Increasing Geriatric Care Capability in Hawai‘i’s Healthcare Systems through the Pacific Islands Geriatrics Workforce Enhancement Program (GWEP) at the University of Hawai‘i

Abstract

There is an increasing shortage of skilled healthcare workers to provide care to the aging US population. In response, the Geriatrics Workforce Enhancement Program (GWEP) was developed in 2015 by the Health Resources and Services Administration (HRSA). This article describes the objectives, accomplishments, and lessons learned by the Pacific Islands GWEP at the University of Hawai‘i (UH) over the past 5 years. The program’s multi-pronged approach includes: (1) Developing partnerships between academia, primary care delivery sites/systems, and community-based organizations to educate a geriatrics workforce; (2) Training providers and students in medicine and allied health professions to address the primary care needs of older adults; (3) Transforming clinical training environments to become age-friendly health systems that incorporate the principles of value-based care and alternative-payment models; (4) Delivering community-based programs for patients, families, caregivers, and direct care workers to provide knowledge and skills to improve health outcomes for older adults; and (5) Providing training in Alzheimer’s Disease and related dementias (ADRD), including the value of dementia-friendly communities. The GWEP provided education to over 3000 providers, 700 healthcare trainees, and 1000 patients and caregivers each year in a wide variety of care settings (eg, outpatient, home care, nursing facilities, care home, and hospice). Caregivers feel better able to care for themselves and/or others, find resources, and improve their practice of caregiving. The program is also transforming primary care delivery in underserved areas (eg, Community Health Centers, Family Medicine clinic, and the GRACE Team Care™ model). Outreach included rural areas, neighbor islands, and Pacific Islands.

Introduction

There is an increasing shortage of a skilled healthcare workforce to provide effective care for the aging US population.¹ Thus, the Geriatrics Workforce Enhancement Program (GWEP) was developed in 2015 by the Health Resources and Services Administration (HRSA) to address current and future geriatric workforce challenges, redefine the delivery of care to older adults, and transform geriatric care in the primary care setting.² HRSA tasked the national network of 44 GWEPs to increase adoption of the Age-Friendly Health Systems (AFHS) paradigm, and to help clinical sites achieve AFHS recognition by the Institute for Healthcare Improvement (IHI). The AFHS is based on the 4Ms framework - what Matters, Medication, Mentation, and Mobility.³ The University of Hawai‘i (UH) is home to the Pacific Islands GWEP (PI-GWEP), which provides geriatrics workforce training in Hawai‘i and US Affiliated Pacific Islands (USAPI). This paper describes the objectives, accomplishments, and lessons learned by the PI-GWEP over the past 5 years.

Methods

In order to transform Hawai‘i’s capacity to provide Age-Friendly Health Care, a 5-pronged approach was implemented: (1) develop partnerships with academic, clinical, and community-based entities; (2) train providers and students to assess and address primary care needs of older adults; (3) transform clinical training environments to become AFHS; (4) deliver community-based education for patients, families, caregivers, and direct care workers; and (5) provide training in Alzheimer’s Disease and related dementias (ADRD), including supporting dementia-friendly communities. Accomplishments of each objective are tracked, including number and types of partnerships, number of educational events, number and types of trainees, and number of clinical environments to become AFHS.

Results

Partnerships Established

The PI-GWEP works in partnership with 12 academic, 5 clinical, and 12 community-based entities (Table 1 and Figure 1). Based within the Department of Geriatric Medicine in the John A. Burns School of Medicine (JABSOM), the PI-GWEP partners internally with other JABSOM departments and collaborates with other UH Schools for allied health training and interprofessional education (IPE) activities. Palau Community College (PCC) and Yap Area Health Education Center (AHEC) are important US Affiliated Pacific Island partners.

Table 1.

