 9. A proposal    |
|     was recently funded by Central Office for investigators at        |
|     Tennessee Valley to examine factors that contribute to clinical   |
|     inertia in the treatment of hypertension. These results are being |
|     used to lay an infrastructure and relationship between the VISN   |
|     and Facility performance measurement and quality offices to       |
|     leverage existing assets and resources in the spread of quality   |
|     improvement for implementing evidence based practice. VISN Start  |
|     Date January 2004- present. This ongoing work is laying an        |
|     infrastructure and relationship between VISN and facility quality |
|     improvement that is instrumental to VISN-wide implementation,     |
|     maintenance and spread of evidence-based practice.                |
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| **5. RESEARCH**                                                       |
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| a.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     PI or CO-PI** *([list up to five]{.mark}; for each item provide   |
|     GRECC Core Staff name(s), journal reference, and [up to five      |
|     line]{.mark} description of topic/method/ results/clinical        |
|     significance; use layperson language)*:                           |
|                                                                       |
| -   **Speroff T**, O\'Connor GT. Study designs for PDSA quality       |
|     improvement research. Qual Manage Health Care 2004; 13(1):17-32.  |
|     This paper provides methodology for improving the rigor in study  |
|     design of quality improvement projects and research proposals. A  |
|     companion paper on this project was as follows: Speroff T, James  |
|     BC, Nelson E.C, Headrick LA, Brommels M. Guidelines for appraisal |
|     and publication of PDSA quality improvement. Qual Manage Health   |
|     Care 2004; 13(1):33-39. This paper provides guidelines for        |
|     critical appraisal of quality improvement publications and grant  |
|     proposals.                                                        |
|                                                                       |
| -   **Ely EW**, Shintani A, Truman B, **Speroff T**, **Gordon S**,    |
|     Harrell F, **Dittus RS**. Delirium as a predictor of mortality in |
|     mechanically ventilated patients in the intensive care unit. JAMA |
|     2004; 291:1753-1762. This study showed for the first time that    |
|     the development of ICU delirium was predictive of a 3-fold higher |
|     mortality at 6 months following ICU admission and more long-term  |
|     cognitive impairment. A companion paper on this topic included:   |
|     Ely EW, Stephens RK, Jackson JC, Thomason J, Truman B, Bernard G  |
|     et al. Current opinions regarding the importance, diagnosis, and  |
|     management of delirium in the intensive care unit: a survey of    |
|     912 healthcare professionals. Crit Care Med 2004. This is the     |
|     first ever large scale survey of international opinions and       |
|     practice management issues related to delirium in critically ill  |
|     patients.                                                         |
|                                                                       |
| -   Ledikwe, JH, Smiciklas-Wright H, Mitchell DC, Miller CK, **Jensen |
|     GL**. Dietary patterns of rural older adults are associated with  |
|     weight and nutritional status. J Am Geriatr Soc 52: 589-95        |
|     (2004). Patterns of poor diet quality and micronutrient           |
|     deficiencies have been identified in community-dwelling obese     |
|     older persons.                                                    |
|                                                                       |
| -   Fan, G-H, Sai J, Lapiere L, Goldenring J, **Richmond A**. A       |
|     complex formed by CXCR2 with Rab11-family interacting protein 2   |
|     and myosin Vb is required for receptor recycling and              |
|     receptor-mediated chemotaxis. Mol Biol Cell 2004;15:2456-2469.    |
|     This important paper showed for the first time that inhibition of |
|     CXCR2 chemokine receptor recycling will block chemotaxis in       |
|     response to key factors that recruit neutrophils into sites of    |
|     inflammation.  This work suggests that drugs that inhibit         |
|     receptor recycling may be useful for treating chronic             |
|     inflammatory diseases that affect veterans, including rheumatoid  |
|     arthritis, acute respiratory distress syndrome (ARDS), Crohn's    |
|     Disease, psoriasis.                                               |
|                                                                       |
| -   **Murff HJ**, Spigel DR, Syngal SK. Does this Patient Have a      |
|     Family History of Cancer: An Evidence Based Evaluation of the     |
|     Family History Interview. JAMA. 2004 Sep 22;292(12):1480-9.       |
|     Family history information is important in identifying            |
|     individuals who might benefit from the early initation of cancer  |
|     screening interventions however, little data exists describing    |
|     the accuracy of self-reported family cancer history.  The study   |
|     was a systematic review of all published literature concerning    |
|     the accuracy of a self-reported family cancer history.  Reports   |
|     of colorectal and breast cancer family histories were accurate    |
|     and would rarely require validation, however other malignacies    |
|     were less accurately reported.                                    |
