Geriatrics Recruitment Resources

1. Build an Administrative Infrastructure

The challenge: To build support for administrative infrastructure that allows faculty and fellows to do what they do best—research, training, and clinical care

Summary

A crucial but frequently underdeveloped component of academic geriatrics programs is a sound administrative infrastructure—the basic organizational structures and services needed to support the academic enterprise. Sound infrastructure contributes to longer-term stability, although planning far in advance can be challenging because of staffing and other issues. One leader referred to his own early efforts to build his program’s infrastructure as more “ad hoc” than “strategic.” Certainly, infrastructure is often the most difficult piece of the academic enterprise for which to build support, as until recently, many funders have been relatively uninterested in supporting it.

Nevertheless, building administrative structures and services must become a more strategic process in an increasingly complex and interconnected academic environment. While program and institutional resources, and even institutional culture, may influence how administrative function is structured, trends are evident. These include pooling resources from grants and other sources to support a more stable infrastructure, and the hiring of non-physician experts for higher-level management/administrative positions and specialized activities.

Strategies

Combine programs, share administrators. Some leaders are sharing administrative positions, including higher-level coordinators and managers, across programs. One leader assumed responsibility for both her clinical program and the institution’s aging center, which focuses on education and research, and shared staff for the two programs. The staff included an administrator/manager, an accountant, several administrative support staff, and an academic coordinator. That coordinator works with junior faculty, educators, and researchers on their projects; coordinates all education programs; and, with the program director overseeing educational and research endeavors, is project coordinator for the Hartford CoE.

Pool financial resources. Support for administrative staff and other infrastructures within academic geriatrics comes through combining dollars from various sources. For example, the academic coordinator mentioned above is jointly supported by the aging center and the dean’s office. Funds for other administrative staff come from a mix of recurring annual state funds; clinical contracts (Continuing Care Retirement Communities, for example); and grants, such as the Hartford CoE, which pays for infrastructure and an accountant; and a Donald W. Reynolds Foundation Aging and Quality of Life grant, which helps support administration.

Share administrative resources with affiliated programs. At one institution with a small geriatrics program that has its own administration, a leader is able to draw informally on administrative resources from programs with which he is affiliated. For example, a center with more resources might provide his geriatrics program with a computer, a programmer, or a research assistant for a particular project. When institutional leadership sanctions a culture of sharing administrative resources, barriers are reduced. The flexibility and availability of such resources allows faculty to access them when they are most needed and make the most sense, so administrative support can be built around the needs of individual projects.

Make the case for supporting specific administrative and management functions. Some funders have begun to support administrative components of a grant. Making the case to funders involves articulating how non-clinical staff brings special skills to administrative and management positions that contribute to the overall effectiveness and efficiency of the initiative and maximize the capacity of physicians (and other clinicians) to carry out their roles. One leader, who has seen an increase over the past decade in funders’ willingness to support non-medical experts and administrative staff, recalled that early on, they “didn’t recognize how much further it would get us to use the money for someone who was not a physician.”

Resources

For more on the Reynolds Foundation Aging and Quality of Life Prorgram, see: http://www.dwreynolds.org/Programs/National/Aging/AboutAging.htm

For more on the Health Resources and Services Administration (HRSA) Bureau of Health Professions Geriatric Academic Career Awards, see: http://www.hrsa.gov/grants/gaca/

For more on the Health Resources and Services Administration (HRSA) Bureau of Health Professions and Geriatric Education Centers (GECs), see: http://bhpr.hrsa.gov/interdisciplinary/

For educational resources developed by the GECs, see: http://bhpr.hrsa.gov/geriatric/resources/HRSAdefault.asp

For a clearinghouse of geriatrics educational resources, see: the Portal of Geriatric Online Education: http://www.pogoe.org

For additional educational resources, see the MedEd Portal: http://www.aamc.org/mededportal

2. Centralize Grants Management: A Closer Look

The challenge: To utilize research resources most efficiently and effectively

Summary

A number of geriatrics leaders are pursuing management strategies directed at economies and efficiencies of scale. One model that was developed for more efficient and effective grants management has grown into a larger enterprise at UCLA’s Multicampus Program in Geriatric Medicine and Gerontology. The Research Operations Core (ROC) was one of the first to centralize staff responsible for data collection, data management, data analysis, systems development, and program evaluation. The program director, David Reuben, MD, said he noticed that “the nature of research is surges and slower periods for each project, and some smaller projects don’t need and can’t afford full-time staff.” He concluded that it was easier and more efficient to centralize the process, and designed a business model that works. Dr. Reuben acknowledged that a lot of his “entrepreneurial strategy” came from management training, which included a two-year leadership program through the California Healthcare Foundation, where he received business training, including quality improvement models. (See Resources below.) Because UCLA’s model has been so fully realized and may hold promise as institutions increasingly focus on multi-program collaborative initiatives, it is presented in detail below.

Strategies

Align research goals with a business model that works. Goals for the ROC include:

• Make it as easy as possible for investigators to do research (“This is a competitive environment, and faculty want to have lives outside of work,” noted Dr. Reuben.)
• Share staff across projects
• Ensure that data collection, entry and management are as accurate as possible
• Have the right professional for each job for an efficient operation.

  Find a superb administrator. “I was fortunate to start with an excellent PhD faculty member, Teresa Seeman, PhD, who had extensive prior experience leading field data collection for large studies, and who had an overall vision for our undertaking. She hired an associate director, Heather McCreath, PhD, whose primary responsibility is to administer the research operation. Dr. McCreath reports to the associate chief for research and ultimately to the division director,” Dr. Reuben said.

  Invest in start-up and market broadly. Some start-up money was provided by a Pepper Center grant, and Dr. Reuben steered new people and resources to the ROC, making sure that support for research operations was included in grants. The ROC now serves a variety of groups, including core division faculty, especially junior faculty; faculty in the nursing school; other divisions in medicine; and other departments. In 2008, the ROC provided support for the Pepper Center plus 20 different grants that each contribute to the ROC.

