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GRANTWATCH: REPORTRAND/Hartford Initiative To Build Interdisciplinary Geriatric Health Care Research Centers
A RAND/John A. Hartford Foundation initiative, Building Interdisciplinary Geriatric Health Care Research Centers, seeks to promote such research through developing innovative clinical and health services interventions. Interdisciplinary education, mentoring, and training opportunities, particularly for junior investigators, are the critical components necessary to foster multiprofessional research endeavors.
THIS REPORT DESCRIBES the RAND/John A. Hartford Foundation’s Building Interdisciplinary Geriatric Health Care Research Centers initiative, which seeks to promote interdisciplinary geriatric research by improving institutions’ capacity to conduct such research, focusing on the development of innovative clinical and health services interventions that can be translated into real-world practice, and providing interdisciplinary training opportunities.1 It is also hoped that the centers will be competitive in attracting subsequent extramural, peer-reviewed funding for the design and study of such interventions. The Hartford Foundation’s Web site notes that "interdisciplinary research is vital to improving the care of older people, whose complex needs require the interaction of social, psychological and biological elements."2 The foundation has played an important role in promoting clinical education and academic training in aging across multiple disciplines. Some of the foundation’s most successful efforts have drawn from interdisciplinary research; these include Project IMPACT (Improving Mood-Promoting Access to Collaborative Treatment); the Hospital at Home model; and the Rush University Medical Center Virtual Integrated Practice model.3 Interdisciplinary collaboration is an important characteristic of health research, but there are a number of well-documented barriers to conducting interdisciplinary research.4 Structural barriers include the standard framework of distinct schools and departments with traditional mechanisms for faculty recognition and compensation that reward success within one’s primary discipline; difficulties publishing interdisciplinary papers in journals with a single-discipline focus; and lack of time to learn about another discipline’s potential contributions to one’s work. There are also intellectual or turf barriers, including how to define success and move to consensus on issues to study.5 Despite these barriers, there are ways to foster interdisciplinary research, including requiring interdisciplinary collaboration as a funding condition and establishing research training programs that emphasize the involvement of other disciplines.6 Administrative barriers can be addressed by changing tenure and promotion requirements and by establishing joint centers. Interdisciplinary collaboration is also important for individual researchers’ careers. Exposure to and training in interdisciplinary research is crucial to developing new clinical researchers, as evidenced by the new National Institutes of Health (NIH) Roadmap for Medical Research awards that support training in interdisciplinary strategies and encourage interdisciplinary depth in projects.
Between 2002 and 2005, RAND and the Hartford Foundation conducted the first round of the Building Interdisciplinary Geriatric Health Care Research Centers initiative; the five centers funded were at Duke University; Boston University; University of California, Los Angeles (UCLA); University of Pennsylvania; and Yale University. The centers were required to incorporate three complementary interdisciplinary elements: (1) geriatric research, (2) geriatric health care interventions, and (3) geriatric education and training. Each center undertook a range of activities to improve interdisciplinary geriatric research. Pilot projects enabled researchers participating in the initiative who were from the core disciplines of medicine, nursing, and social work; related disciplines such as pharmacy, gerontology, rehabilitation, and psychology; and different career levels to work on new research ideas and methodological approaches. Research retreats convened broad communities of researchers and allowed them to build relationships and discuss potential projects. Career development sessions trained junior faculty to conceptualize projects and develop fundable proposals. Mentorship programs enhanced the knowledge and skills of junior faculty by connecting them with senior-level mentors from multiple disciplines. During the first round, RAND administered the initiative, provided technical assistance to the centers, and conducted an evaluation. RAND also organized a two-day Career Development Institute (CDI) designed to build training capabilities across and within centers. The CDI brought together senior and junior investigators from the funded centers with outside experts and representatives of key funding agencies, such as the National Institute of Mental Health (NIMH) and the Agency for Healthcare Research and Quality (AHRQ). Subsequently, RAND organized a follow-up CDI Booster Session that focused on supporting the career development of junior investigators and building strong mentor-mentee relations.
