+-----------------------------------------------------------------------+
| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2005]{.underline}*                   |
|                                                                       |
| ######## Part II: Accomplishments                                     |
+-----------------------------------------------------------------------+
| **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}**                     |
+-----------------------------------------------------------------------+
| **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).                                           |
+-----------------------------------------------------------------------+
| **1. GRECC NAME/LOCATION**                                            |
+-----------------------------------------------------------------------+
| a.  **GRECC Name:** VISN 19 GRECC                                     |
|                                                                       |
| b.  **Location** *(Salt lake City, VISN)*: Salt Lake City, UT, VISN   |
|     19                                                                |
+-----------------------------------------------------------------------+
| **2. CONTACT PERSON**                                                 |
+-----------------------------------------------------------------------+
| a.  **Name:** Charlene R. Weir, Ph.D.                                 |
|                                                                       |
| b.  **Position:** Associate Director Education and Evaluation, GRECC  |
|                                                                       |
| c.  **Phone, e-mail:** 801-582-1565, ext 5114;                        |
|     Charlene.weir@med.va.gov                                          |
+-----------------------------------------------------------------------+
| **3. GRECC FOCUS AREA(S)**                                            |
+-----------------------------------------------------------------------+
| **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).]{.underline}]{.mark}**                     |
+-----------------------------------------------------------------------+
| -   **Basic Biomedical**: Cellular biology/physiology of cell         |
|     proliferation, cytokines & immunity during aging.                 |
|                                                                       |
| -   **Applied Clinical**: a) Cytokines & steroids: effects on         |
|     aging, b) Aerobic exercise & cognition during aging.              |
|                                                                       |
| -   **Health Services**: Real-time quality assurance                  |
|                                                                       |
| -   **Rehabilitation**:                                               |
+-----------------------------------------------------------------------+
| **4. ADMINISTRATION**                                                 |
+-----------------------------------------------------------------------+
| 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]{.underline} 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})*:                                                   |
|                                                                       |
| -   **[G-HELP]{.underline}**: The Geriatric High-risk Evaluation and  |
|     Liaison Program targets the transition of frail older adults with |
|     previous patterns of high resource utilization. The team          |
|     identifies patients in the hospital, emergency room, and clinic   |
|     settings and provides a multidisciplinary evaluation within 72    |
|     hours of referral. Targeted areas for evaluation include          |
|     pharmacy, specific education concerning medical conditions,       |
|     decision-making capacity, and home safety. Evaluated patients     |
|     receive various types of care coordinating services.              |
|                                                                       |
| -   **[Care Coordination Systems]{.underline}**: GRECC was            |
|     instrumental in the successful application of a VISN 19 grant to  |
|     implement a Care Coordination system at the local station. The    |
|     grant provides approximately 3 FTEE to assist with staffing. The  |
|     care coordination system uses CPRS to identify high resource      |
|     utilization patients for enrollment. Currently [we have an        |
|     average daily census of 320 high-risk patients]{.underline} who   |
|     receive coordinated care utilizing numerous methods. Dr. Byron    |
|     Bair is the Medical Director of this program.                     |
|                                                                       |
| -   **[Poly-pharmacy Telemedicine]{.underline}**: Most telemedicine   |
|     tracking systems focus on single disease entities, while most     |
|     veterans have multiple simultaneous disease processes. The        |
|     poly-pharmacy module of care coordination allows tracking         |
|     symptoms and pharmacy issues regardless of specific diagnoses.    |
|     Patients are targeted based on previous high resource             |
|     utilization. In addition to tracking symptoms and pharmacy,       |
|     pharmaco-economic issues are addressed, such as redundant         |
|     medications and refilling of discontinued medications. The        |
