Enhancing long-term care for older adults: an exploration of interagency collaboration within geriatric education centers.
Abstract: This article examines how the study of geriatric education provides a collaborative environment in which nonprofits can work together and with government in order to effectively manage the challenges in caring for older adults in the coming decades. The U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) provides federal funding to implement and maintain Geriatric Education Centers (GECs) in health care facilities across the country. These GECs have recently been directed to focus on strengthening the availability and quality of comprehensive interdisciplinary training for health care professionals that work with older adults. The funding has come at a time when the nation is faced with both a shortage of health care professionals and a dramatic increase in the older adult population in future years. Due to the critical relevance of GEC offerings for health care and the baby boomer generation, this study provides an exploratory evaluation of programs offered by GECs and the degree of both interdisciplinary and interagency collaboration between GECs, community nonprofits, and government partners in the provision of geriatric health care training. Findings suggest the interdisciplinary and interagency partnerships do exist but are vulnerable to conflicts especially between GECs.
Subject: Education parks (Services)
School facilities (Services)
Long-term care of the sick (Management)
Long-term care of the sick (Demographic aspects)
Nonprofit organizations (Services)
Authors: Ford, Channing R.
Henderson, Jennifer
Handley, Donna Milam
Pub Date: 03/22/2010
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2010 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Spring, 2010 Source Volume: 32 Source Issue: 4
Topic: Event Code: 360 Services information; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8380000 Nonprofit Institutions; 8300000 Social Services & Nonprofit Institutns NAICS Code: 813 Religious, Grantmaking, Civic, Professional, and Similar Organizations; 624 Social Assistance
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250033484
Full Text: As the number of older adults in America continues to increase, the incidence of chronic illness in older adults is also rising. In many states, the current health care system is not prepared to meet the comprehensive healthcare needs of aging adults. Quite often, these adults are treated by physicians that focus on a specific diagnosis, while the patient may be struggling with the challenges of multiple health problems. A lack of coordinated care for older adults results, which often hinders their overall wellness plans and quality of life. This problem may be exacerbated by both the impending shortage of health care professionals, as well as a lack of comprehensive interdisciplinary training for health care professionals. The impending shortage of geriatricians to treat the baby boomer generation along with a fragmented health care system present critical issues, including the ability to practice in an interdisciplinary milieu (Mezey et al, 2008), that require a collaborative approach to find solutions.

In response to these issues, a number of governmental and nonprofit agencies have provided support for supplemental interdisciplinary training for health care providers. These resources emphasize the need to create and implement comprehensive healthcare plans for older adults. One such avenue of support has come through geriatric training programs designed to strengthen the training of healthcare professionals. In 1998, Congress enacted the Public Health Service Act ("the Act") under Title VII Part D, in which they recognized "the beneficial impact that interdisciplinary community-based linkages can have upon the quality and availability of health care services to populations that have traditionally been underserved or are otherwise medically vulnerable" (U.S. Department of Health and Human Services Division of Health Resources and Services Administration, n.d.). The Act provided funding to the U. S. Department of Health and Human Services and specifically the division of Health Resources and Services Administration (HRSA) to provide renewed support for Geriatric Programs that would provide training for physicians, dentists, and behavioral/mental health professionals. From a federal government perspective, a partnership with nonprofit entities was established to provide training for health care professionals committed to a comprehensive care approach, encourage interdisciplinary team care education for health professionals, and enhance the performance measures and inspection guidelines for this type of training (Klein 1995). The partnership was developed through the creation of Geriatric Education Centers (GECs), which are facilities often housed within university medical centers, that incorporate partnerships with the universities, the federal government, other GECs, as well as community agencies and partners.

This article addresses how the field of geriatric education provides a collaborative working environment between and among both nonprofits and government in order to effectively manage the challenges of chronic illnesses in older adults. The research project is conducted within the context of evaluating Geriatric Education Centers as a delivery system for collaborative health care training services. In the case of GECs the opportunity for collaboration may be found in both 1) an interagency approach between the centers, which are located across the United States, and 2) an interdisciplinary approach as each GEC incorporates materials and seeks to train healthcare professionals from a wide range of disciplines to strengthen their knowledge and skills in the geriatric discipline. The primary research question was "to what extent do GECs collaborate with each other in the effort to enhance geriatric education and service provision?" Secondary questions within the research included 1) how existing partnerships operate and 2) the extent to which local and regional communities participate in their jurisdictional GEC operations.

Answering these questions is particularly important as the United States enters an unprecedented time in history with the retirement of the baby boomer generation. Scholars predict that the "silver tsunami" will descend upon the U.S. in 2011 as approximately 35 million baby boomers begin to retire, and it will be in full force by 2030 when the number of people aged 65 and older will increase to 72 million people (Fried and Hall, 2008; Institute of Medicine, 2008). In addition, the United States 2000 Census estimated that adults aged 65 and older made up 16% of the population with that number more than doubling to 36% by 2050 (Simpson et. al, 2005). Thus, the nation faces several problems as the number of older adults increase. The Institute of Medicine asserts that the challenges include 1) the increasing dependence of older adults on the health care system due to suffering from multiple chronic conditions; 2) the demographic diversity of the baby boomer generation, which will be older, more educated, more ethnically and racially diverse, and more widely dispersed from family than previous generations; and 3) the shortage of all types of health care workers, including chronic care settings (2008, p. 1). In summary, the healthcare system will be serving a larger and more diverse population of older adults and the challenges associated require action as soon as possible.

The collaborative nature of GECs is an inherent part of the design of the federal program that funds the centers. GECs are traditionally housed within a university setting due to their medical research center affiliations. In order to provide effective patient care, these university-run programs often partner or work with local medical facilities/agencies to provide training for healthcare professionals. These training opportunities enable GECs to accomplish their missions of providing healthcare training while they also serve the needs of the community in which they function. This research examines existing collaborative networks to see how they are funded and how the partnerships work. In order to answers to questions regarding interdisciplinary and interagency collaboration and Geriatric Education Centers, existing literature on interdisciplinary collaboration within the healthcare profession and specifically the field of geriatrics is reviewed. The use of interagency collaboration between Geriatric Education Centers (GEC) including specific information on five centers located in Alabama, Alaska, Nevada, North Carolina, and Florida is then analyzed. Both recommendations of best practices that are working within this program, as well as policy implications and opportunities for improvement in the coming decades are provided in the conclusion.

