- Email: [email protected]
Foundation funding for geriatric training
APM SYMPOSIUMON GERIATRICEDUCATION/REGENSTREIF
of VA clinical staff at all VA medical centers, in addition, the VA also has continuing education field units that include seven regional medical education centers, nine cooperative health education programs, two dental education centers, and one continuing education center. When system-wide needs occur, a national training program is established in addition to those at regional and local levels. During the past 3 years, national training programs on aging were conducted on health care problems of the elderly, ambulatory care for the elderly, geriatric evaluation and management, medication management, and mental health in nursing homes.
TRAINING SITES AND RESEARCHSUPPORT The VA considers research an integral part of geriatric training, especially at the postdoctoral and fellowship levels. A VA facility hosting a GRECC provides access to research mentors, space, equipment, and computers. The VA has a national research program with annual funding of >$200 million. In addition, special funding is allocated for health services research and rehabilitation and prosthetic research. Of the VA research budget, >50% is allocated for investigator-initiated research. In 1992, of the 63 health services and inves-
tigator-initiated projects, 49% addressed questions important to aging veterans [7]. From the Assistant Chief Medical Director for Geriatrics, Department of Veterans Affairs, Washington, D.C. Requests for reprints should be addressed to Thomas T. Yoshikawa, M.D., ACMDfor Geriatrics (114), Department of VeteransAffairs, 810 VermontAvenue NW, Washington, D.C. 20420.
REFERENCES 1. Office of Strategic Planning,VeteransHealth Administration,Department of Veterans Affairs, Washington, D.C., 1993. 2. DemographicsDivision,Office of Planningand ManagementAnalysis, Department of Veterans Affairs, Washington, D.C., 1993. 3. DemographicsDivision,Office of Planningand ManagementAnalysis, Department of Veterans Affairs, Washington, D.C., 1991. 4. Office of Geriatrics and Extended Care: program guide for geriatrics and extended care. Department of Veterans Affairs, Washington, D.C., 1993. 5. YoshikawaTT. United States Department of VeteransAffairs health care for aging veterans. In: Vellar B, Albarede J, eds. Facts and research in gerontology. New York: Springer, 1992; 263-7. 6. Committee on Leadershipfor Academic Geriatric Medicine. Report of the Institute of Medicine: academic geriatrics for the year 2000. J Am Geriatr Soc 1987; 35: 773-91. 7. Veterans Health Administration. Annual Report to Senate Committee on Aging. Department of Veterans Affairs Activities on Behalf of Older Persons, fiscal year 1992. Department of Veterans Affairs, Washington, D.C., 1993. 8. Veterans HealthAdministration. Site selection for fellowship programs in geriatric psychiatry beginning in academic year 1991-1992. Circular 10-90-001, January 4, 1990, Department of Veterans Affairs, Washington, D.C. 9. Veterans Health Administration. Postdoctoral dental fellowship. Field information letter, August 27, 1990. Department of Veterans Affairs, Washington, D.C.
Foundation Funding for Geriatric Training DONNA I, REGENSTREIF, Ph.D., New York, New York
he Foundation Center in New York City re-
T ports that the nation's 32,401 independent, corporate, community, and operating foundations, which had assets of $142.4 billion, made grants totaling $8.7 billion in 1990. Of the total amount of 1990 foundation giving, 26% was allocated to education and 17% to health care. Figure 1 shows that medical research received 24% of total health funding, hospitals and medical care 36%, and mental health 12%. Funding for health professions education was accounted for under the education category: graduate and professional training received 26%, second only to higher education [1].
