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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2007]{.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}. The **"Report Year"** is from [October 1,  |
| 2006 through September 30, 2007]{.underline}.                         |
|                                                                       |
| You are welcome to use this report format for your own internal       |
| reporting purposes,                                                   |
|                                                                       |
| in which case you may exceed the recommended limits of numbers of     |
| responses and their length                                            |
|                                                                       |
| ("list no more than..." "Describe the three most important..." "limit |
| your response to five lines or fewer")                                |
|                                                                       |
| ***\-\--BUT\--***                                                     |
|                                                                       |
| [Please limit **to ten pages or fewer** the version **SUBMITTED TO    |
| VACO** **.**]{.mark}                                                  |
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| **\*[GRECC Core Staff ]{.underline}**is limited to either **Primary   |
| Core**, **Affiliated Core**, or **Research Core**:                    |
|                                                                       |
| -   **Primary Core =** positions authorized by the original GRECC     |
|     allocation plus any addition in ceiling from VA Central Office    |
|     specifically designated for GRECC.                                |
|                                                                       |
| -   **Affiliated Core** = Staff who work full- or part-time in        |
|     [direct support]{.underline} of the GRECC's research, education   |
|     or clinical activity.                                             |
|                                                                       |
|     -   May be either "contributed" by the VA Medical Center or       |
|                                                                       |
|     -   May have been acquired through centralized                    |
|         enhancements/awards for programs\                             |
|         (e.g., Home-Based Primary Care, Geriatric Evaluation and      |
|         Management Program, etc.)                                     |
|                                                                       |
|     -   To be considered Affiliated Core, staff must be               |
|         organizationally aligned under the GRECC or specifically      |
|         identified by the Medical Center as **"GRECC-affiliated       |
|         staff."**                                                     |
|                                                                       |
| -   **Research Core** = Full-or part-time staff who devote 51% or     |
|     more of their total time to GRECC research and whose salaries are |
|     supported by research funds (either VA or non-VA). Includes all   |
|     GRECC staff whose salaries are paid from research funds, e.g.:    |
|                                                                       |
|     -   Associate Investigator                                        |
|                                                                       |
|     -   Assistant Research Scientist                                  |
|                                                                       |
|     -   Senior Research Career Scientist                              |
|                                                                       |
|     -   Research Career Scientist                                     |
|                                                                       |
|     -   Advanced Research Career Scientist.                           |
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| **[IMPORTANT:]{.underline} Throughout this report, please             |
| AVOID/MINIMIZE JARGON. Each response is much more likely to be        |
| included in secondary communications derived from the Annual Reports  |
| if it can be readily understood by a non-technical readership.**      |
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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** Miami GRECC                                       |
|                                                                       |
| b.  **Location** *(facility, VISN)*: Miami VA Healthcare System, VISN |
|     8                                                                 |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Debbie Berngard                                         |
|                                                                       |
| b.  **Position:** Administrative Officer                              |
|                                                                       |
| c.  **Phone, e-mail:** 305-575-3388, debbie.berngard@va.gov           |
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+----------------------------------------------------------+---+---+---+---+
| **3. GRECC FOCUS AREA(S)**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **NOTE:** Please succinctly list your GRECC's Focus      |   |   |   |   |
| Area(s), one per line below. After each focus area       |   |   |   |   |
| listed, please indicate with a check mark (****) which  |   |   |   |   |
| of the research type(s) suitably describes the work      |   |   |   |   |
| conducted (including planning, implementation, analysis, |   |   |   |   |
| and dissemination/publication) within that focus during  |   |   |   |   |
| the Report Year. Add additional lines by positioning     |   |   |   |   |
| your cursor at the lower right side of the table and     |   |   |   |   |
| striking the "Tab" key.                                  |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **GRECC Focus Area**                                     | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | R |   |   |   |
|                                                          | e |   |   |   |
|                                                          | s |   |   |   |
|                                                          | e |   |   |   |
|                                                          | a |   |   |   |
|                                                          | r |   |   |   |
|                                                          | c |   |   |   |
|                                                          | h |   |   |   |
|                                                          | T |   |   |   |
|                                                          | y |   |   |   |
|                                                          | p |   |   |   |
|                                                          | e |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
|                                                          | > | > | > | > |