|                                                                       |
| -   **Griffin MR**, Stein CM, Graham DJ, Daugherty JR, Arbogast PG,   |
|     **Ray WA**. High frequency of use of rofecoxib at greater than    |
|     recommended doses: cause for concern. Pharmacoepidemiology and    |
|     Drug Safety. 2004;13:339-343. This work has contributed           |
|     importantly to the shaping of pharmco-epidemiology and drug       |
|     policy - The recent withdrawal of rofecoxib because of adverse    |
|     cardiovascular effects highlights the continued need for          |
|     post-marketing evaluation of drugs for unanticipated adverse      |
|     effects and of how prescribers respond to evidence about known    |
|     adverse effects. Dr. Griffin's and Dr. Ray's work included 3      |
|     other examples of similar studies that helped to shape            |
|     pharmaco-epidemiology and drug policy. These include: (a)         |
|     **Roumie CL, Griffin MR.** Over-the-counter analgesics in older   |
|     adults: a call for improved labeling and consumer education.      |
|     Drugs Aging 2004;21:485-98. (b) **Griffin MR**, Stein CM, **Ray   |
|     WA**. Postmarketing surveillance for drug safety: Surely we can   |
|     do better. Clin Pharmacol Ther 2004;75:491-494. (c) **Ray WA**,   |
|     Murray KT, Meredith S, Narasimhulu SS, Hall.                      |
|                                                                       |
| -   **Boord JB**, K Maeda, LMakowski, VR. Babaev, SFazio, MF. Linton, |
|     GS Hotamisligil. Combined adipocyte-macrophage fatty acid-binding |
|     protein deficiency improves metabolism, atherosclerosis, and      |
|     survival in apoE deficient mice. 2004. Circulation 110:           |
|     1492-1498. Key Points: Type 2 diabetes and the metabolic syndrome |
|     are major risk factors for the development of atherosclerosis.    |
|     Fatty acid binding proteins aP2 and mal1 regulate the development |
|     of metabolic syndrome and atherosclerosis in mice and thus        |
|     provide a link between these two diseases. Deficiency of these    |
|     two proteins in mice protects mice from the metabolic syndrome    |
|     and atherosclerosis and results in greater longevity. aP2 and     |
|     mal1 represent potential targets for therapy for prevention of    |
|     the metabolic syndrome and heart disease in humans.               |
|                                                                       |
| -   **Roumie CL**, Grogan EL, Falbe W, **Speroff T, Dittus RS, Elasy  |
|     TA**. A three part intervention to influence the use of hormone   |
|     replacement therapy following the publication of new evidence     |
|     Annals Internal Medicine July 2004; 141(2) 118-25: 3 part         |
|     intervention to influence prescribing of HRT- Developed a three   |
|     part program to notify patients and doctors about results of WHI. |
|     Implications: Communicating study results to patients and their   |
|     healthcare providers through email, personal letters and chart    |
|     alerts might help speed adoption of study findings.               |
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| b.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     Co-Investigators on Projects with Non-GRECC PI (***[list up to    |
|     five]{.mark}; for each item provide GRECC Core Staff name(s),     |
|     journal reference, [and up to five line]{.mark} description of    |
|     topic/method/ results/clinical significance; use layperson        |
|     language)*:                                                       |
|                                                                       |
| -   **Kallianpur AR**, Hall LD, Yadav M, Christman BW, **Dittus RS**, |
|     Haines JL, Parl FF, Summar ML. Increased prevalence of the HFE    |
|     C282Y hemochromatosis allele in women with breast cancer. Cancer  |
|     Epidemiol Biomarkers Prev 2004;13:205-12. This study showed that  |
|     women who carry at least 1 (i.e., 1 or 2) hemochromatosis C282Y   |
|     allele(s) may be at increased risk of developing breast cancer or |
|     having breast cancer that responds poorly to chemotherapy. This   |
|     mutation increases iron absorption and body iron stores. Our      |
|     result is important, because the mutation is very common in the   |
|     general population, and women often take iron supplements, which  |
|     could be harmful if they have the mutation.                       |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Hartert TV, Neuzil KM, Shintani A, Mitchel EF, Snowden MS, Wood   |
|     LB, **Dittus RS, Griffin MR**. Maternal morbidity and perinatal   |
|     outcomes among pregnant women with respiratory hospitalizations   |
|     during influenza season. Am J Obs and Gynecol 2003;189:1705-12.   |
|     Drs. Griffin and Dittus have continued to work with Dr. Tina      |
|     Hartert on defining asthma epidemiology in specific risk groups   |
|     such as pregnant women.                                           |
|                                                                       |
| -   Bailey RL, Ledikwe JH, Smiciklas-Wright H, Mitchell DC, **Jensen  |
|     GL**. Persistent oral health problems associated with comorbidity |
|     and impaired diet quality in older adults. J Am Diet Assoc 104:   |
|     1273-1276 (2004). Dr. Jensen and colleagues found that impaired   |
|     oral health was associated with inadequate dietary intakes of     |
|     important foods and nutrients as well as significant disease      |
|     burden.                                                           |
|                                                                       |
