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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER    |   |   |   |   |
|                                                          |   |   |   |   |
| ### *Annual Report: Fiscal Year [2007]{.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, 2006 through       |   |   |   |   |
| September 30, 2007]{.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:** Cleveland GRECC                      |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location** *(facility, VISN)*: Louis Stokes        |   |   |   |   |
|     Department of Veterans Affairs Medical Center, VISN  |   |   |   |   |
|     10                                                   |   |   |   |   |
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| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **Name:** Thomas Hornick, MD                         |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Position:** Acting Director/GRECC                  |   |   |   |   |
|                                                          |   |   |   |   |
| c.  **Phone, e-mail:** 216-791-3800 ext. 5613,           |   |   |   |   |
|     Thomas.hornick@med.va.gov                            |   |   |   |   |
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| **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 | * |   |
|                                                          | * | * | * |   |
|                                                          | * | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| **Applied Clinical:** Drug Resistance in treatment of    |   | * |   |   |
| infection in the elderly                                 |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| **Health Services:** Aging and cancer care               |   |   | * |   |
|                                                          |   |   | * |   |
|                                                          |   |   | X |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| **Rehabilitation:** Effects of functional electric       |   |   |   | * |
| stimulation in stroke patients                           |   |   |   | * |
|                                                          |   |   |   | X |
|                                                          |   |   |   | * |
|                                                          |   |   |   | * |
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|                                                          |   |   |   |   |
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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}. ***                                  |
|                                                                       |
| -   Interdisciplinary geriatric education opportunities: The GRECC    |
|     planned, coordinated and evaluated a weekly continuing education  |
|     series entitled **"Topics in Geriatric Medicine"** that offered   |
|     contact hours to physicians, nurses, social workers and           |
|     psychologist. Twenty-four sessions were held with content ranging |
|     from bio-medical to psychosocial aging. In addition, this forum   |
|     was used for GRECC core-staff to disseminate and update           |
|     participants on GRECC research activities. Enhanced evidence      |
|     based nursing practice through co-sponsorship of the weekly       |
|     **"Advanced Practice Nursing Continuing Education Series"**, b)   |
|     leadership role on the nursing research committee and annual      |
|     research workshop and c) mentoring/preceptorship and coaching of  |
|     nursing students and other nursing employees.                     |
|                                                                       |
| -   Interdisciplinary Trainee education in geriatrics: More than 200  |
|     trainees were trained in our geriatric programs: internal         |
|     medicine residents, family practice residents, medical students,  |
|     nurse practitioner students, podiatry residents and allied health |
|     students: psychology, nutrition, and pharmacy                     |
|                                                                       |
| -   Clinical demonstration projects: 1)improved follow up care of     |
|     patients with dementia through use of a CPRS dementia progress    |
|     note; 2)improved caregiver satisfaction through facilitation of a |
|     QI project to develop a caregiver's handbook                      |
|                                                                       |
| -   Participated in multisite trials: 1) Randomized clinical trial of |
|     vitamin E and memantine in dementia, 2) Patterns of decision      |
|     making regarding treatment for hip or knee surgery among AA and   |
|     Caucasian veterans, and 3) Cultural issues of communication of    |
|     knee pain in primary care visits.                                 |
|                                                                       |
| -   Assisted in the improvement in efficiency and utilization of the  |
|     cardiology clinics. Key accomplishment: decreased no show rate to |
|     less than 11% for performance period June -- August 2007 (no show |
|     rates went from 14.3% in Oct 06 to 9.2% in August 07).            |
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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}. ***                                  |