|     program has received \$350,000 for FY2005 to expand the program.  |
|                                                                       |
| -   **[Palliative Care Program]{.underline}**: The GRECC has been     |
|     highly instrumental in creating, implementing, and evaluating the |
|     Palliative Care Program at VASLCHCS. GRECC staff assisted in the  |
|     development and testing of key program quality indicators to      |
|     monitor the Palliative Care Program as well as analyzing the      |
|     results for presentation to national VA audiences. In addition,   |
|     the GRECC assisted in the provision of educational materials for  |
|     house-staff, primary care staff, and nursing.                     |
|                                                                       |
| -   **[Acute Mental Status Changes Clinical Protocol]{.underline}**:  |
|     SLC GRECC staff worked closely with representatives from the      |
|     Mental Health care center and the SLC VAMC Patient Safety Office  |
|     to develop and test a protocol for the detection and management   |
|     of Acute Mental Status Changes in the inpatient setting. The      |
|     GRECC created and disseminated training materials that were       |
|     accessible to all clinical staff in the VA through the VISN       |
|     internet educational program, called "MyPeak". In addition, the   |
|     educational material was adopted as a key component of mandatory  |
|     training for Nursing Staff throughout the SLC VA. The protocol is |
|     currently in process.                                             |
+-----------------------------------------------------------------------+
| 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*)*:                                                |
|                                                                       |
| -   **[Geriatrics Steering Committee]{.underline}**: The SLC GRECC    |
|     assumes a leadership role on the VISN Geriatrics Steering         |
|     Committee in the capacity as chair and in terms of specific       |
|     projects. This committee addresses issues concerning geriatrics   |
|     for the VISN. The committee includes representatives from all of  |
|     the local stations within the VISN. In this role, the GRECC has   |
|     direct impact on VISN policies through several visible reporting  |
|     mechanisms, including Action Reports submitted on a regular basis |
|     to the VISN Strategic Planning Committee.                         |
|                                                                       |
| -   **[Dementia Driving & Firearms Protocol]{.underline}**: The GRECC |
|     took the lead to coordinate a response for the VISN regarding a   |
|     Dementia Driving & Firearms Safety initiative. All state laws     |
|     within VISN 19 were tabulated concerning dementia, driving, and   |
|     firearms. A simple CPRS reminder tracking system was then         |
|     developed and coupled with assessment templates to be used in     |
|     primary care. These recommendations were approved and will be     |
|     implemented VISN-wide. In addition, the GRECC developed           |
|     educational materials to support the implementation of these      |
|     protocols to be distributed throughout the VISN. Finally, the     |
|     GRECC will be involved in evaluating the program by through usage |
|     and patient outcome data.                                         |
|                                                                       |
| -   **[GRECC Clinical Conference for CME contact]{.underline}**: The  |
|     GRECC Clinical Conference PolyComm is a monthly conference on     |
|     geriatric topics presented at the Salt Lake City VA and           |
|     teleconference to four or more VISN sites. Educational grants to  |
|     the GRECC originally allowed for the purchase of the equipment    |
|     and the VISN Educational Committee endorsed the activity. CME for |
|     the activity is provided through the University of Utah. Live     |
|     interaction with GRECC staff is encouraged during these           |
|     presentations. These presentations may also be videotaped by the  |
|     distant sites for later use.                                      |
|                                                                       |
| -   **[National Gero-Psych Satellite Presentations]{.underline}**:    |
|     Four nation-wide satellite programs were produced in conjunction  |
|     with EES and GRECC faculty. These programs were presented live    |
|     nationally and then repeated four times each. These presentations |
|     were well-received with overwhelmingly positive evaluations and a |
|     total of more than 294 viewers from 85 different VA sites.        |
+-----------------------------------------------------------------------+
| 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    |
|     year; for each item, provide date, GRECC staff responsible, and   |
|     [up to five line]{.mark} description)*:                           |
|                                                                       |
| -   **[Targeted Research Enhancement Program (TREP]{.underline}).**   |
|     The TREP program application was initiated by John Hurdle, Ph.D   |
|     and Jonathan Nebeker, MD, as co-PIs with collaboration from       |
|     Charlene Weir, PhD, Jennifer Hoffman, PharmD, and Byron Bair, MD. |