COLLABORATION WITHIN THE HEALTHCARE DISCIPLINES

Collaboration is often motivated by parties working together to promote a mutual benefit (Hays, 1999; Linden, 2002; Vogel, Ransom, Wai, & Luisi, 2007). Within the healthcare professions, collaboration may be defined as "a complex phenomenon that brings together two or more individuals, often from different professional disciplines, who work to achieve shared aims and objectives" (Houldin et al, 2004; Fewster-Thuente and Velsor-Friedrich, 2008). Lancaster describes the collaborative process as a list of six Cs: "contribution, communication, commitment, consensus, compatibility, and credit" (1985). Further, various attributes of collaboration may include "shared power based on knowledge, authority of role, and lack of hierarchy" (Fewster-Thuente and Velsor-Friedrich, 2008; Kraus, 1980). It follows that interdisciplinary collaboration should be based upon mutual respect, trust, and a valuing of the unique perspectives that each member of the team represents (Houldin et al, 2004). Thus, collaborative partnerships in which shared goals, mutual commitment and respect, and compromise are valued can promote a more productive environment in advancing towards goal attainment (King, 1981) and positive patient care outcomes.

Interdisciplinary collaboration that focuses on mutual goal achievement and outcomes can have a tremendous impact on patient care. Approximately 70% of adverse patient outcomes are linked to a lack of collaboration and communication between healthcare providers, indicating the direct impact for patient outcomes (Fewster-Thuente and Velsor-Friedrich, 2008). As a result, further research is needed to identify collaborative partnerships and strategies within the healthcare disciplines, and in particular the field of geriatrics, in order to strengthen communications and training opportunities for healthcare professionals. Mezey et al (2008) found that less than 3% of resident positions have a geriatric focus and that fewer than 5,000 internal medicine physicians have qualified in geriatrics. These strikingly small numbers indicate the dire need for interdisciplinary training in order to strengthen the geriatric training for healthcare professionals. Similarities in training across the disciplines, including ethics, critical thinking, and evidence-based practice (Mezey et al 2008) helps to establish the forum for interdisciplinary collaboration within the disciplines for the benefit of fields such as geriatric care. Related problem-solving and systemic goals for the benefit of patient care for aging adults provide the common ground needed to ensure that GECs have a purpose and tremendous benefit.

While the case for interdisciplinary collaboration for the benefit of the healthcare disciplines is clearly justified, Fewster-Thorne and Velsor-Friedrich indicate several barriers to collaboration within the healthcare system (2008). First, the existence of patriarchal relationships within healthcare may inherently cause an inequitable balance of power. This conflict is notably seen within the nurse-physician relationship, as nurses are seen as "playing a more subservient role" (Fewster-Thuente and Velsor-Friedrich, 2008) to physicians which may impede effective partnership development. A lack of time was an additional obstacle to collaboration between disciplines; overloaded schedules and larger patient loads can impose a shortage of time to create, and discuss mutual goals for patient care outcomes across disciplines (Fewster-Thuente and Velsor-Friedrich, 2008). This lack of time may also limit interactions between healthcare professionals and thus relationship building and trust between individuals is delayed (Fewster-Thuente and Velsor-Friedrich, 2008). Third, the issues of gender and culture remain an impediment to collaboration within some disciplines (Fewster-Thuente and Velsor-Friedrich, 2008). For example, gender is more traditionally seen as a barrier in the nurse-physician relationship with women traditionally serving as nurses and men as physicians creating an additional imbalance of power that may lead to miscommunications in patient care (Fewster-Thuente and Velsor-Friedrich, 2008). In addition, while culture can be defined in a number of ways, one major problem may result when healthcare professionals and their patients are from different cultures or speak different languages, thus creating a tremendous barrier to effective healthcare provision (Fewster-Thuente and Velsor-Friedrich, 2008). In recent years, the health care industry has seen an increase in its need to educate more health care professionals not only on comprehensive geriatric care, but also on the areas of cultural competency and health literacy. By 2030, the African American population will have doubled and the Asian, Pacific Islander and Hispanic populations will triple (Simpson et. al, 2005). Of the older adult population, one-fourth reside in rural or non-metropolitan areas (Summer, 2007), which introduces an additional component of health care needs and training for rural areas. In rural areas, the level of education is traditionally lower and the older adults health tends to be poor (Summer, 2007).

This study incorporates research on Geriatric Education Centers in part because of their use of interdisciplinary collaboration within the original program design. As a geriatric model, the GECs incorporate various disciplines that may include medicine, dentistry, pharmacy, nursing, social work, and others in order to build consensus and achieve mutual goals that are shared for the direct benefit of older patient care. Many existing collaborative models in the health care field are based upon collaboration between two disciplines, such as the nurse-physician relationship, indicating the need for further case studies.

Interagency Collaboration

Increasingly regarded as a critical strategy to enhance the coordination of the healthcare professions (van Eyk and Baum, 2002), interagency collaboration creates the potential to develop and promote organizational capacity. Bardach (2001) provides a model of interorganizational collaborative capacity, also called the ICC model, in which individuals or agencies are drawn together in order to address a creative opportunity in order to solve a problem. In the process, intellectual capital is generated, which "concerns the nature and scope of the policy problem and a strategic idea about collaborative action" (p. 153).

Van Eyk and Baum suggest a number of positive outcomes that may result from interagency collaboration within the healthcare professions: improved service delivery for people requiring multiple services; more efficient use of healthcare resources; and a means for managers to share the responsibility of community care and reduce organizational stress caused by pressures of increasing demand for services within a climate of cost containment (2002). Sharing information across agencies in order to achieve these outcomes also strengthens both agency partnerships and communication channels in order to serve a larger population of individuals needing healthcare as agencies expand their outreach efforts into rural areas. As agencies prepare for the increase in aging adults across the nation, sharing best practices and intellectual capital will collectively benefit the agencies in achieving their goals for patient care.

However, interagency collaboration also has limitations. Page notes that two critical challenges include that of sharing power and keeping partners satisfied (2003). When an entity is managing either a single complex agency or an agency with multiple components, coordination problems have the potential to inhibit performance and cause competition for influence within the agency, thereby creating turf barriers and threats of exits from collaborative partners (Page 2003; van Eyk and Baum 2002). Under these conditions, consensus may be difficult to achieve depending on the partners involved, and the extent to which competition for resources exists may cause power struggles, tension and the resulting exit of some partners.

