NYU receives $2.55M HRSA award clinical/community partnership for older adult care

New York University College of Nursing's Tara Cortes, PhD, RN, FAAN, professor of geriatric nursing and executive director of the Hartford Institute for Geriatric Nursing, has been awarded a 3-year $2.55 million Health Resources and Services Administration (HRSA) grant through the Geriatrics Workforce Enhancement Program (GWEP), entitled, "Community/Clinical Primary Care of Older Adults Program (CC-PCOA)." GWEP supports the development of a health care workforce that improves health outcomes for older adults by integrating geriatrics with primary care and community resources to maximize patient and family engagement better manage chronic disease and promote optimum function in older adults.

"This initiative creates a paradigm shift from the traditional perception of primary care as a visit to a doctor to one in which primary care is woven throughout a continuum of locations that extends into the community where care plans can be enhanced to attain better health outcomes through non-traditional interventions," said Dr. Cortes.

Dr. Cortes and her team at the Hartford Institute for Geriatric Nursing will be partnering with Montefiore Health System and Regional Aid for Interim Needs, Inc. (R.A.I.N.), a community organization in the Bronx, to implement an interprofessional, multi-modal educational intervention aimed at creating a culture that values the health of our aging population.

Montefiore was chosen as a partner because of its advanced research and specialized services for patients with Alzheimer's disease and other dementia-related conditions, and because of its extensive primary care network serving many older, frail and vulnerable patients and large medical resident training program. Montefiore also stands out for its leadership in the Pioneer Accountable Care Organization program for Medicare fee-for-service beneficiaries.

R.A.I.N., the community based partner in the grant, is a large not-for profit, multi-service organization that operates multiple senior centers and provides a menu of senior support services in the Bronx and upper Manhattan. R.A.I.N. will provide its expertise through programs that promote overall wellness and provide nutritional, transportation, and care management services to seniors. R.A.I.N. employees and a corps of volunteer community health workers will be trained in geriatric care so that patients and their caregivers can be better supported in the community. This will include a program on caring for patients with dementia targeted at home health aides.

The CC-PCOA will build the capacity of the primary care workforce in clinical and community settings to address health care gaps for older adults and maximize patient and family engagement. The program is designed to meet the National Prevention Strategy's goal of increasing the number of Americans who are healthy at every stage of life through a multidisciplinary educational intervention.

The specific objectives are to:

• Provide educational resources to increase age-sensitive knowledge and skills of primary care professionals and promote team-based patient- and family-centered, evidence-based care that is responsive to the needs of older adults;
• Educate primary care clinical providers and community based networks to be coordinating partners focused on promoting health and self-management of disease at the individual, community and population levels;
• Utilize community resources to educate and support older adults, families and caregivers, to promote healthy aging and manage chronic diseases; and
• Provide a comprehensive Alzheimer's Disease and Related Dementias (ADRD) program to address the needs of providers, patients, families and caregivers through community support networks and educational materials and resources.

"The education will focus on interprofessional geriatric-specific care, care coordination and the promotion of wellness through the Medicare Annual Wellness Visit and managing chronic disease - specifically heart failure and diabetes," said Dr. Cortes. "Community resources will support wellness behavior and chronic disease management."

The project will be implemented in five (5) of Montefiore Medical Group's Patient Centered Medical Homes, the Montefiore Einstein Center for the Aging Brain, and numerous community sites in R.A.I.N.'s network throughout the Bronx, NY.

"Being able to collaborate with primary care physicians, subspecialists and caregivers allows us to create comprehensive care plans and resources for geriatric patients and their families," said Joe Verghese, M.B.B.S., director, Montefiore Einstein Center for the Aging Brain, chief, Integrated Divisions of Cognitive & Motor Aging (Neurology) and Geriatrics (Medicine) at Montefiore and Einstein and professor in the Saul R. Korey Department of Neurology and of Medicine at Einstein. "We are pleased to participate in this important project which will draw upon the expertise of clinicians in the fields of geriatrics, neurology, rehabilitative medicine and psychiatry to inform unmet needs and enable us to strengthen care services for many of our most vulnerable patients."

"R.A.I.N. is elated to be a partner in this important collaboration. With the increased life expectancy of New York City's population and the coming of age of the "baby boom" population, the goals of this initiative are paramount. R.A.I.N. is pleased to bring its extensive integrated community-based geriatric experience and expertise to facilitate enhanced health outcomes and expand primary care among the aging population," said Dr. Torres, CEO of R.A.I.N.

The project's interprofessional advisory team and core leadership will oversee the review of all educational resources already available through the partners, and develop a strategy to educate professionals, patients, families, caregivers and direct care workers in the clinical and community partnership.

ADRD activities will be carried out in the Montefiore Einstein Center for the Aging Brain under a physician, social worker and nurse. Cognitive function screening will be a goal for all primary care practices and the Center will develop an interprofessional pathway with community service referrals for caretaker support.

Provided by New York University