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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2004]{.underline}*                   |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| **NOTE:** The **GRECC Annual Report** reflects status and             |
| accomplishments of **[GRECC Core Staff]{.underline}** (as defined     |
| below) [only]{.underline}. Report year is from [October 1 through     |
| September 30]{.underline}. [This Accomplishments report should be no  |
| more than a [total of ten pages]{.underline}.]{.mark}                 |
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| **GRECC Core Staff** includes **Primary Core**, **Affiliated Core,**  |
| and **Research Core.** **Primary Core =** positions authorized by the |
| original GRECC allocation plus any addition in ceiling from VA        |
| Central Office specifically designated for GRECC. **Affiliated Core** |
| = Staff who work full- or part-time in [direct support]{.underline}   |
| of the GRECC's research, education or clinical activity. May be       |
| either "contributed" by the VA Medical Center or acquired through     |
| centralized enhancements/awards for programs such as Home-Based       |
| Primary Care, Geriatric Evaluation and Management Program, etc. To be |
| considered Affiliated Core, staff must be organizationally aligned    |
| under the GRECC or specifically identified by the Medical Center as   |
| GRECC-affiliated staff. **Research Core** = Full-or part-time staff   |
| who devote 51% or more of their total time to GRECC research and      |
| whose salaries are supported by research funds (either VA or non-VA). |
| Includes all GRECC staff whose salaries are paid from research funds  |
| (e.g., Associate Investigator, Assistant Research Scientist, Senior   |
| Research Career Scientist; Research Career Scientist, Advanced        |
| Research Career Scientist).                                           |
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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** VA Palo Alto Health Care System                   |
|                                                                       |
| b.  **Location** *(facility, VISN)*: 3801 Miranda Ave. (182B), Palo   |
|     Alto, CA 94304                                                    |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Lori Russo                                              |
|                                                                       |
| b.  **Position:** Administrative Officer                              |
|                                                                       |
| c.  **Phone, e-mail:** (650) 493-5000, Ext. 66726                     |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **NOTE:** Each problem area should ideally be approached from the     |
| basic biomedical, clinical [and]{.underline} health services research |
| perspectives, as well as from the rehabilitation research perspective |
| where that expertise exists. The number of problem areas should be    |
| limited to one or two. If the focus of research is different for      |
| basic biomedical, clinical, health services and/or rehabilitation     |
| research, there should be no more than a [total]{.underline} of 4     |
| major areas of investigation. [Changes to GRECC focus area(s) must be |
| approved by VACO (114).]{.mark}                                       |
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| **a. Basic Biomedical**: Sacropenia, vascular biology, skeletal       |
| aging, genetics and aging, endocrinology of aging.                    |
|                                                                       |
| **b. Applied Clinical**: Aging and exercise physiology,               |
| mobility/musculoskeletal dysfunction, osteoporosis prevention and     |
| treatment, and drug action in the elderly.                            |
|                                                                       |
| **c. Health Services**: Clinical practice guideline implementation    |
| for hypertension, and cost-effectiveness of functional status         |
| interventions.                                                        |
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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Current Year** *([list up to       |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific impact on host VAMC research, staff education, program   |
|     evaluation, or clinical care improvements for elderly veteran,    |
|     i.e., how the GRECC has "made a difference" in these areas within |
|     the entire host VAMC; [up to five lines each]{.mark})*:           |
|                                                                       |
|     -   **GRECC provides multiple lecture series** (see Education)    |
|         that are open to VAPAHCS staff, trainees, and members of the  |
|         interdisciplinary team. Subsets of these lectures are also    |
|         available to other divisions and clinics of the health care   |
|         system through **video-conferencing**. Further access is      |
|         provided via **videotapes** of the lectures posted on the     |
|         GRECC website.                                                |
