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| ### *GRECC Annual Report: Fiscal Year [2005]{.underline}*             |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| This GRECC Annual Report covers [October 1, 2004-September 30,        |
| 2005]{.underline}: **the "Report Year"**.                             |
|                                                                       |
| This GRECC Annual Report reflects status and accomplishments of       |
| [**GRECC Core Staff \***only]{.underline}.                            |
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|                                                                       |
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| **1. GRECC NAME/LOCATION**                                            |
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| Durham GRECC Durham, NC                                               |
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| **2. CONTACT PERSON (if there are questions about this report)**      |
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| Connie W. Bales, PhD, RD                                              |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| a.  **Basic Biomedical**: Biology and physiology of frailty;          |
|     mobility, bones and joints; cell biology of immune system and     |
|     cancer                                                            |
|                                                                       |
| b.  **Applied Clinical**: Exercise and chronic disease; cancer care;  |
|     mobility, bones and joints; quality of life, care-giving and end  |
|     of life care                                                      |
|                                                                       |
| c.  **Health Services**: Health promotion and disease prevention;     |
|     medication utilization; geriatric assessment                      |
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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Report Year**\                     |
|     *(list the most important ways in which the GRECC has had         |
|     positive impact on the host VAMc\--i.e., how the GRECC has "made  |
|     a difference"locally.*                                            |
|                                                                       |
| 1\. A **clinical reminder** in CPRS for assessing safety needs of     |
| veterans with dementia, emphasizing driving safety, firearms, and     |
| in-home safety (falls, fire prevention, wandering) was implemented.   |
|                                                                       |
| 2\. GRECC staff (McConnell) worked with Ambulatory Care Nurses to     |
| build their capacity to implement **Evidence-based approach** **for   |
| nursing** management of common geriatrics syndromes.                  |
|                                                                       |
| 3\. The RAND/Hartford Interdisciplinary Geriatric Research Center     |
| provided a number **of innovative geriatric training opportunities**  |
| in 2004-2005, offering an 8-part "Longitudinal Methods Series, a      |
| 6-week "Research Training Series" for junior faculty, and a workshop  |
| entitled, "Secondary Data: Uses and Sources". The audience included   |
| GRECC investigators, VA Fellows, and Gerontological Nursing and       |
| Geriatric Medicine faculty.                                           |
|                                                                       |
| 4\. Greg Taylor served as **Chair** **of the Durham VA Subcommittee   |
| on Biosafety**. His responsibility in this role is to insure the      |
| safety of research personnel for all research that is performed at    |
| this site. The committee (VA members plus local community members)    |
| review all research projects and in addition, educate research staff  |
| and make sure that all projects meet national VA standards.           |
|                                                                       |
| 5\. The **Palliative Care Service** at the Durham VA, led by Dr. Toni |
| Cutson, receives more referrals than any other medical center in the  |
| VISN. This service also takes a leading role in education. The        |
| Palliative Care team has presented in-service training sessions to    |
| Durham VA hospital staff and the EPEC Training session organized by   |
| Dr. Cutson and co-sponsored by GRECC received positive reviews.       |
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| 2.  **GRECC Impact on VISN in Report Year** *\                        |
|     (list the most important ways in which the GRECC has had positive |
|     impact on the host VISN\-- i.e., how the GRECC has "made a        |
|     difference "regionally.*                                          |
|                                                                       |
| 1\. Dr. Harvey Cohen serves on the **VISN Geriatrics and Extended     |
| Care Sub-council**.                                                   |
|                                                                       |
| 2\. GRECC co-sponsored the **VISN-wide Palliative Care Consult Team   |
| Training Program** organized by Dr. Toni Cutson in March, 2005.       |
|                                                                       |
| 3\. **Dr. Eleanor McConnell** served on a VISN-6 task force that      |
| developed and implemented a **clinical reminder in CPRS for assessing |
| safety needs of veterans** with dementia, emphasizing driving safety, |
| firearms, and in-home safety (falls, fire prevention, wandering).     |
