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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:** Bronx/New York Harbor                             |
|                                                                       |
| b.  **Location** *(facility, VISN)*: Bronx VAMC(526), VISN 03         |
|                                                                       |
| 130 West Kingsbridge Road, Bronx, NY, 10468                           |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Sarah Panepinto                                         |
|                                                                       |
| b.  **Position:** Administrative Officer (Act.)                       |
|                                                                       |
| c.  **Phone, e-mail:** (718) 584-9000 ext. 3803,                      |
|     sarah.panepinto@med.va.gov                                        |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **NOTE:** Each problem area should ideally be approached from the     |
| basic biomedical, clinical [and]{.underline} health services research |
| perspectives, as well as from the rehabilitation research perspective |
| where that expertise exists. The number of problem areas should be    |
| limited to one or two. If the focus of research is different for      |
| basic biomedical, clinical, health services and/or rehabilitation     |
| research, there should be no more than a [total]{.underline} of 4     |
| major areas of investigation. [Changes to GRECC focus area(s) must be |
| approved by VACO (114).]{.mark}                                       |
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| a.  **Basic Biomedical**: A research program focusing primarily in    |
|     proteomic and genomic research in geriatric palliative care. In   |
|     particular, the studies in Dr. Pasinetti's laboratory are         |
|     presently characterizing novel predicative biomarkers of          |
|     functional decline associated with frailty and pain among older   |
|     adults. The studies will provide a foundation for designing a     |
|     novel strategic plan aimed at improving quality of life and       |
|     independence in aging.                                            |
|                                                                       |
| b.  **Applied Clinical**: Improving palliative care for patients with |
|     advanced chronic illness and those near the end of life.          |
|     Prevention of functional disability from chronic diseases.        |
|     Improving process and outcomes during transitions between sites   |
|     of care.                                                          |
|                                                                       |
| c.  **Health Services**: (same as applied clinical).                  |
|                                                                       |
| d.  **Rehabilitation**: Not applicable.                               |
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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})*:           |
|                                                                       |
| -   Dr. Granieri started two new **Geriatrics specialty clinics** as  |
|     demonstration projects. Geriatrics-Neurology is now available to  |
|     our veterans and Geriatrics-Psychiatry outpatient clinic will be  |
|     opening in November; a geriatrician is available in the specialty |
|     outpatient clinics one half day per week to provide on-site       |
|     consultation for older veterans. Both clinics were started only a |
|     few months ago so little data is available for evaluative         |
|     purposes, however we have received good feedback both from        |
|     patients and professional staff in the clinics.                   |
|                                                                       |
| -   This year we recruited **more trainees** than ever before. Our    |
|     associated health trainee program has expanded from 9 to 12 this  |
|     year and our Interprofessional Palliative Care Fellowship has     |
|     expanded from 4 to 5 through additional funding from a non-VA     |
|     source.                                                           |
|                                                                       |
| -   A new **Basic Biomedical Research and Training Program** began    |
|     this year at our GRECC. Dr. Giulio Pasinetti and his colleagues   |
|     will be looking at the novel predictive biomarkers of functional  |
|     decline associated with frailty and pain.                         |
|                                                                       |
| -   An **outpatient palliative care clinic** was started this fiscal  |
|     year. To this point, all of our discharged palliative care        |
|     patients were followed by primary care providers who are not as   |
|     well equipped to care for the needs of this patient population.   |
|                                                                       |
| -   Several **junior and senior researchers were recruited** to the   |
|     GRECC in FY 2004. Notably: R. Sean Morrison, MD; Giulio           |
|     Pasinetti, MD, PhD; Carol Luhrs, MD; Lap Ho, PhD; and, Nathan     |
|     Goldstein, MD. This will expand the breadth and depth of the      |
|     GRECC research portfolio and will increase the funding streams    |
|     available to support additional GRECC staff.                      |
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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*)*:                                                |
|                                                                       |
| -   This year our GRECC held it's 4^th^ annual **multi-site video     |
|     conference** on emerging issues in aging. Through increased       |
|     interest and promotion of the videoconference, the number of      |
|     locations grew to 26 in 2004 across five VISNs including 2, 3, 5, |
|     10 and 11. Attendees represented participants from a range of     |
|     professions, of whom 70% were VA employees, as well as students   |
|     from New York City High Schools. This year the topic was,         |
|     Geriatric Mental Health and Disaster Preparedness: Mental Health  |