|                                                                       |
| -   **ELNEC (End-of-Life Nursing Education Consortium) Continuing     |
|     Education programs** are given to nurses of all levels.           |
|     Presentations on Ethical/Legal Issues, Symptom Management, and    |
|     Preparation and Care at the Time of Death are some of the topics  |
|     covered.                                                          |
|                                                                       |
|     -   The establishment of an **Outpatient Geriatric Consultation   |
|         Clinic** during FY 2004, separate from the GRECC Geriatric    |
|         Interdisciplinary Team Clinic, enables the GRECC to directly  |
|         reach out to primary care and specialty providers who are     |
|         increasingly seeking guidance in caring for an increasingly   |
|         frail aging veteran population. Our goals have been to        |
|         provide guidance and education with respect to managing the   |
|         following broad areas of patient needs: (1) cognitive and     |
|         functional decline, (2) geriatric syndromes (such as          |
|         incontinence, falls, depression, weight loss, frailty,        |
|         dementia), and (3) care coordination.                         |
|                                                                       |
|     -   As part of the GRECC Tuesday afternoon Geriatric Seminars the |
|         topic of **"The Older Driver: A Roundtable Discussion"** was  |
|         presented on August 10, 2004. The OIG report dated June 18,   |
|         2004 emphasized concern about patients with dementia and      |
|         automobile driving. This timely topic focused on educating    |
|         healthcare professionals about the California State law       |
|         concerning the reporting of dementia and driving issues.      |
|                                                                       |
|     -   **Employee support group meetings** are held monthly at the   |
|         lunch hour and are open to all VA Staff who are caring for a  |
|         parent or family member with chronic illness or dementia.     |
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| b.  **GRECC Impact on VISN in Current Year** *([list up to            |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific VISN-wide impact on research, education/training,        |
|     program evaluation, or clinical care improvements for elderly     |
|     veterans, i.e., how GRECC participation in VISN-wide activities   |
|     has "made a difference" in these areas within the entire VISN;    |
|     [up to five lines each]{.mark}.* NOTE: GRECCs are intended and    |
|     expected to serve as a [regional]{.underline}, and not merely     |
|     local resource*)*:                                                |
|                                                                       |
| -   **ATHENA---[A]{.underline}ssessment and [T]{.underline}reatment   |
|     of [H]{.underline}ypertension: [E]{.underline}vidence-based       |
|     [A]{.underline}utomation Decision Support System (DSS) Project**, |
|     for implementation of clinical practice guidelines for            |
|     hypertension using computer generated patient specific            |
|     recommendations. ATHENA DSS for drug therapy of hypertension      |
|     (Palo Alto HCS, Durham and San Francisco VAMCs) to improve        |
|     clinician adherence to guidelines. ATHENA DSS generates treatment |
|     recommendations to clinicians that appear in a pop-up window in   |
|     CPRS-GUI during primary care clinic visits. This system was       |
|     successfully implemented at the three VAMC's and used to generate |
|     recommendations about management of hypertension to primary care  |
|     clinicians for thousands of patients. The clinicians interacted   |
|     with the system extensively, demonstrating its usefulness and     |
|     usability.                                                        |
|                                                                       |
|     -   Worked with VISN 22 to organize the **National GEC/GRECC      |
|         Leadership Conference** held in San Francisco, CA on April    |
|         19-21, 2004. Fostered collaboration with GECs and GRECCs on   |
|         important issues related to geriatric health care. It also    |
|         provided a forum for discussion regarding GRECC's educational |
|         and clinical goals.                                           |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **A poster about the VAPAHCS AHEAD II project** was presented at  |
|     the GEC & GRECC Leadership Conference held in San Francisco,      |
|     April 19-21, 2004, and at the Updates on Dementia Conference at   |
|     Stanford University Medical Center on June 16, 2004.              |
|                                                                       |
|     -   **Collaboration with investigators** in this institution, in  |
|         the VA network, and in public and private institutions,       |
|         providing instruction, advice and guidelines, by giving       |
|         lectures, seminars, and grant reviews. (see Education)        |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [1999]{.underline}** *([list up to five]{.mark} most significant  |
