Independence Center.

At the GRECCs we visited, collaboration with non-VA agencies on local or regional issues resulted in
cooperative initiatives for assisting the nearby elderly population. However, these initiatives were generally
not divulged to VA facilities outside the region. For example, in Miami, VA and other agencies had conducted
a survey of elderly people in the Miami area, which disclosed a need for better ways to inform the elderly
about available programs and issues which concern them. The Miami geriatric treatment community was
collaborating on an initiative to establish local television programming which could serve as a means of
broadcasting information which benefits elderly people. This initiative could be beneficial in other areas but
was not being pursued at Puget Sound and was not reported in annual progress reports to VACO G&EC
officials.

In our view, more universal communication would be beneficial, particularly to other GRECCs or to other VA
health care facilities. Individual GRECCs should consider using the Internet/World Wide Web to
communicate to a larger audience and exchange innovative and beneficial ideas. A test of the interest
demonstrated that several of VA's GRECCs currently have home pages for the dissemination of information.
Use of the Internet/World Wide Web would not replace the need to continue cooperating in regional initiatives
or publishing information in medical journals. At Puget Sound, facility management agreed to pursue
distributing the quarterly GRECC Newsletter, currently distributed by the mail system, via the Internet/World
Wide Web to reach a larger audience and reduce publishing costs.

DUM FR

THE

DER SECRETARY FOR HEALTH

Department of
Memorandum

[Veterans Affairs

Date: January 17, 1997

From: Under Secretary for Health (10/105E)

Subj: OIG Draft Report: Audit of DVA Geriatric Research, Education, and

Clinical Centers (GRECO) Program

To: Assistant Inspector General for Auditing (52)

1. This report has been reviewed by appropriate VHA program officials and we are pleased with your
lpositive assessment of GRECC program initiatives. We also concur in the report recommendation. The
laccompanying action plan details current and planned activities that VHA has undertaken to accomplish
the goals of the recommendation.

2. The Geriatrics and Extended Care Strategic Healthcare Group, in close coordination with other involved
lprogram offices and the GRECCs, has already develope: mprehensive long-term plan of action to
\disseminate GRECC clinical treatment modalities and training materials throughout the VA system. A work
lgroup has also been designated to explore the most effective ways to provide for the systemwide transmittal
lof needed information. By February 1997, a catalog of GRECC educational tools is expected to be
|published, followed by distribution to targeted Network and field facility staff. Headquarters staff are also in’
Ithe process of coordinating development ofa strategic plan to expand implementation of GRECC clinical
models. Criteria for selecting specific models/interventions will be developed by April 1997 and
implementation guidelines for Network and facility-level managers are expected to be finalized within five
months of that date.

3. We agree with your conclusion that the Internet/World Wide Web has significant potential in facilitating
transmittal of information and preliminary work is underway to identify technology needs for establishment



« Reductions in rates of discharge from hospitals to nursing homes.
« Reductions in nursing home stays and hospital readmissions.

« Reductions in the amount of medications prescribed per patient.

- Lowered mortality rate.

«Increased likelihood of living at home.

Exportation of GRECC-developed clinical programs, other than GEM, has tended to focus on diagnostic and
assessment tools, rather than complete clinical care programs. Further, GRECCs generally exported to nearby
affiliated medical centers or to VA medical centers physically located near the GRECC, but did not export to
VA medical centers systemwide.

Conclusion

GRECC's integration of research, education, and clinical demonstration activities at major academically
affiliated VA facilities is an effective method for addressing the health concerns of the elderly. VHA should
enable GRECC efforts to benefit more veterans by exploring methods of instituting GRECC-developed
models and educational programs at facilities which lack geriatricians and specialized staff, and should also
enhance access to information about GRECC initiatives.

For More Information

Appendix II, pages 7-11, describes the history, mission, and purpose of the GRECC program, including its
organizational structure and GRECC locations.

Appendix ITI, pages 12-17, provides detailed information on our audit, including results of reviews at two
GRECCs.

Recommendation

We recommend that the Under Secretary for Health develop a methodology for enabling broad
implementation of successful GRECC-developed models and programs, and enhance access to information
about GRECC initiatives.

Under Secretary for Health Comments

The Under Secretary for Health concurred with our conclusions and recommendation and provided an
acceptable implementation plan. (The full text of the Under Secretary's response is included on pages 18-21 as
Appendix IV)

In his response, the Under Secretary delineated the current and planned activities undertaken to accomplish the
goals of the recommendation. Specifically, VHA's Geriatrics and Extended Care Strategic Healthcare Group,
in close coordination with other involved program offices and the GRECCs, has already developed a
comprehensive long-term plan of action to disseminate GRECC clinical treatment modalities and training
materials throughout the VA system. A work group has also been designated to explore the most effective
ways to provide for the systemwide transmittal of needed information. By February 1997, a catalog of GRECC
educational tools is expected to be published, followed by distribution to targeted Network and field facility
staff. Headquarters staff are also in the process of coordinating development of a strategic plan to expand
implementation of GRECC clinical models. In additions, criteria for selecting specific models/interventions
will be developed by April 1997, and implementation guidelines for Network and facility-level managers are
expected to be finalized within 5 months of that date.