|                                                                       |
| -   **Interdisciplinary geriatric education opportunities (developed  |
|     by the GRECC):** The "Topics in Geriatric Medicine" series        |
|     continued to be accessible at VISN facilities and CBOC. This past |
|     fall, the Chillicothe VA and the Dayton VA have begun to          |
|     participate regularly. In addition, the Ft. Thomas NH associated  |
|     with the Cincinnati VAMC is waiting for equipment to be installed |
|     so they can begin to participate. The VISN Workforce Development  |
|     Council continued to value this program by providing annual       |
|     funding as it is the only VISN level interdisciplinary continuing |
|     education series available to all facilities. **Interdisciplinary |
|     geriatric education opportunities (co-sponsored by the GRECC):**  |
|     Examples include the State-Wide Geriatric Medicine Annual         |
|     Conference, the International Dementia Conference and the         |
|     Advanced Practice Nursing Series, which is now being              |
|     teleconferenced to Chillicothe and Columbus. The GRECC has        |
|     contacts at each facility that allow for dissemination of         |
|     training opportunities that become available. In addition, the    |
|     VISN Workforce Development Council is also a means to disseminate |
|     and alert facilities of such opportunities.                       |
|                                                                       |
| -   **Consultation:** The GRECC was consulted by a VISN group         |
|     interested in submitting a proposal for the Caregiver RFP.        |
|     Members of the GRECC worked in developing and writing the         |
|     proposal and in identifying VISN/University experts that might    |
|     have interest in collaborating. As a result, Wright State         |
|     University is overseeing the interviews, questionnaires and data  |
|     entry aspects of the evaluation and the University of Cincinnati  |
|     is overseeing the analysis and evaluation outcomes of the         |
|     demonstration project. This group was one of the funded proposals |
|     that included a multi-site intervention at the Dayton &           |
|     Cincinnati VAMCs. In addition, much of the intervention and       |
|     consultation has been informed by the Model I project that was    |
|     evaluated by this GRECC with the intervention occurring at the    |
|     Dayton VAMC.                                                      |
|                                                                       |
| -   **Ohio Hospice Veterans Partnership**: This included              |
|     collaboration with a consortium of Ohio community hospices and    |
|     VISN 10 VAMCs to improve access of home-hospice care to veterans. |
|     GRECC staff remains members of the steering committee of this     |
|     consortium. In participating, the GRECC was consulted by a local  |
|     hospice, Hospice of the Western Reserve, to help improve their    |
|     outreach to veterans. GRECC staff is now on their Veterans        |
|     Advisory Council. The role included helping this group better     |
|     understand how the VA works, provide unique insights about        |
|     veterans and identify how to improve outreach to veteran          |
|     populations who might need home hospice. In addition, this agency |
|     was struggling with PTSD at end-of-life as their veteran outreach |
|     expanded. The GRECC was consulted with training experts           |
|     identified and education provided to their front-life hospice     |
|     staff.                                                            |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2002]{.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. ***          |
|                                                                       |
| -   Exploration and identification of a defect in **aging heart       |
|     mitochondria**, which recent findings implicate as the cause for  |
|     increased mortality in myocardial infarctions in the aged. Hoppel |
|     2002.                                                             |
|                                                                       |
| -   The use of functional electrical stimulation **(FES)** for        |
|     post-stroke rehabilitation to improve transfer and mobility and   |
|     enhance the speed of motor function recovery. Ruff 2003           |
|                                                                       |
| -   Partnership with **Western Reserve Geriatric Education Center     |
|     (WRGEC)**. The WRGEC and the GEC network are often consulted for  |
|     curriculum, speakers, aging experts and programs that can be      |
|     brought/shared at the VA. We continue to collaborate on two       |
|     annual programs related to Ethics and HIV in the elderly. In      |
|     addition, the WRGEC has significant community involvement and     |
|     refer appropriately to the GRECC when issues of aging and         |
|     veterans arise. Rose 2007                                         |
|                                                                       |
| -   **New approaches to the prevention and management of bacterial    |
|     infections.** Molecular biology of antibiotic resistance: we have |
|     defined the prevalence of ceftazidime resistant gram negative     |
