**[GRECC Annual Report]{.underline}**

**[April 24, 2007]{.underline}**

**National Overview**

Geriatric Research, Education, and Clinical Centers (GRECCs) emerged as
a concept in 1973 as a response to the realization that a wave of aging
veterans with unique health needs would soon challenge the resources and
expertise of the Veterans Health Administration (VHA). The first six
GRECCs were initiated in 1975. In 1980 Public Law 96-330 mandated GRECCs
to **"advance scientific knowledge regarding the medical, psychological,
and social needs of older veterans, and the means for addressing them,
through: (1) geriatric and gerontological research; (2) the training of
personnel providing health care services to older persons; and (3) the
development and evaluation of improved models of clinical services for
eligible, older veterans."**

In 1985, Public Law 99-166 authorized up to 25 sites to be designated as
GRECCs. Presently, twenty GRECCs are in operation in nineteen Veterans
Integrated Service Networks (VISNs); all VISNs except VISN 2 and VISN 18
have at least one GRECC (Table 1).

***Table 1: Geriatric Research, Education and Clinical Centers (April
25, 2007)***

+-----+---------------------+------+-----------------+----------------+
| **  | **GRECC name**      | **Es | **GRECC         | **Primary      |
| VIS |                     | t.** | Director**      | Academic       |
| N** | (sites)             |      |                 | affiliate(s)** |
+-----+---------------------+------+-----------------+----------------+
| **  | **New England**     | 1975 | Neil Kowall,    | Boston         |
| 1** |                     |      | MD, PhD         | University,    |
|     | (Boston, Bedford)   |      |                 | Harvard        |
|     |                     |      |                 | University     |
+-----+---------------------+------+-----------------+----------------+
| **  | **Bronx/NY Harbor** | 1999 | Albert Siu, MD, | Mt. Sinai      |
| 3** |                     |      | MSPH            | School         |
|     |                     |      |                 |                |
|     |                     |      |                 | of Medicine    |
+-----+---------------------+------+-----------------+----------------+
| **  | **Pittsburgh**      | 1999 | Steven Graham,  | University of  |
| 4** |                     |      | MD, PhD         | Pittsburgh     |
+-----+---------------------+------+-----------------+----------------+
| **  | **Baltimore**       | 1992 | Andrew          | University of  |
| 5** |                     |      | Goldberg, MD    | Maryland       |
+-----+---------------------+------+-----------------+----------------+
| **  | **Durham**          | 1984 | Kenneth         | Duke           |
| 6** |                     |      | Schmader, MD    | University     |
|     |                     |      | (acting)        |                |
+-----+---------------------+------+-----------------+----------------+
| **  | **B                 | 2000 | Richard Allman, | UAB, Emory     |
| 7** | irmingham/Atlanta** |      | MD              | University     |
+-----+---------------------+------+-----------------+----------------+
| **  | **Gainesville**     | 1984 | Ronald I.       | University of  |
| 8** |                     |      | Shorr, MD       | Florida        |
+-----+---------------------+------+-----------------+----------------+
| **  | **Miami**           | 1991 | Bernard Roos,   | University of  |
| 8** |                     |      | MD              | Miami          |
+-----+---------------------+------+-----------------+----------------+
| **  | **Tennessee         | 1999 | Robert E.       | Vanderbilt     |
| 9** | Valley**            |      | Dittus, MD, MPH |                |
|     |                     |      |                 | University     |
|     | (Nashville,         |      |                 |                |
|     | Murfreesboro)       |      |                 |                |
+-----+---------------------+------+-----------------+----------------+
| **1 | **Cleveland**       | 1999 | Thomas Hornick, | Western        |
| 0** |                     |      | MD (acting)     | Reserve        |
|     |                     |      |                 | Univiversity   |
+-----+---------------------+------+-----------------+----------------+
| **1 | **Ann Arbor**       | 1989 | Neil Alexander, | University of  |
| 1** |                     |      | MD              | Michigan       |
+-----+---------------------+------+-----------------+----------------+
| **1 | **Madison**         | 1991 | Sanjay Asthana, | University of  |
| 2** |                     |      | MD, PhD         | Wisconsin      |
+-----+---------------------+------+-----------------+----------------+
| **1 | **St. Louis**       | 1975 | John Morley, MD | St. Louis      |
| 5** |                     |      |                 | University     |
+-----+---------------------+------+-----------------+----------------+
| **1 | **Little Rock**     | 1975 | Dennis          | University of  |
| 6** |                     |      | Sullivan, MD,   | Arkansas       |
|     |                     |      | PhD             |                |
+-----+---------------------+------+-----------------+----------------+
| **1 | **San Antonio**     | 1988 | Michael S.      | University of  |
| 7** |                     |      | Katz, MD        | Texas          |
+-----+---------------------+------+-----------------+----------------+
| **1 | **Salt Lake City**  | 1991 | Mark Supiano,   | University of  |
| 9** |                     |      | MD              | Utah           |
+-----+---------------------+------+-----------------+----------------+
| **2 | **Puget Sound**     | 1977 | John Breitner,  | University of  |
| 0** |                     |      | MD, PhD         | Washington     |
|     | (Seattle, American  |      |                 |                |
|     | Lake)               |      |                 |                |
+-----+---------------------+------+-----------------+----------------+
| **2 | **Palo Alto**       | 1975 | Thomas Rando,   | Stanford       |
| 1** |                     |      | MD, PhD         | University     |
+-----+---------------------+------+-----------------+----------------+
| **2 | **Greater Los       | 1975 | Larry Z.        | University of  |
| 2** | Angeles**           |      | Rubenstein,     | California --  |
|     |                     |      |                 | Los Angeles    |
|     | (Sepulveda, West    |      | MD, MPH         |                |
|     | Los Angeles)        |      |                 |                |
+-----+---------------------+------+-----------------+----------------+
| **2 | **Minneapolis**     | 1977 | Maurice Dysken, | University of  |
| 3** |                     |      | MD              | Minnesota      |
+-----+---------------------+------+-----------------+----------------+

