Geriatric Research Education and Clinical Center (GRECC)
GRECC Clinical Innovations: January - March 2018
Baltimore GRECC Clinical Innovations
Local contact: Jacob Blumenthal, MD
P: 410-605-7000 ext. 5426
E: Jacob.Blumenthal@va.gov
RISE
In Rise Veterans who are at risk for falls or mobility difficulties participant in a combination of balance exercises, strength training, and an obstacle course. While the program is still in its initial stages so far participants are reporting large improvements. One Veteran reports that after three months of participation in the program he is able to genuflect at Mass for the first time in many years. Another participant who recently completed six months of the study reports that he can now walk better and stand on one leg. Previously he reported difficulty when trying to stand from a chair and was unable to stand on one leg without falling.
https://www.research.va.gov/currents/1117-Stepping-up-their-game.cfm
Vets Foster Pets
Training veterans to be companion dog foster caretakers improved their quality of life and increased leisure-time physical activity, a novel project led by Dr. Heidi Ortmeyer at the Baltimore GRECC has revealed. This progam was so well-received that its expansion has been proposed (with partnership with the VISN 5 Mental Illness Research, Education and Clinical Center -- MIRECC) to target older Veterans with PTSD.
Birmingham/Atlanta GRECC Clinical Innovations
Local contacts:
Alayne Markland: alayne.markland@va.gov
Camille Vaughan: elizabeth.vaughan2@va.gov
Telehealth Initiatives
- GRECC Connect - Provides geriatric consultation for rural Veterans and their providers in Alabama and Georgia through clinical video telehealth. GRECC Connect started in 2017 and continues in 2018 with support from the Bronx VAMC and the Office of Rural Health.
- Geriatric Continence Consultation Services – Provides geriatric continence consultation for evaluation and treatment of Veterans with bladder or bowel incontinence and their caregivers in Alabama and Georgia through clinical video telehealth and telephone visits. Program started in 2018.
- Home Telehealth Programs – Designed to develop a cost-effective method of successfully delivering an evidence-based pelvic floor muscle training program for Veterans to help them regain bladder control. Current models being tested include web-based home telehealth programs to reduce incontinence in men undergoing prostate cancer surgery and for women Veterans.
- Stroke Rehabilitation Services for Rural Veterans - Investigates feasibility and effectiveness of accessible tele-robotic stroke therapy provision to Veteran stroke survivors in rural underserved locations. This project was selected by the Office of Rural Health as a VA Promising Practice.
- VA Tele-SAVVY - Dementia Caregiver Program - Designed to provide education and support to Veterans with dementia and their caregivers. Currently, a clinical research study is ongoing to evaluate outcomes related to this novel home program.
Bronx GRECC Clinical Innovations
Local Contact:
Annette Hintenach
P: 718-584-9000, ext. 3853
E: Annette.Hintenach@va.gov
RHIO-Enhanced Care Transition Intervention Program Bridges Care for Older Veterans Who Utilize Non-VA Acute Care
Patients who transition from acute care to primary outpatient care are at high risk for adverse outcomes such as readmissions and medication errors. Primary care patients at the VA who utilize non-VA acute care services are at particularly high risk for these adverse outcomes due to lack of coordination between non-VA and VA sites. The Bronx Regional Health Information Organization (RHIO), a community electronic health information network system, provides an opportunity to improve care coordination between non-VA and VA sites by providing a platform for sharing clinical data among facilities. The VISN 2 GRECC, based at the James J. Peters VA Medical Center, has developed a Care Transitions Intervention (CTI) to serve Veterans who are recently discharged from a non-VA hospital, utilizing push messages from the RHIO system for notification. Upon notification of the acute care event, a CTI is delivered by a care transitions coach through a home visit and telephone follow-up calls. The intervention contains a structured protocol of monitoring and retrieval of non-VA hospital and emergency department discharge information using the Bronx RHIO, coordination of urgent and follow-up appointments, condition specific patient education and communication, medication reconciliation, and provider communication. The project has led to improved communication between care teams and identification and meeting unmet care needs for Veterans during transitions of care. The project has also helped inform the transitional care program at the VA Hudson Valley Health Care System, and the use of push messages has disseminated to the Indianapolis VA Medical Center. A rigorous evaluation using a randomized study approach is ongoing at the Bronx and Indianapolis sites. Related journal article: Hung WW, Morano B, Moodhe N, Boockvar K. Regional Health Information Organization (RHIO): its potential uses to improve veteran health care. Federal practitioner.