To further understanding of interagency collaboration, this study examined communication across GECs and the extent to which they are involved in collaborative partnerships with nonprofit agencies within their communities or jurisdictions. This information sharing across GECs to strengthen training efforts across the nation and sharing models of success in similar communities and states is encouraged by the Federal government funder to enhance outcomes. In addition, interagency collaboration with other nonprofits and community agencies should enhance trust, mutual goal-setting, and communication within geographic areas resulting in direct benefits to patients seeking care through the GECs.

Geriatric Education Centers

The HRSA Bureau of Health Professions is the governing agency for all GECs located within the United States. HRSA governs a number of different programs but each program shares a common goal to "train health care professionals and place them where they are needed most" (Health Services and Resources Administration, 2008). Created in June 1967, HRSA Health Professions programs began as a component of the Public Health Service. However, these programs were then moved under the umbrella of the National Institutes of Health before finally landing back at the Health Resources Administration (which later became HRSA).

As the lead agency in data collection, HRSA is responsible for certifying communities as Health Professional Shortage Areas, which establishes eligibility for federal and state aid (Health Services and Resources Administration, 2008). This assistance may come in the form of loan repayment for nurses, or Rural Health Clinic Certification. One of the many programs HRSA offers through grant opportunities is the Geriatric Education Centers program. The objective for these programs is to "educate and train health professional faculty, students and practitioners in the diagnosis, treatment and prevention of disease, disability and other health problems of the aged" (Health Services and Resources Administration, 2008).

The first GECs were funded in 1984 with centers located at SUNY Buffalo, Michigan, Harvard and University of South Carolina with an additional 16 locations receiving funding the following year (Lansdale, 2000). Today there are 48 funded GECs serving the same mission: to provide professional development opportunities for health care professionals (both practitioners and educators) to expand their knowledge in geriatrics and to assist them with educating other health care providers and students that will work with older adults (Lansdale, 2000).

GECs are funded through the President's executive budget and have generally been supported due to the growing number of older adults. However, in 2006 budget constraints led HRSA to eliminate funding for a number of programs including the GECs to prevent employee lay-offs (BHPr employees will not lose jobs due to budget cuts, Duke says, 2006). This decision resulted in the closing of a number of long-standing GECs that were unable to maintain their educational practices without government funding. In 2007, HRSA reinstated the program budgets and revised the program to include specific training objectives for health care providers. The curriculum was redesigned to explicitly include interdisciplinary collaboration and opportunities to enhance both health literacy and cultural competency of trainees for the benefit of the U.S. population that continues to become more diverse as it grows older. As an example, HRSA tasked GECs with the creation of faculty development training opportunities that included at least 20 hours of education focusing on health literacy. These new requirements have thus re-established the government-nonprofit relationship while responding to the needs and demands of the older adult population.

The 2007 call for proposals stipulated that each GEC's program must include geriatric training for faculty, students and practitioners in the areas of diagnosis, treatment, prevention, disability, and other health related issues present in older adults (Health Resources and Services Administration, 2007). It also stipulated that all training must be interdisciplinary and must include enrollments from at least three disciplines (e.g., medicine, nursing and two others) within the training classes. The interdisciplinary training must include at least four academic disciplines and must address the following purposes:

1. Improve the training of health professionals in geriatrics.

2. Develop and disseminate curricula relating to the treatment of the health problems of older adults.

3. Support the training and retraining of faculty to provide instruction in geriatrics.

4. Support continuing education of health professionals who provide geriatric care.

5. Provide students with clinical training in geriatrics in nursing homes, chronic and acute disease hospitals, ambulatory care centers, and senior centers (Health Resources and Services Administration 2007, p. 4).

These primary purposes outlined in the federal grant do encourage both interdisciplinary and interagency collaboration. Interdisciplinary strategies are inherent within purpose number one, three, four and five as healthcare professionals and students are instructed to be taught in a more comprehensive manner on the field of geriatrics. The dissemination of curricula for the training, as well as in hosting training sessions at various sites encourages collaboration both with community partners and with other GECs that provide similar programming. By providing this training for health care professionals, the presence of a GEC sets participating providers apart from other facilities. These programs provide an alternative approach to learning that is quite different from traditional programs that offer continuing education on discipline specific issues.

To obtain funding, GEC applicants were required to adhere to the following stipulations: all five purposes must be addressed, all training must be interdisciplinary in nature and include four or more disciplines (one must be either allopathic or osteopathic medicine), the project director must be actively involved in the project allocating at least 10% of his/her time, and the project director must have a minimum of five years working experience in education and geriatrics training with health professionals (Health Resources and Services Administration, 2007). Due to the loss of earlier funding, all grant applications were considered "new" applicants and required to provide a list of activities including a timeline that outlined planning and development (year 1) and the operational plan for addressing all five purposes (by year 2) (Health Resources and Services Administration, 2007). While in previous years, the granting cycle had been five years, the new funding was allocated for two years with the possibility for a third.

Forty eight GECs received funding (see Appendix A for complete list of active GECs in the U.S.) in the 2007 round of funding. Since the centers are located in only 36 states, a number of states house more than one GEC. Figure 1 shows the distribution of GECs and the state's percentage of older adults. Interestingly, the states with multiple GECs do not have the highest percentage of older adults living in their area. Currently, six states have multiple GECs: California, Florida, New York, North Carolina, Pennsylvania and Texas. Of these six, three (Florida, New York and Pennsylvania) show a higher percentage of adults over the age of 65 than the remaining three (California, North Carolina and Texas). While many states with a larger older adult population currently host a GEC, other states without GECs will see a dramatic increase in the aging population over the next five years and they will have access to the GEC training to prepare their health care professionals. On the other hand, the states with established multiple centers will have the advantage of substantially more educational opportunities for their health care providers.

COMPARATIVE STUDY OF U.S. GECS

To explore the collaborative relationships that exist across GEC's in the U.S., program objectives, educational opportunities and collaborative efforts of five centers were reviewed. All active U.S. GECs were contacted via email to request information on their program operations. To examine similar information across the centers, the Program Narratives submitted with their federal grant applications were requested. Five GECs provided the requested information for a ten percent response rate. Since many GECs operate within academic environments, a major stumbling block for participation in a nationwide study appears to be restrictions posed by some university Institutional Review Boards (IRBs) in regard to the sharing and storing of information. The following discussion reveals additional details on the agencies that responded to our request for information.

