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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER    |   |   |   |   |
|                                                          |   |   |   |   |
| ### *Annual Report: Fiscal Year [2008]{.underline}*      |   |   |   |   |
|                                                          |   |   |   |   |
| ######## Part II: Accomplishments                        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **NOTE:** The **GRECC Annual Report** reflects status    |   |   |   |   |
| and accomplishments of **[GRECC Core Staff]{.underline}  |   |   |   |   |
| \*** (as defined below) [only]{.underline}. The          |   |   |   |   |
| **"Report Year"** is from [October 1, 2007 through       |   |   |   |   |
| September 30, 2008]{.underline}.                         |   |   |   |   |
|                                                          |   |   |   |   |
| You are welcome to use this report format for your own   |   |   |   |   |
| internal reporting purposes,                             |   |   |   |   |
|                                                          |   |   |   |   |
| in which case you may exceed the recommended limits of   |   |   |   |   |
| numbers of responses and their length                    |   |   |   |   |
|                                                          |   |   |   |   |
| ("list no more than..." "Describe the three most         |   |   |   |   |
| important..." "limit your response to five lines or      |   |   |   |   |
| fewer")                                                  |   |   |   |   |
|                                                          |   |   |   |   |
| ***\-\--BUT\--***                                        |   |   |   |   |
|                                                          |   |   |   |   |
| [Please limit **to ten pages or fewer** the version      |   |   |   |   |
| **SUBMITTED TO VACO** **.**]{.mark}                      |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **\*[GRECC Core Staff ]{.underline}**is limited to       |   |   |   |   |
| either **Primary Core**, **Affiliated Core**, or         |   |   |   |   |
| **Research Core**:                                       |   |   |   |   |
|                                                          |   |   |   |   |
| -   **Primary Core =** positions authorized by the       |   |   |   |   |
|     original GRECC allocation plus any addition in       |   |   |   |   |
|     ceiling from VA Central Office specifically          |   |   |   |   |
|     designated for GRECC.                                |   |   |   |   |
|                                                          |   |   |   |   |
| -   **Affiliated Core** = Staff who work full- or        |   |   |   |   |
|     part-time in [direct support]{.underline} of the     |   |   |   |   |
|     GRECC's research, education or clinical activity.    |   |   |   |   |
|                                                          |   |   |   |   |
|     -   May be either "contributed" by the VA Medical    |   |   |   |   |
|         Center or                                        |   |   |   |   |
|                                                          |   |   |   |   |
|     -   May have been acquired through centralized       |   |   |   |   |
|         enhancements/awards for programs\                |   |   |   |   |
|         (e.g., Home-Based Primary Care, Geriatric        |   |   |   |   |
|         Evaluation and Management Program, etc.)         |   |   |   |   |
|                                                          |   |   |   |   |
|     -   To be considered Affiliated Core, staff must be  |   |   |   |   |
|         organizationally aligned under the GRECC or      |   |   |   |   |
|         specifically identified by the Medical Center as |   |   |   |   |
|         **"GRECC-affiliated staff."**                    |   |   |   |   |
|                                                          |   |   |   |   |
| -   **Research Core** = Full-or part-time staff who      |   |   |   |   |
|     devote 51% or more of their total time to GRECC      |   |   |   |   |
|     research and whose salaries are supported by         |   |   |   |   |
|     research funds (either VA or non-VA). Includes all   |   |   |   |   |
|     GRECC staff whose salaries are paid from research    |   |   |   |   |
|     funds, e.g.:                                         |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Associate Investigator                           |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Assistant Research Scientist                     |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Senior Research Career Scientist                 |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Research Career Scientist                        |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Advanced Research Career Scientist.              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **[IMPORTANT:]{.underline} Throughout this report,       |   |   |   |   |
| please AVOID/MINIMIZE JARGON. Each response is much more |   |   |   |   |
| likely to be included in secondary communications        |   |   |   |   |
| derived from the Annual Reports if it can be readily     |   |   |   |   |
| understood by a non-technical readership.**              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **1. GRECC NAME/LOCATION**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **GRECC Name:** VISN 3 GRECC (formerly James J       |   |   |   |   |
|     Peters/NY Harbor GRECC)                              |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location** *(facility, VISN)*: James J Peters VA   |   |   |   |   |
|     Medical Center, Bronx, NY; VISN 3                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **Name:** Barbara Morano                             |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Position:** Administrative Officer                 |   |   |   |   |
|                                                          |   |   |   |   |
| c.  **Phone, e-mail:** 718-584-9000 x3803;               |   |   |   |   |
|     barbara.morano@va.gov                                |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **3. GRECC FOCUS AREA(S)**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **NOTE:** Please succinctly list your GRECC's Focus      |   |   |   |   |
| Area(s), one per line below. After each focus area       |   |   |   |   |
| listed, please indicate with a check mark (****) which  |   |   |   |   |
| of the research type(s) suitably describes the work      |   |   |   |   |
| conducted (including planning, implementation, analysis, |   |   |   |   |
| and dissemination/publication) within that focus during  |   |   |   |   |
| the Report Year. Add additional lines by positioning     |   |   |   |   |
| your cursor at the lower right side of the table and     |   |   |   |   |
