National Health Policy Forum Hosts Guided Care Site Visits

On August 7th , 2009, the National Health Policy Forum hosted a site visit to Johns Hopkins University in Baltimore, Maryland, for more than 40 senior staff members of numerous federal executive and legislative agencies. It was titled Coordinating Care for Persons with Multiple Chronic Conditions: the Guided Care Model and Other Innovative Approaches. This was the second Guided Care site visit by policymakers, with the first having been oversubscribed.

Chad Boult, MD, MPH, MBA, Director of the Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public Health and the Principal Investigator of the randomized control trial of Guided Care, described the key components of Guided Care and presented the preliminary results from the RCT to the visitors: improved quality of patients’ care, reduced use and cost of expensive services, reduced caregiver strain, and improved physician satisfaction with chronic care.

Chad Boult, MD, MPH, MBA, Director of the Roger C. Lipitz Center for Integrated Health Care.

“Guided Care is the first form of comprehensive health care for high-risk Americans that a rigorous scientific study has shown to be cost-effective,” said Dr. Boult.

Participants included representatives from the Congressional Budget Office, the Congressional Research Service, the Office of Management and Budget, the U.S. Department of Health and Human Services, the U.S. Department of Veterans Affairs, the U.S. Government Accountability Office, the U.S. House of Representatives, the U.S. Senate, and the John A. Hartford Foundation, one of the funders of the recently completed, three-year, multi-site randomized controlled trial (RCT) of Guided Care.

Others involved in Guided Care were on hand to share their experiences. Three Guided Care nurses described their role and how they interact with physicians, patients, family caregivers, and other health care providers. One nurse explained what is involved in initial home assessments and how she works with her physician partners, using health information technology, to develop evidence-based “Care Guides” and patient-friendly “Action Plans” for her patients. Another nurse described how she helps patients make smooth transitions from hospitals to home.

During one panel discussion, three patients and a family caregiver expressed what Guided Care means to each of them. “Having my Guided Care nurse – someone to relieve my anxiety, reconcile my problems and coordinate my care – is a priceless asset. She is more than a nurse; she is my friend and I believe she is the missing piece of the health care system,” said a patient. Another patient stated, “I don’t know if I would here today without my Guided Care nurse. I could not have gotten through my health crisis without her.”

For the family caregiver, who cares for her elderly mother-in-law, the Guided Care nurse has been a critical asset in getting timely answers to questions and dealing with emergencies, especially when they surface while she is at work. When a meeting participant asked if the panel members felt Guided Care helped to avoid the need to go to the ER, all the members emphatically answered “yes.”

"A Guided Care Patient Who Shared His Thoughts about the Program."

The lunch discussion featured three primary care physicians who explained the challenges they face when dealing with patients with multiple chronic conditions. They described how Guided Care helped improve patient care and how they work with the Guided Care nurse. “Guided Care is a model that will attract physicians into primary care in the future,” said a physician.

The meeting concluded with a discussion of the policy issues that affect the delivery and financing of chronic care. For Guided Care to be disseminated widely, Dr. Boult proposed that insurers support Guided Care physicians with monthly care management fee, plus performance bonuses that focuses on the quality of care.

As a concluding remark, one participant said, “There is broad demand for a model like Guided Care, and the patients we heard from today are so passionate. As a nation, can we afford to wait?”

The John A. Hartford Foundation thanks the National Health Policy Forum for sharing Guided Care with these audiences and for creating a platform for discussing the widespread adoption of Guided Care and other innovative models of care for older adults with complex conditions.

Posted: 08.24.2009

Geriatrics and Palliative Medicine Meet to Plan Collaborations

In July, representatives from the American Geriatrics Society and the American Academy of

Deborah Cleeter of the Sawgrass Leadership Institute kicks off the Geriatrics and Palliative Care Medicine Leadership Summit.

Hospice and Palliative Medicine met at the John A. Hartford Foundation for a first ever two-day Geriatrics and Palliative Care Medicine Leadership Summit. Over 20 leading geriatricians, palliative care and hospice medicine physicians, and executive staff from the two organizations came together to learn about and discuss important issues in each field and find overlapping interests. A joint declaration of shared concerns and plans for future collaboration, drafted during the meeting, will be presented to each organization’s respective Board for ratification.

From the American Geriatrics Society (AGS), President-elect Sharon Brangman, MD (SUNY, Syracuse) presented an overview of the organization’s history, goals, committee and governance structure, membership profile, and a summary of meeting and program activities. The American Academy of Hospice and Palliative Medicine’s (AAHPM) President-elect, Sean Morrison, MD (Mt Sinai School of Medicine), presented a similar overview of the AAHPM.

Smaller task groups worked throughout the weekend to catalog and prioritize opportunities, challenges, and potential next steps in each of five core issue areas: Education & Training, Research, Public Policy, Clinical Care, and Leadership & Organizational Structure. Each task group’s report will circulate among all participants, and a summary white paper of the meeting’s findings and recommendations for next steps will be prepared for joint publication in the Journal of the American Geriatrics Society and the Journal of Pain and Symptom Management.