|     GRECC research, education or clinical innovations in past five    |
|     years; for each item, provide date, GRECC staff responsible, and  |
|     [up to five line]{.mark} description)*:                           |
|                                                                       |
| -   The VAPAHCS AHEAD II team developed a **resource handout and a    |
|     glossary of terms handout for caregivers of patients with         |
|     dementia**. In addition, in 2003 they developed the "Dementia     |
|     Continuity of Care" template, which flags as a posting on CPRS    |
|     for patients with dementia. Caregivers of outpatients with        |
|     dementia provide the information for this template. It provides   |
|     key information on ADLs, behaviors, communication issues, pain,   |
|     and other issues, so that health professionals in any setting     |
|     across the health care system can easily access it. This template |
|     has been initiated at the VAPAHCS and has been shared with        |
|     national AHEAD I and II teams. Betty Wexler, RN, CNS, has been    |
|     the day-to-day leader for this quality improvement project since  |
|     2002.                                                             |
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| **5. RESEARCH**                                                       |
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| a.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     PI or CO-PI** *([list up to five]{.mark}; for each item provide   |
|     GRECC Core Staff name(s), journal reference, and [up to five      |
|     line]{.mark} description of topic/method/ results/clinical        |
|     significance; use layperson language)*:                           |
|                                                                       |
|     -   Dr. Tony Wyss-Coray's laboratory discovered that reduced      |
|         expression of a factor called TGF-β1 in mice results in       |
|         spontaneous neurodegeneration and increases their             |
|         susceptibility to brain injury. Because some humans have much |
|         lower levels of TGF-β1 in the brain than others, this finding |
|         could have important implications for susceptibility to       |
|         neurodegeneration. (Brionne T.C., Tesseur I., Masliah E., and |
|         [Wyss-Coray T.]{.underline} (2003) Loss of TGF-β1 leads to    |
|         increased neuronal cell death and microgliosis in mouse       |
|         brain. *Neuron*, 40:1133-1145.)                               |
|                                                                       |
|     -   Dr. Tony Wyss-Coray's laboratory, in collaboration with Dr.   |
|         Huang at UCSF, discovered that neuronal overproduction of     |
|         apolipoprotein E4, the major genetic susceptibility factor    |
|         for Alzheimer's disease, results in the development of        |
|         pathological abnormalities typically found in Alzheimer's     |
|         brains. This finding provides a possible mechanism for the    |
|         increased risk of apolipoprotein E4 carriers to develop       |
|         Alzheimer's disease. (Brecht W.J., Harris F.M., Chang S.,     |
|         Tesseur I., Yu G.Q., Xu Q., [Wyss-Coray T.]{.underline},      |
|         Buttini M., Mucke L., Mahley R.W., and Huang Y. (2004)        |
|         Neuron-Specific Apolipoprotein E4 Proteolysis Is Associated   |
|         with Increased Tau Phosphorylation in Brains of Transgenic    |
|         Mice. *J. Neurosci.,* 24:2527--2534.)                         |
|                                                                       |
|         -   Dr. Thomas A. Rando's laboratory discovered that muscle   |
|             stem cells from old mice are capable of being rejuvenated |
|             to regenerate muscle as effectively as muscle stem cells  |
|             from young mice by directly activating a biochemical      |
|             pathway called the Notch signaling pathway (Conboy IM,    |
|             Conboy MJ, Smythe GM, [Rando TA]{.underline} (2003)       |
|             Notch-mediated restoration of regenerative potential to   |
|             aged muscle. Science, *302*: 1575-1577).                  |
|                                                                       |
| • Dr. Ting-Ting Huang's laboratory has documented the "Identification |
| of Genetic Modifiers and Lifespan Extension of Mn Superoxide          |
| Dismutase (MnSOD) Mutant Mice." Complex Trait Consortium 2004         |
| meeting. The poster described the identification of a genetic         |
| modifier, nicotinamide nucleotide transhydrogenase (NNT), in          |
| modulating the phenotype of MnSOD deficient mice. The function of the |
| modifier gene belongs to the NADPH generation pathway, which then     |
| feeds into the glutathione (GSH) regeneration pathway. Our discovery  |
| points to the importance of GSH in maintaining the redox balance in   |
| the mitochondria. [Huang TT]{.underline}, Naeemuddin M, and Epstein   |
| CJ.                                                                   |
|                                                                       |