By law, each GRECC has a tripartite mission of geriatric and
gerontological research, education, and clinical innovation

-   **The research mission** at each site consists of funded,
    peer-reviewed investigations within one or more circumscribed focus
    areas in the basic biomedical, applied clinical, and health
    services/rehabilitative issues surrounding aging, the aged, and
    their health care and functional needs;

-   **The education mission** is focused on the training of health
    providers in the care of the elderly, at undergraduate and
    postgraduate levels; among both VA staff and community providers,
    and in partnership with academic affiliates; within local as well as
    regional and national spheres; and covering a broad range of
    disciplines; and

-   **The clinical innovation mission** is intended to advance the
    practice of geriatric care through the development and evaluation of
    new approaches---which when demonstrated as effective, are to become
    integrated into the fabric of, and supported by, the parent health
    care system; and then, ideally, exported elsewhere within VA and
    beyond.

**GRECC Performance Measures**

From their outset, GRECCs have been intensely studied, monitored, and
tracked. A detailed annual report is required from each site and a
Congressionally-mandated, VA Secretary-appointed advisory committee of
non-VA geriatrics and gerontology experts conducts periodic site visits.
Recent maturation of data management systems has permitted detailed,
multidimensional, longitudinal analyses of GRECC activities and
outcomes. Prior to 1997, GRECCs were funded centrally, but beginning in
1997, GRECCs were supported under the Veterans Equitable Resource
Allocation (VERA) allocation methodology, which shifted a measure of
control of the programs from VA Central Office to the VISNs. In the face
of decentralized funding, the need was recognized for a standardized
means of accountability using national GRECC Performance Measures.
National GRECC Performance Measures were initiated in 1995 and tracked
through FY2006.

Recently, realization that these measures had tracked conformity to the
original GRECC mission but not to current VHA strategic initiatives
mandated an extended, in-depth review that resulted in a number of
changes to the GRECC Performance Measures. The GRECC Performance
Measures for FY2007, which include a number of measures for which
baseline data must be tracked and trended before thresholds can be set,
are listed in Table 2 (next page).

During FY2007, the Deputy Under Secretary for Health for Operations and
Management (DUSHOM) included three of these GRECC Performance Measures
among his Performance Monitors for the VISNs. The Measures selected to
drive this notably high-level interest were #s 10c, 10d, and 11
(indicated on table, following page).

