North Florida/South Georgia Veterans Health System
Geriatric Research, Education, and Clinical Center: Clinical Care & Innovation
John Meuleman, M.D.
Associate Director for Clinical Care & Innovation
Clinical activities of the GRECC are integrated within programs of both the Gainesville and Lake City sites. GRECC clinical activities occur in the following settings: the nursing home care unit, geriatric evaluation and management unit (GEM), home-based primary care, respite care program, geriatric primary care clinic, gait/balance clinic, and community hospice/palliative care unit.
Geriatric Evaluation and Management (GEM) Unit
The Geriatric Evaluation and Management Unit (GEM) is a 18 bed subacute care unit located on the third floor of the Nursing Home Care Unit Building. The GEM provides interdisciplinary, transitional care to older patients whose complex medical and functional problems jeopardize their ability to live at home. The GEM Director is Colleen Campbell, ARNP, a member of the GRECC. An interdisciplinary team provides care and meets weekly. The GEM serves as a site for training, with regular rotations by Medicine residents, fourth year medical students, pharmacy residents, psychology and social work trainees and others.
The GEM unit at the VAMC provides Medicine residents the opportunity to learn about geriatric and palliative care medicine. The GEM unit provides sub-acute care to veterans who are not able to go to extended nursing care or home. During the GEM month, residents are part of a large intra-disciplinary team that includes physical therapists, occupational therapists, speech therapists, dieticians, and case managers. Residents learn about many of the issues that geriatric patients face in their medical care.
Palliative Care Unit
The Palliative Care Unit (PCU) is an 8 bed unit which provides end of life care to terminally ill patients. It is located on the third floor of the Nursing Home Care Unit building. An interdisciplinary team, many of whom are also members of the GEM team, addresses the medical, emotional and spiritual needs of the patients and their families. The PCU Director is Leslye Pennypacker, MD, a member of the GRECC. The PCU serves as an educational site for trainees from many disciplines.
Gait & Balance Clinic
The Gait and Balance Clinic is a multidisciplinary clinic involving a senior GRECC neurologist, GRECC fellows, neurology residents, staff and trainees in pharmacology, and physical therapists with particular expertise in the treatment of disorders of gait and balance. It provides consultative service and treatment for patients with impairment of balance and walking, and patients with falls related to multifactorial disequilibrium, neurodegenerative disorders such as Parkinson's disease, orthopedic disorders, chronic pain, vertigo, orthostatic hypotension, and syncope. The clinical team recommends diagnostic evaluation and renders advice on medical treatment, and the physical therapy group provides gait rehabilitation, home gait treatment programs for patients who cannot regularly visit the hospital, orthotic and gait appliances, and modifies homes to minimize fall risk. Through involvement of trainees, the Gait and Balance Clinic serves as a major venue for education. A HIPAA compliant database exists to enable monitoring of the impact of Clinic interventions and to enable investigators to perform treatment studies.
Inherent in the GRECC mission is the development of innovative programs which to improve the care of older veterans. The contiguous placement of basic scientists, clinical scientists and clinicians under one roof fosters these projects. Some examples of NF/SG GRECC clinical demonstration projects are described below.
Patient-Directed Home Safety Assessment
The North Florida South Georgia Veterans Health Care System (NF/SGVHA) and its assigned Geriatric Research Education Clinical Center (GRECC) are located in rural North Central Florida and South Georgia. The Florida Chart Book on Disability and Health identifies that 5 of the top 10 counties with the highest proportion of elders with self care deficits lie within NF/SGVHA System’s boundaries. Because of the large geographical size of NF/SGVHA catchment area it is difficult to obtain in-home safety assessments.
In keeping with the goal of improving the functional status of the frail older adult, Colleen Cambell and colleagues developed a clinical demonstration project to examine whether a family member can act as the “eyes” of an Occupational Therapist (OT) and obtain meaningful home safety assessment data.
The project team purchased a low cost, easy to operate video camera. The team also developed a 1 page measurement guide for the families to record width of doorways and height of entry ways. Patients who participated in the project usually lived distant from our medical center. The OT assured a family member could operate the video camera, read a measuring tape, understood the measurement guide and which areas to film. Once the family member returned the video camera, the Therapist analyzed the video and measurement guide results. Feedback was provided to the GEM interdisciplinary team, patient and their family. Appropriate durable medical equipment was ordered and recommended home modifications were explained to the patient and the family. Response to the project has been quite positive. All patients and their families approached agreed to participate. Disabilities of patients included the sequelae of a variety of health issues such as stroke, falls, amputation and deconditioning.
Several problem areas in the home were targeted such as the bathroom and the entry into the home. Every patient assessed had bathroom safety concerns. Sixty percent of the patients required an assistive device for mobility within the home. Among the 29 patients in the pilot group 38 percent required modifications to the home entry.
The OTs spent up to an hour teaching the family camera usage and then reviewing home video data. This freed up approximately 116 hours that would have been required for travel and in-home assessments. The video project team was consistently satisfied that family members had obtained meaningful video information which allowed the OTs to individualize their home safety recommendations.