|                                                                       |
| 4\. **VISN-wide GRECC Conference on Osteoporosis**, June 8, 2005.     |
|                                                                       |
| 5\. Dr. Connie Bales served on **planning committee for Geriatric     |
| Primary Care Advance Clinic Access training** **program** presented   |
| in summer 2005.                                                       |
|                                                                       |
| 6\. Dr. Connie Bales served on the **GRECC EES Partnership Council**  |
| that is working to take advantage of education resources available    |
| through EES to enhance GRECC educational initiatives.                 |
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| 3.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2000]{.underline}**\                                             |
|     *(list the most significant research, education or clinical       |
|     innovations originating in your GRECC in the past five years.     |
|     Please limit your response to five innovations or fewer. For each |
|     item, succinctly describe the innovation, specify the time frame  |
|     of its earliest impact, whom it benefited, where it occurred, and |
|     why it was important.*                                            |
|                                                                       |
| **1. [Development of Knock-out Mouse Models for Aging Research        |
| Applications]{.underline}:** (1) We have developed mouse models of    |
| increased susceptibility to infectious disease, by inactivating       |
| members of the p47 GTPase gene family. We have shown these genes to   |
| encode critical factors for innate resistance to *Mycobacterium       |
| tuberculosis* and other bacteria and protozoa relevant to aging       |
| populations. Current work is focused on defining mechanisms of action |
| of these proteins and exploring the possibility of therapeutic        |
| applications. (2) We have developed a mouse model of cognitive        |
| impairment by inactivating the neurally expressed gene, P311. We are  |
| currently defining the phenotype of these mice, which have deficits   |
| in amygdala-based short term memory. Our other data suggest that P311 |
| could be involved in brain tumor formation.                           |
|                                                                       |
| # 2. [Medications Appropriateness                                     |
| Index and Applications]{.underline}: We have developed and tested the |
|  Medications Appropriateness Index (MAI) and distributed it internati |
| onally for widespread use to measure prescribing appropriateness in t |
| he elderly. Investigators in the US, Europe and Australia have used t |
| he MAI as an outcome measure of prescribing appropriateness in epidem |
| iology and intervention studies in older adults. Pharmacists have use |
| d the MAI clinically to optimize medication regimens in older adults. |
|                                                                       |
| 3\. **[GEM Research and applications to elderly cancer                |
| patients:]{.underline}** GRECC staff members HJ Cohen, MD, KW Lyles,  |
| MD, and P Seo, MD, started a research program evaluating elderly      |
| cancer patients receiving chemotherapy or chemo-radiation therapy in  |
| the ECRC unit, GEM unit and outpatient geriatric clinic using         |
| multidisciplinary geriatric assessment tools in 2003. By better       |
| understanding and detecting health changes in these elderly persons,  |
| beneficial supportive measures can be provided to these persons in    |
| future endeavors.                                                     |
|                                                                       |
| 4\. **[Projects LEAD and RENEW]{.underline}**: This research program  |
| seeks to positively impact older cancer survivors' physical           |
| functioning by intervening on lifestyle behaviors, including exercise |
| and diet. Work began in 2001, within the context of a Pepper Center   |
| intervention development study where promising results led to RO1     |
| funding for a large clinical trial from NCI, that is currently is in  |
| the field (2005). This work, which shows early potential of           |
| benefiting functioning and quality of life of the older cancer        |
| survivors, occurred at the Durham VA and Duke University Medical      |
| Center.                                                               |
|                                                                       |
| 5\. **Faculty** **Development for Advances in Geriatric               |
| Education**.**.** Through the Program for Faculty Development for the |
| Advancement in Geriatrics Education (FD\~AGE), we have developed the  |
| Geriatrics Excellence in Teaching Series, which offers faculty and    |
| fellows practical instruction on basic topics in clinical education,  |
| including adult learning theory, small and large group teaching,      |
| providing feedback, and curriculum design.                            |
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| **5. RESEARCH**                                                       |
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| a.  **Most Noteworthy Findings Published in Report Year by GRECC Core |
|     Staff as PI or CO-PI\                                             |
|     ***(Please list five or fewer. For each noteworthy finding,       |
|     include the GRECC Core Staff name(s), journal reference, and a    |