**Table 2: GRECC Performance Measures**

+---+------------------------------------------------------------+-----+
| * | **Description**                                            | *   |
| * |                                                            | *Ta |
| \ |                                                            | rge |
| # |                                                            | t** |
| * |                                                            |     |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
| * | Negotiate with VISN Director to identify VISN Performance  | **T |
| * | Measure(s) and expected target(s)                          | BD\ |
| 1 |                                                            | *** |
| * |                                                            |     |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
| * | a\. Average number funded aging-related research projects  | **1 |
| * | on which each GRECC investigator is project leader in      | or  |
| 2 | prior 12 mos.                                              | mor |
| * |                                                            | e** |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
|   | b\. % of GRECC investigators who at some time during the   | **  |
|   | prior 24 months, have been a project leader on one or more | 80% |
|   | funded aging-related research project.                     | or  |
|   |                                                            | mor |
|   |                                                            | e** |
+---+------------------------------------------------------------+-----+
|   | c\. %Increase in research funding over five years prior to | **5 |
|   | report                                                     | %/5 |
|   |                                                            | y   |
|   |                                                            | r** |
+---+------------------------------------------------------------+-----+
| * | a\. Average number papers, concerning topic relevant to    | **2 |
| * | mission of the GRECC, authored/ co-authored by each GRECC  | or  |
| 3 | professional core staff in peer-reviewed journals.         | mor |
| * |                                                            | e** |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
|   | b\. % of GRECC professional core staff who, during the     | **  |
|   | prior 24 months, have published four or more papers in     | 80% |
|   | peer-reviewed journals, concerning one or more topics      | or  |
|   | relevant to the mission of the GRECC.                      | mor |
|   |                                                            | e** |
+---+------------------------------------------------------------+-----+
|   | c\. Average number papers, concerning topic relevant to    | **3 |
|   | mission of GRECC, authored/co-authored in peer-reviewed    | or  |
|   | journals by each GRECC research investigator.              | mor |
|   |                                                            | e** |
+---+------------------------------------------------------------+-----+
|   | d\. % of GRECC research investigators who, during the      | **  |
|   | prior 24 months, have published six or more papers in      | 80% |
|   | peer-reviewed journals, concerning one or more topics      | or  |
|   | relevant to the mission of the GRECC.                      | mor |
|   |                                                            | e** |
+---+------------------------------------------------------------+-----+
|   | e.Total number of papers published by GRECC core staff in  | *   |
|   | peer-reviewed journals during the reporting year.          | *21 |
|   |                                                            | or  |
|   |                                                            | mor |
|   |                                                            | e** |
+---+------------------------------------------------------------+-----+
|   | f\. Percent of publications in peer-reviewed journals by   | *   |
|   | GRECC core staff listing their VA affiliation.             | *95 |
|   |                                                            | %** |
+---+------------------------------------------------------------+-----+
| * | a\. Percent of GRECC professional core staff members who   | *   |
| * | devote 20% or more of his/her GRECC time to research       | *80 |
| 4 | activities.                                                | %** |
| * |                                                            |     |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
|   | b\. Average percent of GRECC time attributed to research   | **  |
|   | activities by GRECC professional core staff members        | 45% |
|   |                                                            | or  |
|   |                                                            | mor |
|   |                                                            | e** |
+---+------------------------------------------------------------+-----+
| * | Number of GRECC clinical postdoctoral trainees or GRECC    | **  |
| * | core staff who are junior faculty who submitted a research | One |
| 5 | career development award application, or who were          | or  |
| * | supported by one, during the reporting period.             | mor |
| * |                                                            | e** |
+---+------------------------------------------------------------+-----+
| * | a\. Number of GRECC host facility(s) clinical staff who    | **  |
| * | were provided education/training by GRECC core staff in    | TBD |
| 6 | care of elderly veterans.                                  | (   |
| * |                                                            | min |
| * |                                                            | )** |
+---+------------------------------------------------------------+-----+
|   | b\. Number of person-hours of training represented by (6a) | **  |
|   | above                                                      | TBD |
|   |                                                            | (   |
|   |                                                            | min |
|   |                                                            | )** |
+---+------------------------------------------------------------+-----+
|   | c\. Number of clinical staff of VAs OTHER THAN THE GRECC   | **  |
|   | Host FACILITY provided education/training by GRECC core    | TBD |
|   | staff in care of elderly veterans.                         | (   |
|   |                                                            | min |
|   |                                                            | )** |
+---+------------------------------------------------------------+-----+
|   | d\. Number of person-hours of training represented by      | **  |
|   | above                                                      | TBD |
|   |                                                            | (   |
|   |                                                            | min |
|   |                                                            | )** |
+---+------------------------------------------------------------+-----+
| * | \# of educational programs, at least one of which had at   | **  |
| * | least 51% of its participants from the host facility and   | 2** |
| 7 | at least one of which had at least 51% of its participants |     |
| * | from VAs other than the host facility, each of which is    |     |
| * | characterized by [all]{.underline} of the following:       |     |
|   |                                                            |     |
|   | i.  There were at least 25 participants in the program     |     |
|   |                                                            |     |
|   | ii. A program evaluation was completed at the end of the   |     |
|   |     program by at least 50% of participants;               |     |
|   |                                                            |     |
|   | iii. A secondary evaluation of the program objectives was  |     |
|   |      conducted within 3 months of program completion to    |     |
|   |      measure use/implementation of acquired knowledge or   |     |
|   |      behavior/practice change; and                         |     |
|   |                                                            |     |
|   | iv. A description of the evaluation, including the         |     |
|   |     methodology, findings and conclusions, is included in  |     |
|   |     the Annual Report narrative.                           |     |
+---+------------------------------------------------------------+-----+
| * | a\. % of internal medicine and family medicine housestaff  | **  |
| * | training months spent assigned to a GRECC-affiliated       | TBD |
| 8 | program.                                                   | (   |
| * |                                                            | min |
| * |                                                            | )** |
+---+------------------------------------------------------------+-----+
|   | b\. % of graduating medical school class at affiliated     | **  |
|   | medical school who had a total of at least 80 hours        | TBD |
|   | assigned to, exposed to, and/or working with one or more   | (   |
|   | GRECC-affiliated program prior to graduation               | min |
|   |                                                            | )** |
+---+------------------------------------------------------------+-----+
|   | c\. Total \# of medical student hours attributed to all    | **  |
|   | GRECC-affiliated programs                                  | TBD |
|   |                                                            | (   |
|   |                                                            | min |
|   |                                                            | )** |
+---+------------------------------------------------------------+-----+
| * | \# of associated health disciplines (which must include    | **3 |
| * | nursing) represented among VA-paid and non-VA-paid         | or  |
| 9 | trainees who received at least 80 hours training in a      | mor |
| * | GRECC-affiliated program                                   | e** |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
| * | a\. Average percent of GRECC professional core staff time  | **  |
| * | attributed to education and training activities.           | 10% |
| 1 |                                                            | or  |
| 0 |                                                            | mor |
| * |                                                            | e** |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
|   | b\. % of GRECC professional core staff who have 10% or     | **  |
|   | more of GRECC time attributed to education                 | 75% |
|   |                                                            | or  |
|   |                                                            | mor |
|   |                                                            | e** |
+---+------------------------------------------------------------+-----+
|   | c**\*\***. Average number of scholarly or educational      | **4 |
|   | presentations during the reporting period concerning a     | or  |
|   | topic relevant to the mission o f the GRECC, given by      | mor |
|   | GRECC core staff with a professional degree                | e** |
+---+------------------------------------------------------------+-----+
|   | d**\*\***. GRECC AD/EE or a suitable proxy for the AD/EE   | *   |
|   | is a participant with full privileges on one or more       | *YE |
|   | VISN-level committee(s) that has input into the selection  | S** |
|   | of and support for educational activities in the Network.  |     |
+---+------------------------------------------------------------+-----+
| * | Number of innovative clinical demonstration projects       | **  |
| * | underway and under evaluation for improving care of        | Two |
| 1 | elderly veterans                                           | or  |
| 1 |                                                            | mor |
| \ |                                                            | e** |
| * |                                                            |     |
| \ |                                                            |     |
| * |                                                            |     |
| * |                                                            |     |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
| * | a\. Percent of GRECC core staff with a professional degree | **  |
| * | who devote 30% or more of their GRECC time to one or more  | TBD |
| 1 | clinical demonstration projects that are or will be        | (   |
| 2 | evaluated for their impact on care of the elderly          | min |
| * |                                                            | )** |
| * |                                                            |     |
+---+------------------------------------------------------------+-----+
|   | b\. Average percent of GRECC time attributed to clinical   | **  |
|   | service and related education activities (i.e. not         | TBD |
|   | clinical demonstration projects) by GRECC core staff       | (   |
|   | members with a clinical degree.                            | max |
|   |                                                            | )** |
+---+------------------------------------------------------------+-----+