|                                                          |   |   |   |   |
|                                                          | * | * | * | * |
|                                                          | * | * | * | * |
|                                                          | B | A | H | R |
|                                                          | a | p | e | e |
|                                                          | s | p | a | h |
|                                                          | i | l | l | a |
|                                                          | c | i | t | b |
|                                                          | > | e | h | i |
|                                                          |   | d | > | l |
|                                                          | B | > |   | i |
|                                                          | i |   | S | t |
|                                                          | o | C | e | a |
|                                                          | m | l | e | t |
|                                                          | e | i | r | i |
|                                                          | d | n | v | o |
|                                                          | i | i | i | n |
|                                                          | c | c | c | * |
|                                                          | a | a | e | * |
|                                                          | l | l | s |   |
|                                                          | * | * | * |   |
|                                                          | * | * | * |   |
+----------------------------------------------------------+---+---+---+---+
| Bone and cartilage metabolism                            | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Neurodegeneration                                        | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Prostate neoplasia                                       | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Reparative use of adult stem cells                       | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Osteoporosis and osteoarthritis                          |   | * |   |   |
|                                                          |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Metabolic syndrome, diabetes, and cardiovascular risk    |   | * |   |   |
| factors                                                  |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Frailty                                                  |   | * | * |   |
|                                                          |   | * | * |   |
|                                                          |   | X | X |   |
|                                                          |   | * | * |   |
|                                                          |   | * | * |   |
+----------------------------------------------------------+---+---+---+---+
| Vitamin D and soy isoflavones                            |   | * |   |   |
|                                                          |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Telehealth and care coordination for high utilizers      |   |   | * |   |
|                                                          |   |   | * |   |
|                                                          |   |   | X |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| Clinical decision support systems                        |   |   | * |   |
|                                                          |   |   | * |   |
|                                                          |   |   | X |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| Prevention (MOVE, frailty, diabetes)                     |   |   | * |   |
|                                                          |   |   | * |   |
|                                                          |   |   | X |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| Falls and injuries                                       |   |   |   | * |
|                                                          |   |   |   | * |
|                                                          |   |   |   | X |
|                                                          |   |   |   | * |
|                                                          |   |   |   | * |
+----------------------------------------------------------+---+---+---+---+
| Exercise interventions                                   |   |   |   | * |
|                                                          |   |   |   | * |
|                                                          |   |   |   | X |
|                                                          |   |   |   | * |
|                                                          |   |   |   | * |
+----------------------------------------------------------+---+---+---+---+

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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Report Year***: list **the**       |
|     **most important ways** in which the GRECC has had specific       |
|     impact on **host VAMC's** research, staff education, program      |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VAMC) during the Report Year. **Please     |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   The Metabolic Syndrome Clinic, initiated in April 2007, provides  |
|     comprehensive metabolic screening and intervention for all MOVE   |
|     (Management of Overweight/Obesity in Veterans Everywhere)         |
|     patients and increases opportunities for patients\'               |
|     self-management of disease. The clinic supports the monitoring of |
|     blood pressure, other cardiovascular risks, and diabetes          |
|     indicators.                                                       |
|                                                                       |
| -   GRECC\'s prescriptive exercise program in the Nursing Home is a   |
|     diagnosis/prescription model to determine the patient\'s specific |
|     functional limitations and then to provide a targeted exercise    |
|     prescription addressing the patient's functional deficits and     |
|     provide better and safer mobility.                                |
|                                                                       |
| -   The nurse educator in long-term care and nursing administration   |
|     have reviewed the available training modules on GeriU. Nursing    |
|     staff are currently using some of the modules and this fiscal     |
|     year all nursing service long-term staff are required to review   |
|     the GeriU online program titled "Approaches to Older Persons Who  |
|     Have Fallen" as part of their quality improvement activities on   |
|     patient safety.                                                   |
|                                                                       |
| -   The provision of Geriatrics Grand Rounds has provided medical     |
|     center staff with nationally recognized visiting experts in       |
|     clinical, scientific, policy, and research aspects of geriatrics  |
