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| ### *GRECC Annual Report: Fiscal Year [2005]{.underline}*             |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| This GRECC Annual Report covers [October 1, 2004-September 30,        |
| 2005]{.underline}: **the "Report Year"**.                             |
|                                                                       |
| This GRECC Annual Report reflects status and accomplishments of       |
| [**GRECC Core Staff \***only]{.underline}.                            |
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| **\*[GRECC Core Staff ]{.underline}**is limited to either **Primary   |
| Core**, **Affiliate 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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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** West Los Angeles GRECC                            |
|                                                                       |
| b.  **Location** *(facility, VISN)*: VA Greater Los Angeles           |
|     Healthcare System - VISN 22                                       |
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| **2. CONTACT PERSON (if there are questions about this report)**      |
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| a.  **Name:** Theodore J. Hahn, M.D.                                  |
|                                                                       |
| b.  **Position:** Director, GRECC                                     |
|                                                                       |
| c.  **Phone, e-mail:** (310)268-4110 <Theodore.Hahn@Med.VA.Gov>       |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| GRECCs are required to conduct research in a basic biomedical area,   |
| an applied clinical area, and either a health services or             |
| rehabilitation topic. The number of specific research foci in each    |
| perspective should be limited to two or fewer. Please enter a         |
| succinct phrase that best characterizes the focus area(s) recognized  |
| for your GRECC in the first two and either the third or fourth (or    |
| both) category below:                                                 |
|                                                                       |
| a.  **Basic Biomedical**: Cellular & molecular basis of osteoporosis  |
|     & osteoarthritis; cellular & molecular basis of immunosenescence  |
|                                                                       |
| b.  **Applied Clinical**: Pathogenenesis & management of              |
|     osteoporosis, immunology/infectious diseases, falls prevention    |
|                                                                       |
| c.  **Health Services**: Evaluation of clinical programs, geriatric   |
|     rehabilitation cost-effectiveness, minority elderly health care   |
|     utilization                                                       |
|                                                                       |
| d\. **Rehabilitation**: Geriatric rehabilitation                      |
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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         |
|     positive impact on the host VAMc\--i.e., how the GRECC has "made  |
|     a difference" locally. **Please limit your response to five ways  |
|     or fewer.** Please be as succinct as possible but specify the     |
|     GRECC contribution, what the impact was and whom it benefited,    |
|     where it occurred, and why it was important. **Please limit the   |
|     description of each bullet item to 5 lines or fewer**)*           |
|                                                                       |
| -   The WLA GRECC has played a major role in developing improved new  |
|     systems of care for older veterans at GLA and throughout the      |
|     VISN. During the current year, GRECC staff have began the         |
|     implementation of new decisional capacity assessments, patient    |
|     medication education, and geriatrics-specific Care Coordination   |
|     Home Telehealth (CCHT) programs to better manage frail elderly    |
|     veterans at risk for functional decline and to improve the        |
|     outcomes of post hospital discharge rehabilitation programs for   |
|     older adults.                                                     |
|                                                                       |
| -   WLA GRECC clinicians support 12 inpatient and outpatient          |
|     geriatrics acute, subacute and long-term care clinical programs   |
|     at GLA, providing primary care, attending coverage and teaching.  |
|     A total of 4.3 Primary Core WLA GRECC staff FTEE (1.7 MD, 0.9 SW, |
|     0.8 GNP, .9 LVN), corresponding to 8,640 hours/year of clinical   |
|     care time and \$504,000/year in salary and benefits, are devoted  |
|     to providing direct patient care delivery at GLA. Additional      |
|     major clinical care delivery is provided by GRECC clinical        |
|     trainees (see below).                                             |
|                                                                       |
| -   WLA GRECC core staff provides geriatrics and gerontology training |
|     for [\>]{.underline} 230 medical, nursing, dentistry, psychiatry  |
|     and allied health care professional trainees/year. The majority   |
|     of these trainees provide direct care delivery and a number of    |
|     them return to fill key clinical positions at GLA after           |
|     graduation. The Geriatric Social Work Education Consortium        |
|     (GSWEC), coordinated by the GRECC is an award-winning program     |
|     that provides field social worker instruction in geriatric care   |
|     to social workers from four different academic institutions.      |
|                                                                       |
| -   WLA GRECC research programs provided national leadership in a     |