**\*TBD = "to be determined"**

**\*\*GRECC Performance Measures selected as DUSHOM Performance Monitors
for FY2007.**

**Research Contributions of the GRECCs**

GRECCs are required by statute to conduct research on aging-related
topics, including basic biomedical, applied clinical, and health
services research; rehabilitation research is also strongly encouraged.
GRECC primary core staffing is recommended to include 5.0 research FTEE,
and an average research effort of at least 40% time by all GRECC
research staff is required. Total GRECC-reported research expenditures
for 2006 were nearly \$109 million, of which more than \$25 million were
VA-supported research (e.g., Merit, Cooperative study, Career
Development, etc.), nearly \$77 million were non-VA governmental and
other peer-reviewed funding (e.g., National Institutes of Health (NIH),
university support); and nearly \$7 million were private corporation,
donated, or proprietary funds (Table 3).

**Table 3: 2006 GRECC Research Funding**

  -------------------- -------------- -------------- ------------- ---------------
  **GRECC**            **VA funding   **non-VA       **Private**   **Total
                       (Merit,        Government,                  Research
                       Cooperative,   University,                  Support**
                       etc.)**        etc.**                       

  Ann Arbor            \$ 1,130,877   \$ 3,746,650   \$ 591,489    \$ 5,469,016

  Baltimore            \$ 574,665     \$ 8,277,252   \$ 103,347    \$ 8,955,264

  Birmingham/Atlanta   \$ 2,268,163   \$ 2,605,701   \$ 111,660    \$ 4,985,524

  Bronx/NY Harbor      \$ 1,190,051   \$ 1,524,904   \$ 632,766    \$ 3,347,721

  Cleveland            \$ 277,001     \$ 1,813,604   \$ 21,172     \$ 2,111,777

  Durham               \$ 372,798     \$ 2,981,585   \$ 1,335,298  \$ 4,689,681

  Gainesville          \$ 399,900     \$ 3,149,202   \$ 100,004    \$ 3,649,106

  Little Rock          \$ 851,142     \$ 8,393,013   \$ 426,181    \$ 9,670,336

  Madison              \$ 751,418     \$ 4,172,023   \$ 340,081    \$ 5,263,522

  Miami                \$ 3,669,466   \$ 967,171     \$ 38,228     \$ 4,674,865

  Minneapolis          \$ 645,909     \$ 2,133,423   \$ 212,896    \$ 2,992,228

  New England          \$ 3,512,329   \$ 4,495,747   \$ 90,686     \$ 8,098,762

  Palo Alto            \$ 1,081,249   \$ 4,127,220   \$ 729,889    \$ 5,938,358

  Pittsburgh           \$ 655,811     \$ 3,509,514   \$ 119,696    \$ 4,285,021

  Puget Sound          \$ 1,306,748   \$ 7,064,743   \$ 774,878    \$ 9,146,369

  Salt Lake City       \$ 363,048     \$ 785,981     \$ 357,281    \$ 1,506,310

  San Antonio          \$ 1,690,849   \$ 3,382,796   \$ 541,387    \$ 5,615,032

  St. Louis            \$ 503,300     \$ 1,198,848   \$ 145,000    \$ 1,847,148

  Tennessee Valley     \$ 553,000     \$ 9,016,562   \$ 100,000    \$ 9,669,562

  Greater LA           \$ 3,285,009   \$ 3,359,236   \$ 188,924    \$ 6,833,169

  **TOTAL**            **\$           **\$           **\$          **\$
                       25,082,733**   76,705,175**   6,960,863**   108,748,771**
  -------------------- -------------- -------------- ------------- ---------------

The GRECC research portfolio has steadily increased 6-11% per year,
averaging an 8.6% increase over the past eight years (Figure 1, next
page).