|     and gerontology who have also provided critique and advice for    |
|     our geriatrics activities.                                        |
|                                                                       |
| -   Dr. Florez was a leader of the diabetes performance improvement   |
|     measure for the medical center. Under his leadership the medical  |
|     center improved performance measures on glycemic control, annual  |
|     retinopathy screening, and neuropathy screening. He just received |
|     approval for an Insulin Titration Clinic to improve glycemic      |
|     control in veterans with diabetes who need to be started on       |
|     insulin.                                                          |
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| b.  **GRECC Impact on VISN in the Report Year:** *list **the** **most |
|     important ways** in which the GRECC has had specific impact on    |
|     the **host** **VISN's** research, staff education, program        |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VISN) during the rating period. **Please   |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   To strengthen the interactions and input from the GRECC in        |
|     geriatrics education and QI, our education director has been      |
|     assigned to the VISN 8 Education Council, and other GRECC leaders |
|     have joined the Primary Care and Extended Care committees.        |
|                                                                       |
| -   Four statewide PICs (Performance Improvement Curricula)           |
|     conferences were conducted near 4 large population centers        |
|     (Miami, Tampa, Jacksonville, and Orlando). At these conferences,  |
|     module-based (DVD and/or online) training in assessing pain,      |
|     prevention of falls, understanding depression in dementia, and    |
|     Alzheimer's disease were demonstrated to administrators,          |
|     trainers, and educators to institute the training for staff in    |
|     their own long-term care facilities.                              |
|                                                                       |
| -   Partnership with the state's Teaching Nursing Home continues to   |
|     produce strong statewide linkages and educational products. We    |
|     have developed new online modules, available to all VISN staff,   |
|     on Culture Change in Dining, Confusion Assessment Method (CAM),   |
|     Urinary Incontinence & Overactive Bladder, and Physician/Nurse    |
|     Communication.                                                    |
|                                                                       |
| -   GRECC staff spoke at the FAHSA (Florida Association of Homes and  |
|     Services for the Aging) annual meeting about what is available in |
|     educational best practices. This included a description and       |
|     demonstration of materials available for teaching dementia,       |
|     depression, and culture change through dining to staff in the     |
|     long-term care environment.                                       |
|                                                                       |
| -   In addition, also during the FAHSA meeting we initiated the       |
|     development of ACE (Academy of Clinical Educators) in long-term   |
|     care. This program is based on a needs analysis of training needs |
|     in long-term care throughout the state. Educators at individual   |
|     nursing homes will form groups of 5-6 and select an existing      |
|     training module for improvement. They will work together to       |
|     create an educational best practice in their chosen topic and     |
|     share the final result. We have obtained a list of volunteers to  |
|     begin the program.                                                |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2002]{.underline}**: *list **the** **most significant** GRECC    |
|     research, education or clinical innovations in the past five      |
|     years. For each item, provide date or date range, GRECC core      |
|     staff responsible, and a description. **Please limit your         |
|     response to 5 or fewer innovations; and please limit each of the  |
|     five innovation descriptions to five lines or fewer. ***          |
|                                                                       |
| -   [Isolation and characterization of a unique population of stem    |
|     cells, the MIAMI cells, for reparative medicine]{.underline};     |
|     2004-07, responsible staff: PC Schiller, GA Howard, G D'Ippolito, |
|     HS Cheung, BA Roos                                                |
|                                                                       |
| > The team has defined a subpopulation of adult stem cells derived    |
| > from bone marrow ([m]{.underline}arrow-[i]{.underline}solated       |
| > [a]{.underline}dult [m]{.underline}ultilineage                      |
| > [i]{.underline}nducible \[MIAMI\] cells) for studies of skeletal,   |
| > cardiac, and neural tissue repair and regeneration. Extramural      |
| > support is being finalized for pre-clinical studies using the MIAMI |
| > cells.                                                              |
|                                                                       |
| -   [Just-in-Time Education for Pain]{.underline}; 2006; responsible  |
|     staff: JG Ruiz, BA Roos                                           |
|                                                                       |
| GRECC leadership has designed and implemented a major VA-based        |
| innovation in performance improvement -- just-in-time education on    |
| pain delivered to VA physicians, based on pain assessment and         |
| management performance measures. Success in improving physicians'     |
| pain-related performance measures will open the way to data-driven    |
| training approaches for improving clinical performance in other       |
| areas.                                                                |
|                                                                       |
| -   [Establishment of The Geriatrics Institute, based within the      |
|     Miami GRECC]{.underline}; 2003; responsible staff: BA Roos, JG    |
|     Ruiz, MJ Mintzer, GA Howard                                       |
|                                                                       |
| > Under this umbrella we have been awarded a multi-million dollar     |
| > grant from the Donald W. Reynolds Foundation to develop a           |
| > competency-based curriculum in geriatric syndromes, with a focus on |
| > the effectiveness of learning by medical students and residents.    |
|                                                                       |
| -   [A Novel Methodology to Identify and Measure Calcium Crystals in  |
|     Arthritic Synovial Fluids]{.underline}; 2006; responsible staff:  |
|     HS Cheung                                                         |
|                                                                       |
| A VA patent was filed for this invention by Dr. Cheung for an assay   |