|     number of aging-related research areas, including basic, clinical |
|     and health services research in osteoporosis, osteoarthritis, and |
|     immunosenescence; clinical studies in dementia detection and      |
|     management, access to care, outpatient management outcomes, and   |
|     development of innovative geriatrics-specific CCTH programs.      |
|     GRECC research funding provided \$612,417 in post-discount VERA   |
|     Research Support dollars to GLA in FY05.                          |
|                                                                       |
| -   The WLA GRECC has provided numerous educational programs for GLA  |
|     staff and trainees, including in-service education programs, such |
|     as aging related competency training for JACHO reviews, Medicine  |
|     Rounds, and multiple lectures and seminars of a broad range of    |
|     topics in geriatrics and gerontology for GLA staff. These         |
|     programs greatly increase staff and trainee awareness of, and     |
|     competency in, age-related disorders and new methods for          |
|     improving the care of older veterans.                             |
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| b.  **GRECC Impact on VISN in Report Year** *\                        |
|     (list the most important ways in which the GRECC has had positive |
|     impact on the host VISN\-- i.e., how the GRECC has "made a        |
|     difference "regionally. **Please limit your response to five ways |
|     or fewer.** Please be as succinct as possible but specify the     |
|     GRECC contribution, what the impact was and whom it benefited,    |
|     where it occurred, and why it was important. **Please limit the   |
|     description of each bullet item to 5 lines or fewer**)*           |
|                                                                       |
| -   The WLA GRECC continued to provide extensive support to the VISN  |
|     Geriatrics and Extended Care Executive Committee (GECEC) which    |
|     oversees VISN wide GEC program operations. This group, chaired    |
|     since its inception by Dr. Hahn, has continued to significantly   |
|     enhance the number, scope and quality of VISN GEC programs,       |
|     improved GECEC care efficiency, and enhanced care access          |
|     throughout the VISN. VA-based and community-based care capacity   |
|     has been expanded to reach and exceed VACO targets.               |
|                                                                       |
| -   GRECC staff played a lead role in establishing a VISN CCTH        |
|     program and Coordinating Committee. This group has facilitated    |
|     the implementation of CCHT programs at all 5 VISN medical         |
|     centers, and the GRECC led previous successful applications to    |
|     VACO and the VISN for \$1.2 million in required startup CCTH      |
|     equipment funds. GRECC staff are currently developing and         |
|     implementing and evaluating new geriatrics-specific CCHT programs |
|     to better manage frail elderly veterans at risk for functional    |
|     decline and to improve home-based rehabilitation outcomes.        |
|                                                                       |
| -   As discussed below, GRECC staff have initiated, implemented, and  |
|     played the lead role in a 5-year collaborative planning process   |
|     with VACO and the State of California that has resulted in the    |
|     approval and funding of a new 400-bed academic California State   |
|     Veterans Home (CSVH) to be located in VISN 22 on the WLA campus.  |
|     This new facility will increase VISN GEC LTC care and training    |
|     resources, and will provide continuing education programs for the |
|     VISN CSVH system.                                                 |
|                                                                       |
| -   The GRECC provides three annual CME conferences on subjects       |
|     relating to geriatrics and extended care, targeted in particular  |
|     to VISN GEC staff and trainees. In addition, the GRECC sponsors   |
|     an annual VISN GEC staff retreat with seminars, lectures and      |
|     working groups focused on GEC topics of current importance to the |
|     VISN.                                                             |
|                                                                       |
| -   GRECC senior staff serve on a number of standing and ad hoc VISN  |
|     committees, and provide expertise and ongoing administrative      |
|     support for VISN initiatives.                                     |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2000]{.underline}**\                                             |
|     *(list the most significant research, education or clinical       |
|     innovations originating in your GRECC in the past five years.     |
|     Please limit your response to five innovations or fewer. For each |
|     item, succinctly describe the innovation, specify the time frame  |
|     of its earliest impact, whom it benefited, where it occurred, and |
|     why it was important. **Please limit the comments concerning each |
|     innovation to 5 lines or fewer**)*:                               |
|                                                                       |
| -   VISN Geriatrics and Extended Care Executive Committee (GECEC)     |
|     Leadership -- In 2001, Drs. TJ Hahn, J Kramer, S McDougall and LZ |
|     Rubenstein developed the VISN 22 GECEC, with representatives from |
|     each of the 5 medical centers, to improve the scope, access,      |
|     quality and efficiency of GEC care VISN-wide, and to enhance GEC  |
|     related education and research activities. This Committee,        |
|     chaired by Dr. Hahn, has been highly successful in all of these   |
|     areas, bringing VISN VA and community-based GEC care levels up to |
|     and above VACO standards.                                         |
