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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:** Durham                                            |
|                                                                       |
| b.  **Location** *(facility, VISN)*: Durham, VISN 6                   |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Connie W. Bales, PhD, RD                                |
|                                                                       |
| b.  **Position:** Associate Director for Education/Evaluation         |
|                                                                       |
| c.  **Phone, e-mail:** 919-286-6932, bales001@mc.duke.edu             |
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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:                                                 |
|                                                                       |
| -   Biology & physiology of frailty                                   |
|                                                                       |
| -   Mobility, bones, and joints                                       |
|                                                                       |
| -   Cell biology of immune system & cancer                            |
|                                                                       |
| b.  Applied Clinical:                                                 |
|                                                                       |
| -   Exercise & chronic disease                                        |
|                                                                       |
| -   Cancer care                                                       |
|                                                                       |
| -   Mobility, bones & joints                                          |
|                                                                       |
| -   Quality of life, care-giving & end of life care                   |
|                                                                       |
| c.  Health Services:                                                  |
|                                                                       |
| -   Health promotion & disease prevention                             |
|                                                                       |
| -   Medication utilization                                            |
|                                                                       |
| -   Geriatric assessment                                              |
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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 veteran,    |
|     i.e., how the GRECC has "made a difference" in these areas within |
|     the entire host VAMC; [up to five lines each]{.mark}):            |
|                                                                       |
| 1\. The **Shingles Prevention Study** (VA Cooperative Study #403) is  |
| a landmark, randomized controlled trial at 22 sites to determine if   |
| the varicella-zoster vaccine can reduce the incidence and/or          |
| complications of herpes zoster. Dr. Schmader is an Executive,         |
| Operating and Clinical Evaluation Committee member, and Durham site   |
| PI. The Durham site enrolled 2272 participants (number 3 nationally)  |
| and has generated significant resources for the research service and  |
| hospital. In addition, this work has brought high visibility to the   |
| Durham VAMC nationally.                                               |
|                                                                       |
| 2\. **Geriatrics Fellowship Program**: Dr. Lyles is Director of the   |
| Durham GRECC's Fellowship Program in Geriatrics. Over the past year   |
| the four 1^st^ year and two 2^nd^ year Geriatric Physician Fellows    |
| have provided outstanding clinical care to veterans in the ECRC, the  |
| GEM Unit and the VA Primary Care Geriatrics Clinic. Our Geriatric     |
| Fellows, under the supervision of GRECC faculty, care for over 300 of |
| this Medical Center's frailest veterans.                              |
|                                                                       |
| 3\. The **Hartford Interdisciplinary Geriatric Research Center**      |
| (Clipp, PI; Schmader Co-PI) aims to improve health outcomes for older |
| adults through enhanced productivity of gerontological nurses and     |
| geriatricians. These activities have positively affected the host VA  |
| and GRECC investigators (Clipp, Schmader, Cohen, McConnell, Seo,      |
| Ruby, Pieper, Morey) through pilot grant funding and multiple         |
| opportunities for research training (targeted and VA-wide). GRECC has |
| partnered with HSR&D and General Internal Medicine in activity        |
| coordination.                                                         |
|                                                                       |
| 4\. **Gerofit**. The Gerofit exercise and health promotion program    |
| continues to serve as an extraordinary model program of clinical care |
| for aging veterans that interfaces within the host VAMC in multiple   |
| domains of clinical care, staff education, program evaluation, and    |
| research. Because of our high visibility within the host VAMC our     |
| services are widely used in formal and informal teaching and          |
| mentoring. Most recently Gerofit published findings reported that     |
| older, sedentary veterans were more impaired functionally than        |
| age-matched peers on national norms, thus highlighting the importance |
| of our activities.                                                    |