  Think “one for all, all for one.” Because of the ROC’s centralized and shared research infrastructure, “we can apply for larger grants and we can attract new investigators who are now conducting aging research because they like working with us. We have also provided a model for the department of medicine to use core labs,” Dr. Reuben said. He cited the example of an AIDS researcher who added a description of ROC services to his grant, which facilitated grant preparation and improved the quality of the submission. “With the ROC up and running, researchers have an operation they can trust that supports multiple research functions; they aren’t afraid that if they get a grant award they won’t be able to do the work.” The economies of this centralized, shared approach to research infrastructure include that, “personnel can pinch-hit for others, pregnancies and illnesses can be accommodated, and, given that research demands fluctuate, we can reassign staff to other projects during down-times.” Another benefit is that there is an infrastructure for other projects that are important to the geriatrics division. This includes maintaining a mailing list of people for investigators to contact for recruitment into studies and a software program for tracking teaching time of faculty that was developed by the ROC with an education grant.

  Customize services to enhance buy-in. The ROC offers customized, menu-driven service options for senior investigators. It also facilitates research by junior faculty, who are building their careers and want to begin to hire staff who will be with them for the long run. In this model, those staff are employed, trained by, and responsible to the ROC and have offices in the ROC space. Yet, dedicated research staff can continue to work on the junior faculty member’s grant and any shortfalls in coverage for their time can be picked up by other grants.

  Provide a service for your department with a business model that works. As a result of the ROC’s success, Dr. Reuben was asked by his department chairman to take over a research unit that was off-campus. “It was ethnically diverse and had a wonderful population to draw from. However, while that unit was good at recruiting people for studies, they lacked an efficient organizational structure. They were spending lots of money and did not have a business model that worked.”

  Anticipate challenges. The large-scale ROC enterprise has presented several challenges:

  • Supervision is essential and requires significant staff time. However, it is easier to obtain support for research data collectors than supervisors.
  • Start-up is the hardest period. Until the ROC was able to support a fairly large number of grants, it suffered the same ebb-and-flow problems as individual grants do, only more so. Supporting many grants is much easier.
  • Rent increases and the need for better space are other areas where the ROC can “get into trouble.” Estimating space needs beyond one or two years and negotiating long-term contracts is extremely difficult in the face of uncertain future funding. However, “the division and department help us out,” said Dr. Reuben.

  Resources

  For information about the California Healthcare Foundation’s Healthcare Leadership training program, see: http://www.chcf.org/topics/view.cfm?itemID=19722

  For information on the UCLA Research Operations Core, see the UCLA GeroNet web site at: http://www.geronet.ucla.edu/centers/pepper/pepper_rops.htm

  
  

  3. Pool Resources to Fund Fellows and Junior Faculty

  The challenge: To pursue funding strategies for fellows and junior faculty that reflect programmatic and institutional strengths

  Summary

  The challenge of funding training for fellows and junior faculty research has generated some innovative approaches. These often involve blending sources of funding. Joint fellowships are becoming more common, and geriatrics programs have found ways to fund and manage them. Some institutions have established a tradition of flexible fellowships where they offer joint training with other specialty programs. Targeting fellows who bring their own funding can relieve some of the financial burden. One collaborative CoE draws funding and other resources for training and research from both partner institutions. Philanthropy can also play a role. At one institution, the directors of the geriatrics program and a high profile aging center have designated second-year fellows to receive awards from the center’s fundraising activities.

  Use philanthropic dollars for geriatrics fellowships. “The fundraising board for the Huffington Center on Aging includes families of former patients or people linked to our mission on aging.” George Taffet, MD, Baylor College of Medicine

  Strategies

  Start a tradition of joint fellowships. Some geriatrics programs have a well-established history of joint fellowship training with other specialties. At Duke University, “we have had geriatric medicine fellows train with us and then do training with another program, or fellows from another specialty do some training in geriatrics,” reported CoE director Ken Schmader, MD. “Either way, our aim is to keep them in academia, teaching and doing research in areas such as geriatric oncology or cardiology.” Funding for internal medicine specialty fellows who are interested in aging issues currently comes from the T. Franklin Williams Scholars Program. (See Resources below.)

  Recruit fellows from other specialties who bring their own funds. Yale University focuses on fellows who have completed their clinical training and want to do their research training in an area that combines their specialty with aging. These fellows are already funded through the training program in their specialty, so their salaries are paid by their own training grants or their sections, reported CoE director, Mary Tinetti, MD. Two or three specialty fellows each year receive support through the geriatrics training grant. “We give them money for research training and the CoE provides resources to carry out the research project. They are co-mentored by geriatrics faculty and may also participate in ongoing geriatrics clinical activities.” (Thomas Gill, MD, directs the geriatrics training grant.)

  Blend sources of funding to create protected time for junior faculty. At Duke University, leaders draw on money from the CoE as well as funds and other resources from the Reynolds Foundation, the Pepper Center, and the VA Medical Center, specifically the Geriatric Research Education and Clinical Center (GRECC).

  Find philanthropic dollars for fellowships. At the Baylor College of Medicine, the fellowship program has benefited from the philanthropy of its highly visible Huffington Center on Aging. Dr. George Taffet reported that the center helps raise targeted funds in a unique way: 100 percent of the money raised goes to geriatrics education or research. He works with the center’s director to set funding priorities, which now include funding second-year fellows with money raised at the center’s annual gala. He also has former, current, or potential academic fellows speak to the Huffington Center development board. “The board members would rather hear from an enthusiastic young person than from me,” said Dr. Taffet.

  Close-up Partners “piece it together.” Dr. Richard Allman, University of Alabama at Birmingham and co-director of the Southeast Center of Excellence in Geriatric Medicine (SCEGM), reported that to fund fellows and junior faculty he pools resources with Emory University, and the VA. Funding from the Hartford Foundation secures prestige within the university (as is the case at other institutions). “Both the financial support and the branding help us to secure additional funds and attract the best fellows and faculty.” (Between 1998 and 2008, the SCEGM provided support for 32 Hartford Foundation Scholars.) “Using division funding, the VA, community partners, and contracts with nursing homes, for example, we piece funds together, we leverage, and we match a job with pay,” he said. Dr. Allman added that when they interview someone they really want but they do not have the money themselves, they have candidates meet with people who have the resources. “If the junior faculty gets a grant, that will open the door—we are planting the seed; there are synergies here.”