EXPLICIT SUPPORTFOR GERIATRICTRAINING The John A. Hartford Foundation and the Brookdale Foundation have had the longest explicit com4A-28S
mitment to geriatric training of the major national foundations with an interest in health or aging. The Hartford Foundation's Aging and Health Program began >10 years ago. Commitments to geriatric training since 1983 total >$10 million and have helped the careers of approximately 400 individuals, half of them medical students and the rest ranging up to mid-career faculty. The program's initial goal was training mid-career faculty to become leaders in academic geriatrics. Four geriatric training centers (Harvard, Mt. Sinai, Johns Hopkins, and UCLA) and 29 scholars received support. Although this strategy enabled rapid development of senior academic geriatricians, a more substantial effort was required. Recommendations of the Institute of Medicine led to the Academic Geriatrics Recruitment Initia-
October 17, 1994 The American Journal of Medicine Volume 97 (suppt 4A)
APM SYMPOSIUM ON GERIATRIC EDUCATION / REGENSTREIF
tive (AGRI), which concentrated resources in geriatric "Centers of Excellence." In 1988 commitments of $3 million over 3 years were made to 10 AGRI centers. In 1991 the program was renewed and expanded to 13 centers with level funding and will conclude in 1994. Stimulated by an invitation from The Commonwealth Fund to participate in a national gero-physician-scientist training effort, Hartford awarded nearly $600,000 to the American Federation for Aging Research to train nonmedicine physician specialists in geriatrics. Five scholars, two in anesthesiology and three in gynecology, have now received support. Grants to the American Geriatrics Society supported enhanced geriatric program development and improved geriatric training in relevant specialties. In addition, a 1993 award to the Institute of Medicine will soon result in a report on the geriatric content of medical training at all educational levels. The Brookdale Foundation has offered postdoctoral fellowships to medical, biomedical, and social scientists since 1985. So far, expenditures under this program have totaled approximately $5.7 million, providing 3-year postdoctoral support to 39 fellows to protect research time. During the 1980s, the Charles A. Dana Foundation spent >$2.5 million to train nearly 30 fellows and support medical student research in geriatrics through a grant to the American Federation for Aging Research. The Commonwealth Fund has devoted approximately $1.7 million to training in geriatric medicine since 1982. Recently, the fund has been working through the Alliance for Aging Research to attract corporate and other private donations to establish geriatric leadership centers throughout the country (similar to the "Centers of Excellence" strategy proposed by the Institute of Medicine in 1987 and adopted by the Hartford Foundation at that time). The first leadership center was created at the University of Pennsylvania with a contribution from Smith Kline Beecham. Support is earmarked for senior fellows and/or junior faculty members for a minimum of 3 years. So far, commitments of $6.2 million have been made by the Commonwealth Fund and other donors. Funding explicitly directed toward geriatric training from major national foundations now totals approximately $20 million since such programs began in the early 1980s.
ample, The Henry J. Kaiser Family Foundation's interest in functional outcomes of medical care led to advances in measurement of benefit to geriatric research and care. The long-standing Clinical Scholars Program of the Robert Wood Johnson Foundation so far includes 40 awardees out of 600 who identify geriatrics/gerontology as their specialty. The Healthy Aging initiative of the John D. and Catherine T. MacArthur Foundation supports collaborative research networks of gerontologic scholars at several sites and provides postdoctoral research support to medical and other scientists from participating institutions. The Community Partnership Initiative of the W. K. Kellogg Foundation has committed $42 million to seven health education centers to create nonhospital-based primary care teaching models involving doctors, nurses, and other primary care professionals. A Pew Charitable Trusts' initiative to help health professions schools adapt to the changing health care needs of U.S. citizens will likely be beneficial to geriatrics as well. Many corporations, including Merck, Pfizer, and the Travelers Insurance Companies, have supported medical training, both with and without geriatric labels attached. Donations for geriatric training through formally constituted corporate foundations are reflected in the figures cited previously. Finally, numerous family and community foundations have donated money for salaries and/or research to local or alumni institutions. Comprehensive data for these types of foundation contributions do not exist [2].