| striking the "Tab" key.                                  |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **GRECC Focus Area**                                     | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | R |   |   |   |
|                                                          | e |   |   |   |
|                                                          | s |   |   |   |
|                                                          | e |   |   |   |
|                                                          | a |   |   |   |
|                                                          | r |   |   |   |
|                                                          | c |   |   |   |
|                                                          | h |   |   |   |
|                                                          | T |   |   |   |
|                                                          | y |   |   |   |
|                                                          | p |   |   |   |
|                                                          | e |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
|                                                          | > | > | > | > |
|                                                          |   |   |   |   |
|                                                          | * | * | * | * |
|                                                          | * | * | * | * |
|                                                          | B | A | H | R |
|                                                          | a | p | e | e |
|                                                          | s | p | a | h |
|                                                          | i | l | l | a |
|                                                          | c | i | t | b |
|                                                          | > | e | h | i |
|                                                          |   | d | > | l |
|                                                          | B | > |   | i |
|                                                          | i |   | S | t |
|                                                          | o | C | e | a |
|                                                          | m | l | r | t |
|                                                          | e | i | v | i |
|                                                          | d | n | i | o |
|                                                          | i | i | c | n |
|                                                          | c | c | e | * |
|                                                          | a | a | s | * |
|                                                          | l | l | * |   |
|                                                          | * | * | * |   |
|                                                          | * | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Improving Palliative Care                                |   | * | * | * |
|                                                          |   | * | * | * |
|                                                          |   | X | X | X |
|                                                          |   | * | * | * |
|                                                          |   | * | * | * |
+----------------------------------------------------------+---+---+---+---+
| Prevention of functional disability                      |   | * |   |   |
|                                                          |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Improving processes and outcomes during transitions      |   | * | * | * |
| between sites of care                                    |   | * | * | * |
|                                                          |   | X | X | X |
|                                                          |   | * | * | * |
|                                                          |   | * | * | * |
+----------------------------------------------------------+---+---+---+---+
| Drug discovery for Alzheimer's Disease                   | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+

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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 specific       |
|     impact on **host VAMC's** research, staff education, program      |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VAMC) during the Report Year. **Please     |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   GRECC researchers received \$3,845,760 in VA, NIH and other       |
|     funded grants in FY08.  This has been leveraged to attract new    |
|     investigators (Hung, Hwang) and to successfully compete for an JJ |
|     Peters VA HSRD Center Grant (Penrod PI), The Center for the Study |
|     of Healthcare across Systems and Sites of Care, which will        |
|     support additional capacity building to conduct research on       |
|     chronic and severe illness care and care coordination, and which  |
|     are core issues in Geriatrics.                                    |
|                                                                       |
| -   In consultation with geriatrics primary care, the GRECC developed |
|     a portable learning initiative, named the Geri-Tool Box. From a   |
|     menu of approximately five topics, a clinical program/department  |
|     can chose a topic of interest that will be presented during a     |
|     regularly scheduled meeting. Each presentation is 15 minutes in   |
|     length and results in an exportable tool for future use. The      |
|     initial tool box was taken to Primary Care where a registered     |
|     dietician presented on supplemental nutrition in the elderly.     |
|                                                                       |
| -   The GRECC substantially increased staff training at JJ Peters     |
|     through a variety of staff development activities, including      |
|     onsite trainings offered by the Consortium of NY Geriatric        |
|     Education Centers (CNYGEC), the CNYGEC Geriatric Emergency        |
|     Preparedness Certificate Program, End of Life Nursing Education   |
|     Consortium trainings, quarterly Palliative Care education         |
|     meetings, monthly audio-conferences, Grand Rounds, and two large  |
|     geriatrics conferences. Strengthened partnerships and outreach    |
|     resulted in increased numbers.                                    |
|                                                                       |
| -   The GRECC is responsible for two successful clinical geriatrics   |
|     initiatives: the Bedside Geriatric Consultation Clinic which      |
|     provides comprehensive geriatric assessments for hospitalized     |
|     older veterans and assists the inpatient teams with the           |
|     management of geriatric issues and syndromes in the face of the   |
|     hazards of hospitalization; and the \"embedded\" Outpatient       |
|     Geriatrics Consultation Clinic which provides comprehensive       |
|     geriatric assessments within patients\' primary care clinics      |