|                                                                       |
| > 5\. **Palliative Care Consult Service**: The Palliative Care        |
| > Consult Team (PCCT), directed by Dr. Cutson, provides assistance in |
| > the care (symptom management, including pain) of our veterans       |
| > facing life limiting illnesses (number of consults increased 5 fold |
| > since inception; highest number reported in VISN). PCCT provides    |
| > education for (1) medicine house staff through consults (developed  |
| > laminated "pocket cards" outlining hospice eligibility guidelines,  |
| > brochure describing PCCT) and (2) hospital staff via formal         |
| > presentations.                                                      |
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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, i.e., how GRECC participation in VISN-wide activities   |
|     has "made a difference" in these areas within the entire VISN;    |
|     [up to five lines each]{.mark}.* NOTE: GRECCs are intended and    |
|     expected to serve as a [regional]{.underline}, and not merely     |
|     local resource*)*:                                                |
|                                                                       |
| 1\. Dr. Cohen serves on the **VISN Geriatrics and Extended Care       |
| Subcouncil**. His advice and counsel have been critical to the        |
| achievement of several improvements in care. For example, there has   |
| been increased nursing support for the extended care units, increased |
| support for non-institutional care, and increases in the numbers of   |
| veterans served. He has advocated for increased support for activity  |
| in palliative care, which has been growing within the VISN and        |
| especially successful at the Durham VAMC.                             |
|                                                                       |
| 2\. Over the past year, the VA has decided to accept ownership in the |
| **US Patent (Methods for Preventing or Reducing Secondary Fractures** |
| **after Hip Fracture**, US Provisional Patent Application 60/411,067) |
| (Dr. Lyles). The licensing rights to this patent are shared equally   |
| by Duke University and the Department of Veterans Affairs. The        |
| financial benefit to the Department of Veterans Affairs will occur in |
| approximately two to three years. The Horizon 2310 Recurrent Fracture |
| Prevention Trial, has raised awareness worldwide that hip fractures   |
| are important and such patients are receiving more attention.         |
|                                                                       |
| > 3\. **VISN-wide Palliative Care Consult Team:** Dr. Cutson serves   |
| > as a physician member of the VISN 6 PCCT, which is charged with     |
| > assisting other facilities in the network with palliative care.     |
| > Quarterly conference calls have been initiated to facilitate        |
| > networking and education among VISN PCCT members. The program was   |
| > featured in the VA Nationwide Palliative Care Network Vol3, issue3, |
| > 2004 (web newsletter).                                              |
|                                                                       |
| 4\. The annual **VISN-wide GRECC Conference on Cardiovascular Disease |
| in Late Life: Reducing the Risk of Functional Decline** assembled a   |
| number of experts who presented a full-day program covering the       |
| underlying changes in the aging cardiovascular system and practical   |
| issues for treating the elderly with cardiovascular disease. The      |
| program was designed for physicians, nurses, pharmacists, social      |
| workers and others responsible for the care of geriatric patients and |
| also targeted functional impact of cardiovascular disease in the      |
| elderly patient.                                                      |
|                                                                       |
| 5\. Dr. McConnell and geriatrics clinic staff have consulted with a   |
| **VISN-6 task force** developing a **clinical reminder in CPRS for    |
| assessing safety needs of veterans with dementia,** emphasizing       |
| driving safety, firearms, and in-home safety (falls, fire prevention, |
| wandering). It includes interactive links within CPRS to              |
| VHA-developed patient education brochures for driving and firearms    |
| safety. There is evidence-based decision-support for clinicians       |
| regarding driving safety assessment, counseling resources on state    |
| laws regarding reporting unsafe drivers, and medical center policy    |
| guidance regarding notification of the Department of Motor Vehicles   |
| of unsafe drivers.                                                    |
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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)*:                           |
|                                                                       |
| 1\. **Knock-out Mouse Model for Host Response to Infection:** Since   |
| 1999, we have generated and characterized three knock-out mouse lines |
| for studying host resistance to infection. Each line lacks expression |
| of a gene belonging to a new family of host resistance genes. One of  |
| these lines is an excellent model for the study of tuberculosis       |
| resistance. We have already shared these new models with more than 6  |
| research labs at other medical centers. *[GRECC staff member: Dr.     |
| Gregory Taylor]{.underline}*                                          |
|                                                                       |
| # 2. Medi                                                             |