**Figure 1: Annual GRECC research expenditures, 1999-2006**

![](media/image1.wmf){width="5.735416666666667in"
height="2.3305555555555557in"}

This rate of increase has closely mirrored the rise in the total VA
research portfolio (from all funding sources); GRECCs have accounted for
approximately 10% of that total each year since 2002 (Figure 2)

**Figure 2: GRECC share of total VA research support (all sources)**

![](media/image2.wmf){width="5.052083333333333in"
height="2.0416666666666665in"}

Work funded in this manner has resulted annually in over 1,000
publications by GRECC core staff in five of the past eight years (Figure
3).

**Figure 3: Total number of GRECC publications per year (1999-2005)**

![](media/image3.wmf){width="4.395138888888889in"
height="2.314583333333333in"}

The VERA research allocation based on the GRECCs' self-reported research
productivity in 2006 was over \$36 million (Table 4, Column 4). By
comparison, in 2006, the personnel, equipment, and supplies costs for
GRECCs totaled just under \$37 million (Column 5).

**Table 4: 2006 GRECCs' research accounting for VERA allocation and
expenses**

+-----------+------------+-------------+---------------+--------------+
|           | **[Total   | **          | **[Discounted | *            |
|           | Research.  | [Discounted | Total         | *[Personnel, |
|           | Su         | total\*]{.u | Adjusted for  | supplies,    |
|           | pport]{.un | nderline}** | \"National    | and          |
|           | derline}** |             | Cost of       | equipment    |
|           |            |             | Res           | costs]{.     |
|           |            |             | earch\"\*\*]{ | underline}** |
|           |            |             | .underline}** |              |
+-----------+------------+-------------+---------------+--------------+
| Ann Arbor | \$         | \$          | \$ 1,758,157  | \$ 1,500,085 |
|           | 5,469,016  | 4,088,737   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Baltimore | \$         | \$          | \$ 2,927,630  | \$ 2,627,513 |
|           | 8,955,264  | 6,808,441   |               |              |
+-----------+------------+-------------+---------------+--------------+
| B         | \$         | \$          | \$ 1,827,652  | \$ 1,669,936 |
| irmingham | 4,985,524  | 4,250,354   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Bronx     | \$         | \$          | \$ 1,071,526  | \$ 1,145,838 |
|           | 3,347,721  | 2,491,921   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Cleveland | \$         | \$          | \$ 706,274    | \$ 382,071   |
|           | 2,111,777  | 1,642,497   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Durham    | \$         | \$          | \$ 1,265,409  | \$ 2,008,232 |
|           | 4,689,681  | 2,942,811   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Ga        | \$         | \$          | \$ 1,198,325  | \$ 1,599,021 |
| inesville | 3,649,106  | 2,786,803   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Little    | \$         | \$          | \$ 3,118,552  | \$ 1,370,458 |
| Rock      | 9,670,336  | 7,252,447   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Madison   | \$         | \$          | \$ 1,705,146  | \$ 1,388,246 |
|           | 5,263,522  | 3,965,456   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Miami     | \$         | \$          | \$ 1,893,892  | \$ 2,380,422 |
|           | 4,674,865  | 4,404,401   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Mi        | \$         | \$          | \$ 988,656    | \$ 1,202,082 |
| nneapolis | 2,992,228  | 2,299,200   |               |              |
+-----------+------------+-------------+---------------+--------------+
| New       | \$         | \$          | \$ 2,969,929  | \$ 3,844,857 |
| England   | 8,098,762  | 6,906,811   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Palo Alto | \$         | \$          | \$ 1,874,428  | \$ 1,973,685 |
|           | 5,938,358  | 4,359,136   |               |              |
+-----------+------------+-------------+---------------+--------------+
| P         | \$         | \$          | \$ 1,426,685  | \$ 1,205,143 |
| ittsburgh | 4,285,021  | 3,317,871   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Puget     | \$         | \$          | \$ 2,923,581  | \$ 3,497,498 |
| Sound     | 9,146,369  | 6,799,025   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Salt Lake | \$         | \$          | \$ 447,997    | \$ 1,139,544 |
| City      | 1,506,310  | 1,041,854   |               |              |
+-----------+------------+-------------+---------------+--------------+
| San       | \$         | \$          | \$ 1,876,216  | \$ 1,237,689 |
| Antonio   | 5,615,032  | 4,363,293   |               |              |
+-----------+------------+-------------+---------------+--------------+
| St. Louis | \$         | \$          | \$ 618,635    | \$ 1,693,127 |
|           | 1,847,148  | 1,438,686   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Tennessee | \$         | \$          | \$ 3,156,381  | \$ 1,507,828 |
| Valley    | 9,669,562  | 7,340,422   |               |              |
+-----------+------------+-------------+---------------+--------------+
| Greater   | \$         | \$          | \$ 2,516,217  | \$ 3,379,717 |
| Los       | 6,833,169  | 5,851,667   |               |              |
|           |            |             |               |              |
| Angeles   |            |             |               |              |
+-----------+------------+-------------+---------------+--------------+
| **[TOTAL] | **\$108    | **\$        | **\$          | **\$         |
| {.mark}** | ,748,771** | 8           | 36,271,288**  | 36,752,991** |
|           |            | 4,351,833** |               |              |
+-----------+------------+-------------+---------------+--------------+