|     using the existing interdisciplinary team and working closely     |
|     with the patients\' primary care providers. Now in their second   |
|     year, these programs continue to grow and provide key clinical    |
|     educational experiences for geriatrics fellows and geriatric      |
|     nurse practitioner students.                                      |
|                                                                       |
| -   The GRECC has initiated a monthly Geriatrics/Palliative Care      |
|     lecture series for the internal medicine house staff at the Bronx |
|     VA. Incoming VA interns scored on average 26% on a standardized   |
|     tests of geriatric and palliative care knowledge administered     |
|     during their orientation week. Through the monthly lecture        |
|     series, as well as through bedside teaching by the geriatrics and |
|     palliative care consult teams, the GRECC hopes to increase both   |
|     the depth and breadth of clinical geriatrics and palliative care  |
|     knowledge among the house staff. Palliative care and geriatrics   |
|     electives for senior residents are now available at the Bronx VA  |
|     with these GRECC based consultation teams. A post test will be    |
|     administered to the interns at the end of June 2009. In FY2010 we |
|     plan to begin assessing improvements in clinical management of    |
|     older inpatients by the house staff.                              |
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| b.  **GRECC Impact on VISN in the Report Year:** *list **the** **most |
|     important ways** in which the GRECC has had specific impact on    |
|     the **host** **VISN's** research, staff education, program        |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VISN) during the rating period. **Please   |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   GRECC researchers (Penrod, Luhrs) and other VISN researchers      |
|     (Chang) are collaborating on studies of palliative care (PC)      |
|     programs across VISN 3 that directly affect program               |
|     implementation. In one study, they evaluated a standardized PC    |
|     program using a Web-based report card. The number of patients in  |
|     VISN 3 who received PC consults more than doubled in the first 4  |
|     years of the program and the percentage of deaths with PC         |
|     consultation prior to death increased from 23% in FY02 to 57% in  |
|     FY06 (J Palliat Med. 10:858-60; 2007).                            |
|                                                                       |
| -   A Geriatrics Learning Community (GLS) was launched in FY 2008     |
|     with a one-day conference on 3/14/08 attended by 199 VISN 3       |
|     health providers. Supported by the GRECC, EES, and the VISN 3     |
|     Primary Care, Geriatrics and Extended Care, and Education         |
|     Councils, the conference focused on assessment and treatment      |
|     skill sets for primary care practitioners. While a FY 08 proposal |
|     to EES for an Innovation grant to support the GLS was not funded, |
|     work progressed to create a VISN-wide initiative.                 |
|                                                                       |
| -   The Consortium of NY Geriatric Education Centers (CNYGEC) is      |
|     based at the GRECC, with many of the trainings offered at James J |
|     Peters with scholarships available to all VISN 3 health           |
|     providers. In FY 08 33 VISN staff participated in a CNYGEC        |
|     40-hour certificate program in Geriatrics.                        |
|                                                                       |
| -   The GRECC co-sponsored with the VISN 3 Primary Care Section, a    |
|     VISN wide conference: "Primary Care and Geriatrics at the         |
|     Crossroads: Practical Skills for Meeting the Needs of the Older   |
|     Veteran" on March 12, 2008. Over 200 VA employees representing    |
|     all VISN 3 facilities and disciplines participated in this first  |
|     program for the VISN\'s newly formed Geriatrics Educational       |
|     Community. Next steps include a needs assessment at all VISN 3    |
|     facilities to develop new VISN wide educational and clinic        |
|     programs to improve the care provided to the 94000 + older        |
|     veterans in general primary care clinics where 98% of those over  |
|     65 receive their care.                                            |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2003]{.underline}**: *list **the** **most significant** GRECC    |
|     research, education or clinical innovations in the past five      |
|     years. For each item, provide date or date range, GRECC core      |
|     staff responsible, and a description. **Please limit your         |
|     response to 5 or fewer innovations; and please limit each of the  |
|     five innovation descriptions to five lines or fewer. ***          |
|                                                                       |
| -   GRECC researchers (Boockvar) have conducted physician and         |
|     pharmacist testing of a CPRS medication reconciliation tool when  |
|     veterans are transferred between care sites. Findings from the    |
|     tests are being used to improve the tool's use and effectiveness  |
|     and are being shared with the VA National Medication              |
|     Reconciliation Workgroup for national dissemination.              |
|                                                                       |
| -   GRECC researchers (Ho, Pasinetti) have shown that naturally       |
|     derived grape seed compounds prevent Abeta oligomerization and    |
|     attenuate cognitive deterioration in a mouse model of             |
|     Alzheimer\'s disease (AD) and may be useful agents to prevent or  |
|     treat AD in humans. J Neurosci. 28(25):6388-92 (2008).            |
|                                                                       |
| -   The GRECC spearheads education for VISN 3 staff in palliative     |
|     care (PC) through a multi-focused education initiative. It works  |
|     closely with a planning committee and EES in implementing         |
|     quarterly education meetings, monthly audio-conferences, ELNEC    |
|     training, and other programs, as well as an educational           |
|     e-newsletter, The Cloak. The educational initiative includes      |
|     training future PC leaders through the VACO Interprofessional PC  |
|     Fellowship. The GRECC PC education program was part of a          |
|     symposium at the 07 GSA annual meeting.                           |
|                                                                       |
| -   The GRECC \"embedded\" Geriatrics Consultation Clinic is a new    |
|     model for providing comprehensive geriatric assessments. Patients |
|     are seen in their home clinic at the request of their primary     |
|     care providers. Once the assessment is completed, the             |