|     The name for the TREP is IDEAS (Informatics, Decision             |
|     Enhancement, and Surveillance) and the current director is Matt   |
|     Samore, MD. IDEAS has energized Health Services Research both in  |
|     the GRECC as well as in SLC VAMC in general. It has also          |
|     strengthened the relationship between the University of Utah and  |
|     the VA by increasing collaboration and research interactions.     |
|                                                                       |
| -   **[G-HELP]{.underline}**: The Geriatric High-risk Evaluation and  |
|     Liaison Program targets frail older adults in transition with     |
|     previous patterns of high resource utilization. The team          |
|     identifies patients in the hospital, emergency room, and clinic   |
|     settings and provides a multidisciplinary evaluation within 72    |
|     hours of referral [prior]{.underline} to discharge. Targeted      |
|     areas for evaluation include pharmacy, specific education         |
|     concerning medical conditions, decision-making capacity, and home |
|     safety. Evaluated patients receive various types of care          |
|     coordinating services. G-HELP was initiated by Dr. Byron Bair     |
|     with the assistance of Carol Hughes, NP and Rebecca Mabe, SW      |
|     (affiliated GRECC staff).                                         |
|                                                                       |
| -   **[Dementia Driving & Firearms Protocol]{.underline}**: The GRECC |
|     took the lead to coordinate a response for the VISN regarding a   |
|     Dementia Driving & Firearms Safety initiative. All state laws     |
|     within VISN 19 were tabulated concerning dementia, driving, and   |
|     firearms. A simple CPRS reminder tracking system was then         |
|     developed and coupled with assessment templates to be used in     |
|     primary care. These recommendations were approved and will be     |
|     implemented VISN-wide. In addition, the GRECC developed           |
|     educational materials to support the implementation of these      |
|     protocols to be distributed throughout the VISN. Finally, the     |
|     GRECC will be involved in evaluating the program by through usage |
|     and patient outcome data.                                         |
|                                                                       |
| -   **[Guidelines for Pharmaceutical Management of                    |
|     Dementia]{.underline}:** As part of a VISN level effort to        |
|     achieve consensus on the appropriate use of expensive medications |
|     used to treat dementia, the GRECC produced a guideline containing |
|     recommendations for the use of acetylcholinesterase inhibitors    |
|     and memantine. This guideline contained suggestions about the     |
|     appropriate clinical assessment to determine whether drug         |
|     initiation should take place and described how the drugs should   |
|     be initiated. Most importantly, this guideline contained tools    |
|     for partnering with patients and caregivers to determine the      |
|     therapeutic benefit of these medications, with accompanying       |
|     suggestions for discontinuing, switching, or using these          |
|     medications in combination.                                       |
+-----------------------------------------------------------------------+
| **5. RESEARCH**                                                       |
+-----------------------------------------------------------------------+
| a.  **[Key Findings Published in Current Year]{.underline} -- GRECC   |
|     Core Staff as PI or CO-PI** *([list up to five]{.mark}; for each  |
|     item provide **GRECC Core Staff** name(s), journal reference, and |
|     [up to five line]{.mark} description of topic/method/             |
|     results/clinical significance; use layperson language)*:          |
|                                                                       |
| [1.]{.underline} **[Key Finding: The impact of inflammation on the    |
| aging brain]{.underline}**. Inflammation is a prominent feature of    |
| the aged brain. Many normal components of neuronal survival are       |
| dysregulated with age including inflammatory cytokines and            |
| transcriptional mediators involved in induction of inflammatory       |
| cytokines. In the two publications listed we have described, in       |
| either a mouse model of aging or in tissue culture, the effects of    |
| aging and inflammation on the expression of neuronal nicotinic        |
| acetylcholine receptors (key regulators of cognition and neuronal     |
| survival). These results hold clinical significance toward            |
| determining how to better control the inflammatory processes in the   |
| aged brain.                                                           |
|                                                                       |
| **GRECC Core Staff P.I.s: Lorise Gahring and Scott Rogers**           |
|                                                                       |
| ***[Publications]{.underline}*:**                                     |
|                                                                       |
| 1\) Gahring, L.C., E. L. Days, T. Kaasch, M. Gonzalez de Mendoza, L.  |
| Owen, K. Persiyanov, and S.W. Rogers. 2005. Pro-Inflammatory          |
| Cytokines Modify Neuronal Nicotinic Acetylcholine Receptor Assembly.  |