|     bacilli and vancomycin resistant enterococci (VRE) in our         |
|     population of veterans. These clinical studies have evolved into  |
|     two laboratory based projects. We explored the genotype           |
|     variability of enzymes that confer the ceftazidime resistant      |
|     phenotype in *Klebsiella pneumoniae.* In some circles it is       |
|     believed that these enzymes may have originally evolved in        |
|     elderly patients residing in long term care facilities.           |
|     Mechanisms of inhibition by clavulanic acid was explored in S130G |
|     isolate showing the complexity of the inactivation and suggesting |
|     new avenues for effective antimicrobial drug development. Bonomo  |
|     2005-                                                             |
|                                                                       |
| -   [Model I All-Inclusive Care Pilot:]{.underline} The Model 1 had   |
|     its greatest impact on caregivers receiving the care coordination |
|     intervention by improving their satisfaction and decreasing their |
|     overall burden as compared to those caregivers in the control     |
|     groups. Veteran differences between groups did not demonstrate    |
|     significant differences in satisfaction or utilization. In the    |
|     evaluation between all three pilots, Model I fared similarly as   |
|     Model III (VA contacting all LTC services) in that there was      |
|     noted value within the model but that implementation was highly   |
|     unlikely for system-wide dissemination. Rationale in support of   |
|     Model II was that most VA facilities already utilize contract     |
|     services in providing all-inclusive care and that this is by far  |
|     the more economical and feasible approach across VHA. Rose 2005.  |
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| **5. RESEARCH**                                                       |
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| **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}.*                                      |
|                                                                       |
| -   Aron: QUERI-Diabetes/REAP Results: We have examined several       |
|     issues related to the choice of a target A1c for patients with    |
|     diabetes with specific attention given to the potential adverse   |
|     effects of a dichotomous measure for "optimal" glycemic control,  |
|     i.e., A1c\<7%.                                                    |
|                                                                       |
|     i.  First, we developed a continuous weighted quality measure for |
|         glycemic control. We found that facility rankings varied by   |
|         threshold or continuous methodology. However, because         |
|         significant numbers of individuals are unable to reach        |
|         "optimal" target goals (thresholds) even in clinical trials   |
|         with extensive exclusion criteria, we proposed that a         |
|         continuous measure assessing improvement toward optimal A1C,  |
|         rather than a pass/fail optimal target, is both a fairer      |
|         assessment clinical practice and a more accurate reflection   |
|         of population health improvement. This is particularly        |
|         important to the elderly because of the higher risk of        |
|         hypoglycemia when trying to achieve a stringent (and possibly |
|         inappropriate) threshold level of control.                    |
|                                                                       |
|     ii. We have also utilized this continuous approach to combine     |
|         measures into a summary measure based on the common           |
|         denominator of quality adjusted life years saved. We proposed |
|         that a continuous QALYs-weighted summary measure could        |
|         function as a global measure for the quality of diabetes      |
|         care.                                                         |
|                                                                       |
|     iii. We then evaluated the potential impact of comorbidities on   |
|          an A1c\<7% measure. We found that one in 3 veterans has      |
|          comorbid conditions that would increase the risks or         |
|          decrease the benefits of intensive glycemic control. We      |
|          proposed that a public reporting measure for A1C of less     |
|          than 7% be subjected to exclusion criteria rather than be    |
|          applied to all persons with diabetes mellitus.               |
|                                                                       |
|     iv. Based upon this and other work, we developed a conceptual     |
|         model for quality measurement of A1c targets. (Pogach LM,     |
|         Rajan M, Aron, DC. Comparison of Weighted Performance         |
|         Measurement and Dichotomous Thresholds for Glycemic Control   |
|         in the Veterans Health Administration. Diabetes Care 2006;    |
|         29:241-246, Aron D, Rajan M, Pogach LM. Summary measures of   |
|         quality of diabetes care: comparison of continuous weighted   |
|         performance measurement and dichotomous thresholds.           |
|         International Journal for Quality in Health Care 2007: 19:    |