|     consultation team works with the patient\'s existing              |
|     interdisciplinary team to implement recommendations. The          |
|     \"embedded\" nature of the clinic allows patients to be seen in a |
|     familiar setting and for the referring team to get immediate      |
|     feedback on geriatric issues which may be affecting patients\'    |
|     medical care or independent functioning in the community. This    |
|     program has been welcomed by 2 primary care clinics in the Bronx  |
|     VAMC system and several other clinics with large numbers of older |
|     veterans have requested their own sessions which the team hopes   |
|     to accommodate in FY2009.                                         |
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| **5. RESEARCH**                                                       |
+-----------------------------------------------------------------------+
| **a. Key Findings Published in the Report Year on projects for which  |
| GRECC Core Staff was PI or Co-PI:\                                    |
| ***list **five or fewer;** for each item provide GRECC Core Staff     |
| name(s), journal reference, and description of topic/                 |
| method/results/clinical significance.* *Please limit each response to |
| [5 lines or fewer]{.underline}.*                                      |
|                                                                       |
| -   **Penrod JD**, Litke A, Hawkes WG, Magaziner J, Doucette JT,      |
|     Koval KJ, Silberzweig SB, Egol KA, **Siu AL**. The association of |
|     race, gender, and comorbidity with mortality and function after   |
|     hip fracture J Gerontol A Biol Sci Med Sci. 2008;63(8):867-72. In |
|     this study of 2692 hip fracture patients, whites and women were   |
|     more likely than nonwhites and men to survive to 6 months, and    |
|     whites were more likely to walk independently or with help. These |
|     findings highlight the need for more research on race/ethnicity   |
|     disparities in hip fracture care.                                 |
|                                                                       |
| -   **Ross, J, Keyhani, S,** Keenan, P, Bernheim, S. **Penrod, J,     |
|     Boockvar, KS,** Krumholz, H, and **Siu, AL**. Use of Recommended  |
|     Ambulatory Services: Is the VA Quality Gap Narrowing? Arch Intern |
|     Med 168 (9): 950-8 (2008). The likelihood of receipt of most      |
|     recommended ambulatory care services was greater among adults     |
|     receiving VA care compared to those not receiving VA care, and,   |
|     for 4 services, this gap increased from 2000 to 2004. The         |
|     conclusion is that adults receiving VA care remain more likely to |
|     receive recommended care.                                         |
|                                                                       |
| -   **Boockvar, KS**, Gruber-Baldini, A, Stuart, B, Zimmerman, S, and |
|     Magaziner, J. Medicare costs for nursing home residents triaged   |
|     to nursing home or hospital for acute infection. J Am Geriatr Soc |
|     56 (7): 1206-12 (2008). Among 3,618 cases of infection in nursing |
|     homes in Maryland, mean Medicare payments were \$4,206 greater    |
|     with hospital triage than nursing home triage, with no better or  |
|     worse outcomes. This result may be used to estimate cost savings  |
|     of interventions designed to reduce hospital use by nursing home  |
|     residents.                                                        |
|                                                                       |
| -   Wang J, **Ho L**, Chen L, Zhao Z, Zhao W, Qian X, Humala N, Seror |
|     I, Bartholomew S, Rosendorff C, **Pasinetti GM**. Valsartan       |
|     lowers brain beta-amyloid protein levels and improves spatial     |
|     learning in a mouse model of Alzheimer disease. J Clin Invest.    |
|     2007 Nov; 117(11):3393-402. Study showed that the blood pressure  |
|     medication valsartan reduced AD-type neuropathology and cognitive |
|     deterioration in mice, suggesting that valsartan may have         |
|     AD-modifying activity and may protect against progressive         |
|     Abeta-related memory deficits.                                    |
|                                                                       |
| -   **Zhu CW**, Leibman C, McLaughlin T, Scarmeas N, Albert M, Brandt |
|     J, Blacker D, Sano M, Stern Y. The effects of patient function    |
|     and dependence on costs of care in Alzheimer\'s disease. J Am     |
|     Geriatr Soc. 2008 Aug;56(8):1497-503. In a study of 179           |
|     community-living patients with probable AD, patients\' dependence |
|     and function related differently to direct medical and informal   |
|     cost, suggesting that each measure provides unique information    |
|     for explaining variation in cost of care for patients with AD,    |
|     indicating a value to measuring both.                             |
+-----------------------------------------------------------------------+
| **b. Key Findings Published in the Report Year on work in which GRECC |
| Core Staff served as Co-Investigators to a Non-GRECC PI:** *list      |
| **five or fewer**; for each item provide GRECC Core Staff name(s),    |
| journal reference, and description of topic/method/results/clinical   |
| significance. Please limit each response to [5 lines or               |
| fewer]{.underline}.*                                                  |
|                                                                       |
| -   Hill KP, **Ross JS**, Egilman DS, Krumholz HM. The ADVANTAGE      |
|     seeding trial: a review of internal documents. Ann Intern Med.    |
|     2008 19;149(4):251-8. This study of ADVANTAGE trial documents     |
|     indicates the trial was designed by Merck\'s marketing division   |
|     to fulfill a marketing objective; that Merck\'s marketing         |
|     division handled both the scientific and the marketing data,      |
|     including collection, analysis, and dissemination; & that Merck   |
|     hid the marketing nature of the trial from participants,          |
|     physician investigators, and IRB members.                         |
|                                                                       |
| -   Federman AD, Safran DG, **Keyhani S**, **Siu AL**, Halm EA. Low   |
|     levels of awareness of pharmaceutical cost-assistance programs    |
|     among inner-city seniors. JAMA. 2008;300(12):1412-4 This study    |
|     assessed a diverse sample of inner-city seniors for rates of      |
|     awareness of New York State\'s Elderly Pharmaceutical Insurance   |
|     Coverage and Extra Help programs. 302 individuals (67%) were      |
|     aware of EPIC, and 91 (20%) were aware of Extra Help. These       |
|     observations may partly explain underuse of these safety net      |
|     programs.                                                         |
|                                                                       |
