2012 ANNUAL REPORT
Refining the Vision and Broadening Strategies
Ten years after launching the Aging and Health program, the Hartford Foundation refined its vision and strategies still further. The two program areas were renamed and broadened into 1) academic geriatrics and training and 2) integrating and improving health care services for older adults.
The Foundation also moved beyond geriatric medicine to work with other specialists (Increasing Geriatrics Expertise for Surgical and Related Medical Specialists, Integrating Geriatrics into the Subspecialties of Internal Medicine) and later engaged with two other professions—nursing and social work. Grants to improve health care services increasingly focused on models of coordinated team care. The Foundation began investing larger amounts into faculty development awards and also funded efforts to add aging curricula into schools of social work, nursing, and medicine (Geriatric Social Work Initiative: Curriculum, Curriculum Grants in Nursing, Curriculum Grants in Medicine).
At the same time, the Foundation became more sophisticated in its strategic planning and organizational development and engaged funding partners to help amplify the impact of its programs. Corinne H. Rieder, EdD, Executive Director and Treasurer of the Hartford Foundation, led a strategic planning process in 1996 to assist the Trustees in their decision-making with regard to future grants. As a result of the strategic plan, Trustees and staff took more ownership in the development of a comprehensive grantmaking program. The Trustees encouraged staff to increase the size and duration of grants to ensure projects would make a substantial impact—in keeping with the Foundation’s principles of partnership, engagement, and commitment.
Norman H. Volk
Chairman
The John A. Hartford Foundation
Reaching beyond geriatric medicine to specialist physicians
While all physicians in training are required to have a clinical rotation in pediatrics, few other than pediatricians will ever treat children again. Most, however, will care for older adults, but without adequate training. The Foundation therefore made grants to the American Geriatrics Society in the early 1990s to increase geriatric content in physician training for surgeons and related specialists and subspecialists in internal medicine (Increasing Geriatric Expertise for Surgical and Related Medical Specialists, Integrating Geriatrics into the Subspecialties of Internal Medicine); these grants continue today.
The Trustees encouraged staff to increase the size and duration of grants to ensure projects would make a substantial impact.
When the Health Care Cost and Quality program ended in 1994, all of the Foundation’s grantmaking resources were available to fund Aging and Health initiatives and larger grants were now feasible. These included a 1994 $7.9 million grant to the American Federation for Aging Research, which, with co-funding from other partners, would create the Paul B. Beeson Physician Faculty Scholars in Aging Research Program. These prestigious career development awards for physicians from all specialties develop outstanding junior faculty as leaders in academia. This model was replicated in various forms over the following years in medicine, nursing, and social work.
Improving health care services and investing in team training
The Hartford Foundation also began to address fragmentation in the health care system by supporting models to improve coordination of care among providers across disciplines and settings.
Through the 1992 Generalist Physician Initiative, for example, nursing and social work staff joined primary care practices. One of the most promising of the initiative sites was the Carle Clinic Association, in Champagne, Illinois. Ultimately, the site was selected to participate in the national Medicare Coordinated Care Demonstration project authorized by the Balanced Budget Act of 1997, helping to inform national efforts in health care delivery reform.
The Generalist Physician Initiative showed that the skills necessary for effective team work were sorely lacking in the health professions. This lesson helped shape subsequent programs, such as the Geriatric Interdisciplinary Team Training (GITT) initiative. With GITT, the Foundation hoped to support team training models at academic institutions that would be widely replicated. However, many sites discontinued their programs after grant funding ended.
The failure to make lasting, widespread change was largely due to an entrenched academic culture and a lack of demand from the health care practice environment for team training. Today, national interest in educational programs for team-based collaborative medical practice has resurfaced.
