Learning Center

Earlier this year, with Hartford and SCAN Foundation support, Grantmakers In Aging (GIA) hosted two webinars as part of their new “Conversations with GIA” webinar series. This exciting, year-long series of monthly webinars focuses on topics critical to funders and others interested in improving the experience of aging in America. The first webinar featured Kathy Greenlee, Assistant Secretary for Aging at the U.S. Department of Health and Human Services.

John Feather and Kathy Greenlee

Assistant Secretary Greenlee’s “Conversation” pointed to the importance of GIA’s growing membership of grantmakers in today’s policy environment (Click here to listen to the entire screencast). Particularly, the discussion examined the role of philanthropy vis-à-vis the reauthorization of the Older Americans Act and the federal budget for aging programs. Greenlee encouraged funders and others in the aging network to serve as “ambassadors for seniors,” to talk with others and advocate for the aging services needed in this country (such as Medicaid, low-income housing, and transportation). Funders, particularly at the local level, she noted, can play important roles with their counterparts in government and senior serving agencies. “I’m a big fan of GIA and the foundations that you work with,” Greenlee said.

The February 2012 “Conversation with GIA” continued to explore policy questions, this time from the states’ perspective. Entitled “More With Less: Developing Innovative State-Level Programs to Serve Older Persons in the Community,” the webinar featured Sue Birch, Executive Director of the Colorado Department of Health Care Policy and Financing, a cabinet-level position in the administration of Governor John Hickenlooper.

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It’s easy to feel lost, disconnected, and isolated.  When we feel this way our ability to make change is limited.

In our effort to make a strong, networked community for those engaged with the Foundation and its mission, one possible tool is a discussion forum where people can ask questions and get answers – from all those engaged.

I don’t know if the comment feature of Word Press, the software underlying the blog and learning center is a good fit for this need, but I thought we should find out.

Beginning the Conversation:
Integrating Geriatrics Education and Practice

Background
In 2009-10, the John A. Hartford Foundation conducted a communications audit to explore opportunities to amplify and augment the work of our grantees and impact of the Foundation. One of the audit’s key findings was that respondents encouraged the Foundation to more deliberately link its investments in education and training programs with those made to support the new models of practice and service delivery. This echoes recommendations suggested in the 2008 Institute of Medicine report, “Retooling for an Aging America” and recognizes the critical relationship between the success of clinical and service models designed to improve the care of older patients and what happens in education and training efforts in academic and practice settings.  We also know that information must flow in both directions between clinical care and the education sector in order to create the workforce we need for the 21st Century.

GSA Event: An Initial Conversation
Since the audit, the Foundation has launched a Strategic Planning process that is reviewing its grant making approaches generally.  As part of this work, and in an effort to learn more about how we might better connect our education and service grants more effectively, the Foundation hosted a small, group discussion at the Gerontological Society of America (GSA) Annual Meeting at the Boston Sheraton Hotel on Saturday, November 19.  In addition to Foundation program staff, 19 people attended including several Foundation grantees and a number of service delivery leaders in the Boston area (see Appendix A).  A lively and informative conversation ensued (See Appendix B for the meeting’s agenda).

Christopher Langston, Program Director of the Hartford Foundation, opened the discussion by framing the issue and the gathering’s objective, which was to “start a conversation about the connections between the care needed for older adults and the education and training required to prepare a workforce to deliver that care.”  Ultimately, he said, the Foundation was hoping for ideas that “will make the most difference now in improving the health of older adults.”

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The John A. Hartford Foundation (JAHF) and the National Association of Geriatric Education Centers (NAGEC) recently convened an intensive one-day strategic planning session with twenty key representatives from around the nation. Participants included leaders in geriatrics and geriatrics education, palliative medicine, nursing, public health, planning, and public policy, as well as the Hartford Foundation’s executive staff. Meeting at Foundation headquarters, the group shared experiences in their fields and generated ideas to enhance and improve the work of the Geriatric Education Centers (GEC). The result was a decision to move in new directions.