**\*Total VA-supported funding plus 75% non-VA government/university
funding plus 25% private funding.\
\*\*Prior figure multiplied by 43%, the ratio of Congressional research
allocation to actual VA research grant funding.**

As will be further stressed later in this report, this indicates that
the difference between those two figures (*less than \$500,000*) was the
*net cost* borne by the VISNS for the entire GRECC program: "the price
tag" for ***all*** of the research accomplishments, publications,
affiliated university collaborations, prestige, educational and
administrative efforts, clinical contributions, and over 280 GRECC FTEE
in FY2006.

The magnitude and significance of the GRECCs' aggregate research
activity is not easily summarized because of its diversity and richness.
A list of stated GRECC research foci is nearly a complete cross-section
of geriatric subject matter (Table 5).

**Table 5: Partial alphabetic list of GRECC Research foci from 2006
Annual Reports**

-   Age-related changes in host response to stress and injury

-   Alzheimer's Disease and other neurodegenerative disorders
    *(behavior, pathophysiology, management strategies and models of
    care, genetics, policy, educational and ethical issues)*

-   Andropause ("male menopause")

-   Antibiotic resistance in long-term care

-   Arthritis and other joint disorders

-   Assessment instruments *(nursing home, home, palliative care, mental
    health)*

-   Bioethics/bioethical decision-making

-   Blood pressure regulation in aging

-   Bone, cartilage, and joint changes in aging

-   Cancer in aging

-   Cellular aging *(antioxidants, cytokines, leptins, nutritional
    effects)*

-   Clinical decision support systems

-   Clinical outcomes research

-   Cost effectiveness of new care approaches

-   Delirium *(prevalence, recognition, prevention, management)*

-   Depression in the elderly

-   Diabetes, hyperglycemia, and hypoglycemia in aging

-   Diabetic neuropathy

-   Dysphagia *(prevalence, mechanism, management)*

-   E-learning and geriatrics

-   Ethnicity and aging

-   Exercise in elderly *(effects on glucose metabolism,
    cardiovascular-cerebrovascular-peripheral vascular health,
    cognition, obesity, functional status, immune system, quality of
    life)*

-   Falls *(predictors, preventive regimens)*

-   Informatics

-   Frailty

-   Functional decline in aging *(risk factors, biomarkers, prevention)*

-   Function genomics, genetics, and metabolism in aging

-   Gait and balance

-   Geriatric immunology

-   Geropharmacology *(mechanisms, polypharmacy, compliance)*

-   Glucose metabolism

-   Inflammation and oxidative stress as mechanisms of "aging"

-   Medication utilization in the elderly *(inpatient, outpatient,
    long-term care; polypharmacy)*

-   Muscle and adipocyte biology in aging and obesity

-   Myocardial infarction

-   Neurogenetics

-   Neuroimaging

-   Nursing home infections

-   Nutrition

-   Oral health

-   Osteoporosis *(cause, diagnosis and treatment)*

-   Palliative care/end of life issues

-   Patient safety

-   Prostate disease

-   Quality assurance models applied to geriatrics services

-   Reparative uses for adult marrow-derived stem cells

-   Sarcopenia: muscle loss in aging

-   Sleep disorders in aging and long term care

-   Stroke *(prevention; behavioral, cytologic, electrical rehab.
    Modalities, brain plasticity, communications rehabilitation)*

-   Telehealth applications

-   Transitions between care systems.

-   Urinary incontinence *(medical and behavioral management)*

    **Educational Contributions of the GRECCs**

The GRECCs are charged with a broad education mission, as reflected by
the number and goals of education-related Performance Measures (see
Table 2, Items 6a-d, 7, 8, 9, and 10a-d). GRECCs are required to 1)
provide on-going training in geriatrics for the host facility clinical
staff, 2) provide regional and national continuing medical education, 3)
train medical and healthcare professions students in geriatrics and
gerontology and 4) mentor junior faculty and post doctoral researchers.
All GRECCs have close ties to their affiliated medical school; many
maintain close working relationships with other health professional
programs (e.g., nursing, psychology, dentistry, podiatry, optometry) of
the medical affiliate and of other universities as well.

For clinical training, GRECCs generally offer medical students, medical
residents and associated health professions trainees rotations through a
selection of different inpatient and outpatient geriatric clinical
programs. All GRECCs have geriatric medicine fellowship programs and six
have one or more fellowships in geriatric psychiatry, neurology, or
dentistry as well. Nearly 70% of the geriatric medicine fellows in
training in the United States receive some or much of their training in
GRECCs. In 2006, 165 of the 180 fellows training in GRECCs were in
geriatric medicine. Also available at many sites are advanced research
fellowships and "mini-residencies" for clinicians already in practice.
All GRECCs provide periodic Grand Rounds presentations and most offer
regular research conferences: a total of 2,288 such "teaching
conferences" were reported in 2006. The Office of Academic Affiliations
provides over three hundred trainee stipends totaling over \$5.3 million
to be administered through the GRECCs specifically for GRECC-associated
health trainees. In FY2006 these VA-funded trainees worked in GRECCs for
a total of nearly 6,100 person-weeks.