| used as a diagnostic tool of arthritic disease.                       |
|                                                                       |
| -   [Identification of a Protein Receptor That Stimulates Growth in a |
|     Variety of Cancers]{.underline}; 2007; responsible staff: AV      |
|     Schally                                                           |
|                                                                       |
| > New research showed that a protein receptor activated by a growth   |
| > hormone plays a key role in the growth of a variety of cancers.     |
| > This could have a major impact on cancers that are fueled by        |
| > hormones, like most breast and prostate cancers.                    |
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| **5. RESEARCH**                                                       |
+-----------------------------------------------------------------------+
| **a. Key Findings Published in the Report Year on projects for which  |
| GRECC Core Staff was PI or Co-PI:\                                    |
| ***list **five or fewer;** for each item provide GRECC Core Staff     |
| name(s), journal reference, and description of topic/                 |
| method/results/clinical significance.* *Please limit each response to |
| [5 lines or fewer]{.underline}.*                                      |
|                                                                       |
| -   Howard GA, et al. Unlocking the mysteries of adult stem cells and |
|     regenerative medicine. *Fed Pract* 24:30-37, 2007. GRECC Core     |
|     Staff: GA Howard, G. D'Ippolito, PC Schiller, HS Cheung, BR       |
|     Troen, BA Roos. We report that our isolated subpopulation of      |
|     adult marrow-derived stem cells \[MIAMI cells\] are capable of    |
|     being functioning osteoblasts, chondrocytes, and neuronal cells   |
|     for reparative medicine. Pre-clinical animal studies are being    |
|     done for repair of cardiac function with these cells.             |
|                                                                       |
| -   Tatard VM, et al. Neurotrophin-directed differentiation of human  |
|     adult marrow stromal cells to dopaminergic-like neurons. *Bone*   |
|     40:360-373, 2007. GRECC Core Staff: G D'Ippolito, PC Schiller, J  |
|     Hackman. MIAMI cells were differentiated in vitro to neuronal     |
|     cells in a neurotrophin-dependent fashion. The cells had          |
|     electrophysiological features of mature neurons. Expression of    |
|     molecules involved in dopaminergic differentiation and of         |
|     tyrosine hydroxylase were also shown.                             |
|                                                                       |
| -   Gomez LA, et al. Increased expression of cyclin B1 sensitizes     |
|     prostate cancer cells to apoptosis induced by chemotherapy. *Mol  |
|     Cancer Ther* 6:1534-1543, 2007. We show a positive correlation    |
|     between cyclin B1 protein and apoptosis induced by chemotherapy   |
|     in prostate cancer cells. There is minimal cyclin B1 and          |
|     induction of apoptosis by chemotherapy in nontransformed cells.   |
|     Results suggest higher levels of cyclin B1 in prostate cancer     |
|     cells may be a good marker for chemotherapy.                      |
|                                                                       |
| -   Pang M, et al. AP-1 stimulates the cathepsin K promoter in RAW    |
|     264.7 cells. *Gene* 403:151-158, 2007. GRECC Core Staff: W        |
|     Balkan, BR Troen. Cathepsin K (CTSK) is a secreted protease that  |
|     is essential for bone resorption. Critical regulators of the      |
|     resorption act via the AP-1 signaling pathway. siRNA targeted     |
|     against c-jun or junB suppressed CTSK expression. Results show    |
|     that AP-1 helps regulate the basal and RANKL-mediated stimulation |
|     of CTSK gene expression in RAW 264.7 cells.                       |
|                                                                       |
| -   Florez H, et al. Outdoor exercise reduces the risk of             |
|     hypovitaminosis D in the obese. *J Steroid Biochem Mol Biol*      |
|     103:679-681, 2007. GRECC Core Staff: H Florez, S Levis. Obesity   |
|     is associated with lower levels of serum 25-hydroxyvitamin D.     |
|     After adjusting for age, gender, and ethnicity, subjects          |
|     reporting outdoor exercise were 47% less likely to have           |
|     hypovitaminosis D, while those with obesity had more than twice   |
|     the risk.                                                         |
+-----------------------------------------------------------------------+
| **b. Key Findings Published in the Report Year on work in which GRECC |
| Core Staff served as Co-Investigators to a Non-GRECC PI: *5 or        |
| fewer****; for each item provide GRECC Core Staff name(s), journal    |
| ref-erence, and description of topic/method/results/clinical          |
| significance. Please limit each response to [5 lines or               |
| fewer]{.underline}.*                                                  |
|                                                                       |
| -   Panickar KS, et al. Downregulation of the 18-kDa translocator     |
|     protein: effects on the ammonia-induced mitochondrial             |
|     permeability transition and cell swelling in cultured astrocytes. |
|     *Glia* 55:1720-1727, 2007. GRECC Core Staff: MD Norenberg. In     |
|     hepatic encephalopathy astrocyte ammonia levels are a major       |
|     factor, with upregulation of outer michondrial membrane 18-kDa    |
|     translocator protein. Our in vitro findings highlight the         |
|     important role of the TSPO in the mechanism of ammonia            |
|     neurotoxicity.                                                    |
|                                                                       |
| -   Sotomayor S, et al. Transactivation of HER2 by vasoactive         |
|     intestinal peptide in experimental prostate cancer: antagonistic  |
|     action of an analog of growth-hormone-releasing hormone. *Int J   |
|     Oncol* 31:1223-1230, 2007. GRECC Core Staff: AV Schally. Studies  |
|     with growth-hormone-releasing hormone analogs endowed with        |
|     antagonistic activity for vasoactive intestinal peptide (VIP)     |
|     receptors in prostate cancer cell lines support their potential   |
|     usefulness for prostate cancer therapy.                           |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Burgos M, et al. P2Y(2) nucleotide receptors inhibit              |
|     trauma-induced death of astrocytic cells. *J Neurochem*           |
|     10.1111/j.1471-4159.207.04872.x. GRECC Core Staff: JT Neary.      |
|     Nucleotides as well as other neurotransmitters are known to be    |
|     released to the extracellular space upon injury. Our results      |
|     demonstrate a novel role for P2Y(2) nucleotide receptors and      |
|     extracellular nucleotides in mediating survival responses to      |
|     glial cells undergoing cellular death induced by trauma.          |
