R25 2019 Participant Goals

Institution	Location	Participants	Goal 1	Goal 2	Goal 3
Alta Bates Summit CCC	Berkeley, CA	Bev Hart-Inkster (HartB1@sutterhealth.org) Donna Russell (russelD@sutterhealth.org) Allison Gervis (gervisA@sutterhealth.org)	Create a geriatric oncology education plan within 3 months for the interdiscipinary team (RNs, pharmacists, social workers, dietitians). Will utilize evaluation tool for effectiveness. Goal: within 3 months.	Improve new patient orientation to emphasize the importance of activity and exercise as a part of their treatment plan. We will add to class content, written materials, and provide demonstration. Effectiveness will be evaluated by interviewing patients at cycle 2. Goal: within 9 months.	Pilot chemotherapy toxicity predictor tool for 20 new patients 65 years and older who have solid tumors. The information will be provided to our physician champion. For patients with a >50% risk, the NP in treatment room will be asked to do a more extensive assessment. Effectiveness will be evaluated to see if knowing risk and eval and management will prevent admission for sepsis, unnecessary cognitive decline, and metabolic imbalances. Goal will be completed within 18 months.
City of Hope Women's Center	Duarte, CA	Amber Hewitt (amhewitt@coh.org) Lynne Tehrani (Ltehrani@coh.org) Edyssa Uy (eduy@coh.org) Claire Hy-Hincy (chhincy@coh.org)	Develop a protocol to apply a geriatric assessment for all breast cancer patients ages >/= 70 anticipated to undergo (neo)adjuvant chemotherapy by 12 months (protocol implementation to better identify and manage geriatric breast cancer patient needs).	Beta test: Screen 20 patients in Dr. Sedrak's clinic using the comprehensive geriatric assessment tool over 3 months.	Conduct needs assessment and education on screening results to all breast med onc nurses/ACAs by 6 months.
COH-Community	Duarte, CA	Anne Ireland (aireland@coh.org) Amy Plemons (aplemons@coh.org) Gloria Jauregui (gjauregui@coh.org)	New hire orientation for City of Hope Community Practice RN's will include selected NICHE Geri-Onc modules by August 1st, 2019.	Incorporate Geriatric Nursing Assessment Tools into EPIC by February, 2020.	Create a pilot to incorporate use of the Chemotherapy Toxicity Predictive Tool into the chemo consenting process for patients >= 70 years old by August, 2020.
COH-PATC	Duarte, CA	Michelle Johann (MJohann@coh.org) Peter Hirsch (phirsch@coh.org) Grace Wu (grwu@coh.org)	We will assess PATC/Preop nursing staff on geriatric oncology education needs for patients (ex: cognitive, psychosocial, physical, and spiritual attributes) by June 2019. (10 questions via Survey Monkey)	We will educate PATC/Preop staff regarding geriatric issues and importance of Comprehensive Geriatric Assessment. (Topics are decided by staff's input, buy-in from stakeholders). Goal will be completed by 9/2019.	We will implement geriatric assessments (G8 vs. Minicog) in the PATC surgical oncology, patients ages 65 and older during their consult/new patient visits by December 2019. Select 20-25 patients preop-to-admission with follow-up based on patient's need. Validate with patient satisfaction, improved patient outcomes by addressing needs. Complete by June 2020.
COH-Prof Practice	Duarte, CA	David Rice (drice@coh.org) Kristen Krayer (kkrayer@coh.org) Brian Chen (brchen@coh.org) Dhruti Ramchandani (dramchandani@coh.org)	In partnership with our Gero-oncology nursing team and patient education health specialist, finalize mobility protocol by July 15th, 2019.	Implement and educate to policy to reinforce use and documentation complaince with the Bedside Mobility Assessment Tool (BMAT) on 3E (ICU) and 4E (Heme-Onc). The education will consist of independent review of BMAT video by each RN, followed by a coached return demonstration with each RN by December 15th, 2019.	Implement frailty screening and functional assessment test (TUG) with pre-op surgical gyn patients. Supply patients with ONS Get Up, Get Moving patient education material. Reassess frailty and TUG on 1st or 2nd post-op visit. (Apply to patients over age 65). Analyze data in November, 2019 and May, 2020.