  Resources

  For information about career development awards for junior faculty focusing on the geriatrics aspects of their disciplines, see:

  The T. Franklin Williams Awards for specialties in internal medicine: http://www.im.org/CareerDevelopment/GrantsandScholarships/TFWS/Pages/def...

  The Dennis W. Jahnigen Awards for surgical and related medical specialties: http://www.americangeriatrics.org/hartford/jahnigen.shtml

  
  

  4. Develop a Strong Mentoring Program

  The challenge: To develop an effective, efficient, and replicable mentoring model that builds on faculty and program strengths

  Summary

  Mentoring, whether for students, residents, fellows, or mid-career faculty, has become a cornerstone of geriatrics training programs. The role of mentoring has expanded at times due to the increased numbers of trainees; changing training needs (dual training tracks or training fellows from other specialties); or enrolling trainees with widely different goals, skills, and interests.

  Mentoring has also become more formalized, with more clearly delineated roles and responsibilities for faculty and trainees. One impetus for formalizing mentoring programs has been the availability of funding, such as research training dollars from the NIH and elsewhere, for structured mentoring of students, fellows, and junior faculty. The following mentoring models all aim to draw on faculty and programmatic strengths, to cope with limitations (for example, lack of enough senior geriatrics faculty to serve as mentors), and to become sustainable, so that today’s trainees who remain in academic geriatrics become tomorrow’s mentors.

  Strategies

  Formalize responsibilities for mentors and trainees. For some geriatrics programs, a more formalized mentoring strategy has been spawned by necessity. At UCLA, an interdisciplinary mentoring model was in already in place. It included a mentoring committee, a primary mentor, a content mentor, and a methods mentor outside of the trainee’s discipline. However, between 1999 and 2000, “a bumper crop of fellows arrived to become physician-scientists, and the program did not have an adequate number of mentors,” Dr. David Reuben said. To address this gap, he wrote a proposal for a National Institute on Aging (NIA) K-12 Mentored Clinical Scientist Development Program Award. As a result of this grant “the mentoring committees got teeth—they met quarterly and had to prepare reports, and that kept things on track.” At Yale University, mentors work with subspecialty fellows and junior faculty, providing consultation and hands-on support in the design, implementation, and analysis of their Hartford CoE projects. Mentoring extends to clinical and teaching activities, for which some fellows have developed aging-related curricula based on their subspecialty.

  Identify a leader to keep mentoring on track and to build trust. Mentoring programs require ongoing oversight to keep them functioning well. At the Southeast Center of Excellence for Geriatric Medicine, leadership oversees the overall mentoring process, including timelines. Dr. Joseph Ouslander, former co-director, observed that leaders “stay on top of trainees and require structured reports signed by mentors.” For successful group mentoring, the model used by UCLA, Dr. Reuben cited the importance of centralized, committed leadership, a role he played for the first six years and recently turned over to another faculty member, Alison Moore, MD. “I got to know people really well and built trust and a very cohesive group. Managing mentoring programs requires someone who will take ownership and thinks it is important.”

  Make a match based on faculty expertise and trainee goals. Several leaders emphasized the importance of identifying for candidates, particularly those who want to become academic geriatricians, faculty who have the expertise to assist trainees with their research. Moreover, some programs are called upon to mentor trainees at very different levels of training and with diverse skills and goals. At Yale University, Dr. Mary Tinetti and her colleague Dr. Tom Gill match young subspecialist investigators (fellows or junior faculty) with mentors who include geriatrics faculty with K, T32, and Pepper Center funding. Trainees with clinical interests can take advantage of Pepper Center research cores, and can assist investigators with study design, data collection and analysis, subject recruitment and enrollment, and other services. Trainees with basic science interests can assist Pepper Center basic scientists with research design and help them identify sources of cells from older people.

  Focus on relationships. “Whatever the structure,” said Charles Reynolds, MD, director of the University of Pittsburgh’s CoE in Geriatric Psychiatry, “there is no substitute for relationships. We have multiyear mentoring relationships and mentoring teams. We also have small multidisciplinary research teams to inculcate values.” As an example, he described a geriatric psychiatry fellow who has “two gurus,” himself and a geriatric medicine faculty member. “The three of us are in constant contact. We meet once a month, work with the trainee on his grant application, and have more frequent informal meetings.” In terms of building relationships, the Pittsburgh geriatric psychiatry program recruits early and often. “Some Hartford fellows were already identified as medical students and they came to our residencies and fellowships and have become faculty.”

  (See Resources below for a description of a junior faculty mentoring program designed to navigate the transition from post-doctoral fellowship to junior faculty.)

  Consider alternative models for mentoring. Here are additional approaches to dealing with a shortage of faculty mentors within an academic geriatrics program:

  • Group mentoring. This approach can extend resources when time and faculty are limited. UCLA holds one-hour group mentoring sessions twice a month with about 15 participants and at least one senior mentor. Participants discuss their research questions and problems. Dr. Reuben was surprised at how much information can be conveyed in these sessions by drawing on the anecdotes and experiences of senior faculty. Although these meetings require a time commitment for all involved, there is no prep time for senior faculty, and there is strong group support. Some tips on logistics for this approach include:
    • Identify a convenient and consistent meeting time
    • Early-morning meetings generally have better attendance but note that 8 a.m. meetings are difficult for those with young children
    • Serve food.

    However, these sessions can be successful only if junior faculty participate. Dr. Reuben recommends using the leverage you have to require participation for those receiving salary support. At UCLA, this is done for faculty supported by grants including the Hartford CoE, Pepper Center, and NIH K-12 grants.