| cations Appropriateness Index: We have developed and tested the Medic |
| ations Appropriateness Index and distributed it internationally for w |
| idespread use to measure prescribing appropriateness in the elderly.  |
| It has been successfully applied in the U.S. and abroad for the past  |
| five years. *[GRECC staff member: Dr. Kenneth Schmader.]{.underline}* |
|                                                                       |
| 3\. **Evidence Based Medicine (EBM) Curriculum in Geriatrics:** Prior |
| to 2001, geriatricians-in-training at Duke and the VA received no     |
| formal education in EBM but now we continue to offer a course in EBM  |
| in geriatrics. We recruited faculty from several disciplines to       |
| deliver lectures and designed a website to provide detailed content   |
| and learning aids. We plan to expand a searchable database for        |
| evidence-based summaries or critically appraised topics created by    |
| fellows. The course's website provides specific goals, content and    |
| assignments.                                                          |
| (<http://www.mclibrary.duke.edu/limited/Geriatricsebm/>). *[GRECC     |
| staff member: Dr. Mitchell Heflin]{.underline}*                       |
|                                                                       |
| 4\. **Project Life: (**July 2001-present) is a clinical research      |
| project aimed at promoting physical activity (PA) via a clinical      |
| model of partnership between providers, health counselors and aging   |
| veterans. The model aims to minimize provider burden while maximizing |
| effective PA counseling. Primary care providers are trained in PA     |
| counseling and record automated telephone messages of endorsement and |
| encouragement of PA for year round use. To our knowledge, this is the |
| first use of automated telephone messaging by primary care providers  |
| for PA counseling. *[GRECC staff members: Morey, MC (PI), Crowley GM, |
| Peterson MJ, McConnell E (Co-Inv)]{.underline}*                       |
|                                                                       |
| 5\. **GEM Research**: Our GRECC developed and hosted the only         |
| multi-institution randomized controlled trial of GEM units and        |
| clinics. This trial demonstrated that in-patient GEM units can reduce |
| in-hospital functional decline and GEM clinics had positive effects   |
| on patients' quality of life, although survival duration was not      |
| changed. This study built upon our first randomized trial of          |
| geriatric consultation teams and continues its innovation with our    |
| work on cancer-patient-specific GEM.*[GRECC staff members HJ Cohen,   |
| MD, KW Lyles, MD and P Seo, MD.]{.underline}*                         |
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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)*:                           |
|                                                                       |
| 1\. [Core Staff]{.underline}: G.Taylor, PhD. [Journal                 |
| Reference]{.underline}: Macmicking JD, Taylor GA, and McKinney JD.    |
| (2003) Immune control of tuberculosis by IFN-gamma- inducible LRG-47. |
| *Science* **302**, 654-659.                                           |
|                                                                       |
| [Description:]{.underline} LRG-47 deficient mice and cells from those |
| mice were used to demonstrate that LRG-47 is required for resistance  |
| to Tb in vivo, as well as efficient processing and eradication of Tb  |
| from infected macrophages in vitro. These results define LRG-47 as a  |
| pivotal factor in regulating resistance to Tb. Novel approaches to    |
| therapy for Tb patients may ultimately be derived from these studies. |
|                                                                       |
| 2\. [Core Staff]{.underline} : K. Schmader, MD. [Journal              |
| Reference:]{.underline} Schmader KE, Hanlon JT, Pieper CF, Sloane R,  |
| Ruby CM, Twersky J, Branch LG, Francis SD, Lindblad CI, Artz M,       |
| Weinberger M, Feussner JR, Cohen HJ (2004). Effectiveness of          |
| Geriatric Evaluation and Management on adverse drug reactions and     |
| suboptimal prescribing in the frail elderly. Am J Med 116:394-401.    |
|                                                                       |
| [Description:]{.underline} The GEM Drug Study determined if inpatient |
| Geriatric Evaluation Management Unit (GEMU) and outpatient GEM Clinic |
| (GEMC) care compared to usual care reduces adverse drug reactions     |
| (ADRs) and suboptimal prescribing in frail elderly patients. The      |
| study found that, compared to usual care, outpatient GEMC care        |
| reduces serious adverse drug reactions, and inpatient GEMU and        |
| outpatient GEMC care reduces suboptimal prescribing in frail elderly  |
| patients.                                                             |
|                                                                       |
| 3\. [Core Staff]{.underline} : H.G. Koenig, MD. [Journal              |
| Reference]{.underline}: Koenig HG, George LK, Titus P, Meador KG      |
| (2004). Religion, spirituality, acute hospital and long-term care use |
| by older patients. Archives of Internal Medicine 164:1579-1585.       |
|                                                                       |
| [Description:]{.underline} This study found that hospitalized         |
| African-Americans who pray or read the Bible at least daily are       |
| significantly less likely to spend time in long-term care facilities  |
| during the 10 months following hospital discharge (5 days for those   |