4ental Tealth 12% Jecific iseases 7% Care cing o
Other 6%
FOUNDATIONPROGRAMSWITH INDIRECT GERIATRIC BENEFIT
Public Health 4%
runlet
Management
2%
Foundations also have contributed to training programs not explicitly directed to geriatrics. These programs benefit geriatric education by focusing on basic research and clinical care. For ex-
Figure 1. Percentage of grant dollars. Note: General & Rehabilitative subcategory accounts for 57% of giving in health; subcategory includes Hospitals & Medial Care, Reproductive Health Care, General & Rehabilitative-Other, Public Health, Policy & Management, and Health Care Financing. Source: The Foundation Grants Index Database, 1992.
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)
4A-29S
APMSYMPOSIUMON GERIATRICEDUCATION/ KOWAL CONCLUSIONS
Foundations have pursued a variety of strategies in response to the critical need for geriatric research and training. Even so, the gap between supply and demand remains large. Why hasn't a more concerted and substantial effort occurred? One reason may be the false impression that government efforts are solving the problem. Another reason is that training efforts may not fit the agenda of foundation trustees seeking a "quick fix" to problems. A third factor is the failure of most medical academic institutions to give geriatric education and research the high priority needed to gain the attention of local and national funders. Increased training support directed to geriatric education and research will be neither forthcoming nor successful without a clear commitment to and respect for geriatrics by university presidents, medical school deans, department chairpersons, and opinion leaders at academic medical centers. In the
future, corporate, foundation, and individual philanthropy, along with the government must reinvigorate their efforts to enhance geriatric training at all levels. The elderly must know that their physicians have the knowledge to provide them effective and affordable care. This knowledge base also must be continually fed by basic research that is thoughtfully applied to clinical care. But this cannot be done without drastic changes in attitudes about and support for geriatric training.
From The John A. Hartford Foundation, New York, New York. Requestsfor reprints should be addressedto Donna I. Regenstreif,Ph.D., the John A. Hartford Foundation,55 East 59th Street, New York, New York 10022.
REFERENCES 1. Renz, L., Lawrence,S. FoundationGiving: 1992 Edition. New York: The Foundation Center. 2. GreenbergBR, Gutheil IA, Parker LM, CherneskyRH. Aging: the Burden study of foundational grantmaking trends. New York: The FoundationCenter, 1991.
"Centers of Excellence" and Geriatric Faculty Development JEROME KOWAL, M.D., Cleveland, Ohio
t a 1987 meeting sponsored by the Institute of Medicine [1], funding of geriatrics "Centers of Excellence" was recommended to mobilize and focus scarce resources, provide sites for training new investigators, and enhance creative interaction among scientists in diverse research areas. Three central goals were defined: (a) to develop structured, efficient training programs to attract students and produce faculty; (b) to conduct research to add to clinical knowledge, maintain an academic base, and provide role models for trainees; (c) to provide clinical care in a variety of settings. Currently, 21 geriatric training programs use resources from 16 Veterans Administration (VA) geriatric research, education, and clinical centers (GRECCs); 13 Hartford Foundation recruitment initiative centers of excellence; and eight Claude Pepper older Americans independence centers (OAICs). The importance of GRECC funding is illustrated by the fact that nine Hartford supported programs and four OAICs have GRECCs. The Association of Directors of Geriatric Academic Programs (ADGAP) is comprised of 120 geri-
A
4A-30S
atric leaders designated by the dean of each school of medicine or osteopathy in the United States. ADGAP SURVEY RESULTS
An ADGAP priority is evaluating current training activities and recommending approaches for dealing with current and projected geriatric faculty needs. A 1992 survey of members revealed that many institutions still lacked the hospital-based and ambulatory training sites considered essential for geriatric training (Tables I and II). Only 73% of the 72 responding programs offered any geriatric content in their medical residency programs. The reasons most often given were lack of training sites, lack of geriatric faculty or geriatric-trained practitioners, minimal interest of medical school leaders, and overcrowded curricula. In contrast to the "procedure based" subspecialties that may receive hundreds of applications, the average number of geriatric fellowship applicants in 1992-1993 was only 8.8 per program (Figure 1). A total of 20 programs had no applicants whatsoever. Furthermore, <50% of the applicants were
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)
of VA clinical staff at all VA medical centers, in addition, the VA also has continuing education field units that include seven regional medical education centers, nine cooperative health education programs, two dental education centers, and one continuing education center. When system-wide needs occur, a national training program is established in addition to those at regional and local levels. During the past 3 years, national training programs on aging were conducted on health care problems of the elderly, ambulatory care for the elderly, geriatric evaluation and management, medication management, and mental health in nursing homes.