GRECCs offer continuing education in collaboration with as well as
independent of the Employee Education System (EES), and in collaboration
with and independent of their affiliated universities and health
professions programs. Sixteen of the GRECCs regularly collaborate in
continuing education programs with nearby or co-located U.S. Department
of Health and Human Services (HHS)-funded Geriatric Education Centers. 
Subject matter and mode of delivery vary widely. Annual professional
conferences that showcase research findings in a particular area of
expertise have been a particularly valuable contribution of the GRECCs
to the VHA system.  These conferences are well-regarded and
well-attended by both community and VHA providers although no travel
dollars or tuition offsets are made available.   Other programs
typically offered by GRECCs include background courses in geriatrics for
established providers, age-based competencies as part of New Employee
Orientation, focused training in geriatric assessment, interdisciplinary
team dynamics, and specific geriatrics skills-building. Several GRECCS
also provide Geriatrics Board Review courses.  Almost 41,000 individuals
(over 18,000 of whom were from VA) participated in GRECC educational
activities of this sort in FY2006. Many materials resulting from or
complementary to these learning experiences are available from VA's
Employee Education System and the GRECCs, as stand-alone resources in
written, videotape, CD-ROM and e-learning (Web-based) forms. 

For example, in 2006 the GRECCs began a monthly series of updates in
clinical geriatrics topics for providers, broadcast over the VA National
Teleconferencing System. GRECC core staff from a single or a consortium
of collaborating GRECCs deliver a 45-minute talk supported by visual
materials distributed in advance. Without charge to participants,
Continuing Education credit for a range of disciplines is awarded for
participation in either the live broadcast or a subsequent re-broadcast.
The audiofiles, synchronized with the visual support material (e.g.,
Powerpoint series), can later be accessed through the Internet without
charge from the Portal of Online Geriatric Education ("POGOe"), a
partnership between the American Geriatrics Society and the Miami GRECC,
and then used as on-demand, desktop or I-pod-compatible educational
experiences for both individuals and groups.

GRECCs are active participants in and contributors to prominent national
professional organizations concerned with aging, such as the
Gerontological Society of America (GSA), the American Geriatrics Society
(AGS), and the Association for Gerontology in Higher Education. Each
year, the annual scientific meeting of the GSA includes up to three
multi-GRECC collaborative symposia showcasing GRECC contributions in
research, education, and clinical care. This practice will expand to the
AGS meeting in 2007.

Each GRECC has a minimum of 1.0 FTEE responsible for education and
evaluation, which includes the evaluation and tracking of the geriatrics
experiences and follow-up of

residents, fellows, and trainees; program development and evaluation;
securing program

support resources, and often program content and presentation as well.
Since 1997, the GRECCs have had no dedicated funding (other than the
FTEE support noted) for providing the education and evaluation services,
although EES provided modest annual allotments to each GRECC for
continuing education through 2005. GRECCs therefore must focus efforts
on the identification and procurement of alternative sources of funding
to support their required education missions. In 2006, 14 of the 21
GRECCs reported success in obtaining education/training grant support
that totaled over \$17 million (Figure 4).

**Figure 4: Education Grants to GRECCs, 1999-2006**

![](media/image4.wmf){width="7.097916666666666in"
height="4.022222222222222in"}

**Clinical Care Contributions of the GRECCs**

GRECCs are responsible for impacting clinical care of elderly veterans
through development, evaluation, and dissemination of innovative
approaches to care. Numerous innovative approaches have been developed
in GRECCs in the three decades since the inception of the program, and
some of the models have attained broad acceptance while others have had
more limited applicability.

Outpatient programs recently developed by GRECCs have included an
intra-urban mobile care unit, creative phone support, telehealth, remote
home safety assessments, various home care modalities and group visit
interventions (such as exercise and T'ai Chi), respite evaluation, and a
wide range of clinics focusing on: falls; incontinence; gait and balance
disorders; Alzheimer's disease; Parkinson's disease; male sexuality;
memory disorders; geriatric assessment; obesity management; medication
compliance; driving assessment; pain management; palliative care;
swallowing; sleep disturbance; osteoporosis/andrology; and decisional
capacity.

Inpatient programs developed by GRECCs have included units for geriatric
assessment and management (GEM), delirium, Acute Care for the Elderly
(ACE), palliative medicine, pain control, transition to independent
living, therapeutic activity, and units for environmental management of
individuals with dementia.

Screens, instruments, and care protocols developed by GRECCs have
focused on cognitive assessment, decision-making ability, male aging,
delirium recognition, depression, nutrition, malnutrition, swallowing,
driving, caregiving, activity level, functional ability, nursing home
resident status, palliative care patient status, homecare patient
status, mental health patient status, safety, wound healing assessment,
sleep disturbance, pain management, emergency preparedness for seniors,
and mobility.