| [J. Neuroimmunology]{.underline} (Sept) 166: 88-101.                  |
|                                                                       |
| 2\) Gahring, L.C., K. Persiyanov, E. L. Days, and S.W. Rogers. 2005.  |
| Age-related loss of neuronal nicotinic receptor expression in the     |
| aging mouse hippocampus corresponds with cyclooxygenase 2 and PPARg   |
| expression and is altered by long-term NS398 administration. [J.      |
| Neurobiology]{.underline} (Mar) 62: 453-468.                          |
|                                                                       |
| [2.]{.underline} **[Key Finding: Individual Differences in Response   |
| to Aging]{.underline}**. Aging has certain commonalities and yet some |
| very distinct differences based on individual genetics. We can        |
| measure these individualized responses through the use of mouse       |
| strains (each strain representing a different genetic composition).   |
| We have determined that mouse strains differ substantially in         |
| age-related loss of neuronal nicotinic acetylcholine receptors. The   |
| clinical significance of this lies in defining the range of loss of   |
| neuronal receptors of different individuals with age and the effect   |
| to which the response may be predicted.                               |
|                                                                       |
| **GRECC Core Staff P.I.s: Scott Rogers and Lorise Gahring**           |
|                                                                       |
| ***[Publication]{.underline}*:**                                      |
|                                                                       |
| 1\) Gahring, L.C., K. Persiyanov, and S.W. Rogers. 2005. Mouse        |
| strain-specific changes in nicotinic expression with age.             |
| [Neurobiology of Aging]{.underline} (Jun) 26(6):973-80.               |
|                                                                       |
| 3\. **[Key Finding: Self-Reported Delays Do Not Predict Mortality of  |
| Functional Decline.]{.underline}** Delays in care can result in a     |
| variety of negative outcomes. In a longitudinal cohort study, where   |
| 12% of a sample of 4, 162 individuals over the age of 65 reported     |
| delaying care very often. However, self-reported delays in care was   |
| not associated with mortality or functional decline even after        |
| controlling for multiple predisposing and enabling variables.         |
|                                                                       |
| **GRECC Core Staff P.I.s: Rand Rupper**                               |
|                                                                       |
| ***[Publications]{.underline}*:**                                     |
|                                                                       |
| **1) Rupper, RW, Konrad, TR, Garrett, JM, Miller, W, Blazer, DG.      |
| 2004.** Self-reported delay in seeking care has poor validity for     |
| predicting adverse outcomes. [J. Am Geriatr Soc]{.underline}. Dec     |
| 52(12):2104-9.                                                        |
|                                                                       |
| **4. [Key Finding: The Limitations of Computerized Pateint Care       |
| System in Minimizing Harm and Improving Patient                       |
| Safety.]{.underline}***.* Many authors have suggested that Patient    |
| Care Information Systems will decrease medical errors, improve        |
| communication and decrease patient harm. Recent studies by the SLC    |
| GRECC investigators have highlighted some of the limitations of such  |
| systems, particularly alerts, Provider Order Entry and electronic     |
| documentation. Results from this work highlights the need for more    |
| in-depth knowledge regarding how an information system impacts work   |
| processes, the kind of information that is retrieved and utilized and |
| the quality of communication between providers. The patients who are  |
| at the most risk for poorly organized and structured processes are    |
| the elderly, those with multiple health problems and the financially  |
| disadvantaged.                                                        |
|                                                                       |
| **GRECC Core Staff P.I.'s**: Charlene Weir, PhD and Jennifer Hoffman, |
| PharmD.                                                               |
|                                                                       |
| ***[Publication]{.underline}*(s)**:                                   |
|                                                                       |
| 1\) **Nebeker**, JR, **Hoffman**, JM, **Weir, CR,** Bennett, CL, and  |
| John F. Hurdle. (2005). High rates of adverse drug events in a highly |
| computerized hospital. [Archives of Internal Medicine]{.underline}.   |
| May 23; 165 (10):111-6.                                               |
|                                                                       |
| 2.  **Weir**, **CR**, **Hoffman**, J, **Nebeker**, JR and Hurdle, JF. |
|     (2005). Nurse's role in tracking adverse drug events: The impact  |
|     of provider order entry. [Nurs Admin Q]{.underline}. Vol. 29 (1): |
|     38-43.                                                            |
+-----------------------------------------------------------------------+