TRAINING SITES AND RESEARCHSUPPORT The VA considers research an integral part of geriatric training, especially at the postdoctoral and fellowship levels. A VA facility hosting a GRECC provides access to research mentors, space, equipment, and computers. The VA has a national research program with annual funding of >$200 million. In addition, special funding is allocated for health services research and rehabilitation and prosthetic research. Of the VA research budget, >50% is allocated for investigator-initiated research. In 1992, of the 63 health services and inves-
tigator-initiated projects, 49% addressed questions important to aging veterans [7]. From the Assistant Chief Medical Director for Geriatrics, Department of Veterans Affairs, Washington, D.C. Requests for reprints should be addressed to Thomas T. Yoshikawa, M.D., ACMDfor Geriatrics (114), Department of VeteransAffairs, 810 VermontAvenue NW, Washington, D.C. 20420.
REFERENCES 1. Office of Strategic Planning,VeteransHealth Administration,Department of Veterans Affairs, Washington, D.C., 1993. 2. DemographicsDivision,Office of Planningand ManagementAnalysis, Department of Veterans Affairs, Washington, D.C., 1993. 3. DemographicsDivision,Office of Planningand ManagementAnalysis, Department of Veterans Affairs, Washington, D.C., 1991. 4. Office of Geriatrics and Extended Care: program guide for geriatrics and extended care. Department of Veterans Affairs, Washington, D.C., 1993. 5. YoshikawaTT. United States Department of VeteransAffairs health care for aging veterans. In: Vellar B, Albarede J, eds. Facts and research in gerontology. New York: Springer, 1992; 263-7. 6. Committee on Leadershipfor Academic Geriatric Medicine. Report of the Institute of Medicine: academic geriatrics for the year 2000. J Am Geriatr Soc 1987; 35: 773-91. 7. Veterans Health Administration. Annual Report to Senate Committee on Aging. Department of Veterans Affairs Activities on Behalf of Older Persons, fiscal year 1992. Department of Veterans Affairs, Washington, D.C., 1993. 8. Veterans HealthAdministration. Site selection for fellowship programs in geriatric psychiatry beginning in academic year 1991-1992. Circular 10-90-001, January 4, 1990, Department of Veterans Affairs, Washington, D.C. 9. Veterans Health Administration. Postdoctoral dental fellowship. Field information letter, August 27, 1990. Department of Veterans Affairs, Washington, D.C.
Foundation Funding for Geriatric Training DONNA I, REGENSTREIF, Ph.D., New York, New York
he Foundation Center in New York City re-
T ports that the nation's 32,401 independent, corporate, community, and operating foundations, which had assets of $142.4 billion, made grants totaling $8.7 billion in 1990. Of the total amount of 1990 foundation giving, 26% was allocated to education and 17% to health care. Figure 1 shows that medical research received 24% of total health funding, hospitals and medical care 36%, and mental health 12%. Funding for health professions education was accounted for under the education category: graduate and professional training received 26%, second only to higher education [1].