List of Academic and Community Partnerships of the Pacific Islands Geriatrics Workforce Enhancement Program at the University of Hawai‘i with Acronyms

UNIVERISTY OF HAWAI‘I’S GWEP PARTNERS
John A. Burns School of Medicine (JABSOM)
Department of Geriatric Medicine
Family Medicine and Community Health
Native Hawaiian Health
Area Health Education Center (AHEC)
University of Hawai‘i System
School of Nursing and Dental Hygiene
Daniel K. Inouye College of Pharmacy
Thompson School of Social Work and Public Health
Center on Aging
Kapi‘olani Community College Health Sciences
Community Clinical Sites
Pali Momi Family Medicine Clinic
Kokua Kalihi Valley Comprehensive Family Services
Other Primary Care Providers
AlohaCare
The Queen’s Health System
Veteran Affairs
Community Organizations
AARP
Alzheimer’s Association — Hawai‘i Chapter
DOH — Public Health Nursing Branch
Hawai‘i Primary Care Association (HPCA)
Mountain Pacific Quality Health (MPQH)
Kula No Na Po‘e Hawai‘i
Catholic Charities
Executive Office on Aging
Healthcare Association of Hawai‘i
Adult Foster Homecare Association of Hawai‘i (AFHA)
Adult Residential Care Homes (ARCH)
US Affiliated Pacific Islands
Guam School of Nursing and Health Sciences
Palau Community College (PCC)
Yap Area Health Education Center (AHEC)

Figure 1.

Ecological Model of the Levels of Impact of the Academic and Community Partnerships of the Pacific Islands Geriatrics Workforce Enhancement Program at the University of Hawai‘i

Clinical partners have been engaged to facilitate the spread of AFHS in Hawai‘i. Important community clinical partners are AlohaCare, The Queen’s Health System, Hawai‘i Primary Care Association (HPCA), and Mountain Pacific Quality Health (MPQH). These organizations support training and implementation of AFHS amongst their providers and members. These partners work closely with selected Federally Qualified Health Centers (FQHCs) and other primary care providers in Hawai‘i (eg, Kokua Kalihi Valley Comprehensive Family Services (KKV) and Pali Momi Family Medicine Clinic). The Healthcare Association of Hawai‘i (HAH) and MPQH assist in providing AFHS training to the network of Long-Term Services and Support (LTSS) providers in the state (eg, nursing homes and family/foster care homes). The goal is to help clinical sites achieve AFHS recognition from IHI.

The PI-GWEP works with community partners on the mutual goal of improving care provided by family caregivers of older adults. The partners providing direct outreach include Catholic Charities Hawai‘i, the Alzheimer’s Association Hawai‘i Chapter, AARP, and Kula No Na Po‘e Hawai‘i at Papakōlea (Kula). PI-GWEP also works with the Hawai‘i Department of Health (HDOH) and Executive Office on Aging (EOA) to extend resources for family caregivers.

Training for Providers and Health Students

The PI-GWEP has provided a wide array of educational offerings (Table 2), including monthly Department of Geriatric Medicine Grand Rounds attended by an interdisciplinary audience. This transitioned to tele-education in 2020 due to the coronavirus disease 2019 (COVID-19) pandemic. In partnership with the Hawai‘i AHEC, an all-day Geriatrics Track at the Hawai‘i Healthcare Workforce Summit Conference is sponsored each year, and attended by over 600 primary care professionals, geriatrics specialists, students, residents, fellows and faculty.

Table 2.

Types of Geriatric Training and Number of Learners in the Past 2 Years

Type of Training (2015-2021)	July 2019 – June 2020	July 2020 – June 2021
Department of Geriatric Medicine Grand Rounds (monthly)	475	603
AHEC Hawai‘i Healthcare Workforce Summit Conference (annual)	631	766
Geriatric ECHO series (monthly)	244	270
Long Term Services and Support (LTSS) ECHO: COVID Preparation Series (initially weekly, then twice a month, then monthly)	1,678	346
Long Term Care ECHO: Learning Action Network (LTC ECHO: LAN) (monthly)	N/A	217
AHRQ ECHO COVID Action Network (Phase 1 - 16 sessions: December 2020 to March 2021; Phase 2 – 16 sessions: May to August 2021)	N/A	1,407
Care Homes ECHO (monthly)	N/A	542
Provider Training Total Numbers	3,028	4,151
Geriatric Medicine Fellows	7	7
Residents	30	29
4th Year Medical Student Rotation	78	78
Medical Trainees Total Numbers	115	114
Geriatrics Inter-Professional Panel (GIPP)	223	236
Hawai‘i Interprofessional Team Care Simulation (HIPTCS)	234	251
Family Medicine Annual Wellness Visit Clinic at Pali Momi and AlohaCare interdisciplinary team meetings for GRACE Team Care™ patients	13	14
Kapi‘olani Community College - Community Health Workers (CHW) Program	34	133
Other Allied Health Lectures	105	47
Allied Health Trainees Total Numbers	609	681
Family & Caregivers Trained	1,028	1,263
Dysphagia Videos	430	110
Grand Total of Learners	5,210	6,292