Ranking Member, Subcommittee on VA, HUD, and Independent Agencies, Senate Committee on
Appropriations

Chairman, Subcommittee on VA, HUD, and Independent Agencies, House Committee on Appropriations

Ranking Member, Subcommittee on VA, HUD, and Independent Agencies, House Committee on
Appropriations

Chairman, House Committee on Veterans' Affairs

Ranking Member, House Committee on Veterans! Affairs

Chairman, House Committee on Veterans’ Affairs, Subcommittee on Hospitals and Health Care
Ranking Member, House Committee on Veterans' Affairs

Subcommittee on Hospitals and Health Care


«Falls Clinic.

«Family and Caregiver Support Programs.
«Geriatric Consultation Teams.

«Geriatric Diabetes Clinic.

«GEROFIT Program.

Currently, the GRECCs have a combined total of 37 geriatric inpatient units and 87 geriatric outpatient clinics.
These activities promote the education of health care professionals and provide resources for clinical and
health service research and development studies.

D. Other VA Departments Which Affect GRECCs

Two other VACO departments, Research & Development (R&D) and the Office of Academic Affairs (OAA),
have functions which directly affect the GRECCs. R&D officials have full funding approval over the
intramural research efforts of the VA researchers supported by the GRECCs. In 1995, R&D officials
established a special review board which meets twice yearly to specifically review the merit of research
proposals related to aging issues. OAA officials are responsible for the policies, procedures and funding for
residents, allied health trainees, and geriatric fellows at the GRECCs and funding for GRECC-sponsored
continuing education programs.

R&D and OAA officials had no direct administrative control over the individual GRECCs and no
responsibility for monitoring the GRECCs. R&D officials had quarterly conference calls with Associate
Chiefs of Staff for Research and Development; G&EC was represented on these calls. The individual
GRECCs and their host medical centers were responsible for monitoring the residents, trainees, and fellows.

E. Other Federal Agencies Concerned with Aging

Three other federal agencies, which are all part of the Department of Health and Human Services, have
missions which concern health issues for the elderly:

National Institute on Aging. NIA is one of the 19 National Institutes of Health. NIA is a primary source of
funding for research relating to aging. VA officials are ex-officio members of NIA's Advisory Council on
Aging.

Health Resources and Services Administration. HRSA has been instrumental in establishing Geriatric
Education Centers (GECs) located throughout the country and also has funded teaching fellowships. GECs
provide clinical education and training experiences to a wide range of health professionals and other personnel
including physicians, nurses, dentists, social workers, pharmacists, occupational and physical therapists,
optometrists, and dietitians. As of January 1996, HRSA continued to fund 26 of the 41 GECs. HRSA officials
informed us that funding for the agency may be ending in 1998.

Administration on Aging. AoA has five National Resource Centers, which concentrate on long term care. AoA
officials collaborate with VA G&EC officials periodically in conferences and symposiums.

G&EC officials’ collaboration with NIA, HRSA, and AoA at the national level was effective. G&EC
collaborated with the other federal agencies through working groups, conferences, interagency committee
meetings, symposiums, and geriatric seminars. G&EC officials also collaborated with the other agencies as
part of the White House Conference on Aging.

DETAILS OF AUDIT


Miami, Florida-using a detailed audit guide to measure compliance with policies and procedures established
for the GRECC program and to ensure consistent audit coverage. VACO program officials assisted us in the
selection of the two sites.

«Surveyed the other 14 GRECCs by means of questionnaires.
«Conducted site visits at Geriatric Education Centers, funded by HRSA at Seattle and Miami.

« Reviewed program information on non-VA research and treatment programs which specialized in aging: two
private sector treatment models funded by Medicare, Medicaid, and private sources; and the University of
Michigan's Claude D. Pepper Older Americans Independence Center, funded by the NIA.

We did not extensively rely on computer-processed data. The scope of our review included random testing of
equipment accountability for Fiscal Year (FY) 1995. The audit was conducted in accordance with generally
accepted government auditing standards and included such tests of the procedures and records as were deemed
appropriate under the circumstances.

BACKGROUN

A. History and Mission of GRECC Program

According to G&EC officials, VA has the potential responsibility for a beneficiary population of nearly 27
million veterans. The population of veterans age 65 and older is nearly 8.8 million (approximately 34 percent)
and is projected to be 9.3 million by the year 2000. Older veterans use hospital resources three to four times
more frequently than younger veterans. Older veterans also have more, complex ailments and suffer from
more chronic, progressive, degenerative, and permanent dysfunction. Therefore, increases in the population of
older veterans will require significantly increased health care support.

In the mid-1970's, VHA focused attention on the aging veteran population. GRECC was one program that
evolved from that effort. The mission of the GRECC program is to improve the capability of the VA health
care delivery system to provide services that are effective and appropriate in meeting the medical,
psychological, and social needs of older veterans. The goals of the GRECCs and their host VA medical centers
are to achieve this improvement in capability by (1) developing new knowledge regarding aging and geriatrics
through research, (2) disseminating that knowledge through education and training to health care professionals
and students, and (3) developing and evaluating alternative models of geriatric care.