|     JARGON-FREE description of the finding and its clinical or other  |
|     significance. Please limit your description of each noteworthy    |
|     finding to five lines or fewer.)*                                 |
|                                                                       |
| 1\. [Journal Reference]{.underline}: Seo PH, Pieper CF, Cohen HJ. The |
| effect of cancer history and comorbid conditions on mortality and     |
| healthcare utilization among older cancer survivors.                  |
| [Cancer]{.underline} 2004 Nov; 101(10):2276-84.                       |
|                                                                       |
| Studying a large group of community elderly persons, this study       |
| showed that co-morbid conditions and not a history of cancer          |
| influenced healthcare use and death rates thus recommending to        |
| improve health outcomes in older cancer survivors, focus should       |
| continue on improving other co-morbid conditions.                     |
|                                                                       |
| 2\. [Journal Reference:]{.underline} Reid IR, Miller P, **Lyles KW**  |
| et al. Comparison of a single infusion of Zoledronic Acid with        |
| Risedronate for Paget's Disease. [N Eng J Med]{.underline}            |
| 353;898-908, 2005.                                                    |
|                                                                       |
| The results of this research showed that treatment with a single      |
| infusion of zoledronic acid produces more rapid, more complete, and   |
| more sustained responses in Paget's disease patients than does the    |
| traditional daily treatment with the FDA-approved drug risedronate.   |
|                                                                       |
| 3\. [Journal Reference]{.underline}: Oxman MN, Levin MJ, Johnson GR,  |
| **[Schmader KE]{.underline}**, Straus SE, Gelb LD et al. and the      |
| Shingles Prevention Study Group. A vaccine to prevent herpes zoster   |
| and postherpetic neuralgia in older adults [N Engl J                  |
| Med.]{.underline} 2005;352:2271-84.                                   |
|                                                                       |
| Herpes zoster (HZ) and postherpetic neuralgia (PHN), the chronic pain |
| following herpes zoster, cause substantial suffering in older adults  |
| and are difficult to treat. A recent VA Cooperative Trial tested the  |
| hypothesis that the zoster vaccine would decrease the incidence,      |
| severity, or both of herpes zoster (HZ) and postherpetic neuralgia    |
| (PHN) among older adults in a randomized, double-blind placebo        |
| controlled trial of 38,546 adults 60 years of age or older. The       |
| zoster vaccine reduced the burden of illness (pain intensity by       |
| duration) due to HZ by 61%, reduced the incidence of PHN by 67%, and  |
| reduced the incidence of HZ by 51%. The vaccine was safe and          |
| well-tolerated. This landmark study showed that the zoster vaccine    |
| markedly reduced morbidity from HZ and PHN among older adults, and    |
| demonstrated, for the first time, that an intervention is available   |
| that can prevent HZ and PHN in older adults.                          |
|                                                                       |
| 4\. [Journal Reference:]{.underline} **Peterson MJ**, **GM Crowley**, |
| RJ Sullivan and **MC Morey**. Comparing physical function in older    |
| sedentary and exercising veterans to national norms. [J Rehabil Res   |
| Dev]{.underline}. 41 (5): 653-658, 2004.                              |
|                                                                       |
| This study found that older veterans enrolling in Gerofit had poorer  |
| functional status than the average for national norms. After 6        |
| months, those who regularly attended Gerofit, a geriatric-based       |
| outpatient exercise program at the Durham VA, had significantly       |
| better functional fitness than their sedentary counterparts. Older    |
| veterans can have normal levels of functional strength and endurance  |
| by engaging in regular, structured exercise.                          |
|                                                                       |
| 5\. [Journal Reference:]{.underline} Butcher, BA, Greene, RI, Henry,  |
| SC, Annecharico, KL, Weinberg, JB, Denkers, EY, Sher, A, and          |
| **Taylor, GA** (2005) p47 GTPases regulate Toxoplasma gondii survival |
| in activated macrophages, [Infect. Immun]{.underline}. 73, 3278-3286. |
|                                                                       |
| In this study, we address the mechanism through which p47 GTPases     |
| regulate resistance to T. gondii, as well as other protozoa and       |
| bacteria. We found that some of these proteins -- IGTP and LRG-47 --  |
| regulate killing of T. gondii in IFN-gamma-activated macrophages,     |
| cells that are critical for innate resistance to pathogens.           |
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| b.  **Most Noteworthy Findings Published in Report Year -- GRECC Core |
|     Staff as Co-Investigators on Projects with Non-GRECC PI\          |
|     **                                                                |
|                                                                       |
| 1**.** [Journal Reference:]{.underline} Krucoff MW. Crater SW. Gallup |
| D. Blankenship JC. Cuffe M. Guarneri M. Krieger RA. Kshettry VR.      |
| Morris K. Oz M. Pichard A. Sketch MH Jr. **Koenig** **HG**. Mark D.   |
| Lee KL.                                                               |