|                                                                       |
| -   Care Coordination Home Telehealth (CCHT) -- Starting in 2003, WLA |
|     GRECC staff led the development of a new VISN-wide CCTH program   |
|     and Coordinating Committee. Accomplishments to date have included |
|     successful applications to the VISN and VACO for \$1.2 million in |
|     startup CCTH equipment, establishing active CCTH programs at all  |
|     5 VISN sites, enrolling more than 650 patients VISN wide.         |
|                                                                       |
| -   California Veterans State Home (CSVH) -- Ongoing negotiations     |
|     with VACO and the State of California begun in 1999 by Drs. TJ    |
|     Hahn, J Kramer and J Damron-Rodriguez culminated in 2004 with the |
|     approval and funding of a new \$280 million 400-bed academic CVSH |
|     to be located in the WLA campus, with two 60-bed/50 ADHC          |
|     satellites in the San Fernando Valley. The WLA CVSH will be       |
|     unique nationally, serving as a major regional training resource  |
|     in long term care and providing continuing medical education to   |
|     the entire CSVH system.                                           |
|                                                                       |
| -   GRECC's leadership in the GSWEC (Geriatric Social Work Education  |
|     Consortium) comprised of 4 graduate schools in social work and 7  |
|     centers of excellence (including VA GLA's WLA and Sepulveda       |
|     GRECC) has created the largest geriatric social work practicum    |
|     partnership program in the country and has been used as a model   |
|     nationally.                                                       |
|                                                                       |
| -   Factors Influencing Utilization of VA Care -- The previously      |
|     unexamined roles of various combat related, ethnic and            |
|     socioeconomic factors in determining veterans' attitude toward,   |
|     and utilization of, VA healthcare services were investigated by   |
|     WLA GRECC staff in a series of innovative studies. Rates of       |
|     utilization, and acceptance, of VA based care varied              |
|     significantly between WWII, Korean, Vietnam, and later veterans,  |
|     and with ethnic background. Analysis of this reason will lead to  |
|     improved access to and utilization of VA care by all veterans.    |
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| **5. RESEARCH**                                                       |
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| a.  **Most Noteworthy Findings Published in Report Year by GRECC Core |
|     Staff as PI or CO-PI\                                             |
|     ***(Please list five or fewer. For each noteworthy finding,       |
|     include the GRECC Core Staff name(s), journal reference, and a    |
|     JARGON-FREE description of the finding and its clinical or other  |
|     significance. Please limit your description of each noteworthy    |
|     finding to five lines or fewer.)*                                 |
|                                                                       |
| -   With increasing comorbidity (chronic illnesses) in older adults,  |
|     there is a proportional decrease in immune response. This study   |
|     demonstrated that the level of comorbidity correlates with the    |
|     impaired immunity that is distinct from normal aging and suggests |
|     that microenvironmental effects related to chronic disease and    |
|     medications contribute to impaired immunity. This finding         |
|     provides an opportunity to both screen for impaired immunity and  |
|     target novel strategies to boost host response to infections in   |
|     frail elderly. [Castle SC, Uyemura K, Makinodan T: J Amer Geriatr |
|     Soc 53: 1565-9, 2005]{.underline}.                                |
|                                                                       |
| -   Native Americans highly identify with the military service but    |
|     may turn to the Indian Health Service (IHS) for their medical     |
|     care, thus supporting the current VA policy of strengthening      |
|     coordination with the HIS to ensure that the medical needs of     |
|     native American Veterans are met. [Harada ND: Military Medicine   |
|     170(9):782-6, 2005]{.underline}.                                  |
|                                                                       |
| -   Cellular senescence after multiple cell replications              |
|     (reproduction cycles) was studied in mouse MC3T3-E1 osteoblast    |
|     (bone forming cell) precursors in culture. Multiple replications  |
|     of these osteoblast precursors in culture led to an increasing    |
|     percentage of these cells entering a senescent nonreplicating     |
|     phase. However, the number of cell replications before senescence |
|     could be increased by specific alterations in the extracellular   |
|     environment, particularly the extracellular matrix proteins.      |
|     These findings could ultimately lead to improved management of    |
|     osteoporosis in older veterans[. Peterson WJ: Cell Prolif. 2004   |
|     Oct;37(5):325-36]{.underline}.                                    |
|                                                                       |
| -   Age-related osteoporosis is characterized by decreased osteoblast |
|     (bone forming cell) number and increased fat cell content in      |
|     bone. It was shown that specific combinations of oxysterols,      |
|     which are naturally occurring cholesterol derivatives, markedly   |
|     enhance mouse stem cell differentiation toward osteoblast         |
|     production, and away from fat cell generation in culture. These   |
|     findings suggest that oxysterols could have important therapeutic |
|     potential for treatment of osteoporosis in older veterans. [Hahn  |