Public Law 96-330, enacted in 1980, authorized VHA to establish 15 GRECCs. The law also established the
Geriatrics and Gerontology Advisory Committee (GGAC), which performs external reviews of each GRECC
3 years after its date of establishment and every 3-4 years thereafter. The GGAC is composed of
nongovernment persons who have expertise in geriatric and gerontological research, education, and clinical
activities. Public Law 99-166, enacted in 1985, authorized an increase in the number of GRECCs from 15 to
25. VA's financial data showed that for FY 1995 VHA spent a total of $23.6 million to support the GRECCs.

Nationwide, VHA operates 16 GRECCs. The following table identifies the locations for these programs.

Ann Arbor, MI Minneapolis, MN
Baltimore, MD Palo Alto, CA
Boston, MA Puget Sound, WA
Durham, NC Salt Lake, UT
Gainesville, FL San Antonio, TX
Little Rock, AR Sepulveda, CA
Madison, WI St. Louis, MO

Miami, FL West Los Angeles, CA


The Under Secretary agreed with our conclusion that the Internet/World Wide Web has significant potential in
facilitating transmittal of information. Preliminary work is underway to identify technology needs for
establishment of a GRECC Web site. In January 1997, a proposal for the project will be submitted for funding
consideration. In this case, however, as with all other plans for program expansion requiring supplemental
resource support, budgetary constraints may hinder full accomplishment of recognized goals.

In addition to these planned and ongoing actions, concerted efforts are being made to share GRECC-related
clinical initiatives through development and implementation of performance standards for geriatrics and
extended care programs that are based on GRECC outcomes research projects. These performance measures
have recently been finalized and in the months to come, extensive implementation training at the Network and
field facility levels will be scheduled.

Office of Inspector General Comments

The Under Secretary for Health's comments satisfactorily address the recommendation and provide an
acceptable implementation plan. We consider the recommendation resolved and we will follow up on the
implementation until completed.

OBJECTIVE, SCOPE, AND METHODOLOGY

Objective

The objective of the audit was to evaluate the effectiveness of VA's GRECC program in meeting the needs of
VA's elderly veteran patients. The audit focused on the following key questions:

«Has an administrative and organizational structure been established that supports the accomplishment of
GRECC program goals?

« Have GRECCs developed and evaluated clinical education and training programs for caregivers and
developed improved models of clinical services for older veterans?

« Have advancements gained from GRECCs been exported throughout the VA health care system to improve
services for older veterans?

«Is there duplication of effort among federal agencies in addressing the health concerns of the elderly?
Scope and Methodology

To answer the above key questions as they relate to VA's GRECC program, we:

«Reviewed the legislative and regulatory basis for the GRECC program.

« Assessed how VHA oversees the GRECCs and collaborates with non-VA programs on aging and long term
care.

- Assessed the role of VACO Office of Research and Development officials in relation to GRECC research
projects and funding.

« Assessed the role of VACO Office of Academic Affairs officials in relation to GRECC education and
training programs and funding.

«Interviewed officials of the National Institute on Aging (NIA), Administration on Aging (AoA), and Health
Resource and Services Administration (HRSA).

«Conducted site visits at two GRECCs-a two-division program at Puget Sound, Washington, and a program at


Research. GRECC research is a balanced program of basic biomedical, clinical and health services research
related to health problems of aging. Each GRECC concentrates on foci that are related to the program's
particular resources and expertise. The GRECCs perform research in 23 foci, which include:

« Cancer.

« Infectious disease.

« Cardiovascular disease.

« Cognitive and motor dysfunction and neurobiology.
« Endocrinology.

- Exercise physiology.

« Geropharmacology.

«Immunology.

« Metabolism and nutrition.

« Osteoporosis and arthritis.

At each host VA medical center, VA funding was managed by Research Service, while non-VA funding was
managed by the affiliated academic institution(s).

Education. GRECC staff are responsible for disseminating new knowledge and research findings through
publications; national, regional, and local professional activities; and training and education programs.

GRECCs also have a primary responsibility to integrate new and existing geriatric knowledge and skills into
clinical practice. This function is accomplished through GRECC education and training programs provided to
fellows, residents, students, and VA staff. The GRECCs serve as local, regional, and national resources for
geriatric education and training. The GRECC education programs include:

« Training and education of medical students and associated health trainees.
« Continuing education programs for both VA staff and community staff involved in geriatric health care.

For the continuing education program, the GRECCs collaborate with other agencies (both VA and non-VA) to
enhance educational opportunities for staff. Some of the continuing education programs are co-sponsored by
Geriatric Education Centers, VA Regional Medical Education Centers, Interdisciplinary Team Training
Programs, and community agencies. This collaboration provides for a more diverse and extensive number of
educational programs to be available to VA staff than would otherwise have been available.

Clinical care. The clinical program involves the design, implementation, and evaluation of clinical care
models for elderly veterans. Each GRECC must have one or more clinical demonstration programs that engage
in the assessment, treatment, and specialized study of elderly patients. Examples of specialized clinical
programs that have been developed by GRECCs and are undergoing evaluation include:

«Geriatric Evaluation and Management Unit/Clinic.
«Hospice Unit for Late Stage Dementia Patients.