| -   Dr. Ting-Ting Huang's laboratory examined the role of oxygen free |
|     radical-mediated damage and carcinogenesis in CuZn superoxide     |
|     dismutase (CuZnSOD) deficient mice. CuZnSOD deficiency leads to   |
|     persistent and widespread oxidative damage and                    |
|     hepatocarcinogenesis later in life. Oncogene (in press). This     |
|     study describes the histopathological, biochemical, and gene      |
|     expression alterations in the liver of CuZnSOD deficient mice,    |
|     and how these alterations ultimately lead to                      |
|     hepatocarcinogenesis. Our study showed that increased oxidative   |
|     damage, especially to the nuclear DNA, can be a primary cause of  |
|     carcinogenesis. Elchuri S, Oberley TD, Qi W, Eisenstein RS,       |
|     Roberts LJ, Van Remmen H, Epstein CH, and [Huang TT]{.underline}  |
|     (2004).                                                           |
|                                                                       |
| -   Dr. Salman Azhar's laboratory has documented "Dimerization of the |
|     scavenger receptor class B type I: Formation, function, and       |
|     localization in diverse cells and tissues." For the first time,   |
|     this study has led to demonstration that the scavenger receptor   |
|     class B type I (SR-BI), \[a receptor that facilitates cellular    |
|     uptake of cholesterol from HDL ('good cholesterol') by a          |
|     specialized process which is commonly referred to as 'selective'  |
|     uptake pathway\] exists in two physical forms: monomeric and      |
|     dimeric/ oligomeric forms, and that the latter form is            |
|     responsible for selective removal of cholesterol. The level of    |
|     dimeric/oligomeric form of SR-BI is thus a critical determinant   |
|     in removing excess cholesterol in vivo and preventing heart       |
|     disease and that this molecular form is a potential target for    |
|     the therapeutic intervention. *J. Lipid* *Res.* 45:513-528 (Role  |
|     on the project: PI). (Reaven E, Cortez Y, Leers-Sucheta S, Nomoto |
|     A, [Azhar S.]{.underline} (2004).                                 |
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| b.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     Co-Investigators on Projects with Non-GRECC PI (***[list up to    |
|     five]{.mark}; for each item provide GRECC Core Staff name(s),     |
|     journal reference, [and up to five line]{.mark} description of    |
|     topic/method/ results/clinical significance; use layperson        |
|     language)*:                                                       |
|                                                                       |
| -   Dr. Salman Azhar's laboratory discovered the "Interaction of      |
|     hormone-sensitive lipase with steroidogenic acute regulatory      |
|     protein." Hormone-sensitive lipase (HSL) is responsible for       |
|     hydrolyzing the cholesteryl esters in steroidogenic tissues,      |
|     while steroidogenic acute regulatory protein (StAR) facilitates   |
|     cholesterol transport to mitochondria for steroid synthesis. Our  |
|     studies indicate that interaction of HSL with StAR increases      |
|     hydrolytic activity of HSL and that two molecules together        |
|     facilitate cholesterol movement from lipid depots to mitochondria |
|     for steroid synthesis. These studies thus have identified new     |
|     players which play pivotal roles in the regulation of human       |
|     steroidogenesis. (*J. Biol. Chem.* 278:43870-43876. Role on the   |
|     project: Co-PI. Shen W-J, Patel S, Natu V, Hong R, Wang R, [Azhar |
|     S]{.underline}, Kraemer FB. (2003).                               |
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| **6. EDUCATION**                                                      |
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| **NOTE**: Do not list trainee and conference data here. Those data    |
| are reported in the GRECC Electronic Database.                        |
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| a.  **Innovations in Educational Activities Implemented During        |
|     Current Year** (*[list up to five]{.mark}; for each item, [up to  |
|     three lines]{.mark} on how it is innovative)*:                    |
|                                                                       |
| -   Weekly multidisciplinary geriatrics/gerontology seminar series    |
|     **"Aging and Cellular Degeneration Seminars,"** alternating among |
|     clinical geriatrics, clinical gerontology, health services        |
|     research, and biomedical research in aging. Speakers present work |
|     on various diseases or disease mechanisms related to aging and    |
|     cellular degeneration including cardiovascular disease, muscular  |
|     dystrophy, cancer, Alzheimer's and other neurodegenerative        |
|     diseases.                                                         |
|                                                                       |
| -   Monthly **"Healthy Aging Lecture Series"** is targeted for a lay  |
|     audience. VA staff, veterans and members of the surrounding       |
