Action Awards were one-year grants for up to $10,000 that were made available to interprofessional teams led by alumni of a John A. Hartford Foundation funded program for the purpose of achieving meaningful change to practice or policy that improves the health and wellbeing of older adults and/or their families.
Read about the 34 Action Awards projects that have been funded by clicking the links below.
Learn from Change AGEnts who spent a year implementing evidenced-based practice change projects. View the final report presentations.
The Hartford Change AGEnts Initiative Policy Institute provided an opportunity for Change AGEnts to gain new knowledge and acquire skills necessary to mobilize for action on policy issues to bring about improvements in health care and quality of life for older adults. Institute topics ranged from federal policy and regulatory change to state and local policy action. The Institute helped Change AGEnts gain a stronger understanding of the complex policy-making environment and the role that Change AGEnt involvement can play in driving policy outcomes.
The Change AGEnts Communications Institute provided Change AGEnts with the communications knowledge and skills needed to help bring about improvements in health care and quality of life for older adults. The focus of the institute was communications in practice and policy change—topics covered ranged from messaging, elevator speeches, and value propositions to working with the media/social media and leading change in practice and policy arenas.
The vision of the Patient-Centered Medical Home (PCMH) Network was to transform PCMHs through recognizing, facilitating, encouraging, and ultimately improving the care of older adults and their caregivers. By advocating for and promoting the thoughtful insertion of geriatrics into the PCMH model, the PCMH Network sought to improve outcomes for older adults in the Comprehensive Primary Care (CPC) initiative and other PCMH sites.
The focus of the PCMH Network was to identify ways to improve the skills of PCMH clinicians who may not have had formal geriatric training at both the patient and population level. These efforts included evidence-based geriatrics education on specific topics, appropriate risk identification and stratification, and more geriatric-sensitive care management.
The PCMH Network was co-chaired by David Dorr, MD, MS, Associate Professor and Vice Chair, Medical Informatics and Clinical Epidemiology at Oregon Health & Science University in Portland, OR, and Rob Schreiber, MD, CMD, Medical Director of Evidence-based Programs at Hebrew SeniorLife and Medical Director of the Healthy Living Center of Excellence in Boston, MA.
Additionally, the Network enlisted seven geriatrics experts in the field of health care. The PCMH Network members were:
The vision of the Network was to transform PCMHs to recognize, facilitate, encourage, and ultimately improve the care of older adults and their caregivers. We also proposed to enhance their connection to relevant resources, including family caregivers and community-based resources. By advocating for and promoting the thoughtful insertion of geriatrics into the PCMH model and the eventual implementation of two to three geriatrics-specific pilot projects in PCMH settings, the Network sought to improve outcomes for older adults in CPC and other PCMH sites. A large thrust of the Network was to identify ways to improve the skills of PCMH who may not have had formal geriatric training, at both patient and population level. These efforts included evidence-based geriatric education on specific topics, appropriate risk identification and stratification, and more geriatric sensitive care management.
It was the goal of the Network to support better policy and implementation by reframing the PCMH model to establish the value of caring for older adults and defining a set of PCMH models and policy changes that increase the likelihood of better outcomes for older adults. In order to meet these objectives, the Network team members collaborated to distill our ideas into measurable, actionable, and timely goals. The Network also sought input from other Hartford Foundation initiatives and geriatrics experts in health care.
To read an overview about the Network click here.
To read the bios of the co-chairs and members click here.
To access the PCMH Paper: "Patient-Centered Medical Homes and the Care of Older Adults: How comprehensive care coordination, community connections, and person-directed care can make a difference" click here.
The Hartford Change AGEnts Initiative Dementia Caregiving Network (DCN) worked to achieve improvements in services, supports, and care for persons with dementia and their family caregivers. Initiated in January 2014, the DCN was composed of the following interdisciplinary group of nationally recognized leaders with expertise in practice, policy and research related to caregiving and dementia:
Highlights of DCN activities and information about work which continues to advance include:
Profiling evidence-based interventions that address the needs of family caregivers. Using interprofessional teams, the DCN developed and tested a carefully defined methodology for conducting comprehensive reviews of evidence-based programs for persons with dementia and their family caregivers. This work will help provider and payer organizations and other potential users understand the available evidence-based programs and care practices and make decisions about which ones to provide, pay for, and use. Separate grant funding was sought for creation of a “community-friendly” online decision support tool to make comprehensive information about programs’ research and implementation characteristics more broadly accessible, with program-comparison features, as well as feedback from current implementation sites. For more information, click here.
Developing a practical approach to identifying family members in the electronic health record who are providing care to older adults. This DCN project worked to define strategies and means of including reliable and culturally sensitive tools in the electronic health record (EHR) to assist in the identification of those providing care to family members. The goals of this work have been built around the following tenets:
For more information, click here.
Improving dementia care and the identification, engagement, and support of family caregivers in the dually-eligible population. The DCN contributed to documenting, evaluating, and disseminating the promising practices of California’s Dementia Cal MediConnect program that strengthened the training and capacity of health plans to better coordinate dementia care with community agencies providing supportive services to family caregivers. The DCN mobilized necessary actors in other states and communities to adopt these promising practices in dementia care and family caregiver support. Texas and Rhode Island are including these practices and resources in their duals demonstration projects. With funding from the Administration for Community Living, Dementia Cal MediConnect has produced a toolkit with essential resources for health plans, community organizations, care managers, and family caregivers. For more information, click here.
Contributing to ongoing work on the development of performance/quality measures for dementia care that is person- and family-centered. DCN members submitted comments on national quality measures that resulted in substantive changes in work produced by the National Quality Forum. Commentary was also provided to the American Academy of Neurology/American Psychiatric Association for their proposed quality measures for dementia management, Dementia: Quality Measurement Set Update. DCN members also completed a policy commentary, “Improving Measurement of Dementia Care Quality to Advance Person-Centered Care,” for peer-reviewed publication (Gary Epstein-Lubow et al., 2016).
Fostering collaboration across national, state, and local organizations. To enhance the network of support services for dementia caregivers and influence practice change in all domains, DCN members nurtured collaborations. One or more DCN members provided leadership or participated in the activities described in the one-page summary.
To read a one page summary of the work of the DCN, please click here.
While the Change AGEnts Leadership Team believed in the value of in-person connections for networking and skill development, it also understood that distance and resource constraints necessitated the use of technology to communicate and organize for action. For this reason, the Change AGEnts Action Communities were developed as a collaborative, online network to learn from each other by sharing published and developing research, personal experiences, and contacts in the field using Change AGEnts Connect. To facilitate the transition to virtual work spaces, the Change AGEnts Initiative offered seed funding to the Action Communities to support off-line as well as on-line activities. Click here to read the Action Communities Overview.