Patient Empowerment Studies
Stroke is the third-leading cause of death in the US, resulting in 1 of every 16 deaths in 2004, half of which occurred out of hospital. Moreover, stroke is the leading cause of serious long-term disability in the US. The VHA estimates that approximately 17,000 veterans were treated for stroke during fiscal year 2005. One year post-stroke mortality for VA inpatients is 20%, while 30% of veterans with stroke are discharged to non-community institutional settings.
Prevention and early intervention are crucial to reducing the burden of stroke, however, rates of public awareness of stroke risk factors are low and vary. One strategy to increase awareness is to utilize a direct-to-consumer strategy to educate patients and influence their health behavior. This approach was the foundation for the pilot project, “Disseminating Stroke Prevention Materials to Veterans: The Development of a Direct-to-Consumer Implementation Strategy (STR-4-347). Several traditional marketing strategies were used to implement this project. For example, a recognizable figure was enlisted to help deliver the “Reduce Your Risk, Prevent a Stroke” campaign message. Mort Walker, Beetle Bailey comic strip creator and WWII veteran, supported the project and generously donated custom cartoons of Army Sergeant “Sarge” Snorkel demonstrating “high-risk” and “prevention” behaviors. Another strategy was to negotiate partnerships with well-established and highly credible stroke-related organizations, the American Stroke Association/American Heart Association and the National Stroke Association, who contributed educational materials to the packets. Other VA entities, including the VHA National Center for Health Promotion and Disease Prevention, the VA Office of Public and Intergovernmental Affairs, and the Office of Research and Development were instrumental in delivering the message to VA clinicians, researchers and employees. These groups provided information about the stroke packets via their Web sites, e-mails, monthly conference calls, the VA Research Currents newsletter, and VA employees’ Earnings and Leave statements. Response to the campaign from veterans, clinicians, and employees has been overwhelmingly positive.
Beyth and GRECC colleagues Ronald Shorr, MD, MS, Constance Uphold, PhD, ARNP, as well as collaborators from the University of Florida College of Journalism and Communications have now received VA funding from the VA HSR&D QUERI program for a second project, “Intervention Development for Shared Decision Making in Stroke Prevention” (QUERI, RRP #07-305), that will use the direct-to-consumer approach to create a video to activate patients with atrial fibrillation to ask their providers about anti-thrombotics to prevent stroke. The use of direct-to-consumer marketing for health promotion is a promising strategy to increase awareness about modifiable risk factors and health behaviors. As evidenced by our pilot project, large numbers of participants can easily be reached, and prompted into action. With the increasing burden of comorbidities on an aging population, and the fragmentation of healthcare that occurs in these vulnerable patients, such tactics are an integral part of the dissemination and translation of research discoveries and innovations into better patient care.
Annually, more than half a million people in the US die either in or shortly after discharge from an Intensive Care Unit (ICU). Our facility is no exception, with more than 40% of in-patient deaths occurring in the ICU's last year. Since ICU patients frequently receive inadequate end-of-life care, Dr. Leslye Pennypacker initiated an effort utilize our electronic medical record system (Computerized Patient Record System- CPRS) to design and implement a "virtual hospice" within our Medical ICU. All clinicians rotating through the MICU between 10/1/05 - 9/30-06 were oriented to the use of "MICU-Hospice" templates regarding goals of care, Do Not Resuscitate (DNR) status, and clinical pathways for pain and symptom management that could be utilized in the care of actively dying patients that were too unstable for transfer. During this one year period, 18% (15 out of 85) of patients who died in the MICU were managed via this approach. Referrals to MICU-Hospice were from housestaff (53%), patient/family (40%), and attending physicians (7%). Analysis of the process of care for MICU-Hospice patients demonstrated that all patients had clear DNR orders, goals of care discussed, and appropriate orders for opioids; restraints were continued in only 20%, Foley catheters in 100%, nasogastric tubes in 33%, mechanical ventilation in 20%, and rectal or PEG tubes in 27%. We believe that, although providing comprehensive palliative care in the ICU setting can be challenging given that the goals of care are more often focused on "cure", our pilot MICU-Hospice program was well received, appropriately accessed, and improved the process of care for actively dying patients in the MICU setting. Future challenges include exporting this program to include our surgical ICU's in an effort to provide palliative care to all actively dying ICU patients within our large, university affiliated VA medical center.
Influenza Prevention Demonstration Project:
Dr. Radonovich is leading a demonstration project that aims to assess whether influenza is transmitted among humans via small particle aerosol and whether upper-room ultraviolet light diminishes influenza transmission in the nursing home setting. This project builds on evidence that hospital-based tuberculosis transmission is diminished with the use of upper-room ultraviolet, a prevention method that has been used for more than fifty years. The North Florida/South Georgia Veterans Health System is a key participant in this collaborative project that also includes the VA Medical Center in Bedford, Massachusetts, the University of Florida, the University of Massachusetts, and Harvard University. A series of precursor studies will assess the incidence of influenza and other common respiratory pathogens in the nursing home setting.
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