In his opening remarks, the Foundation’s Program Director, Christopher Langston, PhD, set the tone: “We have to look at the big picture,” he said. Let’s face it—available monies are greatly diminished when compared to ten years ago. We have to develop non-financial powers. What do I mean by this? I mean convening people; developing new synergies, ideas, and plans; and identifying how the various sectors of society can work together. We must work to determine where our interests and missions intersect and then be able to move forward to create partnerships in new places.”

The meeting revolved around three broad areas: developing partnerships, conducting outcome evaluations, and retooling for an aging America. The morning session included participant speakers, who gave concise topic summaries. Langston provided an overview of the Institute of Medicine’s report, Retooling for an Aging America. Roseanne Leipzig, MD, PhD, of the Brookdale Department of Geriatrics and Palliative Medicine, presented a brief survey of the geriatric education initiative. Janet Frank, DrPH, of the David Geffin School of Medicine at UCLA, discussed developing partnerships to extend GEC. Julia Hannum-Rose, PhD, Professor of Medicine and Palliative Care, Case at MHMC, spoke about current NTACC resources in support of GECs.

Participants then divided into three breakout discussion groups to confer about their assigned issues and develop recommendations for strategic next steps. At the end of the day, everyone reconvened, and group leaders reported the results of their deliberations. These included the following recommendations to HRSA:

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Several years ago, the American Association of Colleges of Nursing (AACN) came to the Hartford Foundation with unsettling news. The AACN, in partnership with other nursing organizations, had developed a new, national consensus model for regulating the licensure, accreditation, certification, and education (LACE) of advanced practice registered nurses (APRNs), which would, in effect, mean the end of geriatric nurse practitioner programs as they currently exist.

The new LACE guidelines would merge the curricula and certification requirements of the previously distinct specialty of geriatric nursing with the much broader field of adult-care nursing for both clinical nurse specialists (CNSs) and nurse practitioners (NPs). Not only were those professionals who were committed to the field of geriatric nursing apprehensive, but as Rachael Watman, senior program officer at the Foundation, explains, “We were somewhat nervous that the gerontology piece would be watered down in the new curricula. We were concerned it would result in “gero-light” competencies, curricular resources, and certification exams.”

AACN was sensitive to JAHF’s concern. “Hartford had a stake in not wanting these programs to turn out nurses who were unable to provide quality care to older adult patients,” says Joan Stanley, senior director of education policy at the AACN and a co-facilitator in developing the consensus model. “To ensure that they really did provide comprehensive preparation to care for the older adult population, we came to the Hartford Foundation and suggested that we needed to create a set of consensus-based standards and competencies for these new or expanded programs in order to ensure nurses would have the knowledge and skills required in the care of older adults.”

As a result, JAHF requested that AACN submit a formal grant proposal. Hartford made the grant in 2008. The solution seemed a good one, although the transition wouldn’t be easy. For many, especially those already established in gero-nursing specialties, the new model proved difficult to accept, but unfortunately, the old way of doing things had produced disappointing results. “The Foundation had funded an effort to develop NPs in gerontology, but nationally the numbers of APRNs specializing in geriatrics were low and did not keep pace with the demographic need,” says Watman. “With the combination of adult and gero, we know that many, many more nurses will graduate with the skills to care for older adults.”

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This year, 2010, marks the 10th anniversary of the Building Academic Geriatric Nursing Capacity (BAGNC) initiative, and we’d like to offer our congratulations to the program’s leaders and its awardees. It has been a decade of remarkable achievement.

The Birth of an Initiative
The BAGNC Initiative began back in January 2000, when the Hartford Foundation held an invitational meeting to give experts and thought leaders an opportunity to discuss the major health care issues of older adults and to identify strategies to improve geriatric nursing care.

By the end of the meeting, two questions had emerged: (1) What were the critical issues in professional nursing that might affect the care of older adults? And (2) what challenges to improving care for older adults were most relevant and amenable to solutions by nursing schools and the Hartford Foundation? To find answers, the Foundation commissioned several papers.