[FIGURE 1 OMITTED]

Carolina Geriatric Education Center

The Carolina Geriatric Education Center (CGEC) is a consortium GEC based primarily out of the School of Health Professions at the University of North Carolina (UNC) at Chapel Hill. Their regional Area Health Education Center partners include the UNC Institute on Aging, the North Carolina Division of Aging and Adult Services, Piedmont Health Services, Inc., American Association of Retired Persons, the United Hmong Association, the Shamrock Senior Center, the Hispanic Health Initiative and the Orange County Department on Aging (Busby-Whitehead & Miller, 2008). The CGEC training programs involve health and human services faculty, students and practitioners and emphasizes the following training components: brain health, disaster preparedness, fall prevention and intervention, health literacy, immigrant elders, mental health, health, oral health and long-term care. To achieve this goal the CGEC offers a number of educational opportunities including a faculty development program in health literacy and aging, conferences and workshops, curriculum development, online education modules, and student training (Busby Whitehead & Miller, 2008).

The faculty development program at CGEC is offered to clinician leaders, either in an academic or health care setting, who educates any or all of the following groups: students, staff, community members and patients (Busby-Whitehead & Miller, 2008). Those that complete the program will be able to: 1) communicate the impact of low health literacy on patient/client outcomes; 2) demonstrate clarity, simplicity and cultural relevance in health communications with patients and/or clients; 3) guide students and other learners in communicating health information clearly when providing care; and 4) identify health system barriers that add to the risk of negative outcomes and apply corrective actions to prevent, detect and/or correct them (Busby-Whitehead & Miller, 2008). The 30-hour program consists of six sessions focusing on the dissemination of health literacy principles and how it can improve patient outcomes. Their goal is to enhance problem-solving skills by providing interactive, outcome-oriented modules within each session (Busby-Whitehead & Miller, 2008).

Nevada Geriatric Education Center

The Nevada Geriatric Education Center (NGEC) is a single institution GEC located at the University of Nevada at Reno, which has developed a curriculum training program that seeks to provide education to all geriatrics-related health professionals across the state. The older adult population continues to increase in the Nevada according to the U.S. Census Bureau estimating that adults aged 65 and older increased 72% between 1990 and 2000 with an additional increase of 19.7% between 2000 and 2005 (Board of Regents of NSHE & University of Nevada, Reno, 2007). Along with the increasing number of older adults in Nevada, it is also home to a diverse population of Hispanics, American Indian and Alaskan Natives. Of the older adults living in Nevada, as of 2004, only 82% identified themselves as Caucasian (Board of Regents of NSHE & University of Nevada, Reno, 2007).

Program objectives for the NGEC are focused on the training or retraining of health professionals in the state, and they include:

1. Site Development: develop and/or enhance clinical teaching sites for trainees in medicine, nursing, social work, speech pathology, nutrition, psychology, public health, pharmacy, physician assistant and dentistry and infuse geriatrics and interdisciplinary team training.

2. Faculty development: create an interdisciplinary faculty development program in health literacy and geriatrics for full-time clinical and volunteer health professions faculty.

3. Continuing education and patient outcomes: the need to provide continuing medical education and continuing education geriatrics training for clinicians who serve older adults many of whom are underserved (Board of Regents of NSHE & University of Nevada, Reno 2007, p. 8-14).

As a result of receiving the grant funds, the NGEC has achieved the first objective by developing clinical sites for interdisciplinary team training for geriatric students as well as supporting clinical site development in the rural location of Fallon (Board of Regents of NSHE & University of Nevada, Reno, 2007). Faculty development programming in the NGEC is offered to the disciplines of medicine, nursing, social work, speech pathology, counseling, nutrition, psychology, public health, health education as well as other interested health professionals. To strengthen the impact of the second objective, NGEC created a mini-fellow program that focuses on health literacy and geriatrics. This 48-hour training course is offered over the course of one year and incorporates a number of educational outlets: interactive video sessions, conference calls, development/implementation of a health literacy project, etc (Board of Regents of NSHE & University of Nevada, Reno, 2007). The program enables those who participate to 1) to understand the full scope of health literacy; 2) to recognize health system barriers faced by patients with low health literacy; 3) to improve verbal and written communications to patients; and 4) to create a "shame-free" environment for patients (Board of Regents of NSHE & University of Nevada, Reno 2007, p. 11).

The NGEC's third objective focuses on the state's need for additional training opportunities for health professionals. Through its partnership with the Health Access Washoe County (HAWC), the NGEC develops interdisciplinary geriatrics training sessions, which are offered as a lunch session on a bimonthly basis to provide networking and educational opportunities for health professionals. Both the NGEC and the Reno Veterans Affairs Medical Center geriatrics fellowship program have developed the curriculum and training used for these sessions. Upon completion of this program, faculty will be able to: 1) discuss the important geriatrics issues related to the diagnosis and care of older patients; 2) Explain the value of other interdisciplinary team members and their importance in managing geriatric patients and developing a care plan, 3) review treatment and referral options for older patients, caregivers, and family, and 4) improve patient outcomes through the implementation of geriatric principles (Board of Regents of NSHE & University of Nevada, Reno 2007, p.14).

Alaska Geriatric Education Center

The Alaska Geriatric Education Center (AKGEC) serves a community that is 97% rural (University of Alaska Anchorage, 2007). Of this community, the 65 and older population grew 60% between 1990 and 2000 according to the U.S. Census Bureau and has a significant Alaskan Native population. To meet the needs of the community it serves, the AKGEC outline three objectives:

1. With a major emphasis on health literacy, health promotion, ethnogeriatrics, and interdisciplinary team clinical practice, the AKGEC will support and enhance instructional capacity in the area of geriatrics for health professionals faculty and students in nursing, social work, psychology, and family medicine.

2. Improve the relevance, effectiveness, and accessibility of geriatric training opportunities for health professionals through establishment of core competency standards and instructional guidelines appropriate for Alaska.