In 2016, PI-GWEP began providing tele-education using the University of New Mexico’s Project ECHO (Extension for Community Healthcare Outcomes) Model.⁴ They established an ongoing monthly Geriatrics ECHO Clinic that addresses the needs of outpatient community providers and allied health professionals. They launched the LTSS ECHO: COVID Preparation Series (April-October 2020) to address the COVID-19 crisis for nursing homes, assisted living, care/foster homes, and hospices. This series was conducted in collaboration with multiple partners: HAH, MPQH, HDOH, and Hawai‘i Emergency Management Agency. As a result, GWEP received the Hawai‘i Public Health Heroes Award in November 2020 for our work to prevent the spread of COVID-19 in LTSS settings. The monthly Long-Term Care (LTC) ECHO: Learning Action Network series launched in October 2020 to assist nursing facilities successfully implement Quality Improvement projects that enhance geriatric care. To augment this effort, they participated in the National Agency for Healthcare Research and Quality (AHRQ) ECHO COVID Action Network in collaboration with University of Massachusetts from December 2020-March 2021 (Phase 1: 16 sessions), and May-August 2021 (Phase 2: 16 sessions). PI-GWEP also launched a new monthly Care Homes ECHO series in April 2021 to enable them to provide better AFHS care.

The PI-GWEP also provided geriatric curriculum and teaching for medical students in all years of medical school. First year students receive feedback on the interview of a standardized older patient. Second year students practice geriatric assessment skills (cognitive, depression, functional screening) in during a “Geri-Lab” session. Third year students engage with interprofessional students in a discharge planning simulation activity. Finally, fourth year students have a required 4-week Geriatrics and Palliative Care Clerkship. Additionally, training is provided for residents in Internal Medicine, Family Medicine, and other specialties through didactics and clinical teaching.

The PI-GWEP collaborated with UH Allied Health Schools to provide several AFHS and innovative interprofessional curricula, including the Geriatrics Inter-Professional Panel focusing on interprofessional roles, and Hawai‘i Interprofessional Team Care Simulation focusing on teamwork. These interprofessional exercises host over 200 students each year from multiple schools. The UH Family Medicine Clinic provides clinical geriatrics experiences for interdisciplinary students from medicine, nursing, social work and pharmacy through their Annual Wellness Visit Clinic. Student learning is augmented through participation at AlohaCare interdisciplinary team meetings. All experiences were converted to a telehealth format in 2020.

At Kapi‘olani Community College (KCC), PI-GWEP faculty have provided lectures for the 2-year Community Health Worker (CHW) curriculum since 2016; this program has grown significantly from an average of 27 per year to 133 in 2020-21. In collaboration with Alzheimer’s Association and Catholic Charities, we developed a geriatrics module curriculum for KCC’s Health Sciences Department faculty with recorded lectures, resources, and assessments. There are currently 7 topics, examples include: healthy brain aging and dementia overview, advanced care planning, caregiver support, and community resources for kupuna (the elderly). The ultimate goal for this training is to lead to a geriatrics specialty certificate. PI-GWEP faculty also provided lectures on geriatrics and AFHS to undergraduate health professions students at UH West Oahu, an underserved area.

