HGNI Summit Seeks New Heights for Geriatric Nursing

On August 12, 2008, 19 project directors of the Hartford Geriatric Nursing Initiative (HGNI) convened at the Foundation office in New York City in an effort to make our geriatric nursing whole greater than the sum of its individual projects.

The goal of the $70 million HGNI is to build strength and capacity in geriatric nursing to improve care of our nation’s older population.  HGNI projects─representing academic institutions and organizations from across the country─are reaching this goal by producing expert faculty, awarding scholarships and fellowships, developing curriculum, promoting leadership development, and providing clinical resources for geriatric nursing. 

This productive meeting focused on three aims: 1) to familiarize HGNI directors with current nursing initiatives, 2) to explore common challenges that should be addressed for the good of the whole, and 3) to determine how to maximize collaboration across projects.  Extensive pre-work went into tailoring an agenda based on the interests of all the participants. 

The meeting kicked off with brief presentations from each of the project directors, creating a common and current understanding of the HGNI’s reach. Small groups then met during the rest of the day to focus on challenges such as PhD recruitment, program growth and sustainability, and leadership development.  Project leaders also discussed ways to collaborate to more easily share information and disseminate their project outcomes. 

Participants reported the meeting provided a forum to “reflect on how we might work more efficiently, effectively, and synergistically” and “made us leave our element and focus undivided attention.”  Another noted, “I like having time to think with colleagues I respect.”  The energy and ideas generated by the meeting, however, are only the beginning. Attendees universally endorsed the idea of convening annually to continue their common work.
           
Norman Volk, Chairman of the Board of Trustees at the Hartford Foundation, attended the meeting and concluded, “In order to advance the nation’s capacity to provide quality nursing care to older adults, we need the vision, intellect, energy, and passion that was embodied by the nursing leaders who attended this meeting.  I expect great things will come about as a result of this productive, positive, and action-oriented event.”

Integrating Geriatrics into the Specialties of Internal Medicine

In 2006 the Hartford Foundation awarded a $2.6 million grant to the Association of Specialty Professors (ASP) to fund a project called Integrating Geriatrics into the Specialties of Internal Medicine: Moving Forward from Awareness to Action. Part of a long-term effort supported by the Foundation to infuse geriatric knowledge into the practice of specialty internists, the initiative is also fostering a broader, deeper base of geriatrics research in fields from cardiology to nephrology, from infectious disease to gastroenterology.

Most recently, in May 2008, ASP, along with the American Society of Nephrology, gathered nephrologists and geriatricians, as well as representatives of the National Institute on Aging (NIA) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) for a research workshop focused on the prediction, progression, and outcomes of chronic kidney disease (CKD) in older adults. Experts discussed types of CKD, the mortality risk it poses, models for explaining its mechanisms, and the impact of several co-morbidities. This meeting was the second of seven funded through the Integrating Geriatrics grant. The first focused on HIV and aging in 2007, and the next, scheduled for December, will examine immunization.

Each of these convenings brings together specialists, geriatricians, representatives from the NIA, and representatives from other parallel specialty institutes at the National Institutes of Health (NIH). The hope is to nurture cross-institute research collaborations, create an interdisciplinary research agenda, and set the stage for unique funding options. The proceedings of both workshops have been published (or been accepted for publication) in leading journals, and the research agendas generated have already begun to shape funding opportunities in these important areas.

“These research meetings have been our biggest successes to date,” said Kevin P. High, MD, MSc, Professor of Medicine at Wake Forest University School of Medicine and principal investigator on the Integrating Geriatrics grant.  “They are enabling us to define geriatrics/specialty-specific research questions and develop cross-institute collaborations to leverage shrinking NIH funding.”

Embedding Geriatrics in the Specialties
The NIH research meetings are only one facet of the Integrating Geriatrics initiative. The project builds on more than a decade of ground-breaking, Hartford-supported work to promote greater understanding and support among key leaders in the internal medicine subspecialties led by the American Geriatrics Society and William R. Hazzard, MD, at Wake Forest University School of Medicine.

 “Our goal is pretty clearly stated in our project’s name (Integrating Geriatrics into the Specialties of Internal Medicine: Moving Forward from Awareness to Action),” says Charles P. Clayton, ASP Vice President for Policy. “We are using this funding to build a more robust academic base for geriatrics in internal medicine specialties, to create groups of specialists focused on geriatric research, and to engage specialty organizations in our agenda.”
 
Expanding the Dialogue on Geriatric Research
In addition to the NIA research meetings, a second, critical element of this initiative is to enhance and improve the longstanding T. Franklin Williams Scholars Program. Hartford funded the program’s start-up, and The Atlantic Philanthropies, in partnership with participating specialty societies, has subsequently assumed sponsorship.  Since 2002, ASP has funded 64 Williams Scholars. Scholars are junior internal medicine faculty conducting research in a geriatric aspect of their specialty.  ASP will host alumni meetings for all scholar cohorts from 2002 to the present to build awareness and dialogue on geriatric issues among this elite group of medical faculty.  In addition, current Williams Scholars receive funding to host visiting professors. 