|         26-36, Pogach L, Engelgau M, Aron D. Measuring progress       |
|         toward achieving hemoglobin A1c goals in diabetes care:       |
|         pass/fail or partial credit. *JAMA, 2007;297:* 520-523,       |
|         Pogach LM, Tiwari A, Maney M, Rajan M, Miller, DR, Aron D.    |
|         Should mitigating comorbidities be considered in assessing    |
|         healthcare plan performance in achieving optimal glycemic     |
|         control? *Am.J Manag.Care, 2007;13:*133-140, Aron DC, Pogach  |
|         LM. One Size Does Not Fit All: A Continuous Measure for       |
|         Glycemic Control in Diabetes: The Need for a New Approach to  |
|         Assessing Glycemic Control. Joint Commission J Qual           |
|         Improvement. 2007; 33:636-643.)                               |
|                                                                       |
| -   Bonomo: Piperacillin/tazobactam and cefepime-containing           |
|     antibiotic regimens may be associated with frequent acquisition   |
|     of VRE in \"real-world\" intensive care unit settings. Although   |
|     piperacillin/tazobactam inhibits the establishment of VRE         |
|     colonization in mice when exposure occurs during treatment, our   |
|     data suggest that this agent may not prevent acquisition of VRE   |
|     in patients. (Paterson et al. Acquisition of vancomycin-resistant |
|     Enterococcus rectal colonization among intensive care unit        |
|     patients treated with piperacillin/tazobactam versus              |
|     cefepime-containing antibiotic regimens. Antimicrob Agents        |
|     Chemother. 2007; \[Epub ahead of print\] )                        |
|                                                                       |
| -   Bonomo**:** Design of new antibiotic: Using what is known about   |
|     the structure of betalactamase in bacteria, new betalactamase     |
|     antibiotics are being designed. A novel penam sulfone derivative  |
|     that forms a more stable trans-enamine intermediate was           |
|     synthesized and tested. This approach holds great potential for   |
|     in vitro antibiotic development to combat multidrug resistant     |
|     bacteria. (Padayatti et al J Am Chem Soc. 2006:                   |
|     128(40):13235-42.)                                                |
|                                                                       |
| -   Ruff: Patients with paraplegia from spinal metastasis benefit     |
|     from rehabilitative efforts. Subjects who received rehabilitation |
|     had less pain, consumed less pain medication, were less           |
|     depressed, and had higher satisfaction with life. The benefits to |
|     the rehabilitated subjects persisted until their deaths. We       |
|     conclude that spinal cord injury rehabilitation for               |
|     non-ambulatory subjects with SEM produces persistent benefits for |
|     pain, depression, and satisfaction with life. Ruff et al:         |
|     Persistent benefits of rehabilitation on pain and life quality    |
|     for non-ambulatory patients with spinal epidural metastasis. J    |
|     Rehabil Res Dev. 2007; 44(2):271-8.                               |
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| **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}.*                                                  |
|                                                                       |
| -   Evaluation of methods for identifying chronic kidney disease in   |
|     patients with diabetes.(Kern EFO, Miller DR, Tseng CL, Maney M,   |
|     Aron D, Pogach L Failure of ICD-9-CM codes to identify patients   |
|     with co-morbid chronic kidney disease in diabetes. Health         |
|     Services Research 2006; 41:564-80.)                               |
|                                                                       |
| -   Evaluation of shared medical appointments for patients with       |
|     diabetes and high cardiovascular risk revealed that glycemic      |
|     control improved by an average drop in hemoglobin A1c 1%. This    |
|     was found with an initial study involving 44 patients, but has    |
|     been confirmed based upon the results in 452 patients. (Kirsh SR, |
|     Watts SA, Pascuzzi K, O'Day ME, Davidson DJ, Strauss GJ, Kern EO, |
|     Aron DC. Shared Medical Appointments Based on the Chronic Care    |
|     Model: A Quality Improvement Project to Address the Challenges of |
|     Diabetic Patients with High Cardiovascular Risk. Quality and      |
|     Safety in Health Care. 2007; 16:349-353.)                         |
|                                                                       |
| -   Aron: We found that hospitalized patients with S. aureus nares    |
|     and/or stool carriage frequently had S. aureus on their skin and  |
|     on nearby environmental surfaces. S. aureus intestinal            |
|     colonization was associated with increased frequency of positive  |
|     skin cultures, which could potentially facilitate staphylococcal  |
|     infections and nosocomial transmission. (Bhalla, Aron and         |
|     Donskey. Staphylococcus aureus intestinal colonization is         |
|     associated with increased frequency of S. aureus on skin of       |
|     hospitalized patients. BMC Infect Dis. 2007 Sep 11(7:105).        |
+-----------------------------------------------------------------------+