| -   Iosifescu A, Halm EA, McGinn T, **Siu AL**, Federman AD. Beliefs  |
|     about generic drugs among elderly adults in hospital-based        |
|     primary care practices. Patient Educ Couns. 2008 Aug 13 \[Epub\]. |
|     This study interviewed older adults in primary care. In           |
|     multivariable analysis, black race (p=0.006) and inadequate       |
|     health literacy (p=0.0004) were associated with negative views    |
|     about generic drugs, indicating that many low-income seniors      |
|     mistrust generic medications, especially African-Americans and    |
|     seniors with low health literacy.                                 |
+-----------------------------------------------------------------------+
| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| **NOTE**: **DO NOT** list trainee and conference data                 |
| here**\--**those data are reported in the GRECC Electronic Database.  |
|                                                                       |
| **NOTE:** You may list educational activities here even if they were  |
| supported by funds that qualified for inclusion in the ePROMISE       |
| (RDIS) database if you wish.                                          |
+-----------------------------------------------------------------------+
| a.  **Innovations in Educational Activities Implemented during the    |
|     Report Year** *(list five or fewer. Please limit each item to [5  |
|     lines or fewer]{.underline} and include clarification of how each |
|     activity is innovative.)*                                         |
|                                                                       |
| -   The GRECC partnered with the Consortium of NY Geriatric Education |
|     Centers (CNYGEC) in a 40-hour certificate program on Geriatric    |
|     Mental Health and Emergency Preparedness, offered at the JJ       |
|     Peters VAMC. 75% of the participants were VA employees.           |
|                                                                       |
| -   The Geri Tool Box is an innovative educational activity which     |
|     serves as a means to educate both geriatricians and               |
|     non-geriatricians on facility and VA relevant clinical topics. By |
|     bringing the tool box to the specific clinical areas during a     |
|     regularly scheduled staff meeting, many scheduling difficulties   |
|     are avoided. It also empowers the individual areas in their       |
|     education by their ability to choose the topic as well as the     |
|     scheduling.                                                       |
|                                                                       |
| -   The GRECC partnered with EES and VISN 3 to deliver three days of  |
|     training based on the End of Life Nursing Education Consortium    |
|     (ELNEC) curriculum at the New York VAMC. Attended by 189          |
|     interdisciplinary staff, the training included topics such as     |
|     nursing care at the end of life, pain and symptom management,     |
|     ethical issues, cultural competency, communication, and the final |
|     hours of life.                                                    |
|                                                                       |
| -   The GRECC continued to expand its VISN-wide Geriatrics Learning   |
|     Community geared to increasing the capacity of primary care       |
|     providers to recognize and screen for geriatric issues and make   |
|     appropriate treatment plans and referrals. During this fiscal     |
|     year we hosted a VISN-wide one-day conference on geriatrics       |
|     primary care (194 VA attendees) and a multi-VISN ½ day            |
|     videoconference on addictions and the elderly of which 103 of the |
|     136 attendees were employed by VA.                                |
+-----------------------------------------------------------------------+
| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year** *List five or fewer of the most     |
|     important products. For each item, limit the response to five     |
|     lines summarizing content, target audience, format, and product   |
|     evaluation plan and results. **Include educational products       |
|     developed in previous years ONLY if this is the [first            |
|     year]{.underline} they have been available for distribution.***   |
|                                                                       |
| -   The Geri-Tool box consists of a mini-lecture by an expert in the  |
|     field, as well as a pocket sized "tool" with relevant data to the |
|     topic. The nutrition in the elderly tool box included the MC      |
|     guidelines in ordering supplemental feeding. All participants     |
|     attending the mini-lecture receive this pocket tool. A product    |
|     evaluation instrument is under development.                       |
|                                                                       |
| -   The Associated Health Curriculum continues to be refined and      |
|     expanded. During this fiscal year, the curriculum was posted on   |
|     the GRECC and CNYNGEC websites. Trainees receive resources (e.g., |
|     detailed module outline, articles) at weekly seminars which are   |
|     added to a tabbed binder. This durable educational product serves |
|     as a valuable resource to trainees in their future careers.       |
|     Yearly evaluations from learners have been consistently strong    |
|     and have informed curriculum revisions.                           |
|                                                                       |
| -   Presentations from the Geriatric Primary Care conference          |
|     (3/14/08), keynoted by Kenneth Shay, DDS, were posted on the EES  |
|     website. Conference evaluations were strong, and a second level   |
|     evaluation found that participants had increased self-efficacy on |
|     10 skill sets, with 3 significant at the .05 level (selecting     |
|     cognitive impairment therapy, assessing sensory impairment, and   |
|     evaluating sleep problems.)                                       |
|                                                                       |
| -   Participants at the two End of Life Nursing Education Consortium  |
|     (ELNEC) conferences received bound syllabi containing ELNEC       |
|     modules, an enduring educational product for attendees. 100% of   |
|     participants agreed that the program objectives were relevant to  |
|     their professional needs and interests.                           |
+-----------------------------------------------------------------------+
| c\. **Educational programs offered by your GRECC during the report    |
| year that were evaluated for impact both immediately and at a later   |
| time, as described in "FY08Instructions" for Performance Measure 7.** |
| *Describe at least **TWO**, each of which had at least 25             |
| participants: one in which the majority of participants was from your |