|     TJ: J Bone Miner Res 19:830-40, 2004.]{.underline}                |
|                                                                       |
| -   Veterans Service Organization (VSO) members utilization of VA     |
|     care was examined. VSO members were more often Caucasian, older,  |
|     retired, of lower income, and more functionally impaired than     |
|     non-members. In addition, veterans who use the VA were more often |
|     African American, of lower income, unemployed, and more           |
|     functionally impaired. VSO members were more likely to use the VA |
|     as their usual source of care. This suggests benefits to          |
|     increasing the diversity of VSO membership, since VSOs play an    |
|     important outreach and informational role for veterans. [Harada   |
|     ND: Military Medicine 169(10):735-40, 2004]{.underline}.          |
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| b.  **Most Noteworthy Findings Published in Report Year -- GRECC Core |
|     Staff as Co-Investigators on Projects with Non-GRECC PI\          |
|     ***(Please list five or fewer. For each noteworthy finding,       |
|     include the GRECC Core Staff name(s), journal reference, and a    |
|     JARGON-FREE description of the finding and its clinical or other  |
|     significance. Please limit your description of each noteworthy    |
|     finding to five lines or fewer)*                                  |
|                                                                       |
| -   There are relatively few studies examining minority elder's       |
|     access to healthcare. This study characterizing ambulatory        |
|     healthcare utilization by older Korean Americans demonstrated     |
|     that educational level and health insurance status were           |
|     significant predictors of number of visits to a physician during  |
|     the previous year (P\<.05). This finding has potentially          |
|     important implications for developing strategies to target        |
|     high-risk minority veterans for improved access to VA healthcare. |
|     [Harada ND: J Am Geriatr Soc. Nov;52(11):1946-50,                 |
|     2004]{.underline}.                                                |
|                                                                       |
| -   Osteoporosis and resulting bone fractures are increasing in the   |
|     older veteran population, and current treatments often have       |
|     limited effectiveness due to poor bone responses in the elderly,  |
|     in part due to oxidative effects on bone cell precursor           |
|     development into mature osteoblasts (bone forming cells). In      |
|     collaborative studies, Dr. Hahn's group has discovered a new      |
|     class of naturally occurring compounds, the oxysterols, that both |
|     increase the development of adult stem cells into functioning     |
|     osteoblasts and reverse the adverse effects of oxidation on this  |
|     process. These findings could lead to more effective new          |
|     treatments for osteoporosis in older veterans. [Hahn TJ: J Cell   |
|     Biochem 95: (6), 1276-83, 2005]{.underline}.                      |
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| **6. EDUCATION**                                                      |
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| a.  **Innovations in Educational Activities Implemented During Report |
|     Year**\                                                           |
|     (*Please list up to five. For each, describe the innovation and   |
|     the context in which it was innovative. Please limit your         |
|     description of each innovation to five lines or fewer):*          |
|                                                                       |
| -   Initiated a new one-month non-clinical rotation for geriatric     |
|     medicine advance fellows to advance their leadership skills. The  |
|     advanced fellows are mentored in developing didactic lectures,    |
|     academic publications and presentations to the lay public.        |
|                                                                       |
| -   WLA GRECC staff prepared medical residents and fellows for board  |
|     certifying exams with a 15-20 minute case-based curriculum before |
|     each geriatric outpatient clinical rotation.                      |
|                                                                       |
| -   An educational conference on decisional capacity led to the       |
|     development of an algorithm to assess decisional capacity in      |
|     older veterans. The algorithm and proceedings of the conference   |
|     were used to develop a didactic curriculum for trainees and the   |
|     algorithm is the basis for future research by S. Castle, MD.      |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year**\                                    |
|     (Please list your most important products. Please limit to five.  |
|     Your description of each item should succinctly summarize the     |
|     content, target audience, format, and product evaluation results  |
|     if any. You may include products developed in prior years ONLY IF |
|     THIS IS THE FIRST YEAR they have been available for distribution. |
|     Please limit each description to five lines or fewer):            |
|                                                                       |
| None.                                                                 |
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| **7. CLINICAL INNOVATIONS**                                           |
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| **NEW DEFINITION:** A "Clinical Innovation" is an untested,           |
| GRECC-initiated clinical effort that ideally is related to one of the |
| GRECC's research foci. A Clinical Innovation may be a wholly original |
| clinical program or an original aspect of or variation on an          |
| established program. A Clinical Innovation must incorporate an        |