3. Expand and enhance the capacity to develop and disseminate health related information and curricula related to the diagnosis, treatment, prevention of disease, disability, and other problems of the elderly through a variety of venues targeting health professionals (University of Alaska Anchorage, 2007, p. 1-2).

To reach the goals of these objectives, the AKGEC developed a number of educational opportunities as well as competencies and standards to address the aging population and the state's future health care needs. The first objective was addressed by the creation of three programs: 1) the development of the Alaska Geriatric Interdisciplinary Team Training (AKGITT) model; 2) the implementation of the AKGITT course and geriatric rotation into the Family Medicine Residency rotation; and 3) the replication of a revised AKGITT model that can be implemented into other primary care venues such as nursing homes, ambulatory care centers, etc (University of Alaska Anchorage, 2007). To comply with the second objective, the AKGEC outlined the development of geriatric competency standards and instructional guidelines for Alaskan health professionals, the support and development of geriatric training based on the identified needs, incorporating competency-based standards and practices into existing geriatric training and lastly, providing technical assistance for distance learning (University of Alaska Anchorage, 2007). Lastly, the AKGEC implemented four opportunities to comply with its third objective: 1) providing and coordinating training opportunities at a variety of venues, including the Alaska Public Health Summit, the National Association of Social Workers Alaska Chapter, etc; 2) the development of training modules in health promotion and aging; 3) furthering the development of geriatric credentialing programs; and 4) maintenance and enhancement of the AKGEC website to provide continued access to geriatric health information (University of Alaska Anchorage, 2007).

University of Alabama at Birmingham Geriatric Education Center

The University of Alabama at Birmingham Geriatric Education Center (UAB GEC) serves a community in desperate need of health care professional training. Within the state, 58 of its 67 counties are rated as Health Professional Shortage areas by HRSA, 65 counties are identified as Medically Underserved areas and the state is ranked 22nd in the nation for population of adults over 65 (University of Alabama at Birmingham & Center for Aging, 2007). By 2000, the older adult population within the state was 13.2% exceeding the national average of 9% and is projected to continue growing as the baby boomers reach the age of 65 (University of Alabama at Birmingham & Center for Aging, 2007). To meet the health care demands for the state the UAB GEC proposed the following four program objectives:

1) Support the training and retraining of faculty and preceptors

2) Develop and disseminate interdisciplinary curriculum

3) Provide continuing education for health professionals

4) Provide students with interdisciplinary clinical training in geriatrics (University of Alabama at Birmingham & Center for Aging, 2007, p. 6-7).

To accomplish these program objectives, the UAB GEC outlined a series of educational/clinical opportunities that could benefit the various levels of health care providers across the state. To accomplish these objectives, the UAB GEC created a 36-hour faculty development plan (Faculty Scholars Program [FSP]) that was originally offered to six disciplines across the campus (seven participated the first year: dentistry, medicine, nursing, social work, psychology, physical therapy and occupational therapy) through web-based and in-person sessions (University of Alabama at Birmingham & Center for Aging, 2007). The program curriculum modules focused on topics of care coordination, medication management, frailty, symptom management and advanced illness while incorporating cultural competency and health literacy throughout.

Following the FSP development, the curriculum was then revised for dissemination to both students and community health care providers. Health care providers can access the materials through the Alabama Mississippi Practice Based Network (a collaboration with Continuing Medical Education) and receive continuing education credit while students have the opportunity to take the created courses through the Graduate School for course credit (University of Alabama at Birmingham & Center for Aging, 2007).

To meet the fourth objective, the UAB GEC is building upon its relationships with its faculty scholars participants to implement an Interdisciplinary Senior Mentors Experience for the students within those disciplines. The UAB GEC hosted a pilot study that allowed students the opportunity to interview an older adult as an interdisciplinary team and then develop a comprehensive care plan for that mentor (University of Alabama at Birmingham & Center for Aging, 2007). This experience also provided the students with a chance to work with disciplines that they have little to no contact with normally (social work, physical therapy) and to see how each discipline can improve the care and quality of life for the older adult.

Florida Coastal Geriatric Resources, Education and Training Center GEC

The Florida Coastal Geriatric Resources, Education and Training Center (GREAT GEC) is a consortium GEC based out of the Nova Southeastern University through its College of Osteopathic Medicine. Its consortium partners include the Aging and Disability Resource Center of Broward County, the West Palm Beach Department of Veterans Affairs Medical Center and SW Focal Point Senior Center (Nova Southeastern University, 2009) with its primary focus on providing interdisciplinary training programs that focus on the culturally diverse needs of the older adults living in underserved areas within earmarked counties. These educational opportunities strive to advance health promotion and prevention, expanding educational resources for undergraduate and graduate level students, as well as innovative teaching and clinical experiences (Nova Southeastern University, 2009).

In compliance with HRSA's requirements, the GREAT GEC outlined the following goals:

1) To provide health professions students with interdisciplinary ethno-geriatric education and clinical training in health promotion, disease prevention, and enhanced quality of life for older adults, through innovative curriculum adaptation and development, involvement in rural and urban clinical placements, geriatric residencies, traineeships and fellowships

2) Develop interdisciplinary student health care teams providing holistic, culturally sensitive, coordinated services for elders to maintain independence and/or improve quality of life

3) Develop and disseminate innovative interdisciplinary geriatric curriculum and other geriatric education materials for health professions students, faculty and practicing professionals using web-based technology and interdisciplinary problem-based methods

4) Establish for future master geriatrics educators within the existing M.S. in Education for Health Professions, a specialization in Interdisciplinary geriatrics education enabling up to 10 health professions and health professions related faculty to obtain up to 18 credit hours yearly and additional faculty development for other faculty

5) Acquire multidisciplinary awareness relevant to the care of older adults in all-hazard preparedness so they are able to participate in prevention, response, and recovery from such events and assist seniors to be prepared for such events as well

6) Provide training, service, technical assistance and research outreach to a South Florida region not being served by a GEC, including the east and west coasts and inland areas

7) Acquire basic knowledge of historical trends, public policy and the legislative process as they impact the health care delivery system for older adults from a local, state and national perspective and integrate this into the core-required course

8) Identify the psychological issues that affect older adults and integrate this within the healthcare they provide (Nova Southeastern University, 2009).