« Depression Clinic.


WO Veterans attairs
Office of Inspector General

AUDIT OF
DEPARTMENT OF VETERANS AFFAIRS
GERIATRIC RESEARCH, EDUCATION,
AND CLINICAL CENTERS
(GRECC) PROGRAM

The GRECC program is meeting its mission to improve care to elderly veterans;
it could be further enhanced by instituting GRECC-developed treatment models
and educational programs at more VA facilities.

Report No.: 7R5-A07-032
Date: January 30, 1997

Office of Inspector General

Washington DC 20420

DEPARTMENT OF VETERANS AFFAIRS
Office of Inspector General
Washington DC 20420

Memorandum to the Under Secretary for Health (10)
Audit of VA's Geriatric Research, Education, and Clinical Centers Program

1. The purpose of the audit was to evaluate the effectiveness of the Department of Veterans Affairs (VA)


comprehensive education and experience in geriatrics through the GRECC education program. The GRECCs
held teaching conferences and sponsored national and/or regional geriatrics conferences.

At the two GRECCs we visited, gerontology activities were benefiting from the host medical center's
residency, fellowship, and allied health programs. The Puget Sound GRECC, in affiliation with the University
of Washington School of Medicine, provided a Geriatric Medicine Residency program and a Geriatric
Psychiatry Residency program at the Seattle Division. At the Tacoma Division, a Geriatric Medicine
Residency program existed between Tacoma's Extended Care Service and Madigan Army Medical Center.
The Miami GRECC, in affiliation with the University of Miami School of Medicine, provided a Geriatric
Medicine Residency program. Affiliations with medical schools provided the capability for better recruiting
and funding for research staff. Fellows, residents, and medical students were obtaining geriatric clinical
experience by rotating through the GEM units, consultation teams, and other geriatric units and clinics.
GRECC continuing education programs were active and outgoing. Of particular note, the Puget Sound
GRECC sponsored three continuing education programs: Gerontology Forums Northwest, Puget Sound
Forums on Aging, and South Sound Forums on Mental Health.

The Miami GRECC was working closely with the Center on Adult Development and Aging and the Miami
Area GEC to develop a weekly television show which would provide education and information on programs
available to the elderly in the community. Sponsorships were to be obtained to help defray the costs of the
program. Although still in the developmental stage, the show should be an effective means of assisting people
with information about programs and training. The program may be aired in January 1997.

C. Overall Assessment of Clinical Programs

Clinical programs met the goal and objectives established for the GRECC clinical activities. GRECC staff
were enthusiastic and dedicated, and emphasized treatment of the whole person, including any physical,
psychological, and social difficulties the patient might experience. Individual GRECCs have been developing
clinical demonstration models which could improve care for elderly veterans systemwide. In Fiscal Year 1995,
the 16 GRECCs reported an average of about 10 such demonstration projects, developed over the past several
years, per GRECC.

We identified some clinical demonstration projects that have been successfully exported to other VA health
care facilities. The best example is GEM, a specialized program in which an interdisciplinary medical and
associated health team performs comprehensive health care assessments, therapeutic interventions, and
rehabilitative care for a targeted group of patients ages 65 or older. The services are performed in an inpatient
or outpatient setting. The targeted group are veterans who have multiple medical, functional, and/or
psychosocial problems and are likely to benefit from an interdisciplinary approach.

Various studies of the GEM program have shown improved survival, decreased rehospitalization rates,
improved functional status, and decreased nursing home placement following admission to GEM units. In
view of these studies, VA established active GEM programs at 131 VA medical facilities.

Further expansion of the GEM treatment model may be possible through a virtual GEM program, such as the
one being developed at the Puget Sound Health Care System. The virtual GEM program would link a GEM
treatment team with distant caregivers via a computer network, enabling them to care for GEM-targeted
veterans. Interactive pictures, sound, and text would disseminate information to these caregivers, as well as to
patients, educators, and students. This program promises a groundbreaking method for providing expert
geriatric and medical appraisals of complexly ill, elderly patients in underserved clinical areas.

Exportation of clinical programs other than GEM has focused more on diagnostic and assessment tools, rather
than complete clinical program concepts. Further, exporting usually is limited to affiliated medical centers, or
to VA medical centers physically located near the GRECC rather than on a nationwide basis.


At VACO and at the two GRECCs we visited, we determined that the administrative activities and the
research, education, and clinical programs met the mission, goals, and objectives which VA established for the
GRECC program. Effective administrative and organizational structures had been established to support the
GRECCs. The GGAC had reviewed the programs at both facilities, and the committee's concerns had been
addressed.

Both GRECCs visited had support from the host VA medical centers, affiliated medical schools, and
community programs for the elderly. The research, clinical, and education segments were closely integrated to
provide advancing treatment to the aging veteran and education and training to healthcare professionals. The
Puget Sound GRECC (with divisions at Seattle and Tacoma) is being used as a model by the VAMC
management as they consolidate and unify the two facilities.