| GRECC's host facility; and one in which the majority of participants  |
| were from VAs other than your GRECC's host facility. For each,        |
| describe the educational intervention briefly and then the            |
| evaluations, including in your description of the latter the          |
| evaluation methodologies, findings, and conclusions. If the second    |
| evaluation has not yet occurred during the report year, describe your |
| plans for it. Limit your description of each intervention and its     |
| evaluation to one-half page.*                                         |
|                                                                       |
| -   The GRECC, EES and the Primary Care, Geriatrics and Extended      |
|     Care, and Education Councils sponsored a one-day Geriatric        |
|     Primary Care Conference on March 14, 2008. This was a major       |
|     initiative in our ongoing development of a Geriatrics Learning    |
|     Community (GLC). The goals of the GLC are to increase basic       |
|     knowledge in key geriatric topics for VA staff personnel,         |
|     identify barriers and opportunities for appropriate geriatric     |
|     care, and to provide ongoing educational opportunities.           |
|     Participants (n=118) were administered a pre-test on              |
|     self-efficacy in carrying out 10 geriatrics-related activities.   |
|     Participants were contacted via email three weeks later, with two |
|     subsequent reminders, and asked to rate their perceived           |
|     self-efficacy on the same skills. An unpaired t-test (n=87) found |
|     statistically significant changes with positive trends on all     |
|     domains as indicated in the following table:                      |
|                                                                       |
| ![](media/image2.wmf){width="5.873611111111111in"                     |
| height="3.872916666666667in"}                                         |
|                                                                       |
| -   The GRECC, in partnership with the CNYGEC and EES, sponsored its  |
|     7^th^ annual multi-site videoconference on June 10, 2008. A needs |
|     assessment had identified addictive behavior such as substance    |
|     abuse and gambling as an area ripe for staff training. A second   |
|     level impact evaluation was conducted, with participants asked to |
|     rate their perceived self-efficacy on ten skills related to       |
|     addictive behaviors prior to the conference. Using Survey Monkey, |
|     all trainees were asked to rank themselves one month after the    |
|     training. A paired t-test (n=19) found significant change on 7 of |
|     the 10 items: identifying signs of gambling addiction, describing |
|     the nature of addictions, assessing addiction problems, selecting |
|     a treatment for substance abuse, selecting a treatment for        |
|     gambling, linking the client to services, and implementing a care |
|     plan.                                                             |
|                                                                       |
| ![](media/image3.wmf){width="4.750694444444444in"                     |
| height="2.872916666666667in"}                                         |
+-----------------------------------------------------------------------+
| **7. CLINICAL DEMONSTRATION PROJECTS**                                |
+-----------------------------------------------------------------------+
| **NOTE:** A clinical demonstration [program]{.underline} is defined   |
| as:                                                                   |
|                                                                       |
| -   an ongoing, clinical, cooperative collaboration between the GRECC |
|     and host VA medical center;                                       |
|                                                                       |
| -   that carries out and evaluates assessment strategies, management  |
|     approaches and/or specialized investigations                      |
|                                                                       |
| -   of a targeted or focused group of elderly patients                |
|                                                                       |
| -   with the intention that findings will be disseminated for the     |
|     advancement of the field.                                         |
|                                                                       |
| A clinical demonstration program is comprised of one or more clinical |
| demonstration [projects]{.underline}, each of which is defined as     |
|                                                                       |
| -   a set of one or more clinical activities                          |
|                                                                       |
| -   integrated and coordinated under a specified protocol             |
|                                                                       |
| -   designed to permit evaluation(s) of processes and/or outcomes.    |
|                                                                       |
| Evaluation of a clinical demonstration program may be a comprehensive |
| assessment of the activity and/or the clinical outcomes.              |
| Alternatively, evaluation may concentrate on a prioritized and        |
| feasible set of more focused or specific, project-related questions,  |
| e.g. related to improved diagnosis, quality of care, patient          |
| satisfaction, drug compliance, functional status, etc.  Ongoing and   |
| subsequent modifications of the care model may also be evaluated as   |
| may be the practicability and outcomes of exporting new clinical      |
| models or variations of models to general care settings and/or        |
| smaller, more resource-limited VA medical centers or outpatient       |
| facilities.                                                           |
+-----------------------------------------------------------------------+
| a.  **Clinical Demonstration Projects Underway in Report Year***:     |
|     list **all** GRECC Clinical Demonstration Projects underway. For  |
|     each item, indicate whether [N]{.underline}ew or                  |
|     [O]{.underline}ngoing in Report Year. You may include up to five  |
|     lines of descriptive text for each Project.\                      |
|     *                                                                 |
|                                                                       |
| > **NOTE:** The number of Projects listed should be equal to the      |
| > number of Clinical Demonstration Projects you have listed and named |
| > in the GRECC Electronic Database.                                   |
|                                                                       |
| -   (Ongoing) In an effort to address geriatric issues and syndromes  |
|     faced by hospitalized older veterans, the GRECC [Inpatient        |
|     Geriatrics Consultation Service]{.underline} provides             |