|     Interventions and Treatment Plans                                 |
|                                                                       |
| -   Much of the GRECC executive leadership is involved in the **VISN  |
|     3 Palliative Care Initiative.** Dr. Carol Luhrs, GRECC Core       |
|     Faculty and New York Harbor liaison is also the Director of the   |
|     VISN 3 initiative. Dr. Howe has collaborated with Dr. Luhrs on    |
|     the educational aspects initiative; Dr. Granieri has collaborated |
|     with Dr. Luhrs on the clinical rollout of palliative care         |
|     services; and Dr. Penrod has collaborated with Dr. Luhrs on the   |
|     research and evaluation aspects. The palliative care initiative   |
|     in VISN 3 is frequently referenced to as one of the model VA      |
|     programs in the nation.                                           |
|                                                                       |
| -   This year, the Bronx/New York Harbor GRECC has started **placing  |
|     associated health trainees to other sites within the VISN.**      |
|     GRECC educational staff coordinate recruitment of trainees and    |
|     preceptors in other sites in VISN 3. Preceptors provide clinical  |
|     teaching and trainees virtually attend (via videoconference)      |
|     Bronx/New York Harbor GRECC classes, noon conferences, and grand  |
|     rounds (when appropriate).                                        |
|                                                                       |
| -   **Dedicated palliative care beds** on nursing home care units,    |
|     one of the original clinical demonstration projects, have been    |
|     exported to all 8 nursing home care units in VISN 3 (New York     |
|     Harbor- Brooklyn, Saint Albans and Manhattan, East Orange, Lyons, |
|     Northport, Hudson Valley).                                        |
|                                                                       |
| -   Likewise, the **palliative care consultation service** model,     |
|     another of our clinical demonstration projects, has also been     |
|     exported to every site in the VISN 3 (New York Harbor- Brooklyn,  |
|     Saint Albans and Manhattan, East Orange, Lyons, Northport, Hudson |
|     Valley).                                                          |
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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)*:                           |
|                                                                       |
| -   In **2002**, **Dr. Judith Howe**, AD, Education and Evaluation    |
|     applied for and received one of six **VA Interprofessional        |
|     Palliative Care Fellowship Programs**. The award provides funding |
|     for four fellows through central office. We are currently on our  |
|     third class of fellows. New this year, Dr. Howe sought additional |
|     non-VA funding for a fifth fellow. Union 1199 is providing salary |
|     and tuition for a masters-prepared social worker from Bronx       |
|     Lebanon Hospital to participate in our program so that she will   |
|     be prepared to return to the facility and assist in establishing  |
|     a palliative care program. To date, we have had a diverse group   |
|     of students: master prepared social workers, physicians, nurse    |
|     practitioners and pharmacists (PharmD). The rigorous one-year     |
|     program, has fellows rotating between VA and non-VA settings and  |
|     in addition to covering the principles of palliative care         |
|     necessary for each particular profession also provides training   |
|     in interprofessional teams, leadership, writing for publication   |
|     and research.                                                     |
|                                                                       |
| -   Dr. Joan Penrod, AD Research successfully competed for a          |
|     **Targeted Research Enhancement Program** (TREP) at the Bronx VA. |
|     This 5-year award provides resources to build a health services   |
|     research program.                                                 |
|                                                                       |
| -   The Bronx/New York Harbor GRECC has been instrumental in our      |
|     VISN's success as a **model Palliative Care Program**. Our GRECC  |
|     designated palliative care as our area of concentration prior to  |
|     the VA's announcement of the national initiative.                 |
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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)*:                           |
|                                                                       |
| *Halm EA, Wang JJ, **Boockvar KS**, **Penrod JD**, Silberzweig SB,    |
| Magaziner J, Koval K, **Siu AL**. Effects of blood transfusion on     |
| functional outcomes in hip fracture. Transfusion. 2003; 43: 1358-65.* |
|                                                                       |
| -   Dr. Siu and colleagues examined the influence of blood            |
|     transfusions on risk-adjusted mortality, readmissions, and        |
|     functional mobility among elderly patients undergoing surgery     |
|     after hip fracture. The investigators found postoperative         |
|     transfusion reduced the risk of readmission but did not decrease  |
|     mortality or improve mobility. This is an important concern       |
|     because anemia and transfusion are common among elderly patients  |
|     requiring surgery.                                                |
|                                                                       |
|     ***Boockvar KS**, Litke A, **Penrod J**, Halm E, **Morrison RS**, |
|     Silberzweig S, Magaziner J, Koval K, and **Siu***                 |
|                                                                       |
|     ***AL**. Patient relocation in the six months after hip fracture: |
|     risk factors for fragmented care. J Am Geriatr*                   |
|                                                                       |
|     *Soc.2004;52: 1826-31.*                                           |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Drs. Boockvar, Siu and Penrod and their colleagues examined the   |
|     causes of hospital readmission after hip fracture and the         |