Dartmouth-Hitchcock Norris Cotton Cancer Center	Lebanon, NH	Elizabeth B McGrath (Elizabeth.B.McGrath@hitchcock.org) Anna Schaal (anna.d.schaal@hitchcock.org) Natasha Schultz (natasha.schultz@hitchcock.org)	Create an interdisciplinary survivorship subcommittee of stakeholders to identify best gero/oncology screening/assessment tools and develop a referral algorithm by June 30, 2019.	Implement gero/onc screening/assessment at the chemotherapy teaching visit with appropriate referrals made by March 2020.	Educate all levels of nursing (LNA/RN/APRN) on elder speak utilizing NICHE curriculum by December 2019.
Duke University Medical Center	Durham, NC	Ashley Potter (ashley.sheely@duke.edu) Margaret Sykora (margaret.sykora@duke.edu) Rebecca Porter (rebecca.a.porter@duke.edu)	Enhance general geriatric nursing knowledge and help create a work culture mindful of geriatric nursing by increasing the number of geriatric RNs from 3 to 5 by end of 2019.	Enhance nurses' knowledge of geriatric principles by creating a 1 hour CE presentation on older adults with hematologic malignancy. Deliver content in person to the nurses both in inpatient and outpatient settings of the program. The course will be completed and ready for presentation by August 2019.	Improve patients and family caregiver knowledge of geriatric syndromes by creating 5 slides to include in new patient class and 5 slides to include in discharge class by February 2020. Content specific to care considerations of older adults with hematologic malignancies.
Eisenhower Health	Rancho Mirage, CA	Melanie T. Lomibao (MLomibao@eisenhowerhealth.org) Laura Latham (LLatham@eisenhowerhealth.org) Marianne Gregorich (MGregorich@eisenhowerhealth.org)	Educate nurses on TUG (Timed up and Go) and importance exercise to decrease chemotherapy side effects within 2 months.	Incorporate TUG into assessment and intake education appointments, provide "work out to go" booklets along with education regarding the importance of exercise while on chemotherapy. Provide referrals to exercise class or PT/OT as appropriate based on TUG greater than or equal to 12 within 4 months. Update education materials in 14.5 font, high contrast lettering.	Screen all new cancer patients for Advance Directives. If necessary, provide information booklet and encourage patient/family to complete advance directive information, document patient education was provided regarding advance directive. Request patient/family to provide a copy of completed Advance Directive to the clinic, for scanning into EMR within 3 months.
El Camino	Mountain View, CA	Roksaneh Larijani (Roksaneh_Larijani@ elcaminohospital.org) Mona Soleimianieh (Mona_Soleimanieh@ elcaminohospital.org) Lorelie Difuntorum (Lorelie_Difuntorum@ elcaminohospital.org)	Educate in-patient medical/surgical oncology patients on the importance of good nutrition in geriatric oncology patients (>65 years) by 8/2019. Conduct needs assessment in 70% of bedside nurses through Survey Monkey. Pick top 3 topics to educate nurses. Each team member will present one topic at UPC (monthly meeting) and upload to Healthstream.	Modify nutritional booklet from out-patient to meet the needs of the in-patient geriatric oncology patients (>65 years) by 8/2019. Conduct risk assessment on admit and every 3 months for 1 year. Assess 7 patients per month. Create sign up sheets to keep track patients.	Improve options for higher calorie/more appetizing snacks for geriatric oncology patients (>65 years) in the in-patient setting by 12/2019. Collaborate with dietary department/RD. Provide list to nurses so they are aware of options for patients.