For more information about the Care Transitions program at JJP VAMC, contact Nicholas Koufacos, Care Transitions Coordinator at (718) 584-9000, ext. 3851.
Cleveland GRECC Clinical Innovations
Cleveland GRECC’s Geriatric Emergency Room
Older Veterans represent about 45% of the patients seen in VA emergency rooms and generate many revisits and admissions. “GERI-VET” adds a comprehensive geriatric evaluation (CGE) performed by “intermediate care technicians” (former military corpsmen) to ER visits for Veterans older than age 75. Follow-up to address issues identified through the CGE is intended to prevent ER revisits and hospital readmissions. Over 250 Veterans have participated in GERI-VET to date outcomes confirm the program’s effectiveness in reducing rates of hospitalizations and ED re-visitations in this high-risk group.
Durham GRECC Clinical Innovations
Local Contacts:
mitchell.heflin@va.gov
Jeffrey.browndyke@va.gov
Phone: (919) 286-6932
Delirium Risk Evaluation and Management
Our Perioperative Optimization of Senior Health (POSH) was recently awarded 125k for a new POSH related project: Delirium Risk Evaluation and Management (POSH-DREAM)
In 2015, the Perioperative Optimization of Senior Health (POSH) program was launched through the Durham VAMC GRECC with support from the Office of Academic Affiliations and Specialty Care Transformation. The overarching goal of the POSH program is to improve surgical outcomes in older Veterans, while optimizing the efficiency of the perioperative clinical processes, as well as providing inter-professional educational opportunities for VHA trainees.
The DREAM project will refocus resources and modernize our existing presurgical screening processes for cognitive and mental health issue via hand held devices to improve delirium risk stratification and postoperative delirium identification and ultimately lead to optimized pre-/postoperative care planning for our older Veterans, their caregivers and VHA intensive care unit staff.
Project objectives include:
Objective 1: Optimize and modernize preoperative screening of cognitive status and psychiatric distress in older Veterans undergoing general surgery
Objective 2: Enhance postoperative detection, monitoring and management of delirium and psychiatric distress in older Veterans undergoing general surgery.
Stay tuned for an outcome update in December 2018.
Miami GRECC Clinical Innovations
Clinical Demonstration Models
What is a “Demonstration Model?” Clinical researchers in the GRECC review a process of care – inpatient or outpatient – and, often with collaborators, modify and study the process in an effort to improve the outcome for our Veterans. Over the years, the GRECC has worked very closely, not only with Geriatrics and Extended Care but also with Urology, Neurology, Rheumatology, Primary Care, Orthopedics, Hospital Medicine and others to improve our care processes for elderly Veterans. An important aspect in the discoveries made by demonstration models is to “get the word out.” GRECC does this through direct feedback to the facility leadership, presentations at local/national meetings, education, publications, etc. For example, to disseminate GRECCs’ discoveries in frailty, the Miami and Gainesville GRECCs collaborated with clinician researchers at the Durham, New England and San Antonio GRECCs to present new discoveries in frailty at the annual VISN 8 Conference in Geriatrics/Palliative Medicine and at the 2018 International Conference on Frailty and Sarcopenia Research. These combined events reached PACT and clinical staff throughout VISN 8 as well as an international audience of clinician researchers and scientists.
Miami GRECC’s most recently funded demonstration model will address the care requirements of High Need/High Risk (HN/HR) Veterans. These Veterans are often frail with many of the same complex needs as Veterans in our home-based primary care program. In collaboration with the GeriPACT team, the “HN/HR demonstration model” will create an outpatient clinic to assess the special needs of these Veterans and develop a list of potential interventions that will allow Veterans to continue care in GeriPACT or pursue care in the home-based primary care program or other Extended Care options. This demonstration model will function for 1.5 to 2.5 years improving our understanding and care of HN/HR Veterans.