| frequently engaged in private religious activities vs. nearly 50 days |
| for those who were infrequently involved in such activities).         |
|                                                                       |
| 4\. [Core Staff :]{.underline} H.J. Cohen, MD. [Journal               |
| Reference]{.underline}: Garman KS, Pieper CF, Seo P, Cohen HJ (2003). |
| Function in elderly cancer survivors depends on comorbidities.        |
| Journal of Gerontology 58A:1119-1124.                                 |
|                                                                       |
| [Description:]{.underline} We studied the impact of cancer status and |
| comorbidities on functional status of elderly cancer survivors using  |
| a population based survey of 4,162 subjects. In a two-way analysis of |
| covariance controlled model, duration of cancer survivorship does not |
| influence most measures of function. Comorbidity significantly        |
| correlates with function status of the cancer survivors. Thus in      |
| older cancer survivors, the presence of comorbidity rather than       |
| history of cancer per se, correlates with impaired functional status. |
|                                                                       |
| 5\. [Core Staff]{.underline} : KW Lyles, MD. [Journal                 |
| Reference]{.underline}: Gold DT, Shipp KM, Pieper CF, Duncan PW,      |
| Martinez S, Lyles KW (2004). Group treatment improves trunk strength  |
| and psychological status in older women with vertebral fractures:     |
| results of a randomized, clinical trial. Journal American Geriatric   |
| Society 52:1471-1478.                                                 |
|                                                                       |
| [Description:]{.underline} Lyles et al. publication of the            |
| NIH-sponsored trial reported that group treatment improves trunk      |
| strength and psychological status in older women with vertebral       |
| fractures. This trial describes an intervention by physical therapist |
| and a social worker that is easily implemented in hospitals,          |
| outpatient clinics and long term care facilities that can improve     |
| quality of life of subjects with vertebral fractures.                 |
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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)*:                                                       |
|                                                                       |
| # 1. [Core Staff]{.underl                                             |
| ine} : G. Fillenbaum, PhD. [Journal Reference]{.underline}: Fillenbau |
| m GG, Hanlon JT, Landerman LR, Artz B, O'Connor H, Dowd B, Gross CR,  |
| Boult C, Garrard J, Schmader KE (2004). Impact of inappropriate drug  |
| use on health services utilization among representative community dwe |
| lling elders. American Journal of Geriatric Pharmacotherapy 2:92-101. |
|                                                                       |
| [Description]{.underline}: Study of inappropriate drugs as defined by |
| drug utilization review or Beers criteria indicated that these        |
| criteria should be used with care because they appear to have minimal |
| impact on use of health services by representative community          |
| residents.                                                            |
|                                                                       |
| 2\. [Core Staff]{.underline} : M.C. Morey, PhD. [Journal              |
| Reference]{.underline}: Purser JL, Pieper CF, Poole C, Morey MC       |
| (2003). Trajectories of leg strength and gait speed among sedentary   |
| older adults: longitudinal patterns of dose response. Journal of      |
| Gerontology: Medical Sciences 58A(12): 1125-1134.                     |
|                                                                       |
| [Description:]{.underline} Walking speed has emerged as one of the    |
| most potent, objective measures of physical function that is highly   |
| predictive of future institutionalization, disability and mortality.  |
| Weak older adults are thought to have a greater capacity for          |
| improvement in functional capabilities following interventions than   |
| older adults with normal or high walking speeds. Using our            |
| longitudinal data, we found that changes in walking speed are more    |
| dependent upon the rate of strength change than on the amount of      |
| muscle weakness present at baseline, indicating that we must alter    |
| our approaches to intervention delivery.                              |
|                                                                       |
| 3\. [Core Staff]{.underline} : C.W. Bales, PhD. [Journal              |
| Reference]{.underline}: Slentz CA, Duscha BD, Johnson JL, Ketchum K,  |
| Aiken LB, Samsa GP, Houmard JA, Bales CW, and Kraus WE (2004).        |
| Effects of the amount of exercise on body weight, body composition,   |
| and measures of central obesity: STRRIDE -- a randomized controlled   |
| study. Archives of Internal Medicine 164:31-39.                       |
|                                                                       |
| [Description]{.underline}: This study of sedentary, overweight men    |
| and women (aged 40-65 years) examined an 8-month exercise             |
| intervention at 3 levels (1) high amount/vigorous intensity, (2) low  |
| amount/vigorous intensity, and (3) low amount/moderate intensity. The |
| high-amount/vigorous-intensity group lost significantly more body and |
| fat mass than the other groups. Compared with controls, all exercise  |
| groups significantly decreased abdominal, minimal waist, and hip      |