Fox Chase	Philadelphia, PA	Diana Kott (diana.dimarcantonio@fccc.edu) Amy Magagna (amy.magagna@fccc.edu) Jennifer Occhipinti (Jennifer.Occhipinti@fccc.edu)	6 month goal: Develop and implement a needs assessment on inpatient RN staff's knowledge of the geriatric oncology patient and then educate the staff on the greatest needs as related to their area (medical/surgical). Post test evaluation will be performed.	12 month goal: Designing a Physical Therapy protocol to be implemented onto the current ERAS order form with special consideration to the geriatric population. This age-friendly assessment will evaluate the patient based on many factors.	18 month goal: Implement Reiki Therapy on the 3rd floor surgical units for geriatric oncology post-op patients and evaluate the relationship of early integrated therapy with ambulatory and recovery time.
Grampians Integrated Cancer Service	Victoria, Australia	Lea Marshall(Lea.Marshall@bhs.org; leamrshll@gmail.com)	We will implement a process to screen for older peoples' (aged 70 and over) needs, including functional status, as near to diagnosis as possible within 3 months. This will use a self-completed patient screen and the findings then be presented at a 2/52 supportive care MDM to plan appropriate supportive care.	We will work with external oncology providers to refer their Wimmera-based older patients into the above process within 6 months. (Wimmera patients frequently travel to other providers for cancer treatment.)	We will develop and evaluate a geriatric assessment education presentation to present to appropriate staff at regional services within 12 months.
Hartford HCI Team 1	Hartford, CT	Noa Mencher (noa.mencher@hhchealth.org) Mary Kate Eanniello (mary.eanniello@hhchealth.org) Ann McBride (ann.mcbride@hhchealth.org)	Create standard curriculum and processes for all RNs to ensure evidence based gero-competency to be implemented and initiated by December 2019. Attendance of all RNs GRN 8hr training. Creation of competency checklist. Identify in each clinical area, champions who will complete additional online NICHE geriatric education modules.	Create standard curriculum and processes for all MAs/PCAs to ensure evidence based gero-competency to be implemented and initiated by 12/2019. Attendance of all RNs GPCA 4hr training. Creation of competency checklist for revised G-8 assessment with competency checklist to validate/document accuracy. Develop structure for audit to ensure consistency and quality. Identify in each clinical area champions who will complete additional online NICHE geri-education modules.	Create standard curriculum and processes for all providers to ensure evidence based gero-competency to be implemented and initiated by 12/2019. Partner with geri onc Physician champion to develop curriculum and processes for oncology providers (MD and APPs). Support geri onc physician with processes and education related to geri onc clinic.
Hartford HCI Team 2	Hartford, CT	Marlene Silvis (marlene.silvis@hhchealth.org) Amanda DiBenedetto (Amanda.dibenedetto@hhchealth.org) Jennifer Zanchi (jennifer.zanchi@hhchealth.org)
HMH/JFK	Edison, NJ	Roda German (roda.german@ hackensackmeridian.org) Lori Sammartino (lori.sammartino@ hackensackmeridian.org) Judith Legaspi (judith.legaspi@ hackensackmeridian.org)	Perform a needs assessment to determine gaps in knowledge in the care of geriatric oncology patients. Provide a pre-test for 100% of the inpatient and outpatient RNs with completion in 2 weeks.	Based on the gaps in knowledge found on the pre-test, tailor the geriatric oncology curriculum to fill the gaps in knowledge. Complete all education of RNs in 9 months. Compile results of increase in knowledge by providing a post-test to all RNs.	Set up an appointment with Senior leadership to present the information about the NICHE program to promote piloting this program on the inpatient oncology unit. (Complete in 2 months, by April 2019).