Progress made. Overall, the first round of this initiative allowed participating institutions to make progress toward achieving and sustaining interdisciplinary research programs. Limitations of the initiative that should be mentioned include the modest amount of funding and the limited funding period of two years. In combination, though, the centers funded twenty-five pilot projects, many of which provided the preliminary data needed to submit grant applications to other funders for larger studies, while others led to published manuscripts and conference presentations. What makes these projects different is that the centers used them as opportunities to bring people together in ways that had not been tried before and to build a basis for collaboration on future work. Examples include a project led by faculty from the School of Public Health at Boston University to design an intervention aimed at improving worker satisfaction and motivation and resident outcomes in long-term care facilities; and another led by a gerontologist in the Yale School of Nursing to develop a methodology to foster shared decision making between older people and their physicians. New grants. During the initiative’s first round, center investigators were awarded 104 new grants totaling nearly $53 million. These included a grant from the NIMH to study the sociocultural context of depression in old age, a grant from the National Institute of Nursing Research (NINR) to examine the outcomes of nursing management in nursing homes, and a grant from the National Cancer Institute (NCI) to examine ethnic and psychosocial influences on the quality of death. Although it is not possible to attribute all of the grants directly to the centers, several clearly derived from the pilot projects or related work of key center participants, or both, and the centers considered those grants as part of their efforts to develop and support interdisciplinary research. Related activities. Center investigators also had 365 manuscripts accepted for publication and gave 162 conference presentations. Further, some investigators achieved notable career advancements. For example, three junior investigators received the Beeson Career Development Award; one received an NIH Mentored Research Scientist Development Award (K01); another received research funding from the Robert Wood Johnson Foundation (RWJF) and Atlantic Philanthropies; and a doctoral candidate won the American Geriatrics Society student research award. The totals for grant awards, manuscripts, and conference presentations include products that came from members of the core center team and related to the centers’ research agenda. Engendering collaboration. Beyond the accomplishments of individuals, the centers created an environment that fostered interdisciplinary collaboration. They created structures for interdisciplinary research, connected researchers from different disciplines, supported junior investigators, and organized work around specific research projects. The centers worked to develop structures that brought people together, gave them a sense of belonging, and worked to hold them together. We adopted the term "centerischkeit" to describe this notion of centeredness. Although none of the centers had a physical space, all of them forged an identity recognized by an interdisciplinary community of geriatric researchers from the core and related disciplines. Center leadership also played an important role in building credibility, attracting resources, and connecting researchers across disciplines. One center’s shared leadership model increased opportunities to network and share resources and avoided relying on a single person to define the center. The RAND/Hartford proposal required the institutions to have ongoing geriatric research activity in two of the core disciplines and at least one related discipline; this ensured that the centers started with some capacity, but most lacked forums for working together. The centers addressed this by conducting research retreats and establishing communication links to inform researchers about center activities. The formal needs assessment required as part of the proposal helped the centers recognize pockets of strength and gaps in substantive areas. They used this information to create a context for involving other disciplines and researchers in their activities. Across the centers, nursing gained the most from the centers’ efforts to achieve greater interdisciplinary collaboration. At several centers, nursing joined with medicine as true partners to plan activities, conduct pilots, and train junior faculty. However, the centers were less successful in engaging social work. At some centers, social work lacked more senior research leadership, thus making it difficult for researchers to participate on equal footing. Support of junior investigators. The centers supported junior investigators in several ways. Research-based training sessions allowed them to form relationships with senior faculty. The new seminar series on topics such as research methodology and proposal development improved their skills. The centers also worked on forming mentoring relationships, both formally through committees and mentoring teams and informally with individual contacts. These activities moved some junior investigators out of isolation by connecting them to faculty who could help further their research and advance their careers. Pilot projects. The centers’ pilot projects were a key component to developing centerischkeit. Several centers devoted a large portion of their Hartford grant to the pilots. By creating opportunities for researchers to come together, the pilot projects enabled them to strategize about research, break down barriers among disciplines, and build relationships across disciplines.