  • Multidisciplinary group mentoring. Whether academic trainees are nurses, physicians, or psychologists, they all have professional tasks in common, such as grant writing, preparing budgets, and serving on committees. So the UCLA program set up a group mentoring process called Academic Advancement. These multidisciplinary groups have some pros and cons. “Some disciplines have more research training than doctors, and they have different insights,” Dr. Reuben said. “This has allowed researchers to collaborate on projects and meet outside of sessions. But, if a content area is too far afield from medicine, the geriatrician may not be interested.” Nevertheless, he cited the group’s “magnanimity of spirit,” even if the research presented is not in their area. “They have found that they grow through these multidisciplinary exchanges.”
  • A collaborative approach to mentoring. The SCEGM mentoring program combines senior faculty from both partner institutions. They help trainees formulate early ideas and offer additional pairs of eyes and ears. Trainees, whether in the research or the clinician-educator track, have at least one primary mentor. Some have mentors from both institutions who review all grant proposals. Salaries for some mentors have been supported by the Hartford CoE grant with additional leverage from the Reynolds Foundation Aging and Quality of Life grant for infrastructure to implement educational interventions.
  • A national mentoring program. An ambitious national approach to an insufficient number of local mentors is the model used by the Beeson Career Development Awards, which are supported by the Hartford Foundation, the Atlantic Philanthropies, and the NIA. Members of the Beeson Program Advisory Committee, who are senior geriatrics faculty from institutions across the country, volunteer to serve as confidants, counselors, and advocates for the Beeson scholars. They agree to meet with their scholars (who may have as many as four mentors) at each Beeson Scholars annual meeting, and to be available between meetings as needed. Mentors offer advice on navigating the pitfalls of an academic career, ensure that scholars link with other scholars, support a continued aging focus in the scholar’s research, and try to ensure that scholars have the protected time they need for their research activities.

  Teach mentoring skills. A senior leader acknowledged his surprise at how poorly prepared junior faculty are to assume mentoring responsibilities. Even those who had gone through fellowships knew little about mentoring. To build a cadre of skilled mentors, teaching mentoring skills to junior faculty is critical, as senior faculty cannot do all the mentoring. (See Resources below for suggestions.)

  Motivate mentors. To motivate faculty to mentor well, leaders often employ the “carrot and the stick,” observed Dr. Reuben. He recalled that when UCLA’s mentoring program first got started, they had between six to eight mentors, drawn primarily from junior and senior faculty. Currently, the approximately 30 mentors are drawn from senior and junior faculty, Pepper Center awardees and CoE grantees, and more recently, aging-related research scholars outside of the geriatrics division. Junior faculty can opt out after two years and are replaced by new junior faculty. Beyond requirements, however, he noted how important the program has been to the mentors themselves.

  Mentoring: a growth industry. CoE directors who are former Beeson scholars credit the program with contributing to their careers, creating opportunities for collaboration, and laying the groundwork for their own role as mentors for Beeson scholars and their own geriatrics programs. Mentoring also keeps senior researchers, whose primary focus is outside of geriatrics, more closely connected to the field. The UCLA program is one example of this, reports Dr. Reuben. “Many assume more senior leadership roles. Mentees become mentors.”

  Close-up Structure, flexibility, and making a match. Finding the right mentors can be challenging, said University of Pittsburgh’s Stephanie Studenski, MD, MPH, who described herself as “the 21st century equivalent of a matchmaker.” In their mentoring program, trainees are asked to present their research ideas. Dr. Studenski and colleagues then consider potential mentors from a list they maintain to develop an individualized plan for the trainee. In addition to an oversight group, each trainee has a team of primary and secondary mentors who bring different areas of expertise. Pittsburgh has created a common platform for mentoring and tracking trainees. It is tailored to trainees, who develop personal career goals and plans for achieving them. In medicine, some fellows are entering advanced fellowships with no research training, while others are taking time off to do combined research and medical school training. Pittsburgh’s approach incorporates reasonable milestones and goals for each trainee, regardless of how much time the trainee spends with the mentor, and uses common axes along which levels of knowledge and mechanisms of learning can be plotted. These include: Human studies research, which includes a foundation in epidemiology and statistics Aging Oral and written communication, grant writing, and research Professionalism, teamwork, and ethics.

  Resources

  For descriptions of successful CoE approaches to research training and mentoring, see the companion publication to this report: Recruitment of Candidates to Advanced Fellowship Training and Junior Faculty Positions in Academic Geriatrics: http://www.geriatricsrecruitment.org/ManualTwo

  For extensive resources on mentoring related to geriatric psychiatry, many with broader applications to geriatric medicine, see the MedEd web site: http://www.mededmentoring.org/medicalupdates.asp?source=newsletter

  For information on how institutions can advance their efforts to support research mentorship, see: Keyser DJ, Lakoski JM, Lara-Cinisomo S, et al. Advancing institutional efforts to support research mentorship: A conceptual framework and self-assessment tool. Academic Medicine 2008;83(3):217-225.

  For information on a mentoring program designed to navigate the transition from post-doctoral fellowship to junior faculty, see: Reynolds CF, Pilkonis PA, Kupfer DJ, et al. Training future generations of mental health researchers: Devising strategies for tough times. Academic Psychiatry 2007;31(2):152-159. http://ap.psychiatryonline.org/cgi/content/full/31/2/152

  For information about mentoring, see: Studenski, S. Chapter 9: Mentoring. In: Multidisciplinary Guidebook for Clinical Geriatric Research. Washington, DC: Gerontological Society of America, 2006.