EXPLICIT SUPPORTFOR GERIATRICTRAINING The John A. Hartford Foundation and the Brookdale Foundation have had the longest explicit com4A-28S
mitment to geriatric training of the major national foundations with an interest in health or aging. The Hartford Foundation's Aging and Health Program began >10 years ago. Commitments to geriatric training since 1983 total >$10 million and have helped the careers of approximately 400 individuals, half of them medical students and the rest ranging up to mid-career faculty. The program's initial goal was training mid-career faculty to become leaders in academic geriatrics. Four geriatric training centers (Harvard, Mt. Sinai, Johns Hopkins, and UCLA) and 29 scholars received support. Although this strategy enabled rapid development of senior academic geriatricians, a more substantial effort was required. Recommendations of the Institute of Medicine led to the Academic Geriatrics Recruitment Initia-
October 17, 1994 The American Journal of Medicine Volume 97 (suppt 4A)
APM SYMPOSIUM ON GERIATRIC EDUCATION / REGENSTREIF
tive (AGRI), which concentrated resources in geriatric "Centers of Excellence." In 1988 commitments of $3 million over 3 years were made to 10 AGRI centers. In 1991 the program was renewed and expanded to 13 centers with level funding and will conclude in 1994. Stimulated by an invitation from The Commonwealth Fund to participate in a national gero-physician-scientist training effort, Hartford awarded nearly $600,000 to the American Federation for Aging Research to train nonmedicine physician specialists in geriatrics. Five scholars, two in anesthesiology and three in gynecology, have now received support. Grants to the American Geriatrics Society supported enhanced geriatric program development and improved geriatric training in relevant specialties. In addition, a 1993 award to the Institute of Medicine will soon result in a report on the geriatric content of medical training at all educational levels. The Brookdale Foundation has offered postdoctoral fellowships to medical, biomedical, and social scientists since 1985. So far, expenditures under this program have totaled approximately $5.7 million, providing 3-year postdoctoral support to 39 fellows to protect research time. During the 1980s, the Charles A. Dana Foundation spent >$2.5 million to train nearly 30 fellows and support medical student research in geriatrics through a grant to the American Federation for Aging Research. The Commonwealth Fund has devoted approximately $1.7 million to training in geriatric medicine since 1982. Recently, the fund has been working through the Alliance for Aging Research to attract corporate and other private donations to establish geriatric leadership centers throughout the country (similar to the "Centers of Excellence" strategy proposed by the Institute of Medicine in 1987 and adopted by the Hartford Foundation at that time). The first leadership center was created at the University of Pennsylvania with a contribution from Smith Kline Beecham. Support is earmarked for senior fellows and/or junior faculty members for a minimum of 3 years. So far, commitments of $6.2 million have been made by the Commonwealth Fund and other donors. Funding explicitly directed toward geriatric training from major national foundations now totals approximately $20 million since such programs began in the early 1980s.
ample, The Henry J. Kaiser Family Foundation's interest in functional outcomes of medical care led to advances in measurement of benefit to geriatric research and care. The long-standing Clinical Scholars Program of the Robert Wood Johnson Foundation so far includes 40 awardees out of 600 who identify geriatrics/gerontology as their specialty. The Healthy Aging initiative of the John D. and Catherine T. MacArthur Foundation supports collaborative research networks of gerontologic scholars at several sites and provides postdoctoral research support to medical and other scientists from participating institutions. The Community Partnership Initiative of the W. K. Kellogg Foundation has committed $42 million to seven health education centers to create nonhospital-based primary care teaching models involving doctors, nurses, and other primary care professionals. A Pew Charitable Trusts' initiative to help health professions schools adapt to the changing health care needs of U.S. citizens will likely be beneficial to geriatrics as well. Many corporations, including Merck, Pfizer, and the Travelers Insurance Companies, have supported medical training, both with and without geriatric labels attached. Donations for geriatric training through formally constituted corporate foundations are reflected in the figures cited previously. Finally, numerous family and community foundations have donated money for salaries and/or research to local or alumni institutions. Comprehensive data for these types of foundation contributions do not exist [2].
