At the Foundation we’ve been doing a lot of focused thinking recently—and even better, a lot of learning. We’ve been stretching all of our change-making abilities, refining our approaches, limbering up (metaphorically) for our return to grantmaking.

And the wait is almost over. Come 2013, we will have paid off the overhang of the grants we made when we were a $700M foundation and be prepared to live within the limits of being a $500M foundation. In 2013, we will become current on payments on our dwindling number of active grants and even need to make grants to get the required payout out the door.

So what are we going to do?

We’ve been listening to our stakeholders (particularly our board and our current grantees (See “Help us spend 100M really well”). We’ve been learning what other players in health and aging are doing, and we’ve been trying to extract lessons from our own history. Since the best learning is by doing, we’ve been trying new things (e.g., a new website, applying to the Social Innovation Fund, grantee capacity building, Beyond the Board Room videos, even public polling).

And here is our current thinking in a nutshell. (You can read more in our annual letter to grantees.)

In 2013 and beyond, we are in a real race with the demographic shift to improve the quality of health care for older Americans before it is too late. And the continuing implementation of health care reform creates opportunities that have only been dreams in the past—such as Medicare medical homes, integrated Medicare and Medicaid funding for the dually eligible, and pay-for-performance. It is time to shift from our “upstream” theory of change—building academic infrastructure in preparation for aging (i.e., “enhancing the nation’s capacity for effective and efficient care”)—to a “downstream” theory, focusing more on practice and more directly improving the health of older Americans. It’s frightening, but I actually hear the words of Donald Rumsfeld in my head: “You go to war with the army you have, not the army you might want or wish to have at a later time.”

So, specifically, what will we be doing and what do we hope to achieve?

We will be seeking improvements in the care of older Americans such as reductions in rates of hospitalization for ambulatory-care sensitive conditions, quality of care improvements as measured by the ACOVE indicators, and improved care coordination between social services and supports and health care.

To achieve these goals, our planning has led us to five strategic grantmaking areas:

• Interprofessional Leadership in Action
• Linking Education and Practice
• Developing and Disseminating Models of Care
• Tools and Measures for Quality Care
• Communications/Policy

To unpack this a bit, here is some of our thinking about the key elements and themes that led us here.

Investing in leadership that goes beyond the lab and the classroom. Part of the reason we believe we should shift from producing new scholars to working with the ones we have is because we know that our current cadre represent the most valuable (and still appreciating) asset that we have and that many of them want to be engaged in new ways. We have already seen in programs like the Health and Aging Policy Fellows, the Practice Change Fellows, and Hartford’s nursing alumni group that members of our network are interested in developing new skills and driving change through new approaches.

Bringing together a broad range of professionals and other stakeholders. In truth, we have been a little horrified to see how high the silo walls between our disciplinary program areas have grown. We believe that we can accomplish more if we bring together broad constituencies, including paraprofessionals, patients, and family representatives. We also know we need better linkages between medical and social services.

Among the high priority targets for our interdisciplinary work groups to engage is primary care. We believe that older people can be healthier and independent longer if they get care that meets their chronic care needs and is prepared to address the way those needs stretch from high-tech medical to high-touch support. We believe geriatrically expert, comprehensive, coordinated, and continuous primary care that spans time and place is the best way to meet older adults’ needs.

We also feel that our work should focus on the multiply chronically ill population, such as dual-eligibles, who are at most risk and where improvement can produce the biggest win-win in health of older adults and reduced cost to the system.

Effective information systems are a high priority to create the infrastructure necessary to support quality care for older adults. This would include records that track important geriatric information such as function and cognitive status, support personalized goal setting for quality measurement, information sharing across relevant providers, and geriatrically expert decision support.

How do we implement this downstream shift? We expect to make final, terminal renewals of our discipline-focused scholar and center grants to enable these programs to find alternative sources of support to continue or to wrap up gracefully. We have seen the errors of other funders (both private and public) who try to turn on a dime, not understanding the impact that such changes have and how much there is to lose from such unpredictability. We understand that there will continue to be a need for more aging-focused faculty and curricula in health professions education and we will provide capacity-building resources to willing grantees to help them continue their work in these areas.

After we make those transition/consolidation grants, we will begin to ramp up new grants that will follow from our new focus on downstream, practice change. We will try to tear down the silos in our program between disciplines and between education and practice. We will try to find ways that we can help committed alumni put their expertise and their passion to work.

Are we sure that this will work better than what we’ve been doing? No. Are we sure that keeping on with what we’ve been doing won’t work fast enough to meet the needs of the swelling ranks of our older patient population? Yes, absolutely.

As one of our academic leaders put it for me, it wouldn’t matter if we changed the average division of geriatrics size from 14 to 19—academic infrastructure alone won’t change the care received by the average older adult. We need to try something new.

We need to move with all deliberate haste to focus on the practice changes that will directly improve the care older adults receive. We look forward to working with our past and current grantees, as they are a vital resource and a powerful network that can play important roles in making this change happen. At the Foundation, we look forward to collaborating with a broad range of partners—some familiar, many new—to use our resources to make high quality, better coordinated care a reality for the growing number of older people who desperately need it.