A. Overall Assessment of Research Programs

We determined that the GRECCs were carrying out active research programs which were directed toward
meeting the goals and objectives established for geriatric research. For FY 1995, the GRECCs reported 672
research projects for the 16 GRECCs. Research reported funding for the projects totaled $77,087,252. Funding
sources were as follows:

VA $11,907,337

National Institute on Aging 15,455,035

Other National Institutes of Health 26,969,576
Other non-VA 22,755,304

Total $77,087,252

Many of the GRECCs reported difficulty recruiting qualified researchers, securing adequate laboratory and
office space, and obtaining funds for research projects and automated data processing equipment.

At the two GRECCs we visited, research programs were active and well integrated. At the Puget Sound
GRECC, staff were active in both research and clinical activities and had published numerous articles on
aging. The GRECC Associate Director for Research was internationally renowned for his work in discovering
a gene that plays a role in the development of Alzheimer's Disease.

A notable aspect of the Miami GRECC research program was the high level of communication and interaction
among the researchers, who met once a month or every 6 weeks to present formal progress presentations.
Researchers from each of the three focus areas also met independently on a weekly basis to share their ideas.
This cooperation facilitated the optimal use of research efforts and resources. Also, the Miami program
included Clinical Research Conferences, which helped fellows and junior staff members develop viable
research protocols and obtain funding for their projects. With the decline in the number of researchers which
has occurred over the past 10 years, this program offered encouragement to staff to enter clinical research.

Our review of 13 individual research projects found that each was appropriately related to geriatric issues, was
properly approved, and was monitored for progress. Expenditures for the projects were properly authorized
and accounted for.

B. Overall Assessment of Education Programs

GRECC education programs effectively contributed to the accomplishment of the GRECC program's mission,
goals, and objectives. The GRECCs offered medical residency and geriatric fellowship training. Continuing
education programs and teaching conferences were active and ongoing, and fellows and trainees obtained


B. Organizational Structure

The Chief Consultant, Geriatrics and Extended Care Strategic Healthcare Group, is responsible for evaluating all VHA
research, educational, and clinical health care programs in the field of geriatrics and gerontology. G&EC makes
recommendations for the GRECC program as follows:

+ Comprehensive, national/system-wide policy.

« Overall strategic direction.

«Criteria and standards.

« Budget development.

«Priority areas for aging research foci in basic science, applied clinical, and health services research.

+ Strategies for expanding geriatric/gerontology education and training activities for staff and students.

« Priority areas for clinical demonstration projects and strategies for dissemination of effective models of care
for elderly veterans.

«Performance measures for ongoing monitoring of performance in research, education/training, and clinical
activities.

Each GRECC has a director who is responsible for the overall activities at the GRECC, reporting
administratively and operationally to the host VAMC's Chief of Staff. The GRECC Directors' responsibilities
include:

+ Directing, coordinating, and integrating activities of the program.

« Maintaining collaborative and collegial relationships among health care disciplines engaged in GRECC
activities.

« Ensuring that research findings are translated into innovative clinical and educational programs and
interventions.

At each GRECC, Associate Directors are responsible for the direction, planning, and coordination of research,
education, and clinical activities. Program oversight is provided locally by the GRECC Advisory Committee,

which is composed of 10 to 12 persons who have expertise or active involvement in geriatric health care. The

committee members:

+ Provide policy making direction for the establishment of goals and objectives.
+ Advise the VAMC Director and GRECC Director on policy matters related to activities of the GRECC.

+ Assist with formulation of policy guidelines for the research, education, and clinical responsibilities of the
GRECC.

« Monitor and evaluate the progress of the GRECC in meeting program goals and objectives.
- Explore sources outside the local community for funding GRECC research programs.
C. Functional Structure

GRECCs are composed of three separate but integrated components: research, education, and clinical care.


VHA could enhance the program's success by instituting GRECC-developed models and programs at more
VA facilities, thus making them available to more elderly veterans. Broad program implementation would
require strategic planning and management support, since GRECC-developed models and programs often
make use of geriatricians and other specialized staff, which are not readily available at some VA facilities.
Other than the Geriatric Evaluation and Management (GEM) program, GRECC-developed models, programs,
and initiatives were not widely implemented throughout VA. Currently, information about GRECC models
and implementation strategies are provided in large part through regional GRECC seminars. Since the
seminars are attended by staff from nearby VA facilities, GRECC program officials reported that
implementation of the models and programs was being limited to those VA facilities in close proximity to the
GRECCs.

VHA could promote the benefits offered by GRECC models and programs and make them available to more
elderly veterans systemwide by developing a system for disseminating GRECC products and providing needed
consultative support. For example, VHA could deal with issues such as the lack of trained geriatricians and
limited availability of travel funds through broader use of the Internet/World Wide Web, video conferencing,
and/or telemedicine, to inform and train more staff, and to assist in diagnosing and treating patients. This
would help facilities to implement successful GRECC programs, particularly where a lack of specialized
staffing exists. And, information about collaborative efforts with regional affiliates to help the elderly, also not
shared systemwide, could be made more accessible.

The audit showed that the goals established for program management, research, education, and clinical
programs were met.