|     community gain useful information from the lectures and           |
|     videotapes. Placing the lectures on-line has expanded access to   |
|     the Healthy Aging Lecture Series.                                 |
|                                                                       |
| -   Weekly didactic seminar series, the \"**Clinical, Social, and     |
|     Scientific Foundations of Geriatrics\"**: This seminar strives to |
|     increase the knowledge base of health care providers and trainees |
|     in their approaches to caring for the aged. We also hold a weekly |
|     didactic seminar series (July-September 2004): the **\"Summer     |
|     Core Curriculum in Geriatrics\"**. Occurring during the initial   |
|     months of the new academic year for trainees, this seminar series |
|     aims to provide a broad base education in caring for older        |
|     adults, geriatric syndromes, and fundaments of interdisciplinary  |
|     team care.                                                        |
|                                                                       |
| -   **ELNEC (End-of-Life Nursing Education Consortium) Continuing     |
|     Education programs** are given to nurses at all levels.           |
|     Presentations on Ethical/Legal Issues, Symptom Management, and    |
|     Preparation and Care at the Time of Death are some of the topics  |
|     covered.                                                          |
|                                                                       |
| -   **Cosponsored conferences** with the Alzheimer's Association,     |
|     Stanford/VA Alzheimer's Disease Research Association, MIRECC,     |
|     SGEC, etc. In FY 2004, conferences included:                      |
|                                                                       |
| ######### \* Primary Care Et                                          |
| hnogeriatrics: Bridging the GAP in Health Care Disparities for Elders |
|                                                                       |
| \* Medical Perspectives In Alzheimer's Disease: Future Trends In      |
| Alzheimer's Research And Neuropathology                               |
|                                                                       |
| ######### \* Updates in Dementia                                      |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Current Year** *([list up to five]{.mark} most    |
|     important products; for each item, [up to three lines]{.mark}     |
|     summarizing content, target audience, format, product evaluation  |
|     results. Include educational products developed in previous years |
|     ONLY if this is the [first year]{.underline} they have been       |
|     available for distribution)*:                                     |
|                                                                       |
|     -   Collaborated with other VA sites and **AHEAD II** national    |
|         leaders to develop two national training videos to help       |
|         improve the quality of care for community-dwelling veterans   |
|         with dementia and their families.                             |
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| **7. NEW CLINICAL MODELS**                                            |
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| **NOTE:** These are new models of care for elderly veterans that the  |
| GRECC is developing and evaluating, in relation to its area(s) of     |
| focus. This is NOT a list of all Geriatrics & Extended Care clinical  |
| programs at the host VAMC.                                            |
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| a.  **New Clinical Models Implemented in Current Year** *(list all    |
|     new clinical models or significant modifications of existing      |
|     models that the GRECC is developing and evaluating. For each      |
|     item, indicate whether [N]{.underline}ew or [O]{.underline}ngoing |
|     in current year; provide [up to five line]{.mark} description)*:  |
|                                                                       |
| -   **Phone-in support group for caregivers of patients with          |
|     dementia** to address caregiver burden, providing education and   |
|     emotional support. *Ongoing*                                      |
|                                                                       |
| -   **Automated Decision Support for clinicians for guideline         |
|     implementation** using ATHENA decision support system. *Ongoing*  |
|                                                                       |
| -   **AHEAD II (Advances in Home Based Primary Care for End-of-Life   |
|     in Advancing Dementia) quality improvement project**, focused on  |
|     development of a template called "Dementia Continuity of Care"    |
|     that provides key information about patients with dementia and is |
|     accessible to all VA professionals as a posting on the electronic |
|     medical record. The template was developed through interviews     |
|     with caregivers of patients with dementia as well as with VAPAHCS |
|     health professionals. Information on patients with dementia is    |
|     available to all healthcare professionals who might see these     |