|                                                                       |
| Music, imagery, touch, and prayer as adjuncts to interventional       |
| cardiac care: the Monitoring and Actualisation of Noetic Trainings    |
| (MANTRA) II randomised study. Lancet. 366(9481):211-7, 2005.          |
|                                                                       |
| This study found no significant effect of double-blinded intercessory |
| prayer on cardiac outcomes; this does not rule out the effectiveness  |
| of prayer, but provides evidence that supernatural effects acting     |
| outside of nature may not be established by natural scientific        |
| methods.                                                              |
|                                                                       |
| 2\. [Journal Reference]{.underline}: Slentz CA, Aiken LB, Houmard JA, |
| Bales CW, Johnson JL, Tanner CJ, Duscha BD, Kraus WE. (2005)          |
| Inactivity, exercise, and visceral fat. STRRIDE: a randomized,        |
| controlled study of exercise intensity and amount. [Journal Applied   |
| Physiology]{.underline} 99:1613-1618.                                 |
|                                                                       |
| In this randomized, controlled study of exercise intensity and        |
| amount, the effects of 6 months of exercise on abdominal obesity were |
| examined in 175 sedentary, overweight men and women. It was           |
| determined that an exercise program equivalent to that recommended by |
| the Centers for Disease Control and American College of Sports        |
| Medicine prevented significant gains in visceral fat and that a       |
| modestly higher exercise level resulted in significant decreases in   |
| visceral, subcutaneous, and total abdominal fat without any           |
| alteration in calorie intake.                                         |
|                                                                       |
| 3\. [Journal Reference:]{.underline} Sleath B, Thorpe J, Landerman    |
| LR, Doyle ME, **Clipp, EC**. African American and White Caregivers of |
| Older Adults with Dementia: Differences in Depressive Symptomatology  |
| and Psychotropic Drug Use. [Journal Am Geriatrics Soc]{.underline},   |
| 53:3, 397-404, March 2005.                                            |
|                                                                       |
| In efforts to examine relationships between race and psychotropic     |
| drug use (i.e., antidepressant, anti-anxiety, sedative/hypnotic       |
| agents) among informal caregivers with depressed symptoms who provide |
| care for elderly veterans with progressive dementia, we discovered    |
| that the majority (81%) of caregivers with depressive symptoms were   |
| not taking antidepressant medication; and that African American       |
| caregivers were less likely than Whites to be taking antidepressants. |
| Results suggest that routine screening for depression among dementia  |
| caregivers may identify unmet needs for antidepressant therapy.       |
|                                                                       |
| 4\. [Journal Reference:]{.underline} Ingram SS, **Seo PH**, Sloane R, |
| **Francis T,** **Clipp EC**, Doyle ME, Montana GS, **Cohen HJ.** The  |
| association of oral health with general health and quality of life in |
| older cancer patients. Journal of the American Geriatric Society,     |
| Sept 2005: 53(9):1504-9, 2005.                                        |
|                                                                       |
| While examining the long-term effects of oral health problems on      |
| quality of life, functional status, pain and general health in older  |
| veterans with cancer, we observed that those who also had mouth or    |
| tooth problems that made it hard to eat were prone to have a lower    |
| quality of life, poorer emotional health, lower levels of physical    |
| functioning, and greater pain than patients without these problems.   |
|                                                                       |
| 5\. [Journal Reference:]{.underline} Kaye KS, Schmit K, Caughlan KF,  |
| Sloane R, Pieper CF, Sexton DJ, **Schmader KE**. The effect of        |
| increasing age on the risk for surgical site infections. [J Infect    |
| Dis]{.underline} 2005;191:1056-1062.                                  |
|                                                                       |
| This study, which showed a novel relationship between aging and risk  |
| for surgical site infections, was the subject of an editorial and     |
| news release by the journal. A large and increasing number of older   |
| persons undergo surgery but the relationship between increasing age   |
| and risk of surgical site infection (SSI) has not been established.   |
| To determine the relationship between increasing age and the risk of  |
| SSI, we performed a cohort study of patients who underwent surgery    |
| over an 11 year period at 11 hospitals, involving 144,485 surgical    |
| patients and1684 SSIs. Risk of SSI increased by 1% per year between   |
| ages 17-65 years old but, unexpectedly, after age 65 years old, risk  |
| of SSI [decreased]{.underline} by 1% for each additional year. These  |
| findings suggest that risk for SSI alone should not deter surgery for |
| patients aged 65 or older.                                            |
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| **6. EDUCATION**                                                      |
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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)*:                    |