|                                                                       |
| -   Huang, C-YC, et al. Effects of fibrinolytic inhibitors on         |
|     chrondrogenesis of bone-marrow derived mesenchymal stem cells in  |
|     fibrin gels. *Biomech Model Mechanobiol* 6:5-11, 2007. GRECC Core |
|     Staff: HS Cheung. The findings suggest that fibrinolytic          |
|     inhibitors used to control degradation of fibrin clots may        |
|     influence transforming growth factor-beta-induced chondrogenesis  |
|     of bone-marrow derived MSCs.                                      |
+-----------------------------------------------------------------------+
| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| **NOTE**: **DO NOT** list trainee and conference data                 |
| here**\--**those data are reported in the GRECC Electronic Database.  |
|                                                                       |
| **NOTE:** You may list educational activities here even if they were  |
| supported by funds that qualified for inclusion in the ePROMISE       |
| (RDIS) database if you wish.                                          |
+-----------------------------------------------------------------------+
| a.  **Innovations in Educational Activities Implemented during the    |
|     Report Year** *(list five or fewer. Please limit each item to [5  |
|     lines or fewer]{.underline} and include clarification of how each |
|     activity is innovative.)*                                         |
|                                                                       |
| -   Urinary Incontinence and Overactive Bladder in Older Adults       |
|     Program: Diagnosis, Web-based module: This is an interactive,     |
|     Web-based, multimedia educational program on UI for medical       |
|     professionals and trainees. The project focuses on 4 aims: (1)    |
|     compiling state-of-the-art and up-to-date educational content on  |
|     UI and overactive bladder; (2) developing specifications for      |
|     producing interactive, multimedia, e-learning; (3) designing and  |
|     creating e-learning modules based on those specifications;        |
|     and (4) evaluating the educational impact.                        |
|                                                                       |
| -   *GeriU*: *GeriU* (www.geriu.org) continues its role as an online  |
|     learning-management system to facilitate geriatrics curriculum    |
|     delivery and related scheduling, communications, and tracking of  |
|     attendance and performance (for UME and GME instructors and       |
|     learners). As more curricular activities go online, we have       |
|     noticed improved learning experiences in the ward and nursing     |
|     home settings. We are concentrating on designing, developing, and |
|     implementing blended-learning courses for professionals and       |
|     trainees.                                                         |
|                                                                       |
| -   Geriatric Assessment Ultralite PDA tools: We have created quick   |
|     decision support tools for the PDA including ADLS-IADLS,          |
|     Mini-Cog, SIGECAPS, PUSH tool.                                    |
|                                                                       |
| -   Geriatric Medicine Fellows OSCE: For the first time we have       |
|     implemented an objective structured clinical examination for the  |
|     fellows. Six months into training, a 16-station OSCE was          |
|     administered to the fellows. Three stations utilized real         |
|     patients to determine competency in common geriatric assessment   |
|     tools and interactions. Six stations focused on communication     |
|     skills with standardized patients; the remaining seven stations   |
|     focused on clinical reasoning in common geriatric syndromes,      |
|     assessing skills using computer-based clinical vignettes.         |
|                                                                       |
| -   GRECC Audioconferences: Our team has collaborated with Ken Shay   |
|     and POGOe in the conversion of the monthly GRECC audioconference  |
|     content to MP3 audio files and computer-based tutorials in which  |
|     the presenter's voice is synchronized with slides for future      |
|     delivery using Articulate. These materials are widely available   |
|     at <http://www.pogoe.org/grecc>.                                  |
+-----------------------------------------------------------------------+
| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year** *List five or fewer of the most     |
|     important products. For each item, limit the response to five     |
|     lines summarizing content, target audience, format, and product   |
|     evaluation plan and results. **Include educational products       |
|     developed in previous years ONLY if this is the [first            |
|     year]{.underline} they have been available for distribution.***   |
|                                                                       |
| -   Introduction to Geriatric Incontinence and the Overactive Bladder |
|     Diagnosis, Web based module: This module covers the relevant      |
|     anatomy, physiology, age-related changes, and classification of   |
|     urinary incontinence using multimedia elements. The target        |
|     audience is medical students, primary care residents, geriatric   |
|     medicine fellows, primary care physicians, nurse practitioners,   |
|     and physician assistants. The plan for evaluation is to use the   |
|     Web-based computer assessment: multiple-choice question exam (see |
|     below).                                                           |
|                                                                       |
| -   Assessment and Diagnostic Evaluation of Geriatric Incontinence    |
|     and the Overactive Bladder, Web-based module: This module covers  |
|     the history, physical exam, and diagnostic tests in older         |
|     patients suffering from urinary incontinence and overactive       |
|     bladder. The target audience is medical students, primary care    |
|     residents, geriatric medicine fellows, primary care physicians,   |
|     nurse practitioners, and physician assistants. The plan for       |
|     evaluation is to use the Web-based computer assessment:           |
|     multiple-choice question exam (see below).                        |
|                                                                       |
| -   Treatment & Management of Geriatric Incontinence and the          |
|     Overactive Bladder, Web-based module: this module covers          |
|     behavioral interventions, drug therapies, surgical and invasive   |
|     therapies, catheters and catheterization procedures, and other    |
|     treatment options. The target audience is medical students,       |
|     primary care residents, geriatric medicine fellows, primary care  |
|     physicians, nurse practitioners, and physician assistants. The    |
|     plan for evaluation is to use the Web-based computer assessment:  |