| circumference measurements.                                           |
|                                                                       |
| 4\. [Core Staff]{.underline} : E.C. Clipp, PhD. [Journal              |
| Reference]{.underline}: Clipp EC, Carver E, Puleo E, Pollack, K,      |
| Emmons, K, Oken, J, McBride, C (2004). Age-Related Vulnerabilities of |
| Older Adults with Colon Adenomas: Evidence from Project Prevent.      |
| *CANCER*, 100:1085-94.                                                |
|                                                                       |
| [Description:]{.underline} This study examined how well established   |
| age-related vulnerabilities affect colorectal cancer risk perceptions |
| and behaviors among older adults following removal of one or more     |
| adenomatous polyps. Data derive from *Project Prevent,* a RCT         |
| designed to reduce behavioral risk factors for CRC among 1,247 adults |
| who had one or more adenomatous colon polyps removed. Results         |
| indicate that certain subgroups of vulnerable older patients may      |
| benefit from behavior change interventions that account for impaired  |
| functional status, inadequate social support, and lower income.       |
|                                                                       |
| 5\. [Core Staff]{.underline} : E. McConnell, PhD., H.J. Cohen, MD.    |
| [Journal Reference]{.underline}: Garman, K.S., McConnell, E.S.,       |
| Cohen, H.J. (2004). Inpatient care for elderly cancer patients: The   |
| role for geriatric evaluation and management units in fulfilling      |
| goals for care. *Critical Reviews of Hematology/Oncology* 51:241-247. |
|                                                                       |
| [Description:]{.underline} We conducted a retrospective chart review  |
| of 36 elderly cancer patients admitted to the DVAMC GEMU (1996 to     |
| 1999) for diversity of treatment goals observed among older cancer    |
| patients, and the extent to which goals were achievable. Four         |
| categories of goals were identified: (1) diagnostic goals, 78% met,   |
| (2) symptom management goals, 73% met, (3) functional improvement     |
| goals, 79% met, and (4) disposition/caregiver support goals, 100%     |
| met. Thus in-patient GEMU services offer a promising approach to care |
| for older cancer patients, deserving further evaluation of benefits   |
| and risks.                                                            |
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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)*:                    |
|                                                                       |
| 1\. Dr. Harold Koenig has started a new **Center for Spirituality,    |
| Theology and Health** available for consultation and educational      |
| activities to the host VA and VA's in the VISN; this is the only such |
| resource involving both research excellence and theology excellence   |
| available anywhere in the country.                                    |
|                                                                       |
| 2\. **Staff development program in clinical pharmacy**. 23 sessions   |
| per year developed by C.Ruby, PharmD, with S. McMillan, PharmD,       |
| Directors of Geri and Pharm Practice Residency programs. These        |
| sessions combined innovative (Resident Interactive Teaching           |
| Experiences) and traditional (landmark/current journal                |
| evaluations/case presentations) teaching methods to incorporate       |
| pharmacocotherapy education and professional development for all      |
| pharmacy residents.                                                   |
|                                                                       |
| 3\. **Comprehensive mentoring models for junior faculty** A           |
| comprehensive mentoring model for junior faculty in gerontological    |
| nursing was developed by Dr. Clipp and implemented through the        |
| Hartford Interdisciplinary Geriatric Research Center (proposal        |
| development group, mock review, manuscript development group, and     |
| peer review evaluation).                                              |
|                                                                       |
| 4\. SGIM/John A. Hartford Foundation Center for Collaboration between |
| General Medicine and Geriatrics. We have developed and delivered      |
| **curricular resources for cognitive impairment, gait instability and |
| falls, and appropriate prescribing.** For each topic, a team,         |
| including a geriatrician, met and drafted goals and objectives,       |
| created a resource table, and developed strategies for delivery and   |
| evaluation.                                                           |
|                                                                       |
| 5\. GRECC staff have developed an education program with a            |
| **Telephone Medicine Curriculum for Long Term Care.** Drs. Twersky,   |
| Cutson and McConnell have mentored geriatric fellows in a program to  |
| improve on-call telephone communication between nurses and physicians |
| in long-term care. A structure for how physicians should answer calls |
| and what information nurses should have when they contact the         |
| physicians was developed.                                             |
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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)*:                                     |
|                                                                       |
| 1\. A 5-part series educational series, **"Clinical and Health        |