Program Management. Geriatrics And Extended Care Strategic Healthcare Group (G&EC) officials at VA
Central Office (VACO) provided adequate oversight of the 16 GRECCs. Individual GRECCs reported
annually to VACO about overall program activities, and research, education, training, clinical and outreach
activities, goals, and objectives. Puget Sound GRECC staff edited, produced, and distributed a national
quarterly newsletter, "GRECC Forum on Aging," under the direction of G&EC. The newsletter contained
information about the accomplishments of all GRECCs. G&EC officials maintained working relationships
with other federal agencies which have missions and programs for the elderly.

Research. At the two GRECCs visited, we found that the research programs were active and well managed.
Our review of 13 individual research projects found that each was appropriately related to geriatric issues.
Each project was properly approved and monitored for progress. Expenditures for these projects were properly
authorized and accounted for. GRECC officials reported that host facilities' affiliations with medical schools
provided the capability for better recruiting and funding for GRECC research staff.

Education. Fellows, residents, and medical students were obtaining geriatric clinical experience by rotating
through VA's GEM units, consultation teams, and other geriatric units and clinics. The GRECCs held teaching
conferences and sponsored national and/or regional geriatrics conferences. GRECC staff disseminated new
treatment knowledge and research findings through publications, professional activities, and training and
education programs. There has also been some success at promoting GRECC-developed educational materials
such as "The Aging Game," a training device for caregivers.

Clinical Care. Individual GRECCs were developing over the past several years an average of about 10
clinical demonstration models which could improve care for elderly veterans. Various studies of the GRECC-
developed GEM treatment model have shown:

«Increases in diagnostic accuracy.
«Improvements in veteran's physical, cognitive, and emotional status.

+ Reductions in hospital lengths of stay.


lofa GRECC Web site. In January 1997, a proposal for the project will be submitted for funding
lconsideration. In this case, however, as with all other plans for program expansion requiring supplemental
resource support, budgetary constraints may hinder full accomplishment of recognized goals.

4. In addition to these planned and ongoing actions, concerted efforts are being made to share GRECC-
related clinical initiatives through development and implementation of performance standards for geriatrics
land extended care programs that are based on GRECC outcomes research projects. These performance
measures have recently been finalized and in the months to come, extensive implementation training at the
[Network and field facility levels will be scheduled.

|VA Form 2105

Mar 1989

THE UNDER SECRETARY FOR HEALTH

Page Two

lOIG Draft Report: GRECC Program

5. Thank you for the opportunity to review this report. If additional assistance or information are required, please|
lcontact Paul C. Gibert, Jr., Director, Reports Review and Analysis (105E), Office of Policy, Planning and
Performance (105), at 273.8355.

[Signed by Thomas L. Garthwaite, M.D. for:]
Kenneth W. Kizer, M.D., MP.H.

|Attachment

THE UNDER SECRETARY FOR HEALTH


At the same time, VHA is making concerted efforts to enhance systemwide access to GRECC-related clinical initiatives through ongoing
development and implementation of performance standards for geriatrics and extended care programs that are based on outcomes research
performed by the GRECCs. After extensive review, the performance measures have recently been finalized. A training program to implement the
performance measures is in the process of being developed and it is anticipated that teams within each Network will be trained by September 1997.
During FY 1998 individual facility teams will also receive training in performance measure implementation.

In consultation with the Geriatrics and Gerontology Advisory Committee (one of whose statutory responsibilities is monitoring of the GRECC
program), VHA Headquarters staff will monitor and evaluate all activities as they are implemented.

In Process FY 1998 and Ongoing

FINAL REPORT DISTRIBUTION
VA Distribution
Secretary (00)
Assistant Secretary for Congressional Affairs (009)
Assistant Secretary for Management (004)
Assistant Secretary for Policy and Planning (008)
Deputy Assistant Secretary for Legislative Affairs (60C)
Deputy Assistant Secretary for Public Affairs (80)
Director, Office of Management Controls (004B)
Under Secretary for Health (105E)
Chief Patient Care Services Officer (11)
Chief Consultant, Geriatrics and Extended Care SHG (114)
Non-VA Distribution
Office of Management and Budget
U.S. General Accounting Office
Congressional Committees:
Chairman, Senate Committee on Governmental Affairs
Ranking Member, Senate Committee on Governmental Affairs
Chairman, Senate Committee on Veterans! Affairs
Ranking Member, Senate Committee on Veterans' Affairs

Chairman, Subcommittee on VA, HUD, and Independent Agencies, Senate Committee on Appropriations


developed treatment models and educational programs at more VA facilities. The Under Secretary for Health
concurred with our conclusions and recommendation and provided an acceptable implementation plan. We
will follow up on the implementing actions until they are completed.