This work led Hartford to formulate two top priorities that would frame a new initiative in nursing: creating centers of geriatric nursing excellence and increasing the number of gerontological nurse researchers. The Foundation’s commitment to these goals marked the birth of the BAGNC initiative.

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The John A. Hartford Foundation supports a number of programs designed to increase the number of physicians who choose academic geriatrics as their career, and others that promote aging-related medical research. One of the Foundation’s most successful initiatives, however, does both: the Medical Student Training in Aging Research (MSTAR) program. Nine percent of the earliest program participants have gone on to become medical school faculty with expertise in aging, compared to the one percent of students nationwide who go into geriatrics fellowships.

MSTAR, administrated by the American Federations for Aging Research (AFAR), gives medical students a taste of aging-related research under the mentorship of top experts in the field at some of the nation’s most prestigious medical schools. At the end of each year’s session, MSTAR scholars crown their training achievements by presenting posters of their research projects and participating in a networking event with prominent scholars of aging at the Annual Scientific Meeting of the American Geriatrics Society (AGS).  The poster session and networking event are sponsored in part by the AGS Foundation for Health in Aging.

Seventy-two of the 2010 MSTAR cohort presented at this year’s AGS conference, held in Orlando, Florida, and by all accounts, their posters proved a resounding success. They covered a broad range of topics, from Alzheimer’s-related changes in the brain to the relationship between depression and disability. You can read more about their presentations on the Foundation’s blog, Health AGEnda.

MSTAR is a continuation of the original Hartford/AFAR Medical Student Geriatric Scholars Program, established in 1994. Today, the Foundation partners with two other major sponsors, the MetLife Foundation and the National Institute on Aging (NIA), in supporting the program. Over the past 16 years, the program has provided training in basic science, clinical, and health services research to 1,354 students from more than 120 medical schools. Any student in good standing who has completed at least one year of study at an accredited medical or osteopathic school in the U.S. can participate in the program.

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At Yale New Haven Hospital, in Connecticut, a group of chief residents are collaborating on a one-day, case-based training session for residents-in-training on ambulatory care rotations. At Marshall University, in Huntington, West Virginia, internal medicine chief resident William Nitardy is surveying residents’ knowledge and use of advance directives in the hope of helping all residents in training understand more about the goals of care for their patients. All around the nation, these and similar programs are up and running, following a series of innovative two-and-a half day training retreats sponsored by the John A. Hartford Foundation.

Over 194  chief residents participated in the Chief Resident Immersion Training (CRIT) program retreats at nine  medical institutions across the country. The gatherings focused on fostering collaboration among disciplines in the management of complex older patients. Hospitalized older patients typically have multiple chronic conditions that need management during their stay, requiring collaboration and consultation across a number of specialties.

As collaboration among disciplines is a major goal of CRIT, representation from multiple specialties is a critical component of the program. This year’s CRIT programs brought together chief resident participants from 18 specialties, including anesthesiology, emergency medicine, family medicine, general surgery, internal medicine, neurology, obstetrics and gynecology, ophthalmology, orthopedic surgery, neurosurgery, otolaryngology, pathology, pediatrics, radiation oncology, rehabilitation medicine, psychiatry, thoracic surgery, and urology.   During the retreats, chief residents worked through an unfolding, interactive surgical case, following a geriatric patient  from first presentation in the emergency department to hospital discharge. The cases were divided into three  modules. Each module included mini-lectures on topics in geriatric medicine, small group interactive exercises, and seminars designed to enhance teaching and leadership skills. The program’s aim was to give new chief residents a greater understanding of geriatrics principles and improved teaching and leadership skills they can use immediately.

All chief residents also attended two or three mentoring sessions throughout the retreat weekend to help them develop a project for implementation in their chief resident year. The projects focused either on resident education, improvement of clinical care, institutional change, administration, or patient education. With a July 1st start date—aligned with the resident education calendar—CRIT program “graduates” are now well underway in their new roles, and action plans developed during their CRIT retreats are in progress.

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