  For information about the Beeson Career Development Awards, see: http://afar.org/pdfs/ 2009BeesonReport.pdf; www.beeson.org

  For the Beeson program’s history, see: Leading Science: 10th Anniversary Report: Paul B. Beeson Career Development Awards 1994-2004. American Federation for Aging Research: New York, NY. http://www.beeson.org/tenth_anniversary_beeson.pdf

  
  

  5. Expand Opportunities through Interdisciplinary Research

  The challenge: To create interdisciplinary research activities to enhance funding and training opportunities in academic geriatrics

  Summary

  Interdisciplinary research and related funding is in the spotlight and offers opportunities for academic geriatricians. Collaboration is not new to academic geriatricians, who view it as essential to approaching complex problems related to aging. What is new is the growing number of funding opportunities (federal and foundation) that require evidence of collaboration, and the range of discussions at institutions across the country about how to enhance collaborations. At the federal level, the NIH Roadmap Initiative is an ambitious redesign of the approach to science. According to its web site (see Resources below) the roadmap is intended to move from the “cottage industry” approach to biological sciences, where “the traditional divisions within health research may in some instances impede the pace of scientific discovery,” towards greater interconnectivity and collaboration. Funding is nested in specific strategies and tools (for example, multiple PIs) that aim to build bridges across disciplines, programs, and institutions. The Hartford Foundation has supported a number of successful interdisciplinary initiatives, including one described below to specifically address institution-wide capacity for interdisciplinary aging research. Geriatrics leaders have been active in a number of collaborative initiatives, three of which are discussed below. Additional resources on these initiatives can be found at the end of this section.

  
  

  THE RAND/HARTFORD BUILDING INTERDISCIPLINARY GERIATRIC HEALTH CARE RESEARCH CENTERS INITIATIVE

  Summary

  This initiative seeks to promote interdisciplinary geriatrics research by improving institutional capacity to conduct such research, focusing on the development of innovative clinical and health services interventions for older adults that can be translated into real-world practice, and providing interdisciplinary education, training, and mentoring opportunities for new and established investigators. Harold Pincus, MD, director of the RAND Coordinating Center, observed, “Institutions that are strong in geriatrics by necessity will have some kind of history in interdisciplinary activity. The question is one of degree and how to strengthen it.” Applying for the award has given people “a reason to get together to go after this opportunity. The award enforces shared goals and stimulates processes and structures to reinforce them.” Currently in its second round of funding, centers funded through the initiative have brought people together in new ways and have created the foundations and linkages for future collaborative work. Dr. Pincus and the RAND team, who provide technical support for the development of centers and their investigators, have identified the following strategies for establishing, expanding, and sustaining interdisciplinary geriatrics research centers.

  Strategies

  Begin by conducting an organizational needs assessment. Identify key areas of strength within the departments, schools, and participating organizations that will support the development of the center. Where do you find complementary areas between geriatrics and other disciplines? How can you advance interdisciplinary collaborations? How do they leverage your institution’s strengths? Identify the factors that could threaten your short- and long-term success, including barriers to developing and/or implementing interdisciplinary collaborations, as well as solutions for overcoming them.

  Aspire to achieve true collaboration across multiple geriatrics disciplines within and beyond your institution as you develop your center. Collaboration should include the core geriatrics disciplines (i.e., medicine, nursing, social work) as well as related disciplines, such as dentistry, nutrition, pharmacy, psychology, public health, public policy, and rehabilitation. Also consider involving trans-institutional arrangements or non-university organizations.

  Cary Reid, MD, PhD, noted that Cornell’s RAND/Hartford Interdisciplinary Geriatric Health Care Research Center, for which he serves as one of the PIs, is a “marriage between geriatrics and home care.” The center blends expertise from geriatrics with that of researchers at the Center for Home Care Policy and Research at the Visiting Nurse Service of New York, and in Ithaca, at Cornell’s Institute for Translational Research on Aging. Citing a recently submitted joint proposal, Dr. Reid noted how the initiative has “opened up opportunities to work with good researchers who are not in an academic setting.”

  Emphasize interdisciplinary research projects that build partnerships that will expand research foci and methods. Develop projects that enable researchers from different disciplines and various career levels to work together on new research ideas that bring multiple theories, skills, and data to bear on a common problem. Encourage researchers to develop unique methodological approaches that integrate conceptual, operational, and analytical components from multiple disciplines, and actively engage investigators holding a variety of professional degrees in the design, implementation, and analysis of the research.

  Provide opportunities to promote interdisciplinary geriatrics education, training, and mentoring. Career development training sessions can help educate and train junior faculty to conceptualize interdisciplinary projects and develop fundable proposals. Through these sessions, junior faculty can gain experience presenting their research ideas and receive useful feedback from mentors and peers. Research mentorship can also serve as an important catalyst for providing researchers with the skills they need to advance successfully in their careers, enhancing the institutional environments within which they work, and fostering the highest levels of professional practice. Interdisciplinary mentorship programs (both formal and informal) can improve interdisciplinary knowledge and skills of junior faculty by allowing them to work with teams of senior mentors from multiple disciplines. Co-mentoring by experts in two disciplines has significant advantages, and is also used by the Clinical and Translational Science Awards. (See below for more information on CTSAs.)

  Based on your needs assessment and the approaches described above, create a business plan for how your research center will operate, including:

  • Roles and responsibilities of co-principal investigators from two or more disciplines as well as other investigators to be involved
  • Types of interdisciplinary projects to be pursued
  • Target groups for the interdisciplinary training and mentoring activities and how they will be implemented
  • Structures and methods to strengthen interdisciplinary connections, and formal and informal opportunities to bring people together around an interdisciplinary geriatrics research agenda (for example, retreats that convene broad communities of researchers and provide them with opportunities to build new professional relationships and discuss potential projects and grant applications)
  • An evaluation strategy to guide your center’s development and ensure its sustainability over time, including ongoing plans for assessment and specific milestones and measures of success
  • Administrative, financial, and coordination processes that will support participation of different types of players, such as institutions/organizations, departments and schools
  • Current, renewable, and future funding sources for infrastructure support, and plans for sharing resources, indirect costs, and credit for products across the center’s partners.