|                                                                       |
| 1\. GRECC staff member **Eleanor McConnell**: **[Evidence-Based       |
| Geriatric Nursing update series]{.underline}**: HRSA-funded, provides |
| training in management of common geriatrics syndromes with leadership |
| skills needed to implement care through paraprofessional staff.       |
| Participants complete a clinical practice improvement project in      |
| their home facility. VA nurses have been routine participants along   |
| side nurses from private sector and regulatory agencies.              |
|                                                                       |
| 2\. **[Faculty Development for Advances in Geriatric                  |
| Education]{.underline}**. GRECC staff members **M Heflin, Cohen**. We |
| have developed a series of "mini-fellowships" for physician faculty   |
| from outside institutions who are seeking to improve their skills at  |
| developing and delivering curricula in geriatrics. Minifellowships    |
| are offered in a number of thematic areas including Evidence-based    |
| Medicine, Medical student and resident education, Palliative care,    |
| Long term care, and subspecialties in medicine.                       |
|                                                                       |
| 3\. GRECC staff member **Dr. Koenig** has developed an all-day        |
| **[workshop on Integrating Spirituality into Patient                  |
| Care]{.underline}**, which was presented at all of the VA Medical     |
| Centers in Ohio this year (2005).                                     |
|                                                                       |
| This is the first intensive training program for medical and nursing  |
| staff on addressing spiritual factors in patient care. This program   |
| has now been held at the 5 VA Medical Centers in Ohio and 3 VA        |
| Medical Centers in Pennsylvania, and based upon participant feedback, |
| has been useful.                                                      |
|                                                                       |
| 4\. GRECC staff member **Dr. Twersky**: A **[curriculum for home call |
| for internal medicine residents]{.underline}** was established***.*** |
| The innovative aspects of the home call training includes the website |
| (care in aging) which provides tips for home call and management      |
| suggestions for the most common problems faced from home call and we  |
| (myself and the geriatric fellow on the ECRC rotation) review calls   |
| at least once a week and discuss management of these cases.           |
|                                                                       |
| 5\. GRECC staff members **Clipp and Schmader**: Through the           |
| RAND/Hartford Interdisciplinary Geriatric Research Center,            |
| **[innovative training opportunities in geriatrics]{.underline}** in  |
| 2004-2005 included a) an 8-part "Longitudinal Methods Series (Sept    |
| 2004 -May 2005)"; b) a 6-week "Research Training Series" for junior   |
| faculty in Gerontological Nursing or Geriatric Medicine & VA Fellows; |
| and c) a half day workshop entitled, "Secondary Data: Uses and        |
| Sources" which featured a panel of 6 senior investigators each of     |
| whom described opportunities in one large data set. The audience      |
| included GRECC investigators, VA Fellows, and Gerontological Nursing  |
| / Geriatric Medicine faculty..                                        |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year**\                                    |
|     *( Your description of each item should succinctly summarize the  |
|     content, target audience, format, and product evaluation results  |
|     if any. [You may include products developed in prior years ONLY   |
|     IF THIS IS THE FIRST YEAR they have been available for            |
|     distribution.]{.underline} )*:                                    |
|                                                                       |
| 1\. **Dr. Eleanor McConnell**: **[Training modules from the           |
| Abilities-Focused Care]{.underline}** initiative were described       |
| during a G&EC National conference call, Dec. 2004. Participant Dr.    |
| Cortina used selected training materials for his presentation at VA   |
| National LTC summit in April, 2005. Dr. McConnell has been asked to   |
| participate in development of VISN-6 level training for LTC staff, as |
| well as in development of national-level audiovisual training         |
| materials.                                                            |
|                                                                       |
| 2\. **Dr. Kenneth Schmader**: With SciMed and Merck funding, we       |
| developed **[a curriculum on herpes zoster and postherpetic neuralgia |
| (PHN) and presentation (CD/DVD/web based]{.underline}**). The content |
| includes the epidemiology, clinical features, treatment and           |
| prevention of herpes zoster and postherpetic neuralgia in older       |
| adults. The target audience for this initiative includes family       |
| physicians, gerontologists, long-term care medical directors,         |
| infectious disease specialists, and other healthcare                  |
| professionals***.***                                                  |
|                                                                       |
| 3\. [**Care in Aging Website: Clinicians' Network**.]{.underline}     |
| This website offers tools for those teaching clinical topics in       |