|     patients as they cross the continuum of care. Providers now have  |
|     easy to access information about the patient's caregiver,         |
|     activities of daily living, sleep, communication and behavioral   |
|     issues, and pain. *New*                                           |
|                                                                       |
| -   As part of the interdisciplinary geriatric clinic, the social     |
|     worker and nurse sometimes make one or two **Extended Clinic Home |
|     Visits** to selected patients who need more assessment time than  |
|     the clinic visit can provide. Patients selected for these visits  |
|     may include, but are not limited to, patients with cognitive      |
|     deficits, complicated medication regimens and non-adherence       |
|     issues, complex medical and/or psychosocial issues, long-term     |
|     planning needs, transitioning to another level of care such as    |
|     hospice or institutionalization and require support during the    |
|     transition phase. *New*                                           |
|                                                                       |
| -   **Group Medical Visits to Improve Hypertension Management**       |
|     addresses the problem of inadequate control of blood pressure in  |
|     the VA. We have started an innovative approach to clinical care   |
|     by setting up a program of group medical visits (also known as    |
|     "shared medical appointments") for patients in primary care who   |
|     have hypertension. Patients see their own primary care physician  |
|     for a medical visit in a group setting. We expect that through    |
|     group interaction, the patients will enhance the sense of their   |
|     own ability ("self-efficacy") to take care of their hypertension, |
|     and will improve their adherence to diet, exercise, and           |
|     medication regimens. *New*                                        |
|                                                                       |
| -   **Group Visits to Improve Medication Compliance in Patients with  |
|     Dementia** is a recently funded study that addresses the need to  |
|     improve adherence to physician's treatment recommendation in      |
|     dementia patients with hypertension. Educational sessions with a  |
|     pharmacist and group facilitator will be aimed at achieving a     |
|     better understanding of hypertension and the crucial role         |
|     medication has in achieving adequate control. Caregivers will     |
|     learn new strategies for managing the patient's hypertension.     |
|     *New*                                                             |
|                                                                       |
| -   **Employee support group meetings** (monthly) open to all VA      |
|     Staff who are caring for a parent or family member with chronic   |
|     illness. *New*                                                    |
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| b.  **Current Year Evaluation Results of New Clinical Models** *([for |
|     each clinical model listed in 7-a above]{.mark}, indicate whether |
|     evaluated by [R]{.underline}esearch or [Q]{.underline}uality      |
|     [I]{.underline}mprovement project; [up to five lines]{.mark}      |
|     summarizing evaluation outcomes, such as changes in access to     |
|     care, patient functioning, satisfaction, cost-effectiveness,      |
|     organizational changes, etc. Note if no evaluation results in     |
|     current year for a particular model)*:                            |
|                                                                       |
| **NOTE:** Do not list patient service utilization data here. Those    |
| data are reported in the GRECC Electronic Database.                   |
|                                                                       |
| -   **Phone-in support group for caregivers of patients with dementia |
|     --**Satisfaction questionnaires are mailed to caregivers          |
|     bi-annually. Results support the continuation of this group. (QI) |
|                                                                       |
| -   **Automated Decision Support for clinicians for guideline         |
|     implementation** using ATHENA decision support system. Clinicians |
|     interacted extensively with the pop-up windows providing          |
|     recommendations about hypertension management, suggesting they    |
|     found the system useful and usable. Additional analysis of the    |
|     impact on clinician drug prescribing and on patient blood         |
|     pressures are underway. (R)                                       |
|                                                                       |
| -   **AHEAD II (Advances in Home Based Primary Care for End-of-Life   |
|     in Advancing Dementia) quality improvement project\-- "Dementia   |
|     Continuity of Care" template**. VAPAHCS' AHEAD II team has been   |
|     teaching providers in all of the Acute and Extended Care Services |
|     about the availability of this posting and the response has been  |
|     excellent. There are challenges ahead that the team is working    |