For the Assistant Inspector General for Auditing

[Signed]
William D. Miller

Director, Operations Division

TABLE OF CONTENTS

Page
Memorandum to the Under Secretary for Health (10) i
RESULTS AND RECOMMENDATION
VHA Needs to Enable More Elderly Veterans to Benefit from
Effective GRECC Initiatives 1
Conclusion 3
Recommendation 3
APPENDICES
I OBJECTIVE, SCOPE, AND METHODOLOGY 5
II BACKGROUND 7
Ill DETAILS OF AUDIT 12
IV MEMORANDUM FROM THE UNDER SECRETARY
FOR HEALTH 18
V FINAL REPORT DISTRIBUTION 22
RESULTS AND RECOMMENDATIONS
VHA Needs to Enable More Elderly Veterans to Benefit from Effective GRECC Initiatives

The GRECC program was meeting its mission of improving the capability of the VA health care delivery
system to provide services that are effective and appropriate in meeting the medical, psychological, and social
needs of older veterans. Mission accomplishment was achieved by the 16 GRECCs and their host VA medical
centers through (1) geriatric and gerontological research; (2) training of health personnel and trainees in the
provision of health care to older individuals; and (3) development and evaluation of improved models of
clinical services.


Geriatric Research, Education, and Clinical Centers (GRECC) program in meeting the needs of VA's elderly
veteran patients. Our audit examined the activities at VA's 16 GRECCs, including an on-site, in-depth review
at 2 of them and questionnaire surveys of the other 14 GRECCs.

2. The mission of the GRECC program is to improve the capability of the VA health care delivery system to
provide services that are effective and appropriate in meeting the medical, psychological, and social needs of
older veterans. Annual GRECC program costs total approximately $24 million. For Fiscal Year 1995, funding
support for the program's research totaled $77 million. VA and some other federal agencies (i.e.,
Administration on Aging, Health Resources and Services Administration, and National Institute on Aging)
collaborate with state and local governments, medical schools, and others to address the concerns of the
elderly. Officials from these involved federal agencies recognize VA as the lead agency for focusing on
ailments which affect geriatric patients and broadcasting the results of their efforts to caregivers. VA's geriatric
mission and programs do not duplicate those of the other federal agencies.

3. We concluded that the Veterans Health Administration's (VHA) GRECC program was meeting its mission
and that the program's success could be enhanced and benefit more veterans by instituting GRECC-developed
treatment models and educational programs at more VA facilities. Our audit showed that GRECC's integration
of research, education, and clinical care activities at major research facilities was an effective method for
addressing the health needs of the elderly. At the two GRECCs we visited, research, education, and clinical
demonstration programs were closely integrated to enhance the education and training of caregivers and to
develop and use advanced methods in treating elderly veterans. Both GRECCs visited worked cooperatively in
the research, education, and clinical care activities of the host VA medical centers, the affiliated medical
schools, and other regional entities to address health care for the elderly. Geriatrics and Extended Care
officials at VA Central Office provided adequate oversight of the GRECCs and kept abreast of national issues
affecting the elderly.

4. Although combined into a single program, each GRECC has a separate set of foci. Each GRECC
concentrates on different ailments which affect the elderly and works cooperatively with the affiliated medical
school and other regionally located entities. This differentiation of focus essentially makes each GRECC a
distinct special program of VHA and gives each GRECC an important role in addressing the needs of the
geriatric population. With 16 distinct activities, it is important to widely disseminate each GRECC's
successfully developed treatment models and educational programs.

5. The audit showed that exportation of GRECC-developed treatment models and educational programs was
not systemwide, with the exception of the Geriatric Evaluation and Management (GEM) program. While
GRECCs published information about their research, treatment models, and educational programs in medical
journals and gave seminars, we found that the exportation of models and programs to other VA facilities was
limited. In most cases, GRECCs reported that their programs were exported primarily to VA facilities in
nearby states. Each GRECC provided seminars which could be useful in instituting GRECC-developed models
and programs, but were primarily attended by staff from nearby facilities. At the two GRECCs we visited,
GRECC-developed models and programs were described which, if implemented systemwide, could benefit
more veterans.

6. Broad implementation of GRECC programs would require strategic planning and management support,
since GRECC-developed models and programs often make use of geriatricians and other specialized staff,
which are not easily available at some VA facilities. For example, VHA could use the Internet/World Wide
Web, video conferencing, and/or telemedicine to train more staff, and to assist in diagnosing and treating
patients at facilities which lack specialized staffing. At the two GRECCs we visited, facility directors agreed
with our suggestion to use the Internet/World Wide Web to provide open access to information about GRECC
programs.

7. We recommended that the Under Secretary for Health develop a method for implementing GRECC-


During our onsite reviews, we identified additional clinical demonstration projects that may have substantial
merit for future export. For example, the Interdisciplinary Prostate Cancer Clinic and Acute Geriatric Unit
(AGU), described below, are in operation at the VA medical center in Miami, Florida.

« The Interdisciplinary Prostate Cancer Clinic, initiated in FY 1993, represents a unique health care delivery
model in the care of aged patients with prostate cancer. Miami GRECC staff developed this clinic model,
which integrates oncologic, surgical, geriatric, and psychiatric care along with educating the patient on the
disease process and potential treatment options. The model uses a holistic, team approach focusing on the
patient, instead of the disease, and using the patient as part of the treatment team. The clinic team includes a
geriatrician, a urologist and urologic nurse, a radiation oncologist, a geriatric psychiatrist, an endocrinologist,
and a patient education specialist. Decisions on whether or how to treat the cancer depend on a consensus of
the team, who factor in the patient's desires as well as medical needs. Use of the model has markedly increased
patient satisfaction and reduced diagnostic testing, medication use, and clinic visits.