Experiences from this initiative’s first round provide important lessons about how to establish and support interdisciplinary geriatric research centers. First, a formal needs assessment in the proposal or development stage helps institutions recognize strengths and discern gaps. The former helps create a context for bringing in other disciplines. The latter helps identify which disciplines and researchers to involve in the different center activities to maximize areas of strength and fill gaps. Second, to make efforts truly interdisciplinary, institutions must have some established geriatric research activity, in several disciplines. Further, institutions that have coleaders from different disciplines will achieve balance among the disciplines, increase the opportunity to network and share resources across disciplines, and avoid relying on one person to define the agenda. Third, research training should also be integral to these centers from the outset, including activities that encourage junior faculty to engage in interdisciplinary research, develop new areas of expertise, and find mentors from other disciplines.
This initiative has implications for policy, in three areas: geriatric health care, geriatric training, and other national initiatives such as the NIH Roadmap. First, the reality of practicing geriatric health care is that providers face patients with multiple problems or conditions and require interventions that involve multiple disciplines. Because it is not centered in one academic department or disciplinary unit, interdisciplinary research (1) can bring multiple theories, skills, and data to bear on a common problem; (2) reflects true collaboration across relevant disciplines; and (3) builds partnerships that expand research foci and methods. Second, with an aging population, substantial knowledge gaps need to be filled. Caring for older Americans will require a continued investment in education and training. The field needs to focus on generating new knowledge to translate science into clinical applications; developing evidence-based practices; creating integrated systems for health care delivery; and improving health, quality of life, and the cost-effectiveness of care. Finally, the NIH Roadmap offers a vision for interdisciplinary research teams of the future and considers such research a major goal. The initiative’s first round positively influenced the interdisciplinary research field more broadly than the five new research centers, as it resulted in some changes in NIH policies related to sharing indirect costs and allowing proposal submissions from multiple principal investigators. Further, many of the interdisciplinary research activities associated with the NIH Roadmap incorporated specific language and directions from the RAND/Hartford initiative. THE FIRST ROUND of this initiative has provided the field with strategies for facilitating interdisciplinary geriatric health care research. It helped build five such research centers that serve as models of how to expand this research. A second round is now getting under way with a set of seven new centers, which were awarded funding in September 2006.7 These centers will use the strategies developed by first-round grantees to improve their effectiveness and productivity. Ultimately, as more interdisciplinary geriatric research centers take root, the field will move closer to the goal of increasing the effectiveness of clinical and health services interventions for the elderly and thereby improving their health outcomes and quality of life.
Harold Pincus (pincush{at}pi.cpmc.columbia.edu) is vice chair for strategic initiatives, Department of Psychiatry, Columbia University, and director of quality and outcomes research at New York–Presbyterian Hospital; both positions are in New York City. He is also a senior scientist at RAND in Pittsburgh, Pennsylvania. Donna Keyser is a senior communications analyst and Dana Schultz, a policy analyst, at RAND’s Pittsburgh office. The authors thank the John A. Hartford Foundation for its generous support of this initiative. They also thank their Hartford project officers, Christopher Langston and James O’Sullivan, and the foundation’s executive director, Corrine Rieder, as well as members of the initiative’s National Advisory Panel, for their valuable guidance throughout the selection, implementation, and evaluation processes. Finally, they acknowledge the five first-round centers and their directors, Rebecca A. Silliman (Boston University), Elizabeth Clipp and Kenneth Schmader (Duke University), David B. Reuben (University of California, Los Angeles), Mary D. Naylor (University of Pennsylvania), and Terri R. Fried (Yale University), for their achievements in supporting and developing interdisciplinary research and researchers.
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