These goals include a number of overlapping opportunities. By creating an interdisciplinary faculty development program that could be used to earn master's level credit was an insightful use of resources. Through the College of Osteopathic Medicine's already established relationship with the School of Education, the GREAT GEC built on that relationship to create this opportunity that would benefit multiple levels of learners in a number of programs including pharmacy, physical therapy, occupational therapy, nursing, psychology, education, physician assistants, audiology, the Center for Bioterrorism, and the Life-long Learning Institute (C. Rokusek, personal communication, June 9, 2009). These modules or courses are disseminated in a multitude of formats such as a classroom setting, online via WebCT, at conferences and in paper presentations (C. Rokusek, personal communication, June 9, 2009).

DISCUSSION

The exploratory nature of this study has provided interesting findings on interdisciplinary and interagency collaboration in the provision of geriatric healthcare. As is often the case in a grant program, the federal government, as the entity providing funding, truly retains ownership of program objectives, implementation, and outcomes. Program design has dictated the GECs must include interdisciplinary training for professionals and students within their programs. However, some degree of discretion has been provided to the centers in choosing the most appropriate strategies to strengthen the geriatric training efforts. This discretionary aspect has resulted in variations in the degree to which GECs involve other community agencies as partners in localized efforts. Further, we find that interagency collaboration across GECs appears to be limited, which may be caused by regulatory and privacy concerns or greater underlying competition issues yet to be fully determined.

Based upon the parameters stipulated by HRSA, each GEC nourishes its faculty development programs in order to further educate health care professionals on geriatric long-term care. As enforced by HRSA, other similarities of the GECs include an emphasis on the following areas:

* Holistic, comprehensive training of faculty

* Provision of interdisciplinary training curriculum and teams of health care professionals

* Outreach for both rural and urban training and placements

* Continuing education components within the curriculum

* Focus on cultural diversity and health literacy

* Implementation of core standards and practices as a model

* Emphasis on patient outcomes

Specific areas worthy of noting in the GECs reviewed indicate that while a number of these characteristics are exhibited, each agency demonstrated unique ways in which they collaborate with community partners. Table 1 includes the various disciplines that are involved in the GEC training sessions. Each of the five centers in the study shared the common disciplines of medicine (or medical related), nursing, social work, and psychology. Other variations existed across the centers.

Table 2 lists the various topics that are emphasized within the GECs included in the study. Many of these topics overlap across the centers, however, the titles of the topics indicate variations that are worthy to note. Other similarities between one or more of the centers include the following examples:

1) the Carolina and Florida GECs are part of a consortium in which a number of other agencies within the community collaborate to provide training and development opportunities.

2) the Nevada, Alaska, UAB, and Florida centers promoted outreach by expanding GEC site development into underserved remote areas within their jurisdictions. Training sessions were held for example in local nursing homes, ambulatory care centers, and nonprofit centers as a way to both attract additional professionals to the training but also to provide a change in venue for residents within the GEC programs.

The researchers also examined the extent to which the GECs existed as a stand-alone center or within a consortium, which might suggest more established partnerships with community agencies. Table 3 indicates that two of the five centers are part of a consortium, although more research is required to determine the benefits of working within this format as compared to working as a single institution. Each of the centers focus on faculty development as expected, and three of the centers provide long-distance educational programming activities.

Throughout the nation, GECs are required to maintain a focus on providing a comprehensive curriculum for training and continuing education across the academic disciplines for health care professionals. In recognition of the shortage of health care professionals to treat older adults, most GECs make the effort to advertise training opportunities across their states in both urban and rural areas. A strong emphasis on cultural competency is a concurrent theme that runs throughout the curriculum in further attempts to serve the needs of patients both now and in future years as the U.S. population continues to diversify. Thus, the partnership between the federal government and the GECs is making significant progress towards educating health care professionals on comprehensive geriatric needs. However, there are developing areas in the partnership that require further attention and opportunity for improvement.

In 2007, the HRSA call for proposals for GEC grant applications required that agencies report additional performance measures more closely identifying the types of outcomes produced in the programs. In an effort to assist agencies with this effort, HRSA has provided assistance to GECs by developing the National Training and Coordination Collaborative (NTACC) program to strengthen evaluation collection, analysis, and reporting procedures. To further enhance this relationship, NTACC offers its own evaluation tracking system, the GEC Tracker. This program infrastructure stores collected data on an outside server which limits its usability to GECs who have restrictions implemented by the hosting university's Institutional Review Board (IRB).

The IRB's concerns regarding the coordination between GECs and NTACC involve the assurance of data security. NTACC assistance requires that all program data be stored on their own servers. While this is a federal effort to oversee data collection and NTACC does provide some degree of data protection, many university IRBs have concerns regarding privacy protection should the NTACC system be compromised. Thus, the limitations imposed are strict constraints that often motivate GECs to gather, enter and store the data collected on their own protected server rather than to use the HRSA funded mechanism.

Interagency collaboration between the GECs across the nation is another area of studied. As expected, the specific program offerings vary depending on the needs of the area. By implementing an assortment of programs, each GEC has the opportunity to learn from others not just about methodology but also alternative training approaches. Across the agencies, a variety of disciplines were included within the GEC training offerings with some differences in their instructional focus areas, as well as various strategies for continuing education sessions, interactive and online modules, and applied learning.

CONCLUSION

Implications of the Research

Since their initial creation, GECs have provided substantial training to health care professionals working with older adults. In 2007, GECs provided 1,491 education and training programs, and 2,334 interdisciplinary team training sessions (American Geriatrics Center, 2009). Through these programs 42,835 health professionals were educated from varying skill levels (i.e. student, faculty, etc) and different cultural and socioeconomic backgrounds (American Geriatrics Center, 2009). Thus, the federal partnership with local and statewide GECs has directly and indirectly impacted health care for older adults through the interdisciplinary instruction of health care professionals.

Community partnerships within GEC agencies have provided another positive example of collaborative practices within the field of geriatrics. Localized GECs within states and/or regions are building and sustaining relationships with community nonprofits which not only expands the outreach and training efforts, but also provides healthcare professionals and trainees with on-site experience with other facilities where patients are being served. The extension of center sites to more rural areas of states where the population is underserved is another positive impact that is critical in trying to reach geriatric patients in need of services.