| evaluation plan for assessing the innovation's efficacy so that, if   |
| the innovation is demonstrated to be an improvement over an existing  |
| approach to care, there is a basis on which it can be exported for    |
| implementation elsewhere.                                             |
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| a.  **Clinical Innovations Underway in Report Year**\                 |
|     *(list all Clinical Innovations underway during the report year.  |
|     For each, indicate whether the innovation is [N]{.underline}ew or |
|     [O]{.underline}ngoing in the report year. Please describe each    |
|     innovation in five lines or fewer)*:                              |
|                                                                       |
| -   Program to Assess Risk of Self-Neglect and Decisional Capacity to |
|     Return Home (PADC) -- The PADC clinical program is at an advanced |
|     stage of development. A protocol that streamlines assessment uses |
|     standardized instruments, and utilizes a template to document     |
|     assessment and provide management assistance has been developed   |
|     and tested. PADC assessments will initially be compared with the  |
|     results of formal Geriatric Psychiatry testing for validation.    |
|                                                                       |
| -   Medication Education Clinic -- The goal of this project is to     |
|     develop a program to educate patients and staff about the risks   |
|     and management of medications in the elderly, to attempt to       |
|     reduce the incidence of adverse drug events in older patients.    |
|     The optimal components for assessment have been determined and a  |
|     new CPRS template implemented. Program implementation has begun   |
|     and evaluation this new clinical approach is in process.          |
|                                                                       |
| -   Geriatrics Specific CCHT Programs -- Initial development and      |
|     piloting is underway on an innovative new clinical demonstration  |
|     project using CCHT to improve the care of 1) frail older          |
|     community-dwelling veterans who are at high risk for further      |
|     functional decline; and 2) de-conditioned older veterans on home  |
|     rehabilitation programs following hospital discharge; and 3) use  |
|     videophone assisted geriatric assessment for evaluation of        |
|     patient s who have difficulty in accessing the GLA campus.        |
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| b.  **Evaluation Results of Clinical Innovations listed in the        |
|     preceding box\                                                    |
|     ***(for each clinical innovation listed in 7-a above, summarize   |
|     evaluation outcome(s) identified in the report year, in five      |
|     lines or fewer. Please specify "no evaluation results" for any    |
|     innovation for which that is the case)*                           |
|                                                                       |
| -   Evaluation is just beginning for the first two clinical models    |
|     that are listed above.                                            |
|                                                                       |
| -   In support of the Elder Abuse due to Self-Neglect, a              |
|     retrospective review of cases referred to the Geriatric program   |
|     found that 31 of 575 (5.4%) of referrals had an elder abuse       |
|     report filed during a three-year period, and self-neglect was the |
|     most commonly reported type of abuse (Moon, in press).            |
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| c.  **Clinical Innovation Exported in Report Year**\                  |
|     *(Please list up to five examples. In three lines or less for     |
|     each example, name or describe the innovation, identify the name  |
|     of the VA or non-VA facility to which it was exported, and the    |
|     method of export)*:                                               |
|                                                                       |
| -   None                                                              |
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| **8. CONSULTATION AND OUTREACH**                                      |
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| **DEFINITIONS:**                                                      |
|                                                                       |
| **"Consultation"** for this section of the report has occurred when   |
| GRECC staff has materially assisted in the development of a non-GRECC |
| research, education or clinical program **[within the host            |
| VAMC.]{.underline}**                                                  |
|                                                                       |
| **"Outreach"** for this section of the report has occurred when GRECC |
| staff has materially assisted in the development of a non-GRECC       |
| research, education or clinical program **[at a facility other than   |
| the host VAMC.]{.underline}**                                         |
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| **Note:**                                                             |
|                                                                       |
| **for the 2005 Annual Report,**                                       |
|                                                                       |
| **Consultation and Outreach activity**                                |
|                                                                       |
| **will NOT be reported here.**                                        |
|                                                                       |
| **It will be reported via the Electronic Annual report Data Base.**   |
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