| **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 International Conference entitled "***Reflections on 100      |
|     Years of Alzheimer's: The Global Impact on Quality of Lives***"   |
|     was held in Cleveland in 11/06. GRECC staff were members of the   |
|     planning of this conference. The GRECC requested and was granted  |
|     five VA staff attendance for free. In addition, the GRECC         |
|     identified a VA leader to speak on care coordination/telemedicine |
|     in dementia care that highlighted some of the trend-sending       |
|     findings identified by VISN 8.                                    |
|                                                                       |
| -   The GRECC identified several weaknesses in attempting to improve  |
|     access to GRECC programs across the VISN. Mainly, there were      |
|     sites interested in participating in education without easy       |
|     access to videoconferencing equipment. These facilities have      |
|     equipment but not in their LTC areas where outreach should be     |
|     priority. The GRECC worked with the VISN satellite coordinator    |
|     who was instrumental in securing funding for equipment            |
|     installation at several sites. These sites will soon be able to   |
|     more reasonably access GRECC education programs. In addition,     |
|     non-VA facilities (e.g. University Hospitals of Cleveland) have   |
|     started communication about how they might have satellite access  |
|     to this series along with the Advanced Practice Nursing Series.   |
|     Technology for such dissemination is possible, thus               |
|     collaborations continue.                                          |
|                                                                       |
| -   The Workforce Development Council (VISN 10) provided \$10,000.00  |
|     toward the Topics in Geriatric Medicine Series. In addition,      |
|     pharmaceutical grants are submitted that allow for the ability to |
|     bring national and local aging experts as faculty in this series. |
|                                                                       |
| -   Medical school curriculum: Development and implementation of the  |
|     Advanced Core/Aging curriculum for 4^th^ year medical students.   |
|     Dr Hornick and the clinical team were instrumental in the design  |
|     and implementation of a mandatory 4 week clinical rotation in     |
|     geriatrics for 4^th^ year CWRU medical students. Feedback from    |
|     the first 20 students has been uniformly positive.                |
+-----------------------------------------------------------------------+
| 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 Podogeriatric continuing education DVD & web-based product    |
|     entitled "***The Fragile Foot***" is ready for pilot testing.     |
|     Once piloting is completed, this DVD will be disseminated to all  |
|     GRECCs and GECs. Dr. Robbins, Chief Podiatry Service, was part of |
|     the development of this product and did include aspects of the    |
|     DVD in a GSA presentation regarding geriatric education products. |
|                                                                       |
| -   Exportable products developed by the WRGEC, (e.g. Action for      |
|     Health & Wellness) curriculum for community-based frail elderly   |
|     continue to be shared and made available to VISN facilities. In   |
|     fact, this curriculum is being distributed at each VISN needs     |
|     assessment focus groups with GRECC consultation for               |
|     implementation offered. The Nursing Assistant focused             |
|     Complementary Therapies program is also being shared with renewed |
|     interest across the VISN. We continue to work toward              |
|     dissemination of the Michigan GEC curriculum on Functional        |
|     Assessment of the Older Adult that is focused on community based  |
|     primary care providers.                                           |
|                                                                       |
| -   The Topics in Geriatric Medicine Series is easily exportable to   |
|     any VA or CBOC who wishes to participate. Beyond VISN 10, this    |
|     series was requested by a NH at the Salisbury VAMC, which         |
|     continues to participate.                                         |
+-----------------------------------------------------------------------+
| c\. **Educational programs offered by your GRECC during the report    |
| year that were evaluated for impact, as described in                  |
| <http://vaww1.va.gov/grecc/docs/2007Measuresinstructions102506.doc>   |
| 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 evaluation, including in your description of the |
| latter the evaluation methodology, findings, and conclusions. Limit   |
| your description of each intervention and its evaluation to one-half  |
| page.*                                                                |
|                                                                       |
| -   The Dissemination of the "***Functional Assessment of the Older   |
|     Adult***" was intended to be a **VISN level** implementation &    |
|     evaluation for performance measure 7. This curriculum included    |
|     introduction and review of the new GEC referral form. To date,    |
|     this curriculum was implemented at only one of the host-VAMCs     |