4ental Tealth 12% Jecific iseases 7% Care cing o
Other 6%
FOUNDATIONPROGRAMSWITH INDIRECT GERIATRIC BENEFIT
Public Health 4%
runlet
Management
2%
Foundations also have contributed to training programs not explicitly directed to geriatrics. These programs benefit geriatric education by focusing on basic research and clinical care. For ex-
Figure 1. Percentage of grant dollars. Note: General & Rehabilitative subcategory accounts for 57% of giving in health; subcategory includes Hospitals & Medial Care, Reproductive Health Care, General & Rehabilitative-Other, Public Health, Policy & Management, and Health Care Financing. Source: The Foundation Grants Index Database, 1992.
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)
4A-29S
APMSYMPOSIUMON GERIATRICEDUCATION/ KOWAL CONCLUSIONS
Foundations have pursued a variety of strategies in response to the critical need for geriatric research and training. Even so, the gap between supply and demand remains large. Why hasn't a more concerted and substantial effort occurred? One reason may be the false impression that government efforts are solving the problem. Another reason is that training efforts may not fit the agenda of foundation trustees seeking a "quick fix" to problems. A third factor is the failure of most medical academic institutions to give geriatric education and research the high priority needed to gain the attention of local and national funders. Increased training support directed to geriatric education and research will be neither forthcoming nor successful without a clear commitment to and respect for geriatrics by university presidents, medical school deans, department chairpersons, and opinion leaders at academic medical centers. In the
future, corporate, foundation, and individual philanthropy, along with the government must reinvigorate their efforts to enhance geriatric training at all levels. The elderly must know that their physicians have the knowledge to provide them effective and affordable care. This knowledge base also must be continually fed by basic research that is thoughtfully applied to clinical care. But this cannot be done without drastic changes in attitudes about and support for geriatric training.
From The John A. Hartford Foundation, New York, New York. Requestsfor reprints should be addressedto Donna I. Regenstreif,Ph.D., the John A. Hartford Foundation,55 East 59th Street, New York, New York 10022.
REFERENCES 1. Renz, L., Lawrence,S. FoundationGiving: 1992 Edition. New York: The Foundation Center. 2. GreenbergBR, Gutheil IA, Parker LM, CherneskyRH. Aging: the Burden study of foundational grantmaking trends. New York: The FoundationCenter, 1991.
"Centers of Excellence" and Geriatric Faculty Development JEROME KOWAL, M.D., Cleveland, Ohio
t a 1987 meeting sponsored by the Institute of Medicine [1], funding of geriatrics "Centers of Excellence" was recommended to mobilize and focus scarce resources, provide sites for training new investigators, and enhance creative interaction among scientists in diverse research areas. Three central goals were defined: (a) to develop structured, efficient training programs to attract students and produce faculty; (b) to conduct research to add to clinical knowledge, maintain an academic base, and provide role models for trainees; (c) to provide clinical care in a variety of settings. Currently, 21 geriatric training programs use resources from 16 Veterans Administration (VA) geriatric research, education, and clinical centers (GRECCs); 13 Hartford Foundation recruitment initiative centers of excellence; and eight Claude Pepper older Americans independence centers (OAICs). The importance of GRECC funding is illustrated by the fact that nine Hartford supported programs and four OAICs have GRECCs. The Association of Directors of Geriatric Academic Programs (ADGAP) is comprised of 120 geri-
A
4A-30S
atric leaders designated by the dean of each school of medicine or osteopathy in the United States. ADGAP SURVEY RESULTS
An ADGAP priority is evaluating current training activities and recommending approaches for dealing with current and projected geriatric faculty needs. A 1992 survey of members revealed that many institutions still lacked the hospital-based and ambulatory training sites considered essential for geriatric training (Tables I and II). Only 73% of the 72 responding programs offered any geriatric content in their medical residency programs. The reasons most often given were lack of training sites, lack of geriatric faculty or geriatric-trained practitioners, minimal interest of medical school leaders, and overcrowded curricula. In contrast to the "procedure based" subspecialties that may receive hundreds of applications, the average number of geriatric fellowship applicants in 1992-1993 was only 8.8 per program (Figure 1). A total of 20 programs had no applicants whatsoever. Furthermore, <50% of the applicants were
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)