| b.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     Co-Investigators on Projects with a Non-GRECC PI (***[list up to  |
|     five]{.mark}; for each item provide GRECC Core Staff name(s),     |
|     journal reference, [and up to five line]{.mark} description of    |
|     topic/method/ results/clinical significance; use layperson        |
|     language)*:                                                       |
|                                                                       |
| **1. [Key Finding: Prostaglandins are key mediators of inflammation   |
| that change with aging and immunologic status.                        |
| ]{.underline}**Activation of the purinergic receptor P2Y2 causes the  |
| collecting duct in the kidney to make prostaglandin PGE~2~ which then |
| causes an increase in urine output. In this study we demonstrated     |
| that chronic dehydration decreases this signaling pathway, while      |
| chronic excessive drinking increases how well this signaling pathway  |
| is activated. This change in sensitivity in signaling and kidney      |
| function represents a novel regulatory mechanism and could be         |
| important to finding new treatments in the elderly population where   |
| patients often are unable to handle changes in water states,          |
| resulting in water and electrolyte imbalances leading to morbid       |
| conditions.                                                           |
|                                                                       |
| **GRECC Core Staff**: Noel Carlson.                                   |
|                                                                       |
| *[**Publication(s)**:]{.underline}*                                   |
|                                                                       |
| 1\) Sun R, **N.G. Carlson**, A.C. Hemmert, B.K. Kishore. 2005. P2Y2   |
| Receptor-Mediated Release of Prostaglandin E2 by IMCD is Altered in   |
| Hydrated and Dehydrated Rats: Relevance to AVP-Independent Regulation |
| of IMCD Function. [Am J Physiol Renal Physiol]{.underline}            |
| Sep;289(3):F585-592., Apr 19.                                         |
|                                                                       |
| 2\. **[Key Finding: New Treatments for Multiple Sclerosis             |
| (MS]{.underline}**). MS is a disease where the immune system attacks  |
| the myelin sheath that facilitates neurotransmission. In this study   |
| we found that treatment with daclizumab (a humanized monoclonal       |
| antibody specific for the IL-2 receptor alpha chain that diminishes   |
| the immune response) was safe and effective in treating MS patients   |
| that did not respond to other therapies. This therapy could offer a   |
| new treatment for MS patients in the VA where the majority of the     |
| patients are males diagnosed between the ages of 40-50. These MS      |
| patients typically develop a progressive disease that can persist     |
| over time into the ages of greater than 70.                           |
|                                                                       |
| **GRECC Core Staff**: Noel Carlson.                                   |
|                                                                       |
| ***[Publication]{.underline}(s):***                                   |
|                                                                       |
| 1\) Rose JW, H.E. Watt, A.T. White, **N.G. Carlson**. 2004. Treatment |
| of multiple sclerosis with an anti-interleukin-2 receptor monoclonal  |
| antibody. [Ann. Neurol]{.underline}*. 56(6):864-867*                  |
+-----------------------------------------------------------------------+
| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| **NOTE**: Do not list trainee and conference data here. Those data    |
| are reported in the GRECC Electronic Database.                        |
+-----------------------------------------------------------------------+
| **Innovations in Educational Activities Implemented During Current    |
| Year** (*[list up to five]{.mark}; for each item, [up to three        |
| lines]{.mark} on how it is innovative)*:                              |
|                                                                       |
| 1.  **[GRECC Clinical Conference for CME contact]{.underline}**: The  |
|     GRECC Clinical Conference PolyComm is a monthly conference on     |
|     geriatric topics presented at the Salt Lake City VA and           |
|     teleconference to four or more VISN sites. Educational grants to  |
|     the GRECC originally allowed for the purchase of the equipment    |
|     and the VISN Educational Committee endorsed the activity. CME for |
|     the activity is provided through the University of Utah. Live     |
|     interaction with GRECC staff is encouraged during these           |
|     presentations. These presentations may also be videotaped by the  |
|     distant sites for later use.                                      |
|                                                                       |
| 2.  **[National Gero-Psych Satellite Presentations]{.underline}**:    |
|     Four nation-wide satellite programs were produced in conjunction  |
|     with EES and GRECC faculty. These programs were presented live    |
|     nationally and then repeated four times each. These presentations |
|     were well-received with overwhelmingly positive evaluations and a |