| Services Intervention Research"** was developed within the Hartford   |
| Interdisciplinary Research Center (Clipp PI, Schmader Co-PI) and put  |
| on the WWW in 2003 (audio concurrent with slides). Series provides an |
| overview of randomized controlled clinical trials, focusing on the    |
| design of interventions to provide quality care at the patient,       |
| provider, and systems levels, how to evaluate interventions, and the  |
| implications of multi-site trials.                                    |
|                                                                       |
| 2\. **Web-Based Module For Fellows:** We have developed a web-based   |
| resource for delivery of the EBM in Geriatrics course---providing     |
| cases and instructional articles for students. Please see the         |
| following URL: <http://www.mclibrary.duke.edu/limited/Geriatricsebm/> |
|                                                                       |
| 3\. **Web-Based Module For Second Year Students:** We provided        |
| web-based materials in support of a week-long educational symposium   |
| on aging, entitled the Intersession on Aging. Please see the          |
| following URL: http://careinaging.duke.edu/students/                  |
|                                                                       |
| 4\. **Clinician Network-SGIM:** We developed a website with the       |
| support of the Hartford Foundation and the SGIM to support            |
| educational activities offered by the Collaborative Center. Please    |
| see the following URL: <http://careinaging.duke.edu/clinicians/>      |
|                                                                       |
| 5\. **VISN-wide Palliative Care Educational programs**: Net Six       |
| educational module was developed outlining the need and scope of      |
| palliative care in the VHA (Drs. T. Cutson, J. Cortina ).             |
+-----------------------------------------------------------------------+
| **7. NEW CLINICAL MODELS**                                            |
+-----------------------------------------------------------------------+
| **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.                                            |
+-----------------------------------------------------------------------+
| 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)*:  |
|                                                                       |
| 1\. Following up on previously published work on a mail-in geriatric  |
| assessment for elderly cancer patients, Drs. Seo, Clipp and Cohen     |
| have initiated a clinical program to **assess elderly cancer patients |
| during their initial visit to oncology clinic**. A geriatric          |
| oncologist, social worker, and pharmacist do the assessment for       |
| vulnerable patients. The goal of this work is to identify areas       |
| needing more in-depth assessment of older cancer patients with more   |
| complex medical and psychosocial profiles and assist the oncologist   |
| in managing these patients. This pilot is [Ongoing]{.underline}.      |
|                                                                       |
| 2\. Dr. Lyles with colleagues describes a clinical trial in which     |
| patients who were within 90 days of hip fracture all receive 100,000  |
| international units of vitamin D~2~ and then daily 800 IU of vitamin  |
| D~3~ and 1000 mg of calcium. This clinical trial will be the first to |
| use such a therapy in patients after hip fracture. Second, this trial |
| is a landmark because it is the first **clinical trial which will use |
| clinical fractures as the primary endpoint to determine the efficacy  |
| of a annual dose of an intravenous bisphosphonate, zoledronic acid**. |
| This clinical trial is [New]{.underline}.                             |
|                                                                       |
| Colon-Emeric C, Current Medical Opinion and Research, 20:903-910,     |
| 2004.                                                                 |
|                                                                       |
| 3\. A model of **"Experiential Training for Cancer Caregivers"** was  |
| developed this year by Dr. Cristina Hendrix (VA WOC) under the VA     |
| GRECC site direction of Drs. Clipp and Twersky. A manual was          |
| developed to systematize the caregiver training process. Currently,   |
| caregivers of elderly persons with cancer who are inpatients on the   |
| VA ECRC Onco-GEM Unit receive bedside training on the tasks           |
| associated with cancer home care, including acute care admission and  |
| symptom distress. Caregivers' self-efficacy for handling these        |
| situations at home is assessed. This model is [New]{.underline}.      |
|                                                                       |
| 4\. Our **Home Care Coordination program** now offers a wide variety  |
| (12) of home care options for                                         |
|                                                                       |
| veterans. A patient database is maintained and updated regularly and  |
| outcomes and patient satisfaction are regularly evaluated. The Durham |
| VAMC received approval to add Adult Day Health Care and Home Respite  |
| during the past year. This program is [Ongoing.]{.underline}          |
|                                                                       |
| 5\. **Provider Training for Physical Activity - Morey, MC**.          |
|                                                                       |
| Within the past four years, Dr. Morey and her GRECC colleagues        |
| Crowley, Peterson, and McConnell, have conducted formal clinical      |