| Geriatrics, including sections on cognitive impairment, falls, end of |
| life care, and polypharmacy. Each section includes an overview        |
| presentation, cases with questions, and resources for teaching and    |
| care. The address is: http://careinaging.duke.edu/clinicians.         |
|                                                                       |
| 4\. **[Care in Aging Website: Long Term Care Network]{.underline}**.  |
| This website offers tools for those teaching clinical topics in Long  |
| Term Care, ideally suited for housestaff and interdisciplinary        |
| audiences. Each section includes an overview presentation, cases with |
| questions, and resources for teaching and care. The address is:       |
| http://careinaging.duke.edu/longtermcare.                             |
|                                                                       |
| 5\. **Morey, McConnell, Crowley and Peterson**: Three **[Physical     |
| Activity Counseling Modules]{.underline}** and a Physical Activity    |
| Assessment form were developed for older adults (for Project LIFE)    |
| and are now posted on the VA Research Rehab Website                   |
| (<http://www1.va.gov/resdev/resources/pubs/LIFE-modules.cfm>). These  |
| forms are intended as easy to use physical activity counseling guides |
| for any VHA health care provider. They provide a step- by- step       |
| approach to counseling that is based on state of the art behavioral   |
| counseling theory. Preliminary evaluation of these forms alone, has   |
| been not been conducted. When coupled with other counseling           |
| strategies, we have noted significant short-term increases in         |
| physical activity.                                                    |
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| **7. CLINICAL INNOVATIONS**                                           |
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| **NEW DEFINITION:** A "Clinical Innovation" is an untested,           |
| GRECC-initiated clinical effort that ideally is related to one of the |
| GRECC's research foci. A Clinical Innovation may be a wholly original |
| clinical program or an original aspect of or variation on an          |
| established program. A Clinical Innovation must incorporate an        |
| evaluation plan for assessing the innovation's efficacy so that, if   |
| the innovation is demonstrated to be an improvement over an existing  |
| approach to care, there is a basis on which it can be exported for    |
| implementation elsewhere.                                             |
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| a.  **Clinical Innovations Underway in Report Year**\                 |
|     (list all Clinical Innovations underway during the report year.   |
|     For each, indicate whether the innovation is [N]{.underline}ew or |
|     [O]{.underline}ngoing in the report year. ):                      |
|                                                                       |
| 1.**Dr. Eleanor McConnell**, along with Carol Feldman, RN, MSN, has   |
| implemented a model for ambulatory care nurses to engage routinely in |
| evaluation and implementation of **[evidence-based clinical practices |
| (EBCP)]{.underline}** in the primary care clinics. This program is    |
| [**Ongoing**.]{.underline}                                            |
|                                                                       |
| 2\. **Dr. Eleanor McConnell** and the geriatrics clinic staff,        |
| including **Drs. Heflin, Ruby**, Hastings, and Potu, participated in  |
| the development and testing of a **[VISN 6-wide Clinical              |
| Reminder]{.underline}**, based on a Office of Medical Inspectors\'    |
| report on firearms and driving use, and informed by inclusion of      |
| recent evidence on dementia safety. The clinical reminder was         |
| developed during FY 04 and FY 05, and implemented system wide during  |
| FY 05. The clinical reminder has been exported to the VHA through a   |
| poster prepared by Terri Murphy, RN, MSN, CS at the May, 2005 VHA     |
| e-Health University (VEHU) meeting in Nashville Tennessee. The        |
| reminder and poster were also shared with Susan Cooley, Office of     |
| Geriatrics and Extended Care. This program is **[new]{.underline}**   |
| this year.                                                            |
|                                                                       |
| 3.**Dr. Eleanor McConnell** is working with geriatric fellows Whitson |
| and Hastings, and the ECRC quality improvement to develop and         |
| implement a **[CPRS-based decision-support tool]{.underline}** for    |
| nurses to use when they call physicians after hours regarding         |
| clinical problems. The program will be evaluated by assessing nursing |
| and medical staff satisfaction with the on-call encounter, and by     |
| examining health services utilization such as referrals to emergency  |
| department before and after implementation of decision-support. The   |
| project is **[new]{.underline}** this year.                           |
|                                                                       |
| 4\. A **[model of "Experiential Training for Cancer                   |
| Caregivers]{.underline}**" was developed this year by Dr. Cristina    |
| Hendrix (VA WOC) under the VA GRECC site direction of **Drs. Clipp    |
| and Twersky**. This model is [Ongoing]{.underline}.                   |
|                                                                       |
| 5\. Our **[Home Care Coordination]{.underline}** program now offers a |