|     multiple-choice question exam (see below).                        |
|                                                                       |
| -   Virtual Patients, Urinary Incontinence and Overactive Bladder in  |
|     Older Adults, Web-based module: Virtual patients (VPs) are        |
|     computer-based programs that simulate real-life clinical          |
|     scenarios in which the learner acts as a health-care professional |
|     obtaining a history and physical exam and making diagnostic and   |
|     therapeutic decisions. These VPs represent the practice section   |
|     for the Urinary Incontinence and Overactive Bladder in Older      |
|     Adults program and represent a case mix of UI in a variety of     |
|     geriatric patients and practice settings.                         |
|                                                                       |
| -   Urinary Incontinence and Overactive Bladder in Older Adults,      |
|     Web-based computer-assessment (multiple- choice question exam and |
|     script concordance tests): This summative evaluation contains     |
|     multiple-choice questions designed to assess learners' mastery of |
|     the content of the UI e-learning modules. We have also developed  |
|     a set of over 120 script concordance test (SCT) questions. The    |
|     SCT is a test with construct validity aimed at measuring clinical |
|     reasoning.                                                        |
+-----------------------------------------------------------------------+
| c\. **Educational programs offered by your GRECC during the report    |
| year that were evaluated for impact, as described in                  |
| <http://vaww1.va.gov/grecc/docs/2007Measuresinstructions102506.doc>   |
| for Performance Measure 7.** *Describe at least **TWO**, each of      |
| which had at least 25 participants: one in which the majority of      |
| participants was from your GRECC's host facility; and one in which    |
| the majority of participants were from VAs other than your GRECC's    |
| host facility. For each, describe the educational intervention        |
| briefly and then the evaluation, including in your description of the |
| latter the evaluation methodology, findings, and conclusions. Limit   |
| your description of each intervention and its evaluation to one-half  |
| page.*                                                                |
|                                                                       |
| -   **Geriatrics Training Program to Miami VA Healthcare System --    |
|     [VA Culture Change in Long-Term Care]{.underline}, July 26,       |
|     2007**                                                            |
|                                                                       |
| The presenter was Dr. Enrique Aguilar, the Associate Chief of Staff   |
| for Extended Care/Geriatrics at the Miami VAMC. He explained the      |
| difference between a medical model of nursing home care and the       |
| transformed culture that focuses on resident center care and          |
| nurturing. He also described the barriers to transforming culture in  |
| nursing home facilities in the VA. Dr. Aguilar presented the key      |
| components of a homelike nursing home environment and identified the  |
| benefits and expected outcomes for staff and residents of transformed |
| culture in long-term-care facilities.                                 |
|                                                                       |
| 1.  Participants: 31 attendees from Miami VA                          |
|                                                                       |
| 2.  A program evaluation was completed at the end of the program by   |
|     at least 50% of participants: 90% of attendees completed the      |
|     program evaluation.                                               |
|                                                                       |
| 3.  A secondary evaluation of the program objectives: we are in the   |
|     process of mailing a new set of evaluations to the participants.  |
|                                                                       |
| 4.  A description of the evaluation, including the methodology,       |
|     findings and conclusions: We evaluated the session through the    |
|     use of survey with a Likert scale (strongly agree, agree,         |
|     disagree, and strongly disagree) addressing the four objectives   |
|     of the presentation. The survey was distributed at the end of the |
|     presentation to all participants. We found that over 90% of the   |
|     attendees at least agreed or strongly agreed that they met the    |
|     learning objectives of the talk. 90% of the attendees thought     |
|     that the material was relevant and well presented, stating that   |
|     they gained a clearer understanding of the topic and that the     |
|     information was applicable to their practice.                     |
|                                                                       |
| -   **Geriatrics Training Outreach to West Palm Beach VA --           |
|     [Polypharmacy/Prescribing in the Elderly]{.underline}: August 9,  |
|     2007**                                                            |
|                                                                       |
| The presenter was Dr. Robert Kaiser, GRECC Investigator. Dr. Kaiser   |
| is a national expert in the field of geriatric drug prescribing. He   |
| described the definitions and prevalence of polypharmacy. He also     |
| discussed the predisposing factors and risk of polypharmacy in older  |
| adults. During his talk he proposed methods for reducing              |
| inappropriate prescribing and polypharmacy in medical practice.       |
|                                                                       |
| a.  Participants: 29 attendees from Palm Beach VA                     |
|                                                                       |
| b.  A program evaluation was completed at the end of the program by   |
|     at least 50% of participants: 48% of attendees completed the      |
|     program evaluation.                                               |
|                                                                       |
| c.  A secondary evaluation of the program objectives: we are in the   |
|     process of mailing a new set of evaluations to the participants.  |
|                                                                       |
| d.  A description of the evaluation, including the methodology,       |
|     findings, and conclusions: We evaluated the session through the   |
|     use of survey with a Likert scale (excellent, good, satisfactory, |
|     and poor) addressing the two main objectives and the quality of   |
|     instruction, materials, and speaker. The survey was distributed   |
|     at the end of the presentation to all participants. The findings  |
|     were that 93% of respondents thought the qualifications and       |
|     effectiveness of the speaker were good or excellent, 79% thought  |
|     that the quality of instruction was good or excellent, and 86%    |
|     thought the quality of audiovisuals and handouts was good or      |