Overall, GWEP geriatrics training reached 8698 providers and students from 2019-2021, including participants from across Hawai‘i and the Pacific (Table 2). GWEP education receives positive evaluations. The overall quality of ECHO sessions are rated an average of 4.6 on a 5-point Likert Scale (1=poor, 5=excellent). Pivoting to virtual and asynchronous education formats has enabled much needed training for students and practicing providers in the midst of COVID-19 restrictions. It enhanced outreach, contact with more disciplines, and enabled greater participation from rural, neighbor island, and Pacific Island providers and caregivers.

Building Age-Friendly Health Systems

According to the IHI AFHS framework, health systems must implement evidence-based practices that address what Matters, Medications, Mentation, Mobility (4Ms), for all older adults. IHI created a mechanism for healthcare organizations to achieve AFHS recognition, level 1 (develop a plan to implement 4Ms) and level 2 (provide 3 months of data to demonstrate early impact of using 4Ms). IHI AFHS recognition demonstrates commitment to excellence in the quality of care for older adults. During the past 2 years, the PI-GWEP has been working to build AFHS through: (1) GRACE Team Care™, (2) KKV, (3) The Queen’s Medical Center (QMC), and (4) Pali Momi Family Medicine Clinic.

GRACE Team Care™ is a geriatric healthcare model created by Indiana University as a strategy to implement AFHS in coordinating care for high-risk patients, where GRACE stands for “Geriatric Resources for Assessment and Care of Elders”.⁵ After 2 years of collaboration between GWEP, HPCA, AlohaCare, and Indiana University to determine sustainability, the model successfully launched in May 2019 at KKV. The GRACE model is a “high touch” model utilizing a nurse practitioner and social work dyad to provide geriatric assessment, resources, and frequent follow-up for vulnerable older adults in their homes, in collaboration with primary care providers (PCP). Since March 2020, with COVID restrictions and staff turnover, the program encountered many challenges and was unable to expand. Despite these challenges, the program maintained its census of about 40 patients, and continued to provide much needed support during the pandemic. The program has received positive feedback, with patients enjoying home visits, increased attention to “What Matters,” and faster resolution of their needs. PCP satisfaction has also increased. The program addressed dementia education, falls screening, medication reconciliation, and resulted in greater completion of advanced healthcare directives, while demonstrating reduction in healthcare utilization costs. The GRACE program and outcomes were presented at the 2020 Hawai‘i AHEC Conference. AlohaCare’s GRACE Team Care™ program was recognized as one of the 2020 Medicaid Managed Care Organization Best Practices and Innovative Initiatives in the category of High-Risk Care Coordination by the Institute for Medicaid Innovation. The goal is to expand and support this AFHS model at other FQHCs.

KKV is an FQHC primary care delivery site that provides care to many Pacific Island peoples and serves as a clinical training site for health sciences students. A workflow was developed to identify and address geriatric concerns using the culturally-adapted Elder Risk Screen tool. Screening began in 2019 at a mass event that coincided with their regular senior exercise program. Positive screens were referred to PCPs. This screening is now administered on a small number of patients monthly, instead of annual screening events. KKV has remained committed to building an AFHS and is working towards achieving IHI AFHS recognition in 2021-2022, with support from HPCA. After establishing an AFHS model at KKV, HPCA will identify other FQHCs interested in applying for IHI AFHS recognition.

The QMC is a major teaching hospital for UH JABSOM and includes residency/fellowship programs for many specialties (internal medicine, cardiology, geriatrics, pathology, psychiatry, surgery, orthopedics), and allied health trainees (nursing, pharmacy). Through partnership with MPQH, GWEP assisted QMC in achieving IHI Level 1 and Level 2 certification as an AFHS Committed to Care Excellence in 2020, for both outpatient and inpatient settings. Eventually, QMC hopes to extend AFHS practices to the entire Queen’s Health Systems.

The Pali Momi Family Medicine Clinic established an interdisciplinary Annual Wellness Visit (AWV) teaching clinic to improve rates of screening for geriatric syndromes such as dementia, improve patient care and patient/family satisfaction, and provide IPE. At this clinical training site, students from schools of medicine, nursing, social work, and pharmacy come together to learn how to provide preventive and supportive care for older patients and their caregivers. They also have the opportunity to apply their learning through interprofessional collaborative practice in an outpatient setting. The Pali Momi Family Medicine Clinic achieved IHI AFHS Level 1 Recognition in March 2021, and Level 2 Recognition in August 2021.