| -   Esteban A, Anzueto A, Frutos-Vivar F, Alia I, **Ely EW**,         |
|     Brochard L et al. Outcome of older patients receiving mechanical  |
|     ventilation. Intensive Care Med 2004; 30:639-646. Dr. Ely, in     |
|     working with this international group of experts in critical      |
|     care, has helped to refine risk factor models that may be used in |
|     the future to help prognosticate on an individual Veteran's       |
|     likelihood of benefiting from expensive and precious ICU          |
|     resources.                                                        |
|                                                                       |
| -   Moore D, Feurer I, **Speroff T**, Shaffer D, Nylander W,          |
|     Kizilisik T, **Butler J**, Awad J, Gorden DL, Chari R, Wright JK, |
|     Pinson CW. Survival and quality of life after organ               |
|     transplanatation in veterans and nonveterans. Am J Surg 2003;     |
|     186(5): 476-80. Comparison of organ transplantation outcomes      |
|     among veterans and nonveterans shows equivalence in quality of    |
|     care.                                                             |
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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        |
|     Current Year** (*[list up to five]{.mark}; for each item, [up to  |
|     three lines]{.mark} on how it is innovative)*:                    |
|                                                                       |
| -   **The VISN 9 Palliative Care Consultation Teams (PCCTs)           |
|     Comprehensive Training Program** is a VISN-wide 24-month program  |
|     where seven teams representing the seven VAMCs in VISN 9 are      |
|     developed professionally as training facilitators for other PCCTs |
|     in their facilities. All teams will participate in the 10-12      |
|     month VISN 9 PCCTs Collaborative that will use the Institute on   |
|     Healthcare Improvement's Collaborative and Quality Improvement    |
|     methodologies.                                                    |
|                                                                       |
| -   **GeriFacts** is an e-newsletter of the VA Tennessee Valley       |
|     GRECC, which was first distributed electronically via Outlook in  |
|     FY03 to all staff in VISN 9 and **in FY04** began distribution    |
|     via the World Wide Web at:                                        |
|                                                                       |
|  [http://www.ethicsconsultant.com](http://www.ethicsconsultant.com/). |
|     The GRECC Associate Director/ Education & Evaluation (VJS) is the |
|     editor and for each issue she works with a GRECC                  |
|     preceptor/trainee team from a different discipline to develop a   |
|     clinical topic.                                                   |
|                                                                       |
| -   A GRECC faculty is mentoring a HRSA Geriatrics Academic Career    |
|     Awardee, who is developing an innovative palliative care module   |
|     for the mandatory one-month medical residency rotation in         |
|     Geriatrics. This module incorporates didactics, role-play on      |
|     end-of-life issues, and direct palliative care experiences along  |
|     the care continuum.                                               |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Current Year** *([list up to five]{.mark} most    |
|     important products; for each item, [up to three lines]{.mark}     |
|     summarizing content, target audience, format, product evaluation  |
|     results. Include educational products developed in previous years |
|     ONLY if this is the [first year]{.underline} they have been       |
|     available for distribution)*:                                     |
|                                                                       |
| -   **The GRECC-FDA Scholars Program** is a train-the-trainer program |
|     where HBCU faculty from four states (TN, AL, MS, and FL) complete |
|     a competency-based curriculum on program planning and research    |
|     methodology that prepares them to conduct community-based         |
|     participatory research in their communities. The program was      |
|     distributed via a panel presented at the national Women's Health  |
|     Summit held in Washington, DC. Several in the audience expressed  |
|     interest in replicating the model. The Program is funded by the   |
|     Food and Drug Administration.                                     |
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| **7. NEW CLINICAL MODELS**                                            |
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| **NOTE:** These are new models of care for elderly veterans that the  |
| GRECC is developing and evaluating, in relation to its area(s) of     |
| focus. This is NOT a list of all Geriatrics & Extended Care clinical  |
| programs at the host VAMC.                                            |
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| a.  **New Clinical Models Implemented in Current Year** *(list all    |
|     new clinical models or significant modifications of existing      |
|     models that the GRECC is developing and evaluating. For each      |
|     item, indicate whether [N]{.underline}ew or [O]{.underline}ngoing |
|     in current year; provide [up to five line]{.mark} description)*:  |
|                                                                       |
| -   Falls prevention program " The Falling Leaf" Quality Improvement  |
|     initiative was implemented in the Geriatric inpatient service, to |