Interventions developed recently by GRECCs that have translated
laboratory findings into clinical care include swallowing assessment and
tongue strengthening; exercise for impacting not just cardiovascular
fitness but cognitive function, mood, independence, and glucose and
lipid metabolism; reestablishment of motor neuron pathways; upper
extremity rehabilitation; osteoporosis management; testosterone therapy;
a variety of post-stroke interventions; a variety of neuro-imaging
techniques; behavioral management of incontinence; use of transcranial
magnetism in refractory depression; and innovative measurement of wrist
activity to study sleep.

Many GRECC core staff with clinical degrees provide clinical services at
their sites. GRECCs annually report distribution of each core staff
member's time; when adjusted by the individual's FTEE contribution and
totaled, the annual, all-GRECC clinical contribution of GRECC Primary
and Research core staff (i.e., those whose effort is attributable to
GRECC support) to local VAMCs ranged from 37 to 51 FTEE annually,
averaging 46.2 from 1999-2006. In 2006, this represented an annual
average of over 2.3 FTEE of clinical effort per GRECC.

**When a very conservative value estimate for this clinical effort
(based on each GRECC's average salary for all employees---not just MDs)
is factored into the comparison of GRECC expenses to the VERA allocation
for GRECC research productivity (see Table 4 above), [the GRECC system
as a whole can readily be shown to be not merely a cost-efficient source
of all its contributions, but rather a fiscal *asset* to the system,
netting several million dollars more annually than it costs to
operate.]{.underline}**

**Additional Contributions of the GRECCs**

The twelve or more core FTEE that form the backbone of each GRECC
contribute to the host facility and VISN in ways that go beyond
research, education, and clinical innovation. The net national clinical
contribution of GRECC core staff to the existing clinical obligations of
the parent facility was detailed above. More difficult to quantify and
describe but no less important are the multiple administrative
contributions that take place within GRECCs' host VAMCs and VISNs. GRECC
core staff are active members and often chairs on Medical Executive
Boards, Quality Assurance Boards, Research and Development Committees,
Medical Records Committees, Education Committees and Education Boards,
Extended Care Boards, Mental Health Boards, Nurse Executive Boards,
Institutional Review Boards, Pharmacy and Therapeutics Committees, Human
Subjects Committees, and Dean's Committees at various facilities.

A second important staffing contribution, also difficult to quantify,
concerns recruitment of talented and productive clinicians to VHA. Many
funded GRECC researcher-physicians report that they would be in
full-time academic positions if not for the resources, collaborations,
research possibilities, stability and mix of responsibilities
represented by a GRECC. These scholars bring tangible and intangible
assets to their VAMCs and university affiliates. They serve as magnets
for other recruitments, trainees, and resources; and assist in
strengthening ties with academic affiliates. And they elevate the
visibility, academic environments, and clinical capabilities of their
host medical centers and of the VA system as a whole.

**Closing Comment**

VA is continuously challenged by emerging demands on its flexibility,
expertise, and resources. The current war is creating a new generation
of veterans with serious, immediate needs. Emphasis on veterans' mental
health needs has grown as a more hopeful outlook on chronic mental
disorders combines with heightened realization of the long-term effects
of military-related stress. Focus on timely care for veterans and their
advocates has led to system-wide modifications in how ambulatory care is
delivered. The recent devastating weather-related tragedy in the Gulf
Coast has brought about only the latest of VA's reshuffling of
priorities as the Agency has risen to its obligation to assist in time
of national emergency.

But the obligation to understand and to address the health and care
needs of the elderly---of last century's soldiers\--will neither
disappear nor diminish, even as that commitment may be transiently
eclipsed by other emerging concerns. On the contrary, that obligation to
care for older veterans feeds the drive for optimizing the longevity and
function of the emerging generation of younger disabled veterans.

Nearly 50% of the veterans who use VHA services are over the age of 65.
The number of veterans over age 85 is projected to exceed one million by
the year 2010. The elderly account for over 40% of healthcare spending
overall in the U.S. Outpatient VA pharmacy cost for veterans over age 65
exceeded \$2 billion in 2006. Yet until relatively recently, few
practicing physicians had received formal training in geriatrics. The
number of geriatrics specialists in the U.S. is less than one-fifth the
level of projected need in the country as a whole, and the ratio of
doctors to patients over age 65 in VA is only a third of the ratio in
the U.S. at large. With the notable growth in the elderly veteran
population in the past three decades, their significant healthcare needs
and costs, and the undersupply of expertise, VHA's system of twenty
GRECCs has proven itself a uniquely valuable resource for addressing a
variety of important and pressing health care issues.

GRECCs were originally conceived as the central VA strategy for
addressing the needs of a rapidly aging veteran population. GRECCs
permitted VA to lead the growth of geriatrics and gerontology in the
country and in the world three decades ago, through knowledge gained
from GRECC-supported research; through GRECCs' development and
evaluation of new models of care; and through GRECCs' dissemination of
that newly acquired knowledge among VA staff, health trainees, and
community providers. Today's elderly veterans, as well as the older
public in general, have benefited immeasurably from the GRECC program's
national, regional, and local accomplishments.

GRECCs continue to serve that role well, and they need to remain central
elements in VA's long range plans. The knowledge gained from caring for
today's elderly veterans is the straightest route for making certain
that this latest generation of American heroes lives their lives as long
and richly as they deserve.