Family/Caregiver Training

Catholic Charities and Alzheimer’s Association are major partners who have facilitated educational opportunities for families and caregivers (Table 2). During the pandemic, they helped caregivers learn to use video-conferencing tools for webinars. GWEP faculty also served as guest lecturers for caregivers with St. Francis Healthcare Systems. We continued to offer a 5-week lecture series attended by over 300 community members each year at JABSOM’s Mini-Medical School for Healthy Aging. In 2017, we developed a dysphagia video to help caregivers better understand dysphagia, strategies for safer feeding, and issues surrounding tube feeding. This video emphasizes Filipino, Hawaiian and Pacific Island communities, and was translated to Samoan, Ilocano, and Chuukese, and continues to receive views.⁶ Culturally sensitive screening tools for Native Hawaiian elders were developed with Kula.

US Affiliated Pacific Islands (USAPI)

Our USAPI initiatives include partnerships with PCC, Yap AHEC, and Guam School of Nursing. The majority of care for seniors in USAPI is provided by family caregivers. Thus, there is a great need to train caregivers in basic geriatric care. In the first GWEP cycle, faculty went to Palau to deliver training in-person in partnership with the Ministry of Health and PCC. GWEP faculty provided the curriculum, training, and technical assistance, empowering PCC to offer the caregiver certificate as part of continuing education in their own language. After Palau’s borders were completely closed to travel and large gatherings were impossible due to COVID-19, the strategy changed to have a videographer film small group trainings. Recorded short video clips on caregiver training allow for more widespread and efficient dissemination. Beginning in 2021-22, the PI-GWEP will partner with Yap AHEC to provide a similar program.

PI-GWEP continues to collaborate with University of Guam’s School of Nursing and Health Science GWEP to share dementia caregiver curriculum and resources. The Guam GWEP contracted with faculty to bring Dementia Friends training to Guam. Dementia Friends is part of a global movement, with the purpose of helping everyone in the community understand dementia.⁷ When post-pandemic travel is possible, Dementia Friends Master Training will be conducted as a train-the-trainer model so GWEP staff in Guam can spread the program independently.

Since 2019, community-based trainings have reached 2831 patients and caregivers. Evaluation data show caregivers feel better able to care for themselves and/or others, find resources, and improve their practice of caregiving (average score 4.5 on 5-point Likert-Scale; 1=poor, 5=excellent).

Dementia Training

PI-GWEP has incorporated dementia screening, resources, and training into clinical training sites and simulation curricula for allied health schools. Dementia-related topics were included in all training events for healthcare professionals and families, caregivers and direct care workers. This year, in collaboration with Alzheimer’s Association and Catholic Charities, geriatrics modules, resources, and assessment tools for KCC’s Health Science faculty were developed to incorporate into their curricula in Fall 2021, with a strong emphasis on promoting dementia capability. Last year, in partnership with the HDOH’s EOA, their “Worried About My Memory” brochure was translated into 7 languages common in Hawai‘i (Ilocano, Tagalog, Simplified and Traditional Chinese, Japanese, Korean, Marshallese).⁸ GWEP faculty have been a part of the HDOH’s ADRD State Planning Committee and have provided input related to workforce development.

Discussion

The HRSA funded GWEP project is a wide-ranging effort to build and transform the healthcare system to provide better care for our growing older population. In the process of implementing GWEP goals, there were important lessons learned about how to achieve these goals effectively:

First, the integration of academic, clinical and community experiences are vital in preparing trainees to provide interprofessional care. The geriatrics team approach amongst different disciplines and organizations is best taught within a clinical setting with integrated interprofessional practice, curriculum and role modeling,⁹ as demonstrated in the success of the AWV clinic and GRACE Team Care™ as clinical teaching models. Second, strong partnerships and leveraging are critical for success. Long-term partnerships were nurtured across sectors over years -through clinical care, teaching, and community support. Relationships were strengthened by cooperation. Meeting regularly provided insights into the accomplishments and challenges faced by the partner organizations. Partner roles were leveraged to achieve common goals. For example, while engaging with health systems leadership to take advantage of payment transformation incentives, academic partners provided education and expertise about geriatric assessments and interventions. Other organizations provided technical assistance with regards to reviewing clinical workflows and applying quality improvement principles to embed 4Ms processes, and community partners provided direct support to caregivers through booklets, seminars, and support groups. With this collaborative approach, GWEP was able to build a supportive network that grew as an AFHS.