|     address the issues of risk assessment, identification and risk    |
|     reduction in the frail elderly population undergoing              |
|     rehabilitation. The program was based on the Falls RCA done on    |
|     all incidents in the facility.                                    |
|                                                                       |
| -   A collaborative interdisciplinary Inpatient Palliative Care       |
|     Consult Service was initiated in conjunction with the Advanced    |
|     Practice nurse, Social worker, case manager, pharmacist and       |
|     pastoral care .The service is able to address the needs medical,  |
|     psychosocial, and spiritual needs of patients with terminal       |
|     illnesses and assist with placement to the optimal level of care  |
|     in a seamless continuum.                                          |
|                                                                       |
| -   A outpatient palliative care clinic has been established within   |
|     the setting of the Geriatric primary care clinics which allows    |
|     the community hospice agencies send the patients with home        |
|     hospice for further evaluation, to optimize management, in the    |
|     outpatient/home setting. This, we anticipate will decrease visits |
|     to the ER as well as allow the more functional patients come in   |
|     for reassessment of their palliation and symptom management.      |
+-----------------------------------------------------------------------+
| b.  **Current Year Evaluation Results of New Clinical Models** *([for |
|     each clinical model listed in 7-a above]{.mark}, indicate whether |
|     evaluated by [R]{.underline}esearch or [Q]{.underline}uality      |
|     [I]{.underline}mprovement project; [up to five lines]{.mark}      |
|     summarizing evaluation outcomes, such as changes in access to     |
|     care, patient functioning, satisfaction, cost-effectiveness,      |
|     organizational changes, etc. Note if no evaluation results in     |
|     current year for a particular model)*:                            |
|                                                                       |
| **NOTE:** Do not list patient service utilization data here. Those    |
| data are reported in the GRECC Electronic Database.                   |
|                                                                       |
| -   The Falling leaf Program: Through continued RCA analysis, we were |
|     able to track the following: 1) Risk assessment increased from    |
|     20% to 95%; 2) Patients were identified as high and low risk and  |
|     wore arm bands that identified them to all care providers, thus   |
|     ensuring safety, in settings outside of their rooms; 3) We saw a  |
|     falls reduction of 40% in the population where program was        |
|     implemented.                                                      |
|                                                                       |
| -   Evaluation of the Palliative care services is in the              |
|     developmental phase                                               |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models Exported in Current Year** *([list up to    |
|     five examples, up to two lines each]{.mark}; provide name of new  |
|     clinical model, name of VA or non-VA facility to which it was     |
|     exported, and method of export, such as "Falls Clinic protocol    |
|     sent to [X]{.underline} VAMC")*:                                  |
|                                                                       |
| -   The Falling leaf program has been exported to all the medicine    |
|     services in the Nashville Campus. It has also been implemented in |
|     the Long-term care units at the York Campus                       |
|                                                                       |
| -   We are currently collaborating with the Hospice Medical Director  |
|     at the York campus, to provide an inpatient consult service model |
|     at the York Campus                                                |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation** = GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach** = GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
+-----------------------------------------------------------------------+
| **a. Current Year Activity Outcomes** *([list up to five              |
| examples]{.mark}, [up to two lines each]{.mark}; 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)*:                |
|                                                                       |
| -   A VISN 9 Professional Development Workshop on **"Improving Health |
|     Outcomes in Older Adults"** was held on November 7, 2003 at the   |
|     Marriott at Vanderbilt University in Nashville, TN. Knowledge and |
|     skills were improved in approximately 100 attendees from the VISN |
|     9 facilities.                                                     |
|                                                                       |
| -   A Faculty Development Workshop on **"Adult Learning: Principles   |
|     and Practices"** was held at the University of Puerto Rico (UPR)/ |
|     Medical Sciences Campus on May 27, 2004 in San Juan, Puerto Rico  |
|     where clinical research teaching knowledge, skills and practice   |
|     behaviors were improved in faculty and staff from the Puerto Rico |
|     VAMC and the UPR.                                                 |
|                                                                       |
| -   The inaugural VISN 9 professional development workshop was held   |