|     total of more than 294 viewers from 84different VA sites.         |
|                                                                       |
| 3.  **[Acute Mental Status Changes Clinical Protocol Educational      |
|     Materials]{.underline}**: SLC GRECC staff worked closely with     |
|     representatives from the Mental Health care center and the SLC    |
|     VAMC Patient Safety Office to develop and test a protocol for the |
|     detection and management of Acute Mental Status Changes in the    |
|     inpatient setting. The GRECC created and disseminated training    |
|     materials that were accessible to all clinical staff in the VA    |
|     through the VISN internet educational program, called "MyPeak."   |
|     In addition, the educational material was adopted as a key        |
|     component of mandatory training for Nursing Staff throughout the  |
|     SLC VA.                                                           |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| 4.  **[Regional Gero-Psych Conference]{.underline}**: A one-day       |
|     conference was held at the SLC VAMC and was attended by more than |
|     90 individuals. The topics ranged from issues of sleep in the     |
|     elderly to determining decision-making capacity. Evaluations were |
|     overwhelmingly positive.                                          |
|                                                                       |
| 5.  **[Delirium]{.underline}** **[Internet Training                   |
|     Module]{.underline}**: Two learning modules were created on the   |
|     assessment, treatment and management of patients with acute       |
|     mental status changes in the inpatient setting. The program was   |
|     incorporated into mandatory Nursing Competencies. Over 57 RNs     |
|     completed the training and evaluations were very positive.        |
+-----------------------------------------------------------------------+
| **Exportable Educational [Products]{.underline} First Available for   |
| Distribution in Current Year** ([list up to five]{.mark} most         |
| important products; for each item, [up to three lines]{.mark}         |
| summarizing content, target audience, format, product evaluation      |
| results. **Include educational products developed in previous years   |
| ONLY if this is the [first year]{.underline}** they have been         |
| available for distribution):                                          |
|                                                                       |
| 1.  **[Acute Mental Status Changes Clinical Protocol Educational      |
|     Materials]{.underline}**: SLC GRECC staff worked closely with     |
|     representatives from the Mental Health care center and the SLC    |
|     VAMC Patient Safety Office to develop and test a protocol for the |
|     detection and management of Acute Mental Status Changes in the    |
|     inpatient setting. The GRECC created and disseminated training    |
|     materials that were accessible to all clinical staff in the VA    |
|     through the VISN internet educational program, called "MyPeak".   |
|     In addition, the educational material was adopted as a key        |
|     component of mandatory training for Nursing Staff throughout the  |
|     SLC VA.                                                           |
|                                                                       |
| 2.  **[Dementia Treatment Tracking Sheet]{.underline}**: This sheet   |
|     assists clinicians evaluating effectiveness of FDA dementia       |
|     treatments using a modification of the CIBI +plus tool. It has    |
|     been exported electronically to VISN 19 sites and to the Roseberg |
|     VAMC, Grand Junction VAMC, and Reno VAMC as well as being         |
|     available on the SLC GRECC web site.                              |
|                                                                       |
| 3.  **[National Gero-Psych Satellite Presentations]{.underline}**:    |
|     Four nation-wide satellite programs were produced in conjunction  |
|     with EES and GRECC faculty. These programs were presented live    |
|     nationally and then repeated four times each. These presentations |
|     were well-received with overwhelmingly positive evaluations and a |
|     total of more than 294 viewers from 84 different VA sites. The    |
|     presentations are available in video.                             |
|                                                                       |
| 4.  **[Guidelines for pharmaceutical management of                    |
|     dementia]{.underline}**: As part of a VISN level effort to        |
|     achieve consensus on the appropriate use of the expensive         |
|     medications used to treat dementia, the GRECC produced a          |
|     guideline containing recommendations for the use of               |
|     acetylcholinesterase inhibitors and memantine. This guideline     |
|     contained suggestions about the appropriate clinical assessment   |
|     to determine whether drug initiation should take place and        |
|     described how the drugs should be initiated. Most importantly,    |
|     this guideline contained tools for partnering with patients and   |
|     caregivers to determine the therapeutic benefit of these          |
|     medications, with accompanying suggestions for discontinuing,     |
|     changing, or using these medications in combination.              |