|     on. For example, how to update this information as needed; how to |
|     gain access to getting this information from patient caregivers   |
|     who are seen outside of HBPC and the GRECC Geriatric Clinic; who  |
|     will enter the data, etc. (QI)                                    |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Extended Clinic Home Visits --**Currently working with Quality  |
|     Management developing policies for the project. *No evaluation    |
|     results.*                                                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Group Medical Visits to Improve Hypertension Management**       |
|     preliminary findings address the problem of inadequate control of |
|     blood pressure in the VA. Preliminary data for the 6-month        |
|     formative evaluation show high levels of both provider and        |
|     patient satisfaction. (R)                                         |
|                                                                       |
| -   **Group Visits to Improve Medication Compliance in Patients with  |
|     Dementia.** *No evaluation results*                               |
|                                                                       |
| -   **Employee support group meetings** (monthly) open to all VA      |
|     Staff who are caring for a parent or family member with chronic   |
|     illness. (QI) *No evaluation results.*                            |
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| c.  **New Clinical Models Exported in Current Year** *([list up to    |
|     five examples, up to two lines each]{.mark}; provide name of new  |
|     clinical model, name of VA or non-VA facility to which it was     |
|     exported, and method of export, such as "Falls Clinic protocol    |
|     sent to [X]{.underline} VAMC")*:                                  |
|                                                                       |
|     -   The **Dementia Continuity of Care template**, developed by    |
|         the VA Palo Alto Health Care System AHEAD II (Advances in     |
|         Home Based Primary Care for End-of-Life in Advancing          |
|         Dementia) quality improvement project was exported to all VA  |
|         facilities nationally, via attachment on Outlook email to     |
|         AHEAD I and II distribution lists, and to AHEAD II project    |
|         directors in Washington, D.C.                                 |
|                                                                       |
|     -   **The Assessment and Treatment of Hypertension:               |
|         EvideNce-based Automation (ATHENA) Decision Support System**  |
|         was installed for testing purposes at Boston-West Roxbury VA  |
|         and Washington, D.C. VA Medical Center. It was installed by   |
|         Robert Coleman with assistance of Information Resources       |
|         Management Service (IRMS) staff at each of those medical      |
|         centers.                                                      |
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| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation** = GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach** = GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
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| b.  **Current Year Activity Outcomes** *([list up to five             |
|     examples]{.mark}, [up to two lines each]{.mark}; summarize        |
|     specific outcomes realized from current year **consultation**,    |
|     e.g., "Host VAMC instituted a Falls Clinic after consultation     |
|     from GRECC staff;" or **outreach**, e.g., [X]{.underline} VAMC    |
|     instituted a Falls Clinic after GRECC outreach via series of      |
|     videoconferences)*:                                               |
|                                                                       |
| -   **Phone-in support group for caregivers of patients with          |
|     dementia** continues meeting once a month by using a conference   |
|     call format. The spouses who attend report that they feel they    |
|     are less alone, are learning about resources in the community,    |
|     and feel less stressed after the call. A poster documenting the   |
|     outcomes of this group will be presented in November 2004 at the  |
|     VA National Case Managers Conference in Washington, D.C..         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Outreach to primary care providers/increased care coordination  |
|     needs.** Geriatrician Peter Cheng, M.D. established a new consult |
|     clinic for geriatrics to address the large number of outpatient   |
|     consult requests received by GRECC, and communicates with the     |
|     referring clinician after the consultation. We are monitoring the |
|     number of consults and classifying them to determine how many may |
|     be managed by provision of information and/or services and a      |
|     return to the original clinic, and how many require transfer of   |
|     the patient to an interdisciplinary team clinic.                  |
|                                                                       |
| -   **Fall prevention** is a strong focus of the geriatric clinic.    |