Palo Alto GRECC Clinical Innovations
Local Contact:
Christine Gould, PhD
Acting Associate Director for Education and Evaluation
Palo Alto GRECC
Phone: 650-493-5000, x68899
Geri-Mobile Health: Supporting Older Veterans’ Use of VA Mental Health Apps.
Dr. Christine Gould of the Palo Alto GRECC received funding from VA Geriatrics and Extended Care for a new clinical innovation program focused on self-management of mental health using VA mental health mobile applications (apps). The program, Geri-Mobile Health, is a proactive approach to mental health care closely aligned with the VA Whole Health initiative. Through the Geri-Mobile Health program, older Veterans will learn how to use three VA mental health apps (Mood Coach, Mindfulness Coach, and PTSD Coach) to manage mood, anxiety, and PTSD symptoms.
As part of the Geri-Mobile Health program, patient education materials will be developed to help older Veterans use VA Mobile Apps. Accompanying provider materials will be developed to assist mental health providers in teaching older Veterans about the apps. The materials will be piloted in the Geri-Mobile Health program in which providers will offer coaching support to: (1) promote technology use to ensure that older Veterans are able to use these self-management apps, and (2) encourage behavior change using the skills taught within the apps, helping Veterans meet their mental health care goals. Veteran-level and program-level outcomes will be evaluated.
Mental health self-management using VA mobile apps has the potential to reduce the large number of deaths by suicide among late-middle aged and older Veterans, a population that accounts for 65% of all Veteran deaths by suicide (Office of Suicide Prevention, 2016).
This project represents a new collaboration between the Palo Alto GRECC and the Dissemination and Training Division of the National Center for PTSD at VA Palo Alto Health Care System.
Pittsburg GRECC Clinical Innovations
Local Contact:
Michelle I. Rossi, MD
Phone: 412-360-1870
Teledementia Caregiver Support Group
The Teledementia Caregiver Support Group was developed to assist caregivers of Veterans receiving care in the Teledementia clinic, an interdisciplinary telehealth clinic at VA Pittsburgh Healthcare System for Veterans with cognitive decline. Caregivers who had indicated high caregiver burden (12 item Zarit burden interview score > 17) were contacted for participation in a monthly support group via clinical video telehealth (CVT). Each caregiver attends the support group at the local Community Based Outpatient Clinic (CBOC) and using CVT technology is able to participate in the support group with other caregivers at other CBOCs. The sessions are led by a psychologist and geriatrician with the initial part of the session being an interactive educational session on common issues found in patients with dementia. The remainder of the session allows the caregiver participant group to share experiences and ask questions.
The first monthly session was held in July 2016 with 15 total sessions occurring through December 2017. Each session was attended by a range of 1-6 participants with an average attendance of 3.5 per session. A total of 12 caregivers have participated in the program with the range of number of sessions attended between 1 to 10 sessions (average 4.08 sessions). After 4 months, satisfaction with the support group was assessed. On a 5 point Likert scale with 5 questions the participants rated the intervention an average of 4.5/5. The participants appreciated the ability to attend a support group with other Veterans’ caregivers without driving a long distance. Further analysis of caregiver burden after support group participation is in process.
Puget Sound GRECC Clinical Innovations
Local Contact:
Jose M. Garcia, MD PhD
GRECC Investigator
(Jose.Garcia@va.gov)
Macimorelin approved for adult growth hormone deficiency (AGHD) diagnosis
The U.S. Food and Drug Administration (FDA) approved the novel drug macimorelin as a diagnostic test for adult growth hormone deficiency (AGHD) on December 20, 2017. This is the first test ever approved in the U.S. for this indication. The approval was based on an international, multicenter, phase III clinical trial led by Puget Sound GRECC investigator and SIBCR member, Dr. Jose Garcia, with participating research sites at VA Puget Sound Health Care System, Seattle division, and Michael E. DeBakey VA Medical Center in Houston, Texas. As AGHD is a problem many returning Veterans with traumatic brain injury (TBI) suffer from, this test may benefit our Veterans as well as other individuals suffering from this condition.