|     CBOC with seven total participants. Pre and post measures were    |
|     assessed using questionnaires regarding assessment skills and     |
|     attitudes toward older adults. Beyond this however, was to        |
|     determine pre and post GEC referral patterns from the sites that  |
|     were trained. Unfortunately, referral data by CBOC was not        |
|     available per QIRMS staff until April-07, so no pre-training      |
|     referral patterns could be determined. The potential value as a   |
|     VISN primary care training program and evaluation of referral     |
|     patterns over time remains an interest of the GRECC education     |
|     team. We are working with Dr. Langhorne, who is one of the        |
|     curriculum developers and trainers to identify new VISN CBOC      |
|     sites outside of the host facility where this can be implemented  |
|     and used to measure referral patterns over time. One significant  |
|     obstacle in implementing this at other CBOC was identifying       |
|     resources at each facility that would be the lead for IRB at      |
|     their site, which will continue to be an obstacle.                |
|                                                                       |
| -   For the **host-facility**, Dr. Kresevic conducted training on     |
|     fall risk assessment and prevention at one of the Advanced        |
|     Practice Nursing continuing education sessions. At this session,  |
|     27 staff attended. A case study and pre-test was developed by Dr. |
|     Kresevic and used as a pre-training assessment of participant's   |
|     knowledge of falls risk and assessment. The 10-item questionnaire |
|     was fairly basic with an average score of 90%. Three-months after |
|     the training all 27 participants were e-mailed a 15-item          |
|     GeroNurse Online falls questionnaire that was used as a           |
|     post-test, which was more comprehensive and complex compared to   |
|     the pre-test. Twenty-four post-test were returned, with an        |
|     average of 96%. In addition and more importantly Dr. Kresevic     |
|     identified herself as a falls expert who could be consulted       |
|     anytime on falls risk and prevention. She continues to receive    |
|     consults by staff seeking her expertise.                          |
+-----------------------------------------------------------------------+
| **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.                                   |
|                                                                       |
| -   **Dementia Guidelines/Checklist/Clinical alert**: Our clinic      |
|     personnel saw a need for a formal set of guidelines to optimally  |
|     manage patients with dementia. Key issues addressed: change in    |
|     cognitive status, emergence of behavioral issues, documentation   |
|     of driving, weapons and competency issues, appropriate and timely |
|     consideration of therapy, ADLs/IADLs, referral to Alzheimer's     |
|     association, respite needs.                                       |
|                                                                       |
| -   **Circadian Rhythms and Light Exposure in Care-giving Elders of   |
|     Persons with Dementia:** Care-giving of patients with cognitive   |
|     impairment may lead to circadian rhythm disruption and increase   |
|     physical burden of care giving. This is an exploratory project to |
|     measure light exposure (especially circadian active light) and    |
|     activity of caregivers of dementia patients in the community.     |
|                                                                       |
| -   **How many Researchers does it take to change a light bulb**?     |
|     Lighting in nursing homes is generally insufficient to maintain   |
|     circadian rhythms of residents. This is collaboration between the |
|     GRECC, the nursing home care unit, GE and RPI to develop          |
|     prototype 14K light bulbs to increase circadian light biologic    |
|     response. The goal is to affect sundowning and adverse behaviors  |
|     among residents, and will be implemented on the dementia ward in  |
|     the nursing home.                                                 |
+-----------------------------------------------------------------------+
| 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.                    |
|                                                                       |
| -   **Dementia Guidelines/Checklist/Clinical alert** for follow up of |
|     patients with dementia. This clinical alert is still being        |
|     piloted in the geriatric clinics. Initial chart review last year  |
|     showed incomplete documentation of key elements important in      |
|     follow up care of dementia. Follow-up evaluation planned in       |
|     Spring of 2008 when enough patients will have had approximate 20  |
|     months of follow up since initiation of the note. Have initiated  |
|     a joint project with Larry Lawhorne of Wright State/Dayton VA to  |
|     disseminate and test the CPRS note as part of a broader dementia  |
|     intervention in CBOCs VISN wide.                                  |
|                                                                       |
| -   **Circadian Rhythms and Light Exposure in Caregiving Elders of    |
|     Persons with Dementia**: R&D and IRB approval in 9/07. First      |