| research (Project LIFE) aimed at promoting physical activity (PA) via |
| a clinical model of partnership between providers, health counselors  |
| and aging veterans. The model under development is directly relevant  |
| to the primary PA goals recommended by the VA National Center for     |
| Health Promotion and Disease Prevention. This ongoing work has        |
| tremendous local and national relevance to the clinical care of our   |
| aging veterans. This program is [Ongoing.]{.underline}                |
|                                                                       |
| 6\. **Palliative Care:** The Palliative Care Consult Team (PCCT),     |
| with Dr. Cutson as director and Linda Lang, LISW as administrative    |
| coordinator, has grown in membership and activity. In addition to a   |
| geriatrician/palliative medicine specialist, nurse, chaplain and      |
| social worker, we now have a nurse practitioner and PharmD as members |
| of the team. The number of consults has increased to 164/year. The    |
| PCCT has been invited to present informational/educational talks      |
| within the hospital to various disciplines and departments. This      |
| program is [Ongoing.]{.underline}                                     |
|                                                                       |
| 7\. Dr. McConnell, along with Carol Feldman, RN, MSN, have            |
| implemented a **model for ambulatory care nurses to engage routinely  |
| in evaluation and implementation of evidence-based clinical practices |
| (EBCP) in the primary care clinics**. With the guidance of Dr.        |
| McConnell and 12 selected physicians, 23 staff nurses have completed  |
| 13 EBCP group learning sessions, and 9 RN/MD mentor sessions to       |
| enhance their skills in questioning their routine clinical practices, |
| acquiring research evidence to improve those practices, appraising    |
| the evidence for its applicability to their patient population, and   |
| applying the evidence to their clinical practice. This program is     |
| [Ongoing]{.underline}                                                 |
+-----------------------------------------------------------------------+
| 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.                   |
|                                                                       |
| 1\. **Clinical evaluation model of elderly cancer patients:** this    |
| project is evaluated as a Research project.                           |
|                                                                       |
| 2\. The **clinical trial to determine the efficacy of a annual dose   |
| of an intravenous bisphosphonate** is a clinical trial that will be   |
| submitted to the FDA for evaluation.                                  |
|                                                                       |
| 3\. The model of **"Experiential Training for Cancer Caregivers"**    |
| (Hendrix with Clipp & Twersky) will be evaluated by research outlined |
| in a proposal submitted for external funding (NIH/NINR).              |
| Specifically, a randomized controlled trial will be used to evaluate  |
| the effectiveness of experiential training and its influence on       |
| caregivers' self-efficacy and psychological well-being.               |
|                                                                       |
| 4\. Our **Home Care Coordination program** is evaluated in a number   |
| of ways. Patient Satisfaction results are aggregated across programs. |
| The data are graphed and forwarded to Process and Systems Improvement |
| on a bi-annual basis. Programs have also been evaluated by SOARS,     |
| SEAQUEST and JCAHO.                                                   |
|                                                                       |
| 5\. **Provider Training for Physical Activity - Morey, MC**.          |
|                                                                       |
| Morey and colleagues evaluated their clinical model using formal      |
| research methods. Provider acceptability to the clinical model rated  |
| the initial training higher than "somewhat helpful" or "very          |
| helpful." In addition, the overall impression of Project LIFE was     |
| rated "somewhat beneficial" or higher by all surveyed. Providers      |
| "strongly agreed" that the counseling materials were easy to use and  |
| made counseling with patients easy. Moreover, patients involved in    |
| the formal exercise trial reported significant increases in physical  |
| activity frequency (p=0.03).                                          |
|                                                                       |
| 6\. The outcomes of the **Palliative Care Service** are assessed      |
| annually (e.g., number of consults, number of patient deaths in-house |
| with consults) and reported to Central Office. There is also          |
| evaluation on-going on a local bases using questionnaires distributed |
| to house staff and attending physicians.                              |
|                                                                       |
| 7\. For the **model for ambulatory care nurses to engage routinely in |
| evaluation and implementation of evidence-based clinical practices    |
| (EBCP) in the primary care clinics**, a database of clinical          |
| questions is maintained and serves as the foundation for selecting    |
| practices for which critically appraised topics are developed. The    |
| first topics completed were 1) assessing the need for dietary         |
| restriction in obtaining fecal occult blood testing, and 2) improving |
| the efficacy of impacted ear wax removal, using cerumenolytics.       |