While training as a whole has been successful, the interagency partnerships between GECs are an area of development that could strengthen the programs both individually and as a collective group. Due to the competitive nature of the grant and renewal process, a lack of communication between GECs is evident, restricting the information passing between the groups. Currently, a newsletter (GEC Pipeline) is the only documented form of communication that exists between agencies. This bimonthly report allows GECs to submit interesting ideas, events or programs in which they have been involved. However, these articles are a brief synopsis of the occurrence, generally short in nature, and are used primarily as an advertising or visibility strategy. Further, limitations imposed by site-specific Institutional Review Boards at the centers located in university facilities create an additional barrier that constrains the sharing of information across GECs. While data security is highly recommended and required by federal law, the formulation of appropriate performance measures and information sharing modules could greatly benefit the entire program.

Limitations and Recommendations for Future Research

While there are approximately 48 GEC's across the country, information beyond what is available to the public on the centers' websites is hard to come by. Thus, the exploratory study presented here compared the types of programs offered by five GECs agencies. While this narrow response rate drastically limits the analysis of GEC offerings, partnerships, and operations, the small respondent group was geographically and programmatically diverse offering an interesting set of findings.

Despite the low response rate, some similarities were abundantly clear. A number of the GEC's indicated the implementation of some type of faculty development program that included multiple disciplines and occurred over six months to a year. For example, while the HRSA grant application required the participation of at least three disciplines (including both medicine and nursing) the responding GECs included between four and seven.

Additional research conducted with a larger sample is needed for further examination of collaboration. Intergovernmental grant programs often consist of competitive cycles in which sub-national government and nonprofit entities compete for funding. The GECs offer a useful context to learn more about the relationships between agencies and why they do or do not share information.

From a practical perspective, although each state has unique characteristics and context, an effort to overview the various GEC programs in a directory would be a valuable resource both to help newly established GECs, agencies that are looking for new ways to implement programs, and potentially reduce the occurrence of overlapping objectives between programs that could be effectively consolidated into a consortium GEC to serve nearby jurisdictions.

Another recommendation that may improve collaboration builds from the reticence of GECs to share information for this study. In trying to obtain information on the active Geriatric Education Centers, the research team concluded from staff member interviews that the competitive nature and the limited number of grants offered precludes communication and thus has imposed an informal sense of secrecy and reluctance to share information. This secrecy could be explained as a strategy for agency's attempt to remain to provide unique educational experiences to warrant continued funding or from a sense of protectiveness. Even the centers that did provide information were somewhat hesitant at first to discuss their programs. While more research is required to determine the extent trust issues or "turf barriers" (Page, 2003) between the agencies, these challenges seem to limit collaboration opportunity for this set of centers. With the goal of increasing communication and sharing of best practices, the centers should consider utilizing the resources currently available to them through the American Geriatrics Society and the Erotological Society of America. Both agencies provide opportunities for GECs to meet and discuss problems, successes and concerns at their annual conferences. Roundtables and panels could provide GECs with avenues to advocate the need for continued funding as well as the opportunity to speak with HRSA administration regarding their vision for the future. An additional method of collaboration would consist of offering program panels that would focus solely on GEC programs through paper and poster presentations at the AGS and GSA conferences. A final regulatory strategy that may help to reduce the threat of competition would involve enhanced federal government involvement. For example, HRSA could provide incentives for the GECs to work together across agencies and share best practice models and strategies.

In summary, the collaborative efforts of Geriatric Education Centers have strengthened the quality of health care training for the professionals that work with older adults. The programs are a resource to help in preparing for the "Silver Tsunami" as larger numbers of older adults look to the health care industry for assistance to retain a desirable quality of life. By providing substantial interdisciplinary training to faculty, students, and community practitioners, GECs are steadily infiltrating the U.S. health care system and more professionals will be trained on chronic illness and long-term health care. While cross agency communications are an area in which the program could be expanded, the GECs are individually making great strides towards enhancing their outreach and training services for their jurisdictions. Continued funding, appropriate levels of federal oversight, and partnerships with local nonprofit agencies are critical to the continued success of the GECs and ultimately improved health care services for older adults in the United States.

REFERENCES

Bardach, E. (1998). Getting Agencies to Work Together. Washington, D.C.: Brookings.

--. (2001). Developmental Dynamics: Interagency Collaboration as an Emergent Phenomenon. Journal of Public Administration Research and Theory 11(2), 149-164.

BHPR employees will not lose jobs due to budget cuts, Duke says. (2006). Health Resources and Services Administration News Summary, 3. Retrieved June 12, 2009, from http://newsroom.hrsa.gov/newssummary/january2006.htm.

Board of Regents of NSHE & University of Nevada, Reno. (2007). Nevada GEC2007-2010 Grant Proposal. Reno, NV: Patricia Swager.

Busby-Whitehead, J. & Miller, C. (2008). Carolina Geriatric Education Center. Retrieved June 8, 2009, from www.med.unc.edu/aging/cgec/.

Fewster-Thuente, L., & Velsor-Friedrich, B. Interdisciplinary Collaboration for Healthcare Professionals. Nursing Administration Quarterly 32(1), 40-48.

Fried, L.P., & Hall, W.J. (2008). Leading on Behalf of an Aging Society. Special Series: The Association of Directors of Geriatric Academic Programs Symposium. The American Geriatrics Society.

Hays, S. (1999). Our Future Requires Collaborative Leadership. Workforce, 78(12), 30.

Health Resources and Services Administration. (2008). Fact Sheet: Health Resources and Services Administration. www.hrsa.gov/about/factsheets/default.htm.

Houldin, A.D., Naylor, M.D., & Haller, D.G. (2004). Physician-Nurse Collaboration in Research in the 21st Century. Journal of Clinical Oncology 22(5), 774-776.

Institute of Medicine of the National Academies. (2008). Retooling for an Aging America: Building the Health Care Workforce. Retrieved June 13, 2009 from http://www.iom.edu/Object.File/Master/53/507/HealthcareWorkforce_RB.pdf

Kovner, C.T., Mezey, M., & Harrington, C. (2002). Who Cares for Older Adults? Workforce Implications of an Aging Society. Health Affairs 21, 78-89.

Kraus, W.A. (1980). Collaboration in Organizations: Alternatives to Hierarchy. Boston, MA: Human Sciences Press.

Lancaster, J. (1985). The Perils and Joys of Collaborative Research. Nursing Outlook 33, 231-238.