|     for on June 23-24, 2004 at the VA Tennessee Valley GRECC in       |
|     Nashville, TN for the 24-month **Palliative Care Consultation     |
|     Teams (PCCTs) Comprehensive Training Program.** A comprehensive   |
|     evidence-based interdisciplinary curriculum is being developed,   |
|     implemented and evaluated VISN-wide, using a train-the-trainer    |
|     approach. Teams of health professionals in VISN 9 working with    |
|     the Palliative Care Consultation Teams (PCCTs) Program will       |
|     complete the training and will be better able to incorporate best |
|     practices in hospice/palliative care into their clinical          |
|     practices and continuously improve the care they provide.         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   GRECC faculty is taking the lead on the Geriatrics and Extended   |
|     Care (GEC) Committee of the VISN 9 Health Systems Committee       |
|     advising leadership on GEC matters. FY04 featured promoting       |
|     uniform standards and policies for the VISN, education of Long    |
|     Term Care Staff concerning Minimum Data Set Quality Indicators,   |
|     and directing expansion of non-institutional care, including the  |
|     recently funded \$1 million telephone care system.                |
|                                                                       |
| -   GRECC faculty is participating on the National VA Long Term Care  |
|     Quality Improvement Committee, sharing clinical demonstration     |
|     data and strengthening geriatrics education for health            |
|     professionals.                                                    |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** (*[list up to five        |
|     examples]{.mark}, [up to two lines each]{.mark}; summarize        |
|     specific outcomes realized from previous years' [**consultation** |
|     to host VAMC]{.underline} or [**outreach** to non-host            |
|     facilities]{.underline}, where results were first realized in the |
|     current year.)*                                                   |
|                                                                       |
| Consultation to host                                                  |
|                                                                       |
| -   A new process of CVP catheter insertion was developed that        |
|     resulted in a lowering of catheter infection rates which has been |
|     spread to other units this year.                                  |
|                                                                       |
| -   A new strategy that enables an organization/provider to get new   |
|     knowledge into clinical practice rapidly was developed.           |
|                                                                       |
| -   The above mentioned new strategy was used to get the new          |
|     information about HRT to female veterans during FY03. This        |
|     improvement was published in the Annals of Internal Medicine.     |
|                                                                       |
| -   The Falls Prevention Program was pilot tested on the GEM Unit and |
|     resulted in a 50% reduction in the rate of falls. The program is  |
|     now being implemented on all inpatient units at the host          |
|     facility.                                                         |
|                                                                       |
| # Outreach to non-host                                                |
|                                                                       |
| -   A similar strategy to the HRT program is being used by GRECC      |
|     faculty in a VA funded study to improve the use of mediations for |
|     hypertension throughout the VISN in a collaborative effort with   |
|     the Chief Medical Officer of our VISN.                            |
|                                                                       |
| ##### Geri-Facts is an electronic newsletter that                     |
|  covers, in 3-5 pages, a different clinical topic (e.g., use of restr |
| aints, nutrition) each month. The newsletter is distributed electroni |
| cally via Outlook to all staff in VISN 9. The GRECC AD/E&E is the edi |
| tor and each month she works with a different discipline composed of  |
| an IFT member and the relevant GRECC trainee(s) to develop that issue |
|                                                                       |
| ##### The Ethics Clinical Case Conference is a training program t     |
| hat uses VANTS Videoconferencing technology to establish a virtual cl |
| assroom where knowledge and skills on the assessment and management o |
| f clinical ethical cases are improved by health professional staff an |
| d trainees throughout VISN 9. The program began broadcasting in FY04  |
| to faculty at the University of Vermont and the Salisbury (NC) VAMC.  |
|                                                                       |
| -   The training manual for administration of the CAM-ICU has been    |
|     distributed throughout the country, to all GRECCs, and has been   |
|     translated into several languages for world-wide distribution.    |
|                                                                       |
| -   GRECC faculty provided consultation to research projects at five  |
|     other VISNs outside our own through interacting with fellows      |
|     within the Quality Scholars Program at UCSF, Iowa, UAB,           |
|     Cleveland, and White River Junction.                              |
+-----------------------------------------------------------------------+