Memory Support for Older Adults with Post-Traumatic Stress Disorder [PTSD] (MSOAP)
This initiative provided an outpatient PTSD group the means to enhance memory skills and PTSD self-management. Alterations of attention/memory are among the diagnostic criteria for PTSD, and is a risk factor for dementia in older Veterans. After participating in the groups, questionnaires assessed PTSD symptoms, cognitive complaints, sense of self-efficacy, satisfaction with the group experience and materials, feedback on group improvement and indices of quality of life. Analyses demonstrate overall satisfaction, decreased depressive symptoms, no increase in PTSD symptoms, and increased sense of self-efficacy.
Tennessee Valley GRECC Clinical Innovations
Local Contact
P: (615) 873-6063
E: sumathi.misra@va.gov
Tennessee Valley GRECC Improves Care in Intensive Care Units through:
- Their ABCDE delirium prevention bundle results in less time on ventilators, 50% delirium reduction, 30% mortality reduction, more than a two-fold reduction in long term cognitive impairment, and reduced ICU and hospital lengths of stay. ABCDE achieves these impressive results by employing Awakening and Breathing trials through Coordinated efforts of nursing and respiratory therapy; Delirium surveillance, prevention, and treatment; and Early mobilization and ambulation.
- The THRIVE ICU Support Group: served ICU survivors and family members in 33 sessions offered October 2016 - July 2017. Of those surveyed, 93% felt emotionally supported, 91% learned from others, 77% now understand common situations related to prolonged ICU stay, 86% would strongly recommend group participation to a friend, and 42% expressed interest in volunteering to provide peer support to others.
- ICU Diaries were kept by 29 staff in 2017. On a 100-point scale, diary knowledge increased from 38.8 to 71.85, belief that diaries are beneficial rose from 62.74 to 76, and comfort level with educating family from 44.4 to 78.46. Benefits noted included increased family engagement, enhanced communication, and an enriched frame of reference for hospitalization.
DINC (Do I Need a Catheter): The program is a 5- component intervention designed to reduced catheter use and CAUTI (catheter-associated urinary tract infections) while also addressing barriers to long-term success. Catheter use declined 35% and time between infections increased (longer is better) from 101 days at baseline to over 400 days following implementation of the DINC project. A multifaceted quality improvement strategy reduces the risk of catheter-associated urinary tract infection. Int J Qual Health Care. 2017 Aug 1; 29(4):564-570
Veterans Cognitive Assessment and Management Program (V-CAMP): V-CAMP provides distance dementia caregiver support. Operating under the GERI-PACT framework, rural patients receive dementia care and caregiver support using Clinical Video Telehealth (CVT). This project involves collaboration with five CBOC’s affiliated with TVHS and is offered as part of the established Dementia Consult Clinic. Over a 13-month period, of 12 patient-caregiver pairs; 30% of patients had mid- stage and 70% had advanced vascular or Alzheimer’s type dementia. 100% patient-caregiver pairs had positive receptiveness to CVT visits, 80% patients remained home, and 20% patients admitted to dementia care units. A total of 30% patients stopped medications because of adverse side effects or lack of perceived efficacy by caregivers.
The Surgery Telephone Postoperative Clinic: Development and evaluation of a general surgery telephone postoperative clinic at TVHS on 200 patients who underwent eligible operations. In-person clinic use decreased from 0.83 visits per eligible patient pre-clinic to 0.40 after clinic (p < 0.01) with no difference in rates of emergency room visits or readmission (0.17 visits/patient pre-intervention vs 0.12 post-intervention; p = 0.36). Complication rates were comparable in both groups (6% vs 8%; p = 0.31). J Am Coll Surg 2016 Oct; 223(4):644-51.