The Hartford Foundation has changed the face of social work education so that the faces of older adults are more visible. It really has been transformative. Nancy R. Hooyman, PhD, MSWDean Emeritus
School of Social Work
University of Washington
Expanding the reach to geriatric nurses and social workers
The Generalist Physician Initiative and GITT also revealed substantial knowledge gaps among nurses and social workers involved in the care of older adults. Because nurses, among all health care professionals, have the most patient contact, they exert a major influence on the quality of care older patients receive. Recognizing this, the Foundation started what would become a 10-year, $10 million commitment to advance geriatric nursing with the creation of the John A. Hartford Foundation Institute for Geriatric Nursing at New York University. In the next decade, the Institute would lead the country in producing clinical tools and resources for all nurses caring for older adults.
The Hartford Foundation made its first commitment to geriatric social work in 1999, with the launch of the Geriatric Social Work Initiative. For older adult patients with complex care needs, navigating the fragmented, poorly coordinated health care and social service systems can be daunting. Few older adults and their family members understand all the appropriate services available and how they interconnect. Social workers play a unique role among health care providers by taking into account how physical, psychological, and socioeconomic factors interact to impact all aspects of a person’s health and quality of life.
Developing expert faculty leaders
Throughout the late 1990s, the Foundation maintained its commitment to academic medicine. In 1997 the Trustees approved a “reboot” of the Academic Geriatric Recruitment Initiative, which had ended in 1994. It became the Centers of Excellence in Geriatric Medicine program, with 13 medical centers participating. The number of centers eventually expanded to 28, supporting hundreds of junior faculty with geriatrics expertise (Centers of Excellence).
“By funding academic physicians at virtually every level of the pipeline—getting medical students interested in geriatrics, providing fellows and junior faculty protected time to develop research or educational programs, and helping senior faculty develop new curriculum and clinical programs—the Hartford Foundation has been instrumental in legitimizing the field of geriatrics,” says David B. Reuben, MD, Director, Multi-campus Program in Geriatric Medicine and Gerontology and Archstone Foundation Chair and Professor at the David Geffen School
of Medicine at UCLA.
In 2000, the centers of excellence concept was applied to schools of nursing. In the Building Academic Geriatric Nursing Capacity (BAGNC) initiative, the Foundation provided grants to establish five Centers of Geriatric Nursing Excellence. Eventually, it would fund a total of nine to recruit and train outstanding geriatric nursing faculty.
The Foundation moved beyond geriatric medicine and engaged with other medical specialists and the critical professions of nursing and social work.
During those years, the Foundation also launched several large faculty career development award programs. These included pre- and post-doctoral scholarships for academic nurses (BAGNC), faculty scholar and doctoral fellow programs for academic social workers (Geriatric Social Work Initiative: Faculty Development), and faculty scholars programs for surgeons and related medical specialists, as well as specialists in the subfields of internal medicine (Increasing Geriatrics Expertise for Surgical and Related Medical Specialists).
The centers of excellence and faculty development initiatives, along with other Foundation initiatives, nurture leaders who will transform health care. Beyond geriatrics clinical and research training, faculty scholars need leadership skills, mentorship, and peer networking to propel them into positions of influence in their academic institutions and the broader field.
The large faculty development initiatives, along with programs in the area of integrating and improving health care services for older adults, extended the geographical reach of Hartford-funded programs to more states across the country. Today, Hartford Foundation initiatives are improving the health of older adults in all 50 states.
The Hartford Foundation has a history of taking risks by providing early funding for programs. Part of their success comes from understanding thats where the breakthroughs come from.Eric A. Coleman, MD, MPH
Professor of Medicine
Division of Health Care Policy and Research
University of Colorado, Denver
Preparing health professionals through competency and curricular development
The Foundation’s efforts in faculty development began to pay off. During the first decade of the new century, geriatrics programs were growing stronger in many academic institutions. An increasing number of faculty with aging expertise were available to teach. Research established evidence-based practices in nursing, social work, and medicine. More leaders were emerging in the three disciplines, and they were mentoring younger colleagues to become future leaders in geriatrics. Aging-focused researchers looking for potential collaborators had a large and growing family of Hartford-funded colleagues to draw upon.