Third, caregiver engagement is a must. The ultimate stakeholders in the AFHS endeavor are patients and caregivers. Understanding patient priorities, cultural context, and providing caregiver support is vital to addressing the needs of older adults. These concepts can be integrated into organizational practices striving to achieve a patient-centered medical home.¹⁰ By engaging caregivers and providing education and resources, caregivers are encouraged to seek more from healthcare and community support systems. Organizational pressure and customer demand can be a driver for health systems transformation.

Fourth, an essential ingredient for successful healthcare system transformation is the need for ongoing quality improvement and feedback.¹¹ In order to meet the IHI AFHS challenge, it was necessary to learn, teach, apply, and reinforce quality improvement principles and skills with all partners. QI principles are taught during some monthly ECHO sessions, including the opportunity to work with a QI coach from MPQH. Learner outcomes, quality measures, and patient outcomes are continuously assessed. Opportunities for updates and feedback during monthly meetings kept processes moving. Semi-annual advisory meetings provided the opportunity for all partners to learn from each other and share ideas.

Fifth, the virtual format of education was transformative. It was important to move beyond the traditional in-person lecture format to provide education with more flexibility to increase reach beyond time and space constraints and make training more relevant. Driven by COVID-19 pandemic restrictions, virtual education significantly increased during the past year. Providing greater access to education and clinical care via tele-education and telemedicine became critical as the vulnerabilities and needs of older adults were highlighted and workforce capacity was stretched. Using virtual strategies, extending outreach to a greater number of people and a wider variety of settings and populations was possible.

In conclusion, the HRSA funded GWEP program has become a powerful agent for change. Transforming geriatric care in Hawai‘i and the Pacific Islands requires collaboration, cooperation, and leveraging among academic, clinical and community partners, and by keeping patients and caregivers as the focal point. These efforts have been further enhanced by embracing quality improvement and virtual education. Through these strategies, it is possible to build a coalition that can transform geriatric care in Hawai‘i and the Pacific Islands.

Abbreviations and Acronyms

AFHS

Age-Friendly Health Systems

AHEC

Area Health Education Center

AHRQ

Agency for Healthcare Research and Quality

ADRD

Alzheimer’s Disease and related dementias

AWV

Annual Wellness Visit

CHW

Community Health Worker

COVID-19

Coronavirus disease 2019

EOA

Executive Office on Aging

FQHCs

Federally Qualified Health Centers

GRACE

Geriatric Resources for Assessment and Care of Elders

HDOH

Hawai‘i Department of Health

HPCA

Hawai‘i Primary Care Association

HAH

Healthcare Association of Hawai‘i

HRSA

Health Resources and Services Administration

IHI

Institute for Healthcare Improvement

IPE

Interprofessional Education

JABSOM

John A. Burns School of Medicine

KCC

Kapi‘olani Community College

KKV

Kokua Kalihi Valley Comprehensive Family Services

Kula

Kula No Na Po‘e Hawai‘i at Papakōlea

LTSS

Long-Term Services and Support

LTC

Long-Term Care

MPQH

Mountain Pacific Quality Health

PCC

Palau Community College

PI-GWEP

Pacific Islands Geriatric Workforce Enhancement Program

PCP

primary care providers

Project ECHO®

Extension for Community Healthcare Outcomes

QMC

Queens Medical Center

UH

University of Hawai‘i

USAPI

US Affiliated Pacific Islands

4Ms

What Matters, Medications, Mentation, Mobility

Conflict of Interest

None of the authors identify a conflict of interest.