The meeting’s facilitator, Deborah Cleeter, EdD, of the Sawgrass Leadership Institute, said, “I believe the energy and new relationships formed from the summit will lead to a commitment on the parts of both associations to move the recommendations forward at a good pace.”

Bruce Leff of Johns Hopkins University and Janet Abrahm of Harvard Medical School map out common ground in the Clinical Care task group.

Planning for the meeting began informally almost two years ago, when leaders from both disciplines found that they were ready and eager to put their issues on the table and see where the conversation led. Christine Ritchie, MD (University of Alabama at Birmingham) led the planning group, which also included Robert Arnold, MD (University of Pittsburgh), Jean Kutner, MD (University of Colorado, Denver), Seth Landefeld, MD (University of California, San Francisco), Wayne McCormick, MD (Harborview Medical Center, Seattle), and Greg Sachs, MD (Indiana University, Indianapolis).

Cory Rieder, EdD, Christopher Langston, PhD, and Gavin Hougham, PhD, all from the Foundation, also attended the meeting and endorsed the effort. “I was gratified and impressed with the seriousness of purpose and forward-looking momentum that everyone brought to the meeting,” said Dr. Rieder at the conclusion of the weekend.

For further information on each of the two professional societies involved in the meeting: The American Geriatrics Society (http://www.americangeriatrics.org/), and the American Academy of Hospice and Palliative Medicine (http://www.aahpm.org/).

Posted: 08.10.2009

Geriatrics Leaders Convene for Leadership Development

Earlier this year, the annual Association of Directors of Geriatrics Academic Programs (ADGAP) Leadership Retreat provided a unique opportunity for current and previous Hartford Geriatrics Leadership Scholars, Senior Leadership Scholars, and other geriatrics program directors to come together and share ideas.

With support from the Hartford Geriatrics Leadership Development Program, ADGAP  works to advance academic geriatrics programs in order to benefit and aid patient care, research, and teaching programs at accredited US medical schools. The annual retreat is one approach ADGAP has created to foster the development of leadership skills among academic geriatricians and provide an ongoing forum where academic program directors and other leaders in the field can discuss the wide variety of issues facing them. The Hartford Foundation believes that developing innovative leadership is critical to transforming the nation’s current health care system into one that can meet the needs of its primary consumers—older adults.

The retreat has three fundamental goals:

• Provide formal leadership training in financial planning, negotiations, fundraising, and other management skills: 
• Build the foundation for interpersonal development, based upon leaders understanding their own strengths and weaknesses;
• Provide opportunities to network with colleagues and mentors and to discuss ways to meet challenging issues in geriatrics.

The Leadership Scholars at this year’s retreat comprised a select group of geriatrics program directors who had assumed their positions during the past six years. The Senior Leadership Scholars group included geriatrics directors who have held their position for at least six years and are looking to further their career advancement. Guest speakers, Hartford Foundation staff, and ADGAP staff also attended.

The retreat kicked off with a dinner and presentation on Geriatrics and Health Policy Making. Dr. John Rother, the executive vice president for policy and strategy at AARP, led the presentation. Small group sessions followed, centering on topics such as Interviewing and Hiring and Unusual Places to Look for Money, as well as panel discussions on how to handle the economic crisis at respective institutions. Other highlights included sessions on problem solving and fundraising.

Many ADGAP members reported that this was their favorite retreat and that they learned new tools for development, self-insight, and staying optimistic in tough times.  Attendees commented on “the incredible value of shared wisdom of program directors,” “the generosity of ADGAP program directors,” and “the importance of mentoring and networking.”

The 2009 retreat was the second in a series of three funded by a grant under Phase 2 of the Hartford Geriatrics Leadership Development Program. In addition to the leadership retreats, the grant also includes the following components:

• Leadership Scholars Program for 20 newly appointed program directors;
• A new Senior Leadership Scholars program for 16 senior leaders;
• Support of the ADGAP Geriatrics Fellowship Directors Group; and
• Support of ADGAP Business Meetings.

You can find information online about ADGAP at www.americangeriatrics.org/adgap.

Posted: 06.12.2009

The Geriatric Social Work Initiative

Project Leaders in the Hartford-funded Geriatric Social Work Initiative (GSWI), with Nancy R. Hooyman at the helm, recently completed a book describes and celebrates the past ten years of the Initiative.  The book, Transforming Social Work Education: The First Decade of the Hartford Geriatric Social Work Initiative, edited by Nancy R. Hooyman, PhD and published by the Council on Social Work Education (CSWE) was launched on March 16, 2009, during the opening day of the annual meeting of the National Association of Deans and Directors (NADD), in Scottsdale Arizona.  All of the Social Work Project Leaders, Barbara Berkman, Linda Harootyan, Nancy R. Hooyman, James Lubben, and Patricia J. Volland were on hand for the festivities.  Each Project Leader, as well as other social work leaders, had authored chapters in the book.