|     comprehensive geriatric assessments (CGA) and works closely with  |
|     the unit's interdisciplinary teams. These consults have proven    |
|     helpful in identifying geriatric issues, especially dementia,     |
|     complicating these patients\' hospital courses and post hospital  |
|     care. In FY 08 the team performed 94 inpatient consultations.     |
|     This program serves as a major clinical educational experience    |
|     for a range of trainees.                                          |
|                                                                       |
| -   [Geriatric Consultation Clinic]{.underline} (Ongoing) has further |
|     developed the concept of \"embedding\" geriatricians where older  |
|     veterans receive most of their care by providing CGA in both the  |
|     Bronx VAMC Primary Care Clinic and the Yonkers CBOC. Physicians   |
|     in both of these clinics had noted that geriatric issues,         |
|     particularly cognitive impairment, had been interfering with      |
|     medical care. In FY 08, 78 outpatient consultations were          |
|     performed with 29 patients on the waiting list for appointment at |
|     the end of FY 08. The clinic also serves as a major clinical      |
|     teaching site.                                                    |
|                                                                       |
| -   The Bronx VA\'s [Palliative Care (PC) Program]{.underline}        |
|     (Ongoing), which consists of an Inpatient Consultation Service,   |
|     an Outpatient Consultation Clinic and a Supportive Care (Hospice) |
|     Unit, is integrated into VISN 3\'s PC Program through the use of  |
|     standardized templates, training and quarterly conferences, and   |
|     serves as the major clinical educational experience for the GRECC |
|     Interprofessional PC Fellowship Program. In FY 08, the team       |
|     performed 319 inpatient consults. The PC consult team followed    |
|     69% of all patients who died at the Bronx VA during FY08.         |
+-----------------------------------------------------------------------+
| b.  **Evaluation of Clinical Demonstration Projects:** *for each      |
|     GRECC Clinical Demonstration Project listed in 7a above,          |
|     summarize the evaluation activity. If no evaluation results are   |
|     available, be explicit as to the focus of the planned evaluation, |
|     and when it is anticipated to occur. If the project has been      |
|     completed during the Report Year, provide key findings and their  |
|     significance.*\                                                   |
|     \                                                                 |
|     **NOTE:** Do not list patient service use data here. Those data   |
|     are reported in the GRECC Electronic Database.                    |
|                                                                       |
| The GRECC recently completed an IRB approved review of 122            |
| consultations performed during the first 2 years of the \"embedded\"  |
| Geriatrics Consultation Clinic that looked at the identification of   |
| previously undiagnosed dementia and depression in patients referred   |
| for Comprehensive Geriatric Assessment (CGA) which includes           |
| assessments for these common geriatric syndromes. Although there are  |
| no current guidelines for the routine cognitive screening of older    |
| adults, the burden of dementia is significant for patients and their  |
| families. Cognitive impairment can affect an individual\'s ability to |
| manage medical conditions and to live safely and independently in the |
| community. The initial signs of dementia may be subtle and can be     |
| easily missed by busy primary care providers (PCPs). This is also     |
| true of depression, which while not more frequent among the elderly,  |
| is often missed during routine care.\                                 |
| \                                                                     |
| CGA is a basic, yet important tool of geriatrics. Recent studies on   |
| CGAs have found that their clinical effectiveness is varied. These    |
| results may reflect inadequate implementation of assessment           |
| recommendations. In order to address this issue, the Bronx VAMC       |
| developed an \"embedded clinic\" model for providing CGAs. In these   |
| clinics, geriatricians see patients in the offices of their own PCPs  |
| with their permission. This eliminates the need for a separate clinic |
| staff and facilitates the sharing of information and the              |
| implementation of some recommended interventions (those that can be   |
| ordered through CPRS).                                                |
|                                                                       |
| As a first step in assessing the effectiveness of this clinical       |
| demonstration project, the GRECC chose to look at its ability to      |
| detect previously undiagnosed dementia and depression among elderly   |
| veterans referred for CGA and thus in identifying unmet care needs in |
| this population.                                                      |
|                                                                       |
| The stated reasons for referral were varied and only noted concerns   |
| about cognition (dementia, confusion) in 36% of all referrals. The    |
| patients had a mean age of 82 and an age range of 58 to 95. All       |
| patients were male. The consultative team initiated work-up, referral |
| and treatment for identified geriatric syndromes. For each patient    |
| seen, information was abstracted from the consultation note itself    |
| and from the CPRS progress notes for the 12 months prior to the date  |
| of the consultation by separate researchers.                          |
|                                                                       |
| Of the 51 patients who met criteria for dementia (44) or probable     |
| dementia (7) on formal assessment during the consultation, only 23    |
| (45%) had a diagnosis of dementia noted in the prior year in CPRS,    |
| and only 18 (35%) had documentation of prior cognitive assessments.   |
| Only 58% of the patients diagnosed with dementia or probable dementia |
| had been referred for evaluation of dementia or confusion thus 42% of |
| those referred for evaluation of other geriatric issues and           |
| syndromes, or simply for CGA, received a diagnosis of dementia or     |
| probable dementia. Of the 73 patients who were noted to have          |
| dependence in some or all IADLs, 40 (55%) were diagnosed with         |
| dementia or probable dementia during the comprehensive geriatric      |
| assessment. Of the 51 patients with dementia or probable dementia, 40 |
| (78%) were noted to be dependent in some or all IADLs.                |
|                                                                       |
| Of the 35 patients who were diagnosed with depression or possible     |