|     relationships between hospital readmission and 6-month physical   |
|     function and mortality. They found that about one third of the    |
|     patients were readmitted to the hospital within six months of the |
|     hip fracture but the reasons were mostly medical, not surgical.   |
|     Readmission was associated with increased morbidity and           |
|     mortality. Reducing the incidence of medical and surgical         |
|     problems that require hospital readmission has the potential to   |
|     prevent functional decline, long-term nursing home residence, and |
|     death after hip fracture.                                         |
|                                                                       |
| **Boockvar KS**, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T.  |
| Adverse events due to discontinuations in drug use and dose changes   |
| in patients transferred between acute and long-term care facilities.  |
| Arch Intern Med. 2004;164: 545-550.                                   |
|                                                                       |
| -   Dr. Boockvar examined medication changes during transfer both     |
|     ways between 2 hospitals and 4 nursing homes (all non-VA), and    |
|     examined adverse drug events (ADEs) caused by these changes.      |
|     Medication use changes were very common, and ADEs attributable to |
|     these changes occurred during 20% of episodes. The overall risk   |
|     of ADE per drug use change was 4.4% (95% CI 2.5-7.4%). Although   |
|     the majority of drug use changes implicated in causing ADEs       |
|     occurred in the hospital, the majority of ADEs occurred in the    |
|     nursing home after nursing home readmission. These findings were  |
|     used to guide design of a pharmacy-based intervention to reduce   |
|     ADEs associated with transfer between sites of care.              |
|                                                                       |
| ***Penrod J**, **Boockvar KS**, Litke A, Magaziner J, Hannan E, Halm  |
| E, Silberzweig S, **Morrison RS**, Orosz G, Koval K, and **Siu AL**.  |
| Physical therapy and mobility two and six months after hip fracture.  |
| J Am Geriatr Soc. 2004; 52: 1114-1120.*                               |
|                                                                       |
| -   Drs. Penrod, Boockvar, Siu and their colleagues examined the      |
|     relationship between physical therapy and mobility 2 and 6 months |
|     after hip fracture in older people. They found that more physical |
|     therapy immediately after hip fracture surgery was associated     |
|     with significantly better mobility 2 months later. However, the   |
|     positive relationship between early physical therapy and mobility |
|     was attenuated by 6 months post-fracture. The effects of later    |
|     therapy on mobility were difficult to assess because of           |
|     limitations of the data. These findings lend support to           |
|     clinician's decisions about when to start therapy after hip       |
|     fracture surgery.                                                 |
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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)*:                                                       |
|                                                                       |
| -   None.                                                             |
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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)*:                    |
|                                                                       |
| -   This year we embarked on an evaluation initiative of several of   |
|     our educational programs. We aggregated data from the participant |
|     evaluations from all 4 of our annual video conferences; from this |
|     data we are able to identify who are audience was (profession,    |
|     demographic information, average number of elderly persons cared  |
|     for each month) which speakers were most effective, and how well  |
|     participants retained the information.                            |
|                                                                       |
| -   We also evaluated the 3 EPEC training programs that we sponsored  |
|     throughout our VISN during the 03-04 training year. 139 health    |
|     professionals were trained, the majority being nurse and          |
|     associated health professionals. Our evaluation found that        |
|     participants knowledge in end of life care improved significantly |
|     following the training.                                           |
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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)*:                                     |
|                                                                       |
| -   **Interdisciplinary Team Training Kit**: An interdisciplinary     |
|     team is beneficial due to the cross-fertilization of ideas,       |
|     knowledge, perspectives and skills. Format includes a variety of  |
|     interactive strategies including the use of case studies,         |
|     videotapes with discussion, videotaped role-play with immediate   |
|     feedback and a brief PowerPoint presentation.                     |
|                                                                       |
| -   **EPEC Training**: End of life training for professionals has     |
|     been conducted in three VISN 3 facilities, with the overwhelming  |
|     number of attendees being nurses. Format includes lecture as well |
|     as interactive strategies such as role-plays. Early test results  |
|     indicate that participant knowledge increased greatly.            |
|                                                                       |
| -   **Palliative Care Team Tool Kit**: Originally distributed to each |
|     of the palliative care consult teams in VISN 3, the Tool Kit      |
|     contains original as well as scholarly resources for developing a |
|     successful interdisciplinary palliative care team. Target         |
|     audience includes all potential members of a team- physicians,    |
|     nurses, pharmacists, etc. The Tool Kit has been distributed at    |
|     three national workshops on teambuilding in Fall 2004, and        |