| wide variety (11) of home care options for                            |
|                                                                       |
| veterans. In FY05 Home Respite grew by 89%, Homemaker/Home Health     |
| Aide by 65%, and Home Based Primary Care by 22% over the 2004         |
| workload levels. This program is [Ongoing.]{.underline}               |
|                                                                       |
| 6\. **[Provider Training for Physical Activity]{.underline}** --      |
| **Dr. Morey**. This program is [Ongoing.]{.underline}                 |
|                                                                       |
| 7\. The **[Palliative Care Consult Team]{.underline}**, with **Dr.    |
| Cutson** as director and Linda Lang, LISW, as administrative          |
| coordinator, continues to lead VISN 6 with the number of referrals.   |
| The Team has presented in-service training sessions to Durham VA      |
| hospital staff. The EPEC Training session organized by Dr. Cutson and |
| co-sponsored by GRECC during FY2005 received positive reviews. This   |
| program is [Ongoing.]{.underline}                                     |
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| b.  **Evaluation Results of Clinical Innovations listed in the        |
|     preceding box\                                                    |
|     ***(for each clinical innovation listed in 7-a above, summarize   |
|     evaluation outcome(s) identified in the report year, in five      |
|     lines or fewer. Please specify "no evaluation results" for any    |
|     innovation for which that is the case)*                           |
|                                                                       |
| 1**. [Evidence-based clinical practices (EBCP):]{.underline}** Two    |
| care nursing care protocols have been revised and we are now          |
| analyzing evaluation data for the following clinical innovations: a)  |
| liberalizing dietary instruction for fecal occult blood testing       |
| (FOBT), and b) using cerumenolytic drops prior to ear irrigation. The |
| evaluation in process will examine improvements in FOBT screening     |
| completed after simplifying the counselling, as well improvements in  |
| successful ear irrigation, compared to prior to changing the          |
| protocols.                                                            |
|                                                                       |
| 2\. **[VISN 6-wide Clinical Reminder:]{.underline}** The program will |
| be evaluated by examining % completion rate of clinical reminders, as |
| well as describing outcomes of clinical reminder-assisted encounters, |
| such as referrals to DMV, referrals to social work or physical        |
| therapy.                                                              |
|                                                                       |
| 3\. [**CPRS-based decision-support** tool:]{.underline} Baseline data |
| collection currently ongoing. A Poster presented at American          |
| Geriatrics Society annual meeting: Whitson, H., Hastings, S.N.,       |
| McConnell, E.S., Lekan-Rutledge, D. (2005). Quality Improvement in    |
| Longterm Care Telephone Medicine. Presented at American Geriatrics    |
| Society Annual Meetings, May 2005. Paper in review: Whitson, H.E.,    |
| Hastings, S.N., McConnell, E.S., Lekan-Rutledge, D.A. (2005 in 2^nd^  |
| review). Interdisciplinary Focus Groups on Telephone Medicine: A      |
| quality improvement initiative. [Journal of the American]{.underline} |
| [Medical Directors Association (JAMDA)]{.underline}.                  |
|                                                                       |
| 4\. A **[model of "Experiential Training for Cancer                   |
| Caregivers]{.underline}**" was developed last year by Dr. Cristina    |
| Hendrix (VA WOC) under the VA GRECC site direction of Drs. Clipp and  |
| Twersky. The model's feasibility was tested in an acute care VA       |
| facility using an individualized caregiver experiential training      |
| program for symptom management at the patients\' bedside. Seven       |
| informal caregivers of older cancer patients who were admitted to the |
| VA ECRC for cancer treatment were enrolled (5 hours training and data |
| collection each). Results showed that the training was feasible and   |
| associated with an immediate increase in caregivers\' efficacy in     |
| symptom management.                                                   |
|                                                                       |
| ***5.*** Our **[Home Care Coordination program]{.underline}** is      |
| evaluated in a number of ways. Patient Satisfaction results are       |
| aggregated across programs. The data are graphed and forwarded to     |
| Process and Systems Improvement on a bi-annual basis. Programs were   |
| also evaluated by JCAHO in August, 2005, with positive feedback.      |
|                                                                       |
| 6\. **[Provider Training for Physical Activity]{.underline}**. We     |
| surveyed a sub-sample of providers who received physical activity     |
| training. They all rated the training session higher than "somewhat   |
| helpful" or "very helpful." The providers "strongly agreed" that the  |
| counseling materials were easy to use and made counseling with        |
| patients easy. Using the counseling materials allowed the providers   |
| to counsel patients in less than three minutes.                       |
|                                                                       |
| ***7.*** The outcomes of the **[Palliative Care                       |