The day began with a keynote speech by Dr. Corrine H. Rieder, executive director of The John A. Hartford Foundation, who gave a “call to arms” for geriatric social work education.  A festive luncheon followed where each of the NADD participants received a copy of the book and as well as a newly created anniversary book mark naming the GSWI programs and providing links for more information.

The anniversary book documents the impact Hartford’s initiatives have had on shaping gerontological social work education as a whole.  Each chapter highlights various aspects of the individual programs of the initiative—its competency-based education, model for curricular and organizational change, community outreach, and strategies for sustainability.

The first of the programs, developed in 1998, the Council on Social Work Education (CSWE) Strengthening Aging and Gerontology in Social Work Education (SAGE-SW) focused on faculty development in gerontology,

In 1999, the Hartford Faculty Scholars Program, which provides financial and career support for talented junior faculty members committed to academic careers in aging-related social work, was begun under the leadership of Barbara Berkman of Columbia School of Social Work and Linda Harootyan at the Gerontological Society of America (GSA).   To date 91 Scholars have been supported in 34 states and 60 universities. 

The Practicum Partnership Program, initiated in 1999 and now called the Hartford Partnership Program for Aging Education (HPPAE), focuses on the advanced MSW field curriculum and has implemented a rotational model of field education and innovative partisanships with community agencies.  Pat Volland of the New York Academy of Medicine established this model and continues to provide her leadership in managing the program.

The Hartford Doctoral Fellows, funded in 2000, provides dissertation support and professional development opportunities.  Jim Lubben at Boston College School of Social Work oversees the direction of the program and of the Fellows along with Linda Harootyan at GSA.  To date, 80 Doctoral Fellows have been selected from 22 states and 35 universities. 

The CSWE Geriatric Enrichment in Social Work Education Project (GeroRich), which emphasized curricular and programmatic change, was funded from 2001 through 2004, under the leadership of Nancy Hooyman at the University of Washington.

The latest initiative, the CSWE National Center for Gerontological Social Work Education (Gero-Ed Center), which began in 2004, encompasses a range of programs to train faculty, recruit students and, design specialized and gero-infused competency-based foundation classroom content in aging.  Nancy Hooyman of the University of Washington School of Social Work and Julia Watkins, Executive Director of CSWE are co- Principal Investigators. These curriculum and program development have reached over 1200 faculty and 1000 students.

Hooyman and colleagues suggest ways of teaching future generations of social workers how to embrace gerontology and contend that building a new generation of scholars and gerontologically competent practitioners can help fill the void within a high-demand field. This book is a one-stop resource on gerontological social work, whether in preparation for teaching foundation or specialty coursework, overseeing field placements, building scholarly and educational capacity in other areas of specialization or disciplines, or practicing social work in  micro, mezzo, or macro settings.  It is also germane to other disciplines seeking to prepare gerontological professionals as well as to other social work practice areas.

New Alliance Gets to Work on Workforce Issues

Seeking to translate many of the recommendations of the Hartford-supported “Re-Tooling for an Aging America” report from the Institute of Medicine (IOM), the recently formed Elder Workforce Alliance (EWA) has begun to educate policy and other decision makers about the nation’s burgeoning eldercare crisis. 

Through a grant to the Meridian Institute, Foundation helped to convene a range of organizations following the IOM report’s release in the Spring of 2008.  Today, the EWA includes 25 national organizations and is a project of the Tides Center and the Tides Advocacy Fund. The Alliance includes national organizations representing consumers, family caregivers, the direct-care workforce, and healthcare professionals.  With additional support from the Hartford Foundation and others, including The Atlantic Philanthropies, these groups have come together to propose practical solutions to strengthen our eldercare workforce and improve the quality of care.

1. Strengthen the Direct-Care Workforce

• Require a minimum of 120 hours of training for certified nursing aides and home health aides, including explicit geriatric care and gerontological content; and create minimum training standards/competencies for non-clinical direct-care workers.
• Increase compensation for direct-care workers through means such as: a) establishing minimum standards for wages and benefits paid under public programs, and b) targeting reimbursements to ensure that public funds directly improve compensation for direct-care workers.

2. Address Clinician and Faculty Shortages

• Increase compensation for clinical professionals and educators with geriatric and gerontological expertise—they will be needed to care for our frailest elders and their families, and to help educate the rest of the workforce.
• Increase funding for federal and state programs that support development of geriatrics faculty and clinician training—such as Title VII and Title VIII.
• Implement federal and state programs that provide incentives—such as loan forgiveness—to those entering careers caring for older adults.

3. Ensure a Competent Workforce

• Encourage agencies and organizations that certify and regulate the eldercare workforce to require demonstrated and continued competence in the care and treatment of older adults.

4. Re-design Health Care Delivery

• Disseminate and adopt cost-effective, comprehensive care coordination models that are evidence-based, and fully fund care coordination components that have demonstrated measurable success.

EWA recently named Alice H. Hedt as its founding Project Director.  Hedt has been Executive Director of the National Consumer Coalition for Nursing Home Reform since 2003 and an impassioned voice in the policy arena for older adults and their families.

For a full description of EWA, please see:  www.eldercareworkforce.org.

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.