Lansdale, D. (Interviewer) & Roush, B. (Interviewee). (2000). Focus On: Geriatric Education Centers (Interview transcript). Retrieved from ElderWeb website: www.elderweb.com/home/node/2275.

Linden, R. (2002). A Framework for Collaborating. The Public Manager 31(2), 3-6.

Mezey, M., Mitty, E., Burger, S.G., McCallion, P. (2008). Healthcare Professional Training: A Comparison of Geriatric Competencies. Journal of the American Geriatrics Society 56, 1724-1729.

Nova Southeastern University. (2009). Florida Coastal Geriatric Resources, Education and Training Center. Retrieved June 8, 2009, from www.nova.edu/gec/about.html.

Page, S. (2003). Entrepreneurial Strategies for Managing Interagency Collaboration. Journal of Public Administration Research and Theory 13(3), 311340.

Preparing for the silver tsunami. (2006). Alliance for Aging Research. Retrieved from http://www.agingresearch.org/content/article/detail/826/.

University of Alabama at Birmingham & Center for Aging. (2007). Alabama Geriatric Education Center Grant Proposal. Birmingham, AL: Christine S. Ritchie

University of Alaska Anchorage. (2007). Alaska Geriatric Education Center Grant Proposal. Anchorage, AK: Rosellen Rosich, Unknown.

United States Census. (2000). Older adult population of the states. Retrieved June 13, 2009 from www.census.gov

United States Department of Health and Human Services, Division of Health Resources and Services Administration. (n.d.) First Annual Report to the Secretary Department of Health and Human Services and to the Congress, Review and Recommendations > Interdisciplinary, Community-Based Linkages, Title VII, Part D Public Health Service Act. Retrieved June 13, 2009 from http://bhpr.hrsa.gov/Interdisciplinary/acicbl/reports/first/c5.htm

Van Eyk, H. and Fran Baum. (2002). Learning about Interagency Collaboration: Trialling Collaborative Projects Between Hospitals and Community Health Services. Health and Social Care in the Community 10(4), 262-269.

Vogel, A., Ransom, P., Wai, S., & Luisi, D. (2007). Integrating Health and Social Services for Older Adults: A Case Study of Interagency Collaboration. Journal of Health and Human Service Administration 30(2), 199-228.

CHANNING R. FORD, JENNIFER HENDERSON, AND DONNA MILAM HANDLEY

University of Alabama at Birmingham
APPENDIX 1: ACTIVE GERIATRIC EDUCATION CENTERS IN THE UNITED
STATES, 2008

State           Institution

Alaska          University of Alaska Anchorage
Alabama         University of Alabama at Birmingham
Arkansas        University of Arkansas for Medical Sciences
Arizona         University of Arizona
California      University of California San Francisco
                University of California Los Angeles
                Leland Stanford Junior University
Florida         Florida State University
                University of Miami
                Florida Coastal Geriatric Resources, Education and
                  Training Center Nova Southeastern University
Georgia         University of Georgia Research Foundation, Inc.
Hawaii          University of Hawaii, Honolulu
Iowa            The University of Iowa
Kansas          University of Kansas Medical Center Research
                  Institute
Kentucky        University of Kentucky Research Foundation
Maine           University of New England
Maryland        John Hopkins University
Michigan        Michigan State University
Minnesota       Regents of the University of Minnesota
Missouri        Saint Louis University
Montana         University of Montana
Nebraska        University of Nebraska Medical Center
Nevada          University of Nevada Reno
New Hampshire   Trustees of Dartmouth College
New Jersey      University of Medicine & Dentistry of New Jersey
                  --School of Osteopathic Medicine
New Mexico      University of New Mexico Health Sciences Center
New York        Mount Sinai School of Medicine
                University of Rochester
                State University of New York, Stony Brook
North Carolina  Duke University
                University of North Carolina at Chapel Hill
Ohio            Case Western Reserve University
Oklahoma        University of Oklahoma Health Sciences Center

Oregon          Oregon Health and Sciences University
Pennsylvania    Thomas Jefferson University
                University of Pennsylvania
                University of Pittsburgh
Rhode Island    University of Rhode Island
South Carolina  University of South Carolina
Tennessee       Meharry Medical College
Texas           University of Texas Health Science Center at San
                  Antonio
                Baylor College of Medicine
                University of Texas Health Science at Houston
                University of Texas Medical Branch Galveston
Washington      University of Washington
West Virginia   West Virginia University RSCH Corp
Wisconsin       Marquette Arquette University
Wyoming         University of Wyoming


Table 1
Disciplines included within the studied GECs

Nevada GEC      Medicine, nursing, social work, speech pathology,
                counseling, nutrition, psychology, public health,
                health education, other health professionals

Carolina        Health and human services faculty, students and
GEC             practitioners, clinical leaders (academic or health
                care)

Alaska GEC      Nursing, social work, psychology, and family
                medicine

University of   Medicine, nursing, dentistry, social work,
Alabama         psychology, physical therapy and occupational
GEC             therapy

Florida Gulf    Health professions students, faculty and practicing
Coast           professionals, pharmacy, physical therapy,
GREAT           occupational therapy, nursing, psychology,
                education, Life-long Learning Institute, physician
                assistants, audiology, and Center for Bioterrorism

Table 2 Focus topics o f the studied GECs

Carolina GEC    Brain health, disaster preparedness, fall prevention
                & intervention, health literacy, immigrant elders,
                mental health, oral health and long-term care

Nevada GEC      Health literacy and geriatrics

Alaska GEC      Health literacy, health promotion, ethnogeriatrics,
                interdisciplinary teams, diagnosis, treatment,
                prevention of disease, disability and other problems
                associated with older adults

University of   Care coordination, medication management, frailty,
Alabama GEC     symptom management, advanced illness, and cultural
                competency

Florida Gulf    Interdisciplinary team training, health promotion,
Coast           disease prevention, hazard preparedness and enhanced
GREAT           quality of life

Table 3
Breakdown of studied GECs

Program   Single        Consortium   Faculty       Long-
          Institution                Development   Distance
                                                   Educational
                                                   Program
CGEC                    X            X             X
NGEC      X                          X
AKGEC     X                          X             X
UAB       X                          X             X
GEC
GREAT                   X            X *
GEC

* Faculty development opportunity results in Masters level credits
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