  
  

  CLINICAL AND TRANSLATIONAL SCIENCE AWARDS

  Summary

  Two geriatrics leaders were interviewed about the NIH-funded Clinical and Translational Science Awards (CTSAs) that support institution-wide efforts to translate bench science into clinical applications. In terms of that broad goal, these leaders viewed these awards as promising initiatives, but not yet transformative. They described CTSAs as closer to a repackaging of funding with new strategies to disperse money, rather than as an initiative that introduces a great deal of new money. University of Michigan’s Dr. Jeffrey Halter observed that the CTSAs put together “several NIH funding mechanisms that were not directly funded together, such as a clinical research center and career development awards, and then run this package of funding in somewhat different ways with somewhat more money.” Yale University’s Mary Tinetti, MD, concurred, adding that the CTSA program is “getting scientists to translate their findings into clinical relevance, with scientists focusing on aging who otherwise would not have.” However, she added, “Most of the resources are helping to bring molecular level and animal models into human research, but getting that into practice will take longer. When you divide up $45 million dollars, it doesn’t generate as much change as was hoped for. However, overall, the CTSA grant has helped advance translational science and, at some institutions, has brought a greater focus to aging-related research.”

  Strategies

  Build capacity in human research, which can make a special contribution. Dr. Tinetti recalled, “When the CTSA was first proposed at Yale, the Program on Aging was the largest human research center. The institution needed the program’s unique resources, as others in the institution mainly did basic science research. Maybe [those researchers] would not have focused on aging, but as a result, aging is seamlessly integrated into the CTSA, and we have helped researchers move from basic science into clinical research. The CTSA provides a big pot of money that gets distributed in a lot of different ways including training, funding younger researchers, biostatistics, and human research management. The Program on Aging helped open the door with our human research focus.”

  Work with CTSA collaborators to expand geriatrics research support. While the Michigan Geriatrics Center has had pilot grants for more than 20 years (with Hartford and NIA funding), Dr. Halter explained that with the CTSA award, “we partner with CTSA leadership and together look at who has applied to the geriatrics center and CTSA, and jointly fund some pilot grants. This provides a greater source of funding for geriatrics than we would have otherwise. Instead of funding four aging awards, we could fund seven, because we funded collaboratively. In addition, the CTSA has funded the career development of junior faculty. The Pepper Center and Hartford CoE have a similar interest, so two junior faculty are partially funded by the CTSA now. This is not written into the CTSA grant. Our junior faculty apply like anyone else, but we encourage them to do so.”

  
  
  PROGRAM/PROJECT CENTER (P) GRANTS

  Summary

  Program/Project Center (P) Grants have been used for some time by geriatrics leaders to fund larger-scale projects. More recently some geriatrics leaders have used them for community-focused interdisciplinary research. This arena offers rich opportunities for geriatrics. But success involves more than expertise in human subjects research. It also requires a keen understanding of local politics and the willingness to build long-term relationships with community organizations. When the community becomes the laboratory, it opens the door to new research approaches that require an interdisciplinary effort.

  Strategies

  To galvanize investigators, go into the community. A shift in focus from institutionalized older patients to community residents often stimulates investigators to develop new approaches to research and collaboration, which are more likely to incorporate functioning, safety, and quality-of-life issues into disease-specific research.

  Collaborate strategically. Partner with community organizations that have mutually compatible goals. Community agencies and organizations can: (1) smooth your entry into the community; (2) lend credibility to your project; (3) act as intermediaries with community residents who might participate in research; (4) connect you with politicians and other power brokers; and (5) help you to translate your research into terms that are meaningful to community members. However, community groups can also impede your project. Negotiations between researchers and community leaders are likely to be ongoing throughout the life of the project. They should begin with clearly written agreements that identify each partner’s expectations for the project including benefits, resources to be contributed, specific responsibilities, and a timeline for implementation. They should also include an evaluation plan that anticipates challenges, identifies red flags, and addresses problems as they arise. Learn how, when and where to persevere, and when to move on.

  Work to build trust. Begin with the assumption that you will need to earn the trust of community members and organizations. Many low-income communities have seen academic research programs come and go with no visible short- or long-term benefits for the community or its residents. This can lead to a disinterest in or even mistrust of academic researchers. Find out from key community insiders what you need to do to build trust and plan ways to invest in the community over the long haul. Create a community advisory board and use it as a sounding board.

  Build community partners’ trust. “A school principal I became close to said she would take a chance on Experience Corps. When she saw the first team of older adults arrive at her school, including one in a wheelchair, she almost cried from worry about her decision. However, this same principal’s views were transformed several months later—this was pretty radical. Project leaders started partnering with city organizations. I was having to be a politician—a huge hurdle for a clinician.” Linda Fried, MD, MPH, Columbia University School of Public Health

  Words count, so avoid jargon. Several leaders spoke about learning how to communicate more effectively with members of the community, whether potential donors, agency staff, or the public. In a community initiative, scientific language, acronyms, jargon, and other shorthand that physicians use among colleagues does not translate well for community leaders and residents. Use straightforward, everyday terms. Align and explain your objectives in ways that resonate with the values and needs of those you want to engage. Test your main ideas with a core group of community members to see if they understand your objectives. Ask for their help in crafting your messages for the community.

  Hire a savvy project manager who has worked with both medical researchers and community groups. This person can help broker agreements between researchers and community organizations, resolve problems, sidestep conflicts, and keep the project and your team on track.