«The AGU is an inpatient unit focused on returning acutely ill geriatric patients to a post-hospitalization
setting in the best possible condition. AGU staff are specifically trained to administer care that minimizes the
debilitating effects of the hospitalization itself. The AGU integrates multiple services in an interdisciplinary
approach. The AGU medical team consists of an attending geriatrician and practitioners from allied
disciplines, a resident, interns, and students. Consultation is provided by geriatric psychiatry, psychology,
social work, dietetics, audiology, and speech pathology as needed.

Acute illness in elderly patients is frequently complicated by frailties not seen in a younger population (for
example, arthritis, memory loss, physical instability, and compromised immune systems). In the past, VA
primarily provided intermediate and long term care for the aged veteran. However, the increasing percentage
of veterans age 65 and older will cause more demand for acute geriatric medical services. The limiting factor
in VA's ability to address this demand will be access to medical staff experienced in geriatrics. Grouping
patients into one area, such as an AGU, allows more effective use of scarce geriatricians and provides a
nursing staff specifically trained for work with the elderly.

Further evaluation of these demonstration projects was necessary to enable the programs to be instituted at
other health care centers, whether VA or private sector. Survey work indicated that GRECCs were measuring
patient outcomes, cost-effectiveness, or other benefits when developing clinical treatment models or training
instruments.

D. Sharing Information

Although the results of GRECC research were divulged to a universal audience, much of the information
about GRECC activities was not widely shared outside the GRECC's geographic area. Each GRECC we
visited operated as part of a regional community on geriatric issues, in terms of identifying common areas of
concern, sharing information, educating health care professionals, and exporting clinical treatment models.
The Puget Sound GRECC pursued common areas of concern with the University of Washington, Madigan
Army Medical Center, Bremerton Naval Hospital, the Northwest Geriatric Education Center, and other entities
in the Pacific Northwest. And, the Miami GRECC pursued common areas of concern with the University of
Miami, the Miami Area GEC, and other entities in the Miami area, but did not generally identify with areas of
concern to north Florida, which has a GRECC at Gainesville.

Our reviews at Puget Sound and Miami showed that GRECCs and GECs had good collaboration when
collocated. However, collaboration was nonexistent when GECs were not within their regional geriatric
treatment community. For example, Little Rock's GRECC was not closely involved with a GEC, since it was
not closely located to one. And, the Ann Arbor GRECC did not collaborate with the Michigan GEC, which is
affiliated with Michigan State University in East Lansing-only 62 miles away. The Ann Arbor GRECC
pursued common areas of concern with the University of Michigan and its Claude D. Pepper Older Americans


Plan in Response to OIG/GAO/MI Audits/Program Evaluations/Reviews

Name of Report: OIG Draft Report: Audit of DVA Geriatric Research, Education,
and Clinical Centers (GRECC) Program

Report Number: none

Date of Report: none

Recommendations/ Status Completion

Actions Date

Recommendation:

We recommend that the Under Secretary for Health develop a methodology for enabling broad implementation of successful GRECC-
developed models and programs, and enhance access to information about GRECC i

Concur

The Geriatrics and Extended Care Strategic Healthcare Group, in close coordination with other relevant program offices and the existing GRECCs,
has developed a comprehensive plan of action to address various aspects of this recommendation. A work group has already been established to
explore the most effective means to disseminate on a systemwide basis the wide variety of educational products that have been developed by the
GRECCs. A catalog of GRECC educational tools is expected to be developed and printed by February 1997, with dissemination of the publication
to targeted facility and Network staff anticipated by the following April. The work group will also plan and implement a method to evaluate how
effectively the educational products are being utilized by VA medical facilities.

In Process August 1997 and ongoing

Geriatrics and Extended Care staff also plan to coordinate development ofa strategic plan to more widely implement GRECC-designed geriatric
clinical models and interventions. Criteria for selecting specific models/interventions will be developed by April 1997, with implementation
guidelines for Network and

MEMORANDUM FROM THE UNDER SECRETARY FOR HEALTH

2. VHA Action Plan/ OIG Draft Report: Audit of GRECC Program

facility-level managers scheduled for completion within five months of that date. During FY 1998, consultation on implementing these
models/interventions will be provided on an ongoing basis. It is also anticipated that a survey will be developed and distributed to all facilities in
an attempt to evaluate how successfully dissemination efforts were accomplished.

Planned Within FY 1998

VHA also fully concurs in the report conclusion that the Intenet/World Wide Web would be a very effective tool in disseminating information
throughout the system and should be utilized more extensively. As in all other areas of program expansion, however, budgetary constraints might
directly impact our ability to fully proceed in this arena. Nevertheless, actions have already been undertaken to institute a GRECC Web site on the
Intemet. A work group was established in October 1996 to identify technology requirements for the proposed Web site. All GRECC sites were also
surveyed for existing technology capability. In January 1997, a proposal for the project will be submitted for funding consideration. If resource
support is forthcoming, development of the Web site will begin the following March, In addition, VHA is in the initial stages of developing a
Geriatric Information Exchange Program (i.¢., "Virtual Gem").

In Process April 1997 and Ongoing