| depression during the consultation, only 17 (49%) had a diagnosis of  |
| depression documented in the progress notes for the prior year. Only  |
| 31 patients (25%) in the study group had documentation of depression  |
| screening (GDS or PHQ-2) during the prior year. Of those diagnosed    |
| with depression or possible depression during the consultation, only  |
| 11 patients (31%) had documentation of depression screening.          |
|                                                                       |
| As dementia and depression can have a profound impact on an           |
| individual\'s ability to manage his or her medical problems and to    |
| function independently in the community, early identification of      |
| these two geriatric syndromes is essential for timely treatment and   |
| care planning. Yet busy primary care providers, who in VISN 3 care    |
| for 98% of all older veterans, often lack the time and expertise to   |
| provide essential cognitive assessments. The \"embedded\" Geriatrics  |
| Consultation Clinic may provide a successful model to address this    |
| issue. Among the patients evaluated in the \"embedded\" Geriatrics    |
| Consultation Clinic for the period studied, many previously           |
| undiagnosed cases of both dementia and depression were identified.    |
| Few patients had had formal evaluation for dementia or depression by  |
| their PCPs in the 12 months prior to CGA.                             |
|                                                                       |
| While the \"embedded\" Geriatrics Consultation Clinic holds promise   |
| as a clinical model that can help to leverage the knowledge and       |
| skills of a limited geriatrics work force in caring for a burgeoning  |
| population of older veterans, additional studies will be needed       |
| before its general adoption in primary care can be recommended. The   |
| current study did not evaluate the effectiveness of this \"embedded\" |
| model to address the treatment and care issues raised by a new        |
| diagnosis of dementia or depression. Nor did it look at the rates of  |
| previously undiagnosed dementia and depression in the general primary |
| care population over 65 and thus the potential demand for expansion   |
| of this model. Finally, while the data on IADL dependencies are       |
| suggestive, the study did not identify a useful guide for to help     |
| primary care providers select the patients who would benefit most     |
| from a comprehensive geriatric assessment. We look forward to future  |
| studies to evaluate and refine the \"embedded\" Geriatrics            |
| Consultation Clinic model.                                            |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models developed at your GRECC that were exported  |
|     in the Report Year** (list up to five examples, up to two lines   |
|     each; 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"):            |
|                                                                       |
| Palliative Care Program: GRECC PC Clinical Demonstration was exported |
| to E. Orange and St. Albans VAMC (new PC Units) and Hudson Valley and |
| JJ Peters VAMC (enhanced programs).                                   |
+-----------------------------------------------------------------------+
| **8. COLLABORATION ACTIVITY**                                         |
+-----------------------------------------------------------------------+
| NOTE: Increasingly, VACO is seeking to characterize the GRECCs as not |
| only isolated programs of excellence, but also, as a group, a potent  |
| and effective system for investigating issues, demonstrating          |
| efficacy, and implementing change. In order to assist the GEC office  |
| in building a resource set of examples of GRECCs working in           |
| complementary manners to advance their own goals and those of the     |
| Department, you asked to provide up to five (5) examples of           |
| collaborative activities you have underway with one or more GRECCs    |
| other than your own. If possible, please try to include at least one  |
| Clinical Demonstration, one Education, and one Research example. Be   |
| sure to specify the GRECC or GRECCs with whom you are collaborating;  |
| and a description, limited to 6 or fewer lines, of the collaborative  |
| activity.                                                             |
+-----------------------------------------------------------------------+
| -   VISN 3 GRECC (Siu, Penrod) and Baltimore GRECC (Magaziner)        |
|     researchers are collaborating on studies of outcomes in hip       |
|     fracture patients that have resulted in 15 publications and 2 NIH |
|     R01 grants. Findings have had implications for the timing of      |
|     surgery, use of physical therapy and other services, and gender   |
|     and race differences in outcomes.                                 |
|                                                                       |
| -   VISN 3 GRECC (Zhu) and Durham GRECC researchers are collaborating |
|     to study longitudinal estimates of medical and informal           |
|     caregiving costs for veterans with dementia. This collaboration   |
|     has resulted in 7 publications with important implications for    |
|     resource use planning for veterans with dementia.                 |
|                                                                       |
| -   VISN 3 GRECC (Boockvar) and Salt Lake City GRECC (Weir, Nebeker)  |
|     researchers are collaborating to study ways to use informatics    |
|     tools to improve care for older adults. This has resulted in a    |
|     publication and HSRD Merit award on the topic of medication       |
|     reconciliation, and provision of input into national VA efforts   |
|     to improve medication reconciliation and re-engineer CPRS.        |
|                                                                       |
| -   The AD/EE (Howe) collaborated with other GRECC AD/EE activities   |
|     including:                                                        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Leading a national inventory of all GRECC Associated Health       |
|     training programs                                                 |
|                                                                       |
| -   Serving on the Planning Committee with the AD/C for the 10/08     |
|     GRECC Implementation conference                                   |
|                                                                       |
| -   Serving as the liaison for AD/EEs to the VACO Palliative Care     |
|     program                                                           |
|                                                                       |
| -   Serving as a faculty member at the April 2008 Cleveland GRECC     |
|     Geriatric Oncology and Primary Care Conference.                   |
+-----------------------------------------------------------------------+