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| **7. NEW CLINICAL MODELS**                                            |
+-----------------------------------------------------------------------+
| **NOTE:** These are new models of care for elderly veterans that the  |
| GRECC is developing and evaluating, in relation to its area(s) of     |
| focus. This is NOT a list of all Geriatrics & Extended Care clinical  |
| programs at the host VAMC.                                            |
+-----------------------------------------------------------------------+
| **New Clinical Models Implemented in Current Year** (list all new     |
| clinical models or significant modifications of existing models that  |
| the GRECC is developing and evaluating. For each item, indicate       |
| whether [N]{.underline}ew or [O]{.underline}ngoing in current year;   |
| provide [up to five line]{.mark} description):                        |
|                                                                       |
| 1.  **[GHELP -- (N)]{.underline}**: The Geriatric High-risk           |
|     Evaluation and Liaison Program targets frail older adults in      |
|     transition with previous patterns of high resource utilization.   |
|     We have changed the composition of the team. The new team         |
|     consists of a NP only; SW involvement is available as needed,     |
|     increasing the economic feasibility of exportation. The team      |
|     targets patients in the hospital, emergency room, and clinic      |
|     settings. Targeted patients receive a multidisciplinary           |
|     evaluation within 72 hours of referral. Targeted areas for        |
|     evaluation include pharmacy, specific education concerning        |
|     medical conditions, decision-making capacity, and home safety.    |
|     Evaluated patients receive various types of care coordinating     |
|     services.                                                         |
|                                                                       |
| 2.  **[Poly-pharmacy Telemedicine (O)]{.underline}**: Most            |
|     telemedicine tracking systems focus on single disease entities,   |
|     while most veterans have multiple simultaneous disease processes. |
|     The poly-pharmacy module of care coordination allows tracking     |
|     symptoms and pharmacy issues regardless of specific diagnoses.    |
|     Patients are targeted based on previous high resource             |
|     utilization. In addition to tracking symptoms and pharmacy,       |
|     pharmaco-economic issues are addressed such as redundant          |
|     medications and refilling of discontinued medications along with  |
|     others.                                                           |
|                                                                       |
| 3.  **[Geriatric Med / Psych Transitional Inpatient                   |
|     Unit]{.underline}** (N): This unit is now functioning to address  |
|     the needs of frail older adults on inpatient units within the     |
|     host VA. Patients are targeted by a review of high cost resource  |
|     utilization. These patients are then transferred post acute       |
|     interventions to the Geriatric Med /Psych transitional Care unit. |
|     Previously these patients were designated as "intermediate" and   |
|     had a length of stay (LOS) averaging 12-13 days. The LOS for      |
|     patients on the Translational Inpatient Unit has and has been     |
|     reduced to 4-5 days. An intensive evaluation system is being      |
|     developed to clarify mechanisms of success.                       |
|                                                                       |
| 4.  **[Dementia Treatment Clinic is in development                    |
|     (O):]{.underline}** This clinic will follow a coumadin clinic     |
|     model where PharmD's will tract the effectiveness of FDA approved |
|     treatments for dementia in terms of clinical outcomes. Protocols  |
|     developed will indicate improvements, stabilization or decline in |
|     patients on these agents. Clinical decisions to remain on         |
|     treatments will be evaluated. Compliance, patient satisfaction,   |
|     and costs will be tracked in addition to clinical response.       |
+-----------------------------------------------------------------------+
| **Current Year Evaluation Results of New Clinical Models** *([for     |
| each clinical model listed in 7-a above]{.mark}, indicate whether     |
| evaluated by [R]{.underline}esearch or [Q]{.underline}uality          |
| [I]{.underline}mprovement project; [up to five lines]{.mark}          |
| summarizing evaluation outcomes, such as changes in access to care,   |
| patient functioning, satisfaction, cost-effectiveness, organizational |
| changes, etc. Note if no evaluation results in current year for a     |
| particular model)*:                                                   |
|                                                                       |
| **NOTE:** Do not list patient service utilization data here. Those    |
| data are reported in the GRECC Electronic Database.                   |
|                                                                       |
| 1.  **[G-HELP]{.underline} (R)**: This program is currently being     |
|     evaluated by quality improvement methods. Over 700 patients have  |
|     been seen over the past year. Data is being collected concerning  |