  Close-ups MOBILIZE Boston. At the Institute for Aging Research of the Hebrew Rehabilitation Center of Boston, a major change in research focus occurred during the early 2000s. Lewis Lipsitz, MD, recalled, “We moved from frail nursing home patients to patients in the community. For the renewal of our Research Nursing Home grant [an NIH Program/Project grant], we wanted to branch out beyond disease-specific studies in nursing home populations, and recruit prospectively for falls in community-dwelling older people, to study novel risk factors for falling. We looked at the role of chronic pain, blood flow to the brain, foot disorders, and peripheral neuropathy in falls, and investigated the effects of vibratory shoe insoles to prevent falling. This galvanized the investigators in our institute—epidemiologists, nurse investigators, statisticians, and population researchers—as each one could participate in this initiative. We created multidisciplinary teams rather than a group of separate investigators doing their own thing and benefiting from our research cores.” To build trust in the community, Dr. Lipsitz and his team, which includes outreach and clinical staff and a community advisory board, actively engaged with the community, provided education, created a newsletter and opportunities to learn about aging through Boston-wide seminars—in 10 different languages. Since the early 1990s they had worked to establish a good relationship with the community. They built the Multi-Cultural Coalition on Aging, whose 60 agencies meet monthly and represent health centers, senior centers, and housing officials, and a variety of ethnically and religiously focused organizations. To let the community know that their research was a collaborative effort and should not pose a threat to participants, they matched actions with words. They named their program project the MOBILIZE Boston Study. MOBILIZE stands for: Maintenance of Balance, Independent Living, Intellect and Zest in the Elderly of Boston.” They named their outreach effort the Harvard Cooperative Program on Aging. By mid-2008, they had established a database of nearly 800 individuals. “Members of the Multicultural Coalition on Aging now ask us if they can participate in research,” Dr. Lipsitz said. “We built a registry of volunteers who were willing to receive offers to participate in research. We encouraged other investigators to recruit through us, and advertise their studies to our registry volunteers.” Experience Corps. Dr. Linda Fried had many reasons for co-founding Experience Corps, an outside of the box way of doing health promotion for older adults. During her tenure as director of the geriatrics division at Johns Hopkins, she saw “patient after patient who was depressed and had no reason to get up in the morning. I used to write prescriptions to ‘do something meaningful.’ That was my experience as a geriatrician.” But as a population scientist, she said, there were other converging reasons for creating Experience Corps, such as keeping older people healthy at the community level, “to complement what I could do as a doctor.” The program embeds social, cognitive, and physical elements of health promotion by creating opportunities for older adults to give back to society, and in this case, make a difference in the lives and literacy of school children. In the first iteration of her project, Dr. Fried and her colleagues discovered that “politicians and bureaucrats had their own ideas; they did not like science and scientists, and they made it hard for us to collect data.” Dr. Fried’s team reassessed the program and found a major partner in a community corporation whose primary goal was improving schools and educational outcomes. While the community-based organization had tried a number of programs that had failed, Dr. Fried recognized that “they offered us trust and links with school principals.” In 1998, the team launched a successful demonstration project, and Experience Corps expanded across Baltimore. Eventually they got huge community, city, and state support, and it became a collaboration between Johns Hopkins and Columbia University, the City of Baltimore and its school system, and the community corporation. “The mayor of Baltimore saw this as signature program.” Fast-forward to 2008, Experience Corps has since become a national organization in 20 cities that is supported by numerous national government, corporate, and private partners. Nevertheless, Dr. Fried acknowledged, “It is still hard to piece together support. Like many best practices with strong evidence, there is no sustainable funding.” She cautioned that, “when you envision something that other people don’t see, it takes years of steadily plodding ahead. In the early years, we could not get anyone to pay for the research and development. I wrote a minimum of 100 proposals. For the first eight years, the NIH would not talk with me. The program was not their thing; it was too outside of the box, there was no program that it matched, and I had no evidence. Foundations that supported programs for older adults said no kids, and children’s foundations said no older adults.” What helped the project turn the corner, along with a belief in their vision and perseverance, was an early (and small) foundation grant that they used to hire recruiters, and pay for a little data collection. Dr. Fried emphasized, “It is only because I had 10 faculty who worked their tails off with no support—that is the reason the program is alive.”

  
  
  Resources

  For information about the RAND/Hartford initiative, including descriptions of CoEs that have received awards, see: Pincus HA, Keyser DJ, Schultz DJ. RAND/Hartford Initiative to Build Interdisciplinary Geriatric Health Care Research Centers. Health Affairs 2007;26(1):279-283.

  For a report on Phase One of the RAND Initiative, see: https://www.rand.org/health/projects/geriatric/rand/programeval/report_v...

  For additional information on the RAND initiative, see: https://www.rand.org/health/projects/geriatric/

  For information about the NIH Roadmap and specific funding initiatives for interdisciplinary research, see: http://nihroadmap.nih.gov/interdisciplinary/

  For information on Clinical and Translational Research Awards, see: http://www.ctsaweb.org/

  For more information about MOBILIZE Boston, see: http://mobilizeboston.org/

  For information about the impact of Experience Corps on volunteers and students, see: http://www.experiencecorps.org/publications/research.cfm

  For information on strategies for effective community partnerships see analysis of 23 initiatives supported by the Robert Wood Johnson Foundation: Bazzoli GJ, Casey E, Alexander JA, et al. Collaborative initiatives: Where the rubber meets the road in community partnerships. Medical Care Research and Review 2003;60(4):63S-94S; and web site link: http://www.rwjf.org/programareas/resources/product.jsp?id=14412&pid=1142...

  
  

  6. Build Collaborative Programs

  The challenge: To expand opportunities for geriatrics to collaborate with others and contribute to institution-wide efforts to build a culture of collaboration

  Summary

  Collaborative and interdisciplinary research is one of the most important directions for the future. The NIH has launched its Roadmap for Medical Research that ties major funding to institution-wide models for and evidence of collaboration across departments and disciplines. Foundations such as Hartford have funded initiatives to strengthen collaborative relationships and research. However, even for some highly successful institutions, the trend towards greater collaboration across programs and departments has not been easy for geriatrics programs to incorporate. Some institutions are better positioned. They have been making investments for some time that have served to build and reinforce a collaborative climate and institution-level planning with incentives backed up with dollars and, sometimes, with significant changes in overall direction. Whatever their institutional environment may be at present, geriatrics leaders have continued to find ways to expand their research and clinical horizons through collaboration. Some leaders are also playing an active role in institution-wide planning to tear down barriers across programs and open the way for faculty to discover new partners and opportunities for research, teaching, and clinical services.

  Strategies

  To build a national profile, find local collaborators. Dr. Harvey Cohen of Duke University recommends that CoEs and other geriatrics programs take advantage of everything their institution has to offer. “Recognize the strengths of the institution; look around the nooks and crannies to see what is going on and what can be leveraged for extra resources. Convince someone to get together and collaborate, and create programs.” His message is similar for interdisciplinary grants and Clinical and Translational Science Awards: “These big programs are looking for people who can bring something to the table. It is a negotiation, so show how your program can be of value. Start with what you have to offer; it may come from your education faculty, for example, if that’s needed for the larger grants. From there you can broaden the relationship. Look for a way in!”