|     excellent.                                                        |
+-----------------------------------------------------------------------+
| **7. CLINICAL DEMONSTRATION PROJECTS**                                |
+-----------------------------------------------------------------------+
| **NOTE:** A clinical demonstration [program]{.underline} is defined   |
| as:                                                                   |
|                                                                       |
| -   an ongoing, clinical, cooperative collaboration between the GRECC |
|     and host VA medical center;                                       |
|                                                                       |
| -   that carries out and evaluates assessment strategies, management  |
|     approaches and/or specialized investigations                      |
|                                                                       |
| -   of a targeted or focused group of elderly patients                |
|                                                                       |
| -   with the intention that findings will be disseminated for the     |
|     advancement of the field.                                         |
|                                                                       |
| A clinical demonstration program is comprised of one or more clinical |
| demonstration [projects]{.underline}, each of which is defined as     |
|                                                                       |
| -   a set of one or more clinical activities                          |
|                                                                       |
| -   integrated and coordinated under a specified protocol             |
|                                                                       |
| -   designed to permit evaluation(s) of processes and/or outcomes.    |
|                                                                       |
| Evaluation of a clinical demonstration program may be a comprehensive |
| assessment of the activity and/or the clinical outcomes.              |
| Alternatively, evaluation may concentrate on a prioritized and        |
| feasible set of more focused or specific, project-related questions,  |
| e.g. related to improved diagnosis, quality of care, patient          |
| satisfaction, drug compliance, functional status, etc.  Ongoing and   |
| subsequent modifications of the care model may also be evaluated as   |
| may be the practicability and outcomes of exporting new clinical      |
| models or variations of models to general care settings and/or        |
| smaller, more resource-limited VA medical centers or outpatient       |
| facilities.                                                           |
+-----------------------------------------------------------------------+
| a.  **Clinical Demonstration Projects Underway in Report Year***:     |
|     list **all** GRECC Clinical Demonstration Projects underway. For  |
|     each item, indicate whether [N]{.underline}ew or                  |
|     [O]{.underline}ngoing in Report Year. You may include up to five  |
|     lines of descriptive text for each Project.\                      |
|     *                                                                 |
|                                                                       |
| > **NOTE:** The number of Projects listed should be equal to the      |
| > number of Clinical Demonstration Projects you have listed and named |
| > in the GRECC Electronic Database.                                   |
|                                                                       |
| -   New: A [Computer-Based Clinical Decision Support                  |
|     System]{.underline} was initiated to provide training and a       |
|     point-of-care computer-based clinical decision support system was |
|     provided as part of CPRS for pain management for primary care     |
|     physicians.                                                       |
|                                                                       |
| -   Ongoing: The [Telephone-Linked Computer System (TLC) for Dementia |
|     Care]{.underline} is a technology-supported care-coordination     |
|     program for caregivers of home-dwelling veterans with dementia    |
|     aimed at increasing caregiver competence, reducing caregiver      |
|     burden, and improving quality-of-life and health-care outcomes by |
|     providing education about dementia and support via a system of    |
|     technology-based care coordination.                               |
|                                                                       |
| -   Ongoing: [T-Care]{.underline} is a telehealth care coordination   |
|     program providing care coordination, education, and support to    |
|     patients with chronic illnesses for better management of patients |
|     in their home. It is an integration of low-cost telemedicine      |
|     components utilizing a Health Buddy system into a                 |
|     care-coordination approach for management of chronically ill      |
|     patients in their homes.                                          |
|                                                                       |
| -   Ongoing: The [Geriatric Primary Care Clinic (GPCC)]{.underline}   |
|     serves as an education and research venue for fellows and other   |
|     health-care personnel. Each of the GRECC's geriatric medicine     |
|     fellows attends a weekly 1-day clinic and is assigned a cohort of |
|     patients and a related research project. Besides being the        |
|     fellow's continuity clinic throughout the fellowship, the GPCC is |
|     a venue for research by fellows and staff. Recent studies looked  |
|     at trends in the use of complementary and alternative medicine in |
|     south Florida.                                                    |
+-----------------------------------------------------------------------+
| b.  **Evaluation of Clinical Demonstration Projects:** *for each      |
|     GRECC Clinical Demonstration Project listed in 7a above,          |
|     summarize the evaluation activity. If no evaluation results are   |
|     available, be explicit as to the focus of the planned evaluation, |
|     and when it is anticipated to occur. If the project has been      |
|     completed during the Report Year, provide key findings and their  |
|     significance.*\                                                   |
|     \                                                                 |
|     **NOTE:** Do not list patient service use data here. Those data   |
|     are reported in the GRECC Electronic Database.                    |
|                                                                       |
| -   [Computer-Based Clinical Decision Support System:]{.underline} A  |
|     qualitative needs assessment of primary care practitioners (PCPs) |
|     managing chronic nonmalignant pain in elderly veterans was        |
|     undertaken. It was found that PCPs are moderately comfortable     |
|     managing these patients but are particularly concerned about the  |