|     resource utilization for 1.5 years prior to G-HELP and after      |
|     G-HELP was implemented. Specific resource utilization parameters  |
|     include number of hospitalizations, number of ER visits, number   |
|     of clinic visits, and patient satisfaction. Medication            |
|     discrepancies between home use and prescribed use and             |
|     decision-making capacity are also being evaluated. We have 6-8    |
|     consults per day where we facilitate the initiation, evaluation   |
|     and implementation of geriatric evaluations in a frail            |
|     population.                                                       |
|                                                                       |
| 2.  **[Poly-pharmacy Telemedicine (QI]{.underline}):** This is being  |
|     evaluated as a quality improvement project. Over 3000 separate    |
|     symptoms and patient preferences are being tracked and linked to  |
|     medication regimes. The effectiveness of the interactive dialogue |
|     development is being assessed as well as the impact on care       |
|     utilization, such as hospitalizations, ER visits, and clinic      |
|     visits.                                                           |
|                                                                       |
| 3.  **[Geriatric Med / Psych Transitional Inpatient                   |
|     Unit]{.underline}**: This unit is in the early stages of          |
|     implementation. Evaluation measures include resource utilization  |
|     pre/post unit enrollment, integration into care coordination      |
|     programs, overall LOS for Med/Surg intermediate status patients   |
|     and improvement in hospital bed flow. In addition, qualitative    |
|     information is being gathered from the staff regarding            |
|     perceptions of impact on workflow and effectiveness.              |
|                                                                       |
| 4.  **[Care Coordination / Telemedicine System]{.underline}**: This   |
|     project is being evaluated using quality improvement methods by   |
|     the host VA. Patients are targeted with high resource utilization |
|     and tracked for changes in resource utilization. Development of a |
|     central care coordination office is evaluated based on provider   |
|     satisfaction and access. This is a multidisciplinary approach     |
|     that includes medicine, surgery, and psychiatry. That database is |
|     already identified \$2.3 million in cost avoidance savings. Other |
|     measures of interest are the use of SF-12 and provider            |
|     satisfaction.                                                     |
+-----------------------------------------------------------------------+
| **New Clinical Models Exported in Current Year** *([list up to five   |
| examples, up to two lines each]{.mark}; provide name of new clinical  |
| model, name of VA or non-VA facility to which it was exported, and    |
| method of export, such as "Falls Clinic protocol sent to              |
| [X]{.underline} VAMC")*:                                              |
|                                                                       |
| 1.  **[Dementia Treatment Tracking Sheet]{.underline}**: This sheet   |
|     assists clinicians evaluating effectiveness of FDA dementia       |
|     treatments using a modification of the CIBI +plus tool. It has    |
|     been exported electronically to VISN 19 sites and is available on |
|     the SLC GRECC web site. --modified                                |
|                                                                       |
| 2.  **[Early Screen for Impaired IADL Tool]{.underline}**: This tool  |
|     was developed to be used in the clinic waiting room and evaluated |
|     by the clinician during the visit. It is focuses on functional    |
|     (IADL) changes over the past 5 years. It was exported to Roseberg |
|     VAMC, Grand Junction VAMC, and Reno VAMC. It is also available on |
|     the GRECC web site.                                               |
|                                                                       |
| 3.  **[Dementia and Firearms Assessment and Tracking                  |
|     Protocol]{.underline}**: The GRECC, in conjunction with the VISN  |
|     Geriatric Committee, has developed protocols for assessing and    |
|     tracking a clinician's determination of decision-making capacity  |
|     regarding the use of firearms. Tools are being developed for use  |
|     throughout VISN 19 and have been alpha tested at the Salt Lake    |
|     City and Sheridan VAs. These tools have been distributed to the   |
|     region and are ready to be distributed nationally.                |
|                                                                       |
| 4.  **[Dementia and Driving Assessment and Protocol]{.underline}**:   |
|     The GRECC, in conjunction with the VISN Geriatric Committee,      |
|     developed protocols for assessing and tracking a clinician's      |
|     determination of decision-making capacity regarding the use of    |
|     firearms. Tools are being developed for use throughout VISN 19    |
|     and have been alpha tested at the Salt Lake City and Sheridan     |
|     VAs. These tools have been distributed to the region and are      |
|     ready to be distributed nationally.                               |
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