One indication of the Hartford Foundation’s impact is the increased nurse attendance at the annual meeting of the Gerontological Society of America. Mathy D. Mezey, EdD, RN, a founder of the Hartford Institute for Geriatric Nursing, recalls attending the annual meeting’s special interest group for nurses 15 years ago when a handful of nurses sat around a small table sharing a box of crackers. Today, the special interest group meeting is standing room only, as hundreds of nurses with an interest in geriatrics attend.
Despite these indications of growing interest in the field, however, it was also clear that there would not be enough geriatric specialists in any of the disciplines to meet the impending need. Therefore, it became even more important that all health care professionals, no matter their specialty, learn how to care for their older adult patients.
Making sure faculty with aging expertise were available to teach geriatric content was essential but not sufficient. The Foundation also worked with professional associations and accrediting bodies to identify core competencies and make aging-focused content available, accessible, and mandatory. In addition, programs and materials were created to teach generalist faculty in nursing (Curriculum Grants in Nursing), social work (Geriatric Social Work Initiative: Curriculum), and medicine (Curriculum Grants in Medicine) to use curricular materials with an aging focus.
It became even more important that all health care professionals learn how to care for the older adults they would treat in clinical practice.Magnifying the impact of grantmaking through partnerships
In the 1990s and early 2000s, the Hartford Foundation had launched bold initiatives with ambitious goals, while working with an endowment that was greatly diminished from its heyday in the 1950s and 1960s. The challenge for the Foundation’s small staff was to take relatively modest amounts of grant money and bring about change to the large and complex health care system.
The Foundation believes that even small sums of money invested with the right institutions at the right time can have a profound impact, especially if the funds are leveraged through partnerships. The Trustees and program staff have continuously sought to collaborate with communities, institutions, other funders, and the government to leverage Foundation dollars.
“As a Trustee, I’m proud that we stayed the course in aging and health over the years,” says Norman H. Volk, current Chairman of the Board of Trustees. “Because of that we created credibility that resonated with other funders. We were able to attract other foundations like The Atlantic Philanthropies, the Robert Wood Johnson Foundation, the Donald W. Reynolds Foundation, and many others, which has amplified our ability to build capacity in aging and health.”
In just the last decade, grantees and staff have leveraged approximately $1.8 billion in external funding to support grantees and their projects. The Foundation currently has 86 funding partners, including foundations, nonprofit organizations, corporations, and federal agencies.
The challenge for the Foundation’s small staff was to take relatively modest amounts of grant money and bring about change to the large and complex health care system.
Organizational and staff development to create greater change
During the late 1990s and early 2000s, the Hartford Foundation also began enhancing its organizational infrastructure. The program staff expanded to include health care professionals such as a psychologist, a nurse, and two social workers with training in gerontology.
Hiring health care professionals increased the Foundation’s ability to influence the system. “The Hartford Foundation is unique in that the program officers have significant content expertise,” says Hartford grantee Eric A. Coleman, MD, MPH, Professor of Medicine in the Division of Health Care Policy and Research at the University of Colorado, Denver. “They are a true value partner in this path toward improving the lives of older adults and the health care that they receive. That’s a unique and distinguishing quality.”
“The Hartford Foundation is very hands on,” says Dr. Rieder. “We care about our grantees. We visit them every year. We go to their association and professional meetings. We participate in every way we can.” By being active participants, the Hartford Foundation staff can better understand the nuanced aspects of academic nursing, social work, and medicine.
This allows them to create more effective programs and to challenge the professions to make changes. During this time, the Foundation put more emphasis on evaluation and monitoring. Typical grants are about $1 million over a period of three to four years (and many significantly more). Most projects have at least one renewal award to take projects from proof of principle to large scale testing or from testing to dissemination. Therefore, grant proposals undergo a thorough process of review and revision to hone their logic, refine planned activities, and ensure that the budget is neither less than required nor more than needed. Lessons learned from the evaluation process are built into new grants.