  Look across disciplines for others working in aging. When Dr. Jeffrey Halter came to the University of Michigan, the medical school didn’t have an academic geriatrics program. “So I looked around to see where there were good people, resources, and interest, to build a program. It takes time to develop a range of people with various levels of responsibilities and seniorities, so I looked for others working in aging and related areas. We now have very active participation between the schools of public health, engineering, with basic science in the medical school and others in the schools of nursing and social work.”

  Cultivate Collaborators. “When I go on site visits, I try to help programs focus on where they can collaborate or take advantage of another existing program to provide broad levels of expertise. Sometimes leaders don’t immediately recognize the role that other programs or individuals might play.” Harvey Cohen, MD, Duke University

  Find partners whose strengths complement yours. Noting that one of Michigan’s research strengths is in improving mobility and preventing falls, Dr. Halter described the development of a successful collaboration that began more than 20 years ago as a result of working with senior faculty in engineering, and connecting junior faculty and fellows to get careers started and people trained. “The collaboration evolved over time, so now Neil Alexander, MD, the GRECC director, who has an interest in mobility and falls, and a laboratory, collaborates with engineering. Engineering does some of the more basic methods development, and Dr. Alexander does application to humans. Engineers need clinical input, and a physician-scientist can provide the disease orientation. Otherwise engineers would focus only on healthy people.” Geriatrics has a similar collaboration with faculty in public health, who have served as mentors for junior faculty in geriatrics. “Public health faculty don’t see patients; they read about them, so they benefit from the clinical expertise of geriatrics faculty and geriatrics faculty get wonderful scientific training, methods, and application from their public health mentors.”

  If you want to take a new direction, it is up to you to pave the way. The University of Chicago’s Dr. William Dale described how his relationship with the hematology/oncology department has evolved over time. He participated in a Hartford-American Society for Clinical Oncology funded geriatrics-oncology joint fellowship program. After graduation he continued to collaborate with many fellows who ended up in academic environments elsewhere, where he was invited to present to their sections. While he jokingly admits there were “two strikes against him” from the hematology/oncology perspective—first being a geriatrician (and therefore not a “real” physician; and second, a social scientist with a PhD in public policy (and therefore not a “real” scientist)—he has more than demonstrated his value. He now has a joint appointment in hematology/oncology and receives 10 percent of his salary from them. His contributions include assisting the cancer center to achieve comprehensive status from the NIH using his social science training to enhance the center’s expertise in cancer control and prevention, its weakest area. He also built a geriatrics-oncology clinic (see p 9), which served as the model for two other geriatrics-subspecialty clinics. “I also recruit patients onto my research protocols, which are some of the highest accruing ‘trials’ in genitourinary oncology and demonstrate the value of what we do in geriatrics,” Dr. Dale said. He also works on several collaborative research projects and has access to oncology’s social work staff and use of IV therapy services through his geriatrics-oncology clinic. He has been joined by a recently graduated geriatrics-oncology fellow to create a two-physician care team. “Once you reach a ‘tipping point’ the up-front investment gets rewarded,” Dr. Dale said.

  Close-ups A strong collaborative culture supports academic geriatrics. Dr. Neil Resnick made his move to the University of Pittsburgh because he was drawn to its culture. “You not only need a fertile seed, but also fertile soil, and I found both at Pittsburgh. If we collaborate on research with someone here, both divisions get paid according to the level of effort, whereas at some institutions, there is only one PI, and most of the credit and indirect costs go to just one department or division. The sharing of professional credit and indirect costs is a real benefit, and has existed for decades at Pittsburgh, where people believe that together we can accomplish what no individual can alone.” This collaborative culture is also visible in the Institute on Aging. Dr. Resnick established it six years ago to function as an umbrella for age-related programs throughout the university and the health system. Its Academic Advisory Council and Clinical Advisory Council each work strategically to integrate geriatrics into institutional programs. There are also rare collaborative opportunities provided by having two Hartford CoEs (the other, in geriatric psychiatry, led by Dr. Charles Reynolds, was funded in 2005), a GRECC, Geriatric Education Center, Alzheimer’s Disease Research Center, Cancer and Aging Center, Geriatric Mood Disorders Center, and Pepper Center. Pittsburgh’s geriatrics division has grown from seven faculty when Dr. Resnick first came, to more than 30 fellowship-trained faculty, most with an MPH and/or additional specialty training. Many are actively engaged in collaborative research, training, and mentoring. There is also a high level of cross-specialty and cross-disciplinary research funding for aging. “Pittsburgh is open to new ways of looking at things. The bar is high here, but the door is open,” Dr. Resnick said. A geriatrics safe harbor from which to launch collaborations. For Dr. Lewis Lipsitz, being at Hebrew Senior Life in Boston has been an advantage in advancing academic geriatrics. It is an independently run, private hospital with a closed medical staff and board, licensed as a chronic-care hospital. His program has close relationships with Beth Israel Deaconess Medical Center. “Since 1965, our staff has been on the medical staff of Beth Israel [now Beth Israel Deaconess Medical Center] and could qualify for Harvard faculty positions. In 2008, we became formally affiliated with Harvard Medical School, as we were able to convince the new dean that we do more of the geriatrics teaching and clinical geriatrics research than any other hospital in the Harvard system. At other hospitals geriatrics must compete for resources and space with other divisions and departments. But at Hebrew Senior Life geriatrics is the only show in town. Therefore, the mission of our academic program and that of the hospital are closely aligned. “I have the luxury of working in an institution that cares about aging, supports our faculty, and raises funds for geriatrics. That is the secret to what has kept our program going and growing,” Dr. Lipsitz said. As for collaboration, Dr. Lipsitz observed: “The independent nature of our institution has meant that we could work with anyone. We have collaborations with Boston University, Brown University, the University of Michigan and many others—we are not locked in.”

  
  
  Continue to Chapter 3, Training Subspecialty Physicians in Geriatrics ⇒