|     Patients who present a fall risk are assessed using either the    |
|     "Tinetti Gait and Balance" tool, or the "Timed Get Up and Go"     |
|     tool. Patients assessed at high risk of falls are: (1) referred   |
|     to Physical Medicine and Rehabilitation (PM&R) Service for        |
|     further evaluation for an assistive device and/or physical        |
|     therapy; (2) have a home safety assessment visit arranged by Home |
|     Based Primary Care (HBPC) Occupational Therapy if they are in the |
|     HBPC catchment area; (3) have external hip protectors ordered     |
|     from Prosthetics and Sensory Aids Service to decrease the risk of |
|     hip fracture; and (4) have their medications reviewed.            |
|                                                                       |
| -   [VA Merit Review grant title]{.underline}: **Effects of vitamin E |
|     in a transgenic mouse model of Alzheimer's disease** (Submitted   |
|     for review, Fall 2004). PI: Govind N.T. Vatassery PhD;            |
|     [Co-Investigator: Salman Azhar, PhD.]{.underline} Recently we     |
|     have submitted a collaborative research project with Dr. Govind   |
|     Vatasssery, GRECC, VA Medical Center Minneapolis, MN aimed at     |
|     examining the beneficial effects of vitamin E isoforms in a       |
|     rodent model of the Alzheimer's disease. Dr. Salman Azhar         |
|     assisted him greatly in formulating the ideas, developing the     |
|     Specific Aims and writing the proposal itself. If approved for    |
|     funding, Dr. Azhar will serve as a Co-investigator on this        |
|     project, and proposed studies will be jointly conducted both here |
|     at the Palo Alto GRECC and at the VAMC, Minneapolis GRECC.        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Employee support group meetings** (monthly) for VA staff who    |
|     are caring for family member with chronic illness or dementia     |
|     continues meeting monthly at lunch hour. Small but consistent     |
|     attendance by a wide variety of caregivers. Group is interactive  |
|     and informative as well helpful for emotional discharge.          |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** (*[list up to five        |
|     examples]{.mark}, [up to two lines each]{.mark}; summarize        |
|     specific outcomes realized from previous years' [**consultation** |
|     to host VAMC]{.underline} or [**outreach** to non-host            |
|     facilities]{.underline}, where results were first realized in the |
|     current year.)*                                                   |
|                                                                       |
|     -   In FY 2003 we established a **Section of Geriatrics and       |
|         Palliative Care Medicine within the Division of General       |
|         Internal Medicine (GIM) at Stanford**, creating an academic   |
|         home for the clinical physician staff at VA Palo Alto Health  |
|         Care System (VAPAHCS) in geriatrics and palliative medicine.  |
|         During FY 2004 we saw some of the anticipated benefits of     |
|         this affiliation as several of the staff were appointed as    |
|         Clinician Educators at Stanford in recognition of their       |
|         teaching. The Stanford medical student curriculum group       |
|         increased their attention to geriatrics and requested         |
|         placement of medical students with the VA extended care       |
|         clinicians for clinical training in the next academic year.   |
|         GRECC hosted one of the five divisional educational evening   |
|         conferences sponsored by the Division of GIM during the year, |
|         bringing many general internists to GRECC for a geriatrics    |
|         session.                                                      |
|                                                                       |
| -   Consultation with coordinators for the monthly **Healthy Aging    |
|     Lecture Series** at all VAPAHCS divisions and clinics to discuss  |
|     annual plans, goals, and outreach to patients and the surrounding |
|     community.                                                        |
|                                                                       |
| -   **Phone-in support group for caregivers of patients with          |
|     dementia**. Bi-annual Satisfaction\                               |
|     Questionnaires are mailed to patient caregivers who regularly     |
|     participate in the phone-in support group. Results indicate that  |
|     the group is helpful in alleviating stress, and caregivers would  |
|     like it to continue on a monthly basis.                           |
|                                                                       |
| -   **Dementia Committee.** As a member of the Dementia Committee,    |
|     Betty Wexler, CNS, has been working to expand its efforts into    |
|     the acute care arena where patients with dementia are often       |
|     admitted. A needs assessment is currently under way to evaluate   |
|     educational needs of acute care nurses. Acute care staff members  |
|     have been invited to join the Dementia Committee.                 |
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