| Evaluation is also conducted by nurse manager and Dr. McConnell. A    |
| manuscript is in preparation for the Journal of Nursing               |
| Administration.                                                       |
+-----------------------------------------------------------------------+
| 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")*:                                  |
|                                                                       |
| 1\. The **GEM model of physician, nurse, social worker, pharmacist    |
| team care** is useful in inpatient and outpatient settings for        |
| reducing inappropriate prescribing in the elderly and in outpatient   |
| settings for reducing serious adverse drug reactions in the elderly.  |
| Published and exported nationally.                                    |
|                                                                       |
| 2\. An **Intervention Model for Caregiver Readiness** was developed   |
| with tailored information to address unique needs, including those of |
| military and intergenerational families: It includes a Parent Care    |
| Resource Guide and workbook, a powerpoint presentation with           |
| curriculum for a 5-hour workshop, and a CD-ROM providing automatic    |
| Internet links, resources and information to aid caregivers. This     |
| model was also published this year.                                   |
|                                                                       |
| 3\. **Goals-based GEM for elderly cancer patient's family and patient |
| goals for care** of elderly cancer patients can be accomplished by    |
| GEMU. The model has been exported via publication to all VAMC.        |
|                                                                       |
| 4\. This publication describes a **targeted exercise program and      |
| psychosocial intervention can improve quality of life measures in     |
| women with vertebral fractures**. This paper by Gold, et al.          |
| describes an intervention developed at the Durham VA and Duke Medical |
| Center targeted at improving flexibility and spinal extension         |
| strength in women with vertebral fractures. These interventions can   |
| be adapted for use in various clinical settings.                      |
|                                                                       |
| 5\. Drs. Morey and Sullivan proposed a **new approach to screening    |
| for exercise in older adults**. This work received extensive national |
| coverage in media such as the Los Angeles Times, Health Behavior      |
| Science News, Living Fit Magazine, and The Washington Post and serves |
| as a foundation upon which national guidelines for exercise screening |
| can be built.                                                         |
+-----------------------------------------------------------------------+
| **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.              |
+-----------------------------------------------------------------------+
| b.  **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)*:                                               |
|                                                                       |
| 1\. GRECC staff consulted with Dr. BR Connell from the Atlanta VA on  |
| **identifying informal caregivers from VA administrative data         |
| bases**. Dr. Connell is planning VA research on informal caregivers   |
| of frail elderly focusing specifically on sensory loss.               |
|                                                                       |
| 2\. GRECC staff is consulting with Dr. C Zhu, Health Economist at the |
| Mt. Sinai GRECC, on **Trajectories of Informal Cost in Progressive    |
| Dementia.** This consultation will result in an application to HSR&D  |
| for a Career Development Award.                                       |
|                                                                       |
| 3\. GRECC staff (Morey) consulted with other VAMC's in Jackson, MS    |
| and Gainesville, FL for **research development pertaining to          |
| assessment of physical function and physical activity intervention    |
| development**. One of these consultations resulted in funding of an   |
| HSR&D clinical trial.                                                 |
|                                                                       |
| 4\. GRECC staff participated in the development and delivery of       |
| **materials for physical activity for MOVE (Managing                  |
| Overweight/Obesity in Veterans Everywhere) participants.** GRECC      |
| staff Morey, Crowley and Peterson participated in the Durham VAMC     |
| MOVE program. The MOVE program is part of a national weight loss      |
| initiative sponsored by the VA National Center for Health Promotion   |
| and Disease Prevention.                                               |
|                                                                       |
| 5\. The DVAMC Nursing service has initiated a **Nursing Research      |
| Council**, which now meets monthly, with representatives from each    |
| ward in the hospital, primary and specialty care clinics, and senior  |
| nursing educators and administrators, with Dr. McConnell as research  |
| consultant.                                                           |
+-----------------------------------------------------------------------+
| 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.)*                                                   |
|                                                                       |
| -   All outcomes were realized in the previous year.                  |
+-----------------------------------------------------------------------+