| Service]{.underline}** are assessed annually (e.g., number of         |
| consults, number of patient deaths in-house with consults) and        |
| reported to Central Office. There is also evaluation on-going on a    |
| local basis using questionnaires distributed to house staff and       |
| attending physicians. This feedback is incorporated into the          |
| Palliative Care Consult Team quality improvement.                     |
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| c.  **Clinical Innovation Exported in Report Year**\                  |
|     *(Please list up to five examples. In three lines or less for     |
|     each example, name or describe the innovation, identify the name  |
|     of the VA or non-VA facility to which it was exported, and the    |
|     method of export)*:                                               |
|                                                                       |
| 1\. **Dr. Eleanor McConnell** and the geriatrics clinic staff,        |
| including **Drs. Heflin, Ruby,** Hastings, and Potu, participated in  |
| the development and testing of a **[VISN6-wide Clinical Reminder for  |
| dementia]{.underline}** patients. The clinical reminder has been      |
| implemented throughout VISN-6. Terri Murphy, RN, MSN serves on a VHA  |
| committee that is examining the reminders implemented nationally.     |
|                                                                       |
| 2\. **[Abilities Focused Care National Conference call and related    |
| materials]{.underline}**: **Drs. McConnell** and Connell presented    |
| New Clinical Initiative Project: Lessons Learned Implementing         |
| Evidence-Based Practices in Dementia Care on the Department of        |
| Veterans Affairs National Geriatrics and Extended Care Conference     |
| Call.                                                                 |
|                                                                       |
| 3\. **Morey, McConnell, Crowley and Peterson**: Three **[Physical     |
| Activity Counseling Modules]{.underline}** and a **[Physical Activity |
| Assessment form]{.underline}** were developed for older adults (for   |
| Project LIFE) and are now posted on the VA Research Rehab Website     |
| (<http://www1.va.gov/resdev/resources/pubs/LIFE-modules.cfm>). These  |
| forms are intended as easy to use physical activity counseling guides |
| that are readily accessible for any VHA health care provider. They    |
| provide a step- by- step approach to counseling that is based on      |
| state of the art behavioral counseling theory.                        |
|                                                                       |
| **4. EC Clipp*: ***A **[new instrument, the QUAL-E, was developed to  |
| evaluate the quality and effectiveness of interventions targeting     |
| improved care at the end of life]{.underline}**. It is in use in      |
| multiple studies nationwide and has been exported to the Los Angeles  |
| VA for use in a Palliative Care Intervention trial (K Rosenfeld, PI). |
| Steinhauser KE, Clipp EC, et al. Measuring Quality of Life at the End |
| of Life: Validation of the QUAL-E. [Journal of Palliative and         |
| Supportive Care]{.underline}, 2, 3-14, 2004.                          |
|                                                                       |
| 5\. **K.W. Lyles**. Clinical study findings on the history and        |
| physical parameters that increase the likelihood of **[diagnosis of   |
| osteoporosis]{.underline}** were recently published (JAMA             |
| 292:2890-900. 2004). This information is available to any health care |
| provider in the VA system for use in clinical settings immediately.   |
| With a strong emphasis on osteoporosis prevention and diagnosis for   |
| female veterans this work will have value for their care from the     |
| time it was established.                                              |
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| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| **DEFINITIONS:**                                                      |
|                                                                       |
| **"Consultation"** for this section of the report has occurred when   |
| GRECC staff has materially assisted in the development of a non-GRECC |
| research, education or clinical program **[within the host            |
| VAMC.]{.underline}**                                                  |
|                                                                       |
| **"Outreach"** for this section of the report has occurred when GRECC |
| staff has materially assisted in the development of a non-GRECC       |
| research, education or clinical program **[at a facility other than   |
| the host VAMC.]{.underline}**                                         |
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| **Note:**                                                             |
|                                                                       |
| **for the 2005 Annual Report,**                                       |
|                                                                       |
| **Consultation and Outreach activity**                                |
|                                                                       |
| **will NOT be reported here.**                                        |
|                                                                       |
| **It will be reported via the Electronic Annual report Data Base.**   |
+-----------------------------------------------------------------------+