|     current CPRS-based point-of-care support, which they see focused  |
|     on documentation of performance measures rather than true         |
|     clinical support to assist them in the care of veterans.          |
|                                                                       |
| -   [Telephone-Linked Computer System (TLC) for Dementia              |
|     Care:]{.underline} In a quasi-experimental design, the TLC        |
|     program has shown that care coordination blended with technology  |
|     showed an improvement in caregiver burden over a 12-month period  |
|     using the Zarit Burden Interview. A patient satisfaction survey   |
|     indicated that 85% of the TLC patients would refer this program   |
|     to others. Hospital bed days of care (BDOC) were reduced by 75%;  |
|     nursing home BDOC were reduced by 62%; clinic visits decreased    |
|     51%; ER visits decreased 47%, therefore showing the program's     |
|     potential to impact health-care utilization costs in dementia     |
|     patients.                                                         |
|                                                                       |
| -   [T-Care:]{.underline} In a quasi-experimental study design,       |
|     T-Care has been shown to reduce hemoglobin A1c in diabetics and   |
|     blood pressure in hypertensive patients. It is likely responsible |
|     for a reduction in health-care utilization and therefore cost for |
|     the medical services in the VHA system.                           |
|                                                                       |
| -   [Geriatric Primary Care Clinic (GPCC):]{.underline} The           |
|     effectiveness and safety of vitamin D supplementation in elderly  |
|     veterans were examined in GPCC patients. 25‑OH vitamin D levels,  |
|     PTH, serum and urine calcium were measured at baseline, one,      |
|     three, and six months to determine the effect of vitamin D        |
|     supplementation. At 6 months, the prevalence of hypovitaminosis D |
|     increased in the placebo group from 52% to 82%, and decreased     |
|     from 47% to 18% in the treatment group. Cholecalciferol 2,000     |
|     IU/day is safe and significantly reduces the prevalence of HVD in |
|     elderly men. Further study is required to characterize the        |
|     optimal supplementation with vitamin D.                           |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models developed at your GRECC that were exported  |
|     in the Report Year** *(list up to five examples, up to two lines  |
|     each; 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"):*           |
|                                                                       |
| -   Our MOVE -- metabolic syndrome clinic is being used as a model    |
|     for implementation of MOVE level 3 at the VISN 8 level.           |
+-----------------------------------------------------------------------+
| **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, up |
|     to two lines each; summarize specific outcomes realized from      |
|     current year **consultation**, e.g., "Host VAMC instituted a      |
|     Falls Clinic after consultation from GRECC staff;" or             |
|     **outreach**, e.g., [X]{.underline} VAMC instituted a Falls       |
|     Clinic after GRECC outreach via series of videoconferences):*     |
|                                                                       |
| -   POGOe: We have completed the redesigning of the POGOe Web site, a |
|     clearinghouse of educational resources for geriatrics educators.  |
|     The new site will go public October 2007.                         |
|                                                                       |
| -   GRECC investigators (Cheung and Troen) were contacted by VACO as  |
|     subject experts in arthritis and osteoporosis, respectively, to   |
|     provide a geriatrics slant for 2 articles in *US Medicine*        |
|     magazine (May 2007 issue).                                        |
|                                                                       |
| -   In collaboration with the Gainesville GRECC, a geriatrics         |
|     educational needs assessment is being completed for VISN 8. The   |
|     Extended Care Advisory Group is working with EES to do an online  |
|     survey of geriatric education needs in primary care.              |
|                                                                       |
| -   GRECC staff assisted in the exportation of the geriatric          |
|     curriculum to UM's branch campus in Boca Raton, FL. All the       |
|     geriatric content has been implemented within the branch campus   |
|     curriculum. With this year's new students, the curriculum will be |
|     delivered differently at the Boca site, which will require        |
|     revised implementation and integration of the geriatrics          |
|     material.                                                         |
|                                                                       |
| -   Dr. Mintzer participated on the steering committee in a national  |
|     effort to develop geriatric competencies for medical students     |
|     sponsored by the AAMC. Final competencies have been circulated at |
|     national meetings and they are planned to be published by the     |
|     AAMC early in 2008.                                               |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** *(list up to five         |
|     examples, up to two lines each; 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.)*                                                   |
|                                                                       |
| -   A competency-based curriculum module on urinary incontinence and  |
|     overactive bladder was completed in consultation with Dr.         |
|     Ouslander at Atlanta VAMC. The module is available on GeriU.      |
|                                                                       |
| -   GRECC staff completed the exportation of the geriatric medical    |
|     student curriculum at UM's branch campus at Florida International |
|     University in Boca Raton, FL.                                     |
|                                                                       |
| -   Long-term care nursing has instituted required viewing of several |
|     of our geriatrics training modules.                               |
|                                                                       |
| -   A White Paper from the MOVE national collaboration of GRECCs and  |
|     VAMCs on enhancing the MOVE program for the elderly in the VA has |
|     been finished, but has not yet been published.                    |
|                                                                       |
| -   National Geriatrics Meetings: GRECC programs and activities       |
|     continued to be disseminated through abstracts and presentations  |
|     at national meetings in 2007. The Miami GRECC staff planned and   |
|     organized the three GRECC symposia at the 2006 GSA meeting.       |
+-----------------------------------------------------------------------+