“We will be funding more than 40 visiting professorships,” said Dr. High.  “We are pleased to have so many opportunities for prominent geriatric and subspecialty leaders to speak at a wide range of medical schools and institutions across the country.”

Supporting the Societies
The third leg of the Integrating Geriatrics project is to foster special interest groups focused on geriatrics in the professional societies of the participating disciplines. In April 2008, ASP funded a second round of projects designed by representatives from these specialty societies to improve geriatric education for internists. Each project received $15,000.  The projects include:

• Geriatrics lectures embedded into the American Gastroenterological Association’s annual Digestive Disease Week;
• A workshop on how to pursue geriatric research opportunities for myelodysplastic syndrome (a bone marrow disorder associated with leukemia) developed by the American Society of Hematology;
• A new online curriculum on aging and the kidney developed by the American Society of Nephrology.
• A presentation, pocket card, and journal article entitled, "CMS and the Practice of Infectious Disease," designed to improve physicians' understanding of Medicare coverage related to infectious disease, developed by the Infectious Diseases Society of America; and
• An expansion of the Society of General Internal Medicine’s “Distinguished Professors in Geriatrics” symposium at its annual meeting. 

“These projects will elevate each society's interest in the aging agenda, and ultimately improve the care delivered to elderly patients by internists in these specialties,” said Dr. High.  

 Creating a Virtual Geriatric Network
In addition to the interest group sub-grants, ASP is developing a virtual community in building and changing geriatric education.  In June, ASP launched the Integrating Geriatrics Project Interest Group Web site (http://www.im.org/AAIM/Development/IntegratingGeriatrics/NIH%20Meetings.htm) to serve as a resource for its partner society interest groups.

“We are using this site to increase communications among societies, share ideas and best practices, market products, and to forge the cross-society collaboration needed to make progress in integrating geriatrics within specialties,” said Clayton.

Protecting Nursing Home Residents from Natural Disasters

In 2005, as Hurricane Katrina blasted the Louisiana shoreline with 170 mph winds, nursing home administrators grappled with a life-or-death decision: Should they evacuate residents or shelter them in place? There were no guidelines to go by, and no one to advise them. They took their best guess, and outcomes were often catastrophic. The storm revealed critical weaknesses in the ability of the nation’s long-term care system to respond to natural calamities. The loss of 34 lives at St. Rita’s Nursing Home near New Orleans became an emblem of the disaster.  In response, the Hartford Foundation awarded a 2006 grant to the Florida Health Care Association (FHCA), entitled Hurricane and Disaster Preparedness for Long Term Care Facilities, to establish response and decision-making protocolsfor similar critical situations in the future.

In May 2008, just in time for hurricane season, this work produced an important new document called National Criteria for Evacuation Decision-Making in Nursing Homes. FHCA, along with its partners at Florida University and eight southeastern states, issued this comprehensive guideline to help long-term care facility administrators, like those at St. Rita’s, make critical decisions that protect the lives of their residents during disasters.
These residents are among the most vulnerable when calamity strikes. According to the Centers for Disease Control, while only 15 percent of the affected population in Louisiana were over age 65, 75 percent of those who died in Katrina’s wake were older adults. Of that number, 139 were residents in long-term care nursing homes.

The Florida Healthcare Association and its partners released The National Criteria for Evacuation Decision-Making in Nursing Homes, at their third national disaster preparedness summit in Orlando, Florida. The report documents standards and practices that long-term care and disaster response agencies must follow during critical emergencies like Katrina. You can download a copy of the document at:  http://fhca.org/news/evacsurvey.pdf.

The long-care industry is already responding to this new resource. Genesis Healthcare, for example, has already begun implementing the evacuation criteria. “The guidelines will be of critical support in future disasters,” says Irene Fleshner, Senior Vice President with the company. Genesis Healthcare spans 13 states and serves 26,000 in 650 facilities.

The new guideline grew from a joint effort that included leadership from state emergency command centers, long-term care organizations in Florida, Louisiana, Mississippi, Alabama, Texas, Georgia, Virginia, and North Carolina, as well as federal representation from Federal Emergency Management Agency (FEMA), Centers for Medicare and Medicaid Services (CMS), and the Department of Health and Human Services (HHS), along with representatives from AARP.  

The grant is also helping tackle issues surrounding emergency transportation in collaboration with the American Health Care Association. A report on the Hartford Foundation-funded “Hurricane and Disaster Preparedness for Long-Term Care” project recently appeared in the May/June 2008 GrantWatch in Health Affairs.