|     caregiver/patient enrolled in 10/07. Evaluation ongoing.          |
|                                                                       |
| -   **How many Researchers does it take to change a light bulb**? The |
|     protocol has been developed and submitted for external funding.   |
|     Measurement of light intensity on the ward has demonstrated a     |
|     generally low intensity of light, especially in the blue          |
|     spectrum, suggesting that many of the residents, especially those |
|     with visual impairment, are living in "biologic" darkness; e.g.,  |
|     not enough brightness to synchronize circadian rhythm. Special    |
|     lamps have been created and donated by GE. IRB and R&D approval   |
|     is pending. The installation of lamps and initiation of the       |
|     project is expected in early Spring.                              |
+-----------------------------------------------------------------------+
| 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"):*           |
|                                                                       |
| -   **Dementia Guidelines/Checklist/Clinical alert:** See above;      |
|     Plans to disseminate as part of joint project with Larry Lawhorne |
|     of Wright State/Dayton VA are being pursued.                      |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation** = GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach** = GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
+-----------------------------------------------------------------------+
| b.  **Current Year Activity Outcomes** *(list up to five examples, up |
|     to two lines each; summarize specific outcomes realized from      |
|     current year **consultation**, e.g., "Host VAMC instituted a      |
|     Falls Clinic after consultation from GRECC staff;" or             |
|     **outreach**, e.g., [X]{.underline} VAMC instituted a Falls       |
|     Clinic after GRECC outreach via series of videoconferences):*     |
|                                                                       |
| -   Consultation: A hospital wide **Falls committee** was created.    |
|     Dr. Kresevic's ongoing work and multiple projects contributed to  |
|     the creation of the committee, of which she is a member.          |
|                                                                       |
| -   Consultation: GRECC helped to design the study and implement data |
|     collection for a clinical demonstration project on the rehab      |
|     floor (Ann Drysdale RN, CNS). Goal was to improve clinical care   |
|     and education in post stroke veterans.                            |
|                                                                       |
| -   Consultation: GRECC helped to design the study and implement data |
|     collection for a clinical demonstration project to improve        |
|     caregiving knowledge for caregivers of elderly patients. A        |
|     handbook was created, printed and distributed. Pre and post       |
|     showed improvement in Zait caregiver burden scores.               |
|                                                                       |
| -   **Outreach: Dementia care program**: collaboration with Dr.       |
|     Lawhorne (Wright state/Dayton VAMC) to conduct and evaluate       |
|     educational initiative on dementia combined with the CPRS note    |
|     for dementia care.                                                |
|                                                                       |
| -   **Outreach:** GRECC consulted on the design and evaluation of the |
|     VISN Caregiver pilot project; much of the intervention and        |
|     consultation was informed by the Model I project that was         |
|     evaluated by this GRECC with the intervention occurring at the    |
|     Dayton VAMC. This pilot was funded; the GRECC is not              |
|     participating in the evaluation, but recommended qualified        |
|     groups.                                                           |
|                                                                       |
| -   **Outreach:** Pelvic floor muscle exercises in post prostate      |
|     cancer incontinence. This is collaboration between GRECC, GU, VA  |
|     psychology and Amy Zhang from FPB. This is a comparative study of |
|     support group vs. phone calls conducted in the VA clinics. This   |
|     is a pilot conducted on VA patients to gather data for an R01.    |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** *(list up to five         |
|     examples, up to two lines each; summarize specific outcomes       |
|     realized from previous years' [**consultation** to host           |
|     VAMC]{.underline} or [**outreach** to non-host                    |
|     facilities]{.underline}, where results were first realized in the |
|     current year.)*                                                   |
|                                                                       |
| -                                                                     |
| -                                                                     |
| -                                                                     |
| -                                                                     |
| -                                                                     |
+-----------------------------------------------------------------------+