|     anecdotal responses have been positive to the usefulness of the   |
|     kit.                                                              |
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| **7. NEW CLINICAL MODELS**                                            |
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| **NOTE:** These are new models of care for elderly veterans that the  |
| GRECC is developing and evaluating, in relation to its area(s) of     |
| focus. This is NOT a list of all Geriatrics & Extended Care clinical  |
| programs at the host VAMC.                                            |
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| a.  **New Clinical Models Implemented in Current Year** *(list all    |
|     new clinical models or significant modifications of existing      |
|     models that the GRECC is developing and evaluating. For each      |
|     item, indicate whether [N]{.underline}ew or [O]{.underline}ngoing |
|     in current year; provide [up to five line]{.mark} description)*:  |
|                                                                       |
| -   **N**ew- Two **geriatric outpatient specialty clinics** were      |
|     started this fiscal year, **geriatrics-neurology** and            |
|     **geriatrics-psychiatry** (opening in November). In both, a       |
|     geriatrician is present during clinic and available to give       |
|     on-site consultations.                                            |
|                                                                       |
| -   **N**ew- An **outpatient palliative care clinic** was started     |
|     this fiscal year. To this point, all of our discharged palliative |
|     care patients were followed by primary care providers who are not |
|     as well equipped to care for the needs of this patient            |
|     population.                                                       |
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| 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.                   |
|                                                                       |
| -   As the clinics started up mid-year, there are no evaluation       |
|     results for the current year for the geriatric outpatient         |
|     specialty clinics.                                                |
|                                                                       |
| -   As the clinic started in May, there are no evaluation results for |
|     the current year for the outpatient palliative care clinic.       |
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| 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")*:                                  |
|                                                                       |
| -   **Dedicated palliative care beds** on nursing home care units,    |
|     one of the original clinical demonstration projects, have been    |
|     exported to all 8 nursing home care units in VISN 3 (New York     |
|     Harbor- Brooklyn, Saint Albans and Manhattan, East Orange, Lyons, |
|     Northport, Hudson Valley).                                        |
|                                                                       |
| -   Likewise, the **palliative care consultation service** model,     |
|     another of our clinical demonstration projects, has also been     |
|     exported to every site in the VISN 3 (New York Harbor- Brooklyn,  |
|     Saint Albans and Manhattan, East Orange, Lyons, Northport, Hudson |
|     Valley).                                                          |
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| **8. CONSULTATION AND OUTREACH**                                      |
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| 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.              |
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| 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)*:                                               |
|                                                                       |
| -   GRECC physicians have been attending department meeting in        |
|     internal medicine to heighten awareness of geriatric syndromes.   |
|                                                                       |
| -   The GRECC has organized quarterly Education Meetings at the host  |
|     facility which all members of the Palliative Care Consult Teams   |
|     throughout the VISN attend.                                       |
|                                                                       |
| -   The GRECC, in association with the Consortium of New York         |
|     Geriatric Education Centers, has hosted four videoconferences on  |
|     geriatrics topics with participation from the host facility, all  |
|     facilities within VISN 3, and other VISNs.                        |
|                                                                       |
| -   The GRECC sponsored a one-day teambuilding workshop at the host   |
|     facility with participation by host facility staff as well as     |
|     non-host facilities within the VISN.                              |
|                                                                       |
| -   The Associate Director, Clinical and the VISN Director of         |
|     Palliative Care, with other colleagues, visited 5 sites within    |
|     the VISN to assist in the development of nursing home-based       |
|     palliative care.                                                  |
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| 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.)*                                                   |
|                                                                       |
| -   As a result of GRECC input, this year the Bronx VAMC has agreed   |
|     to allow geriatricians to be inpatient teaching attending         |
|     physicians.                                                       |
|                                                                       |
| -   GRECC faculty began working with medical center executive         |
|     leadership to allow greater interaction between internal medicine |
|     physicians and geriatricians. This year geriatricians have        |
|     started going to internal medicine departmental meetings.         |
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