Kaiser SSC	Sacramento, CA	Tammy Sheehan (tammy.sheehan@kp.org) Catherine Guider (catherine.e.guider@kp.org) Kristie Howlett (kristie.howlett@kp.org)	By June 30, 2019 we will develop a chemotherapy educational binder for patients that will be age friendly. The binder will be given during the chemotherapy class with review. Chemotherapy class will be revamped to be age friendly.	By September 30th, 2019 our nurse navigators will use the G8 assessment tool to identify high risk patients for 70 years old and older. Results will be used to guide referrals to social work, nutrition, PT/OT, rehab, and mental health services.	At staff annual training on May 22, 2019 we will start training RNs how to use the chemotoxicity screening; the usefulness of the screening as it relates to polypharmacy in the geriatric oncology patient. By October 2019 we will start the screening. Screenings will be done at consult and beginning of each new cycle. RNs will compare the screening to detect changes and trends; assess for interdisciplinary referrals. If unable to enter referral, will route chart to primary oncologist or primary care provider for assistance.
Keck Medical Center of USC	Los Angeles, CA	Rotch Delos Santos (rotch.delossantos@med.usc.edu)	Implement a geriatric nursing rounds in the treatment center once a week within 6 months.	Implement a process to assess older patients' functional status on the day of infusion witin 6 months.	Develop an interdisciplinary team to review geriatric oncology cases on a monthly basis within 12 months.
LAC+USC Medical Center	Los Angeles, CA	Erika Gonzalez (erigonzalez@dhs.lacounty.gov) Robin Herman (rherman56@yahoo.com) Justine Constantino (juconstantino@dhs.lacounty.gov)	Develop a plan to present to nursing administration and management team, and build a multidisciplinary team to help support practice changes in the elderly population of LAC+USC Medical Center by 6 months.	Develop objectives, topics of interest, and teaching plan to engage frontline staff as gerontology champions within 12 months.	Develop a geriatric oncology program for patients and family/caregivers by 18 months.
Memorial Sloan Kettering Cancer Center	New York, NY	Catherine Bautista (bautisc1@mskcc.org) Bayley Sharma (sharmab@mskcc.org) Kameelah Brown (brownk4@mskcc.org)	Create and deliver an educational offering for ancillary staff to facilitate care of the delirious patient by June 2019.	Team up with supportive care champions to increase the amount of advance care directives (completed) by geriatric patients by 20% by February 1, 2019.	Incorporate a Geriatric Oncology Nursing series into the current Grand Rounds program by August 1, 2020.
Nebraska Cancer Specialists	Omaha, NE	Margaret Rebensdorf (mrebensdorf@nebraskacancer.com) Lily Salinas (lsalinas@nebraskacancer.com) Kate Spellerberg (kspellerberg@nebraskacancer.com)	Develop education materials and resources for our geriatric population to specifically address the 4 M's, which may affect cancer treatment outcomes. (What matters, meds, mentation, mobility)	Generate and track outcome measures to determine effectiveness and/or areas of improvement of patients 70 years of age and over being evaluated in the Geriatric Assessment Clinic (as a result of medium or high risk on mycarg toxicity test). Provide RN to facilitate appointment for patient support and smooth transition among APRN, OT, and pharmacy components. Implement follow up call within 48 business hours of clinic appointment.	Develop staff education (RNs, APPs, MAs ) to increase knowledge and assessment skills to help identify issues unique to geriatric population. Incorporate CE's where applicable. Develop interdisciplinary rounds for geriatric clinic by 12 month interval.
Olive View LAC	Sylmar, CA	Rhonda Polzin (rpolzin@dhs.lacounty.gov) Ui Young Lee (uylee@dhs.lacounty.gov) Luis Moreno (lmoreno@dhs.lacounty.gov) Johana Joya (jjoya@dhs.lacounty.gov)	We will refurbish/update the educational materials that is handed out in the oupatient chemo-infusion unit to be Gero-Friendly using enlarged fonts, clear copies, appropriate reading level, color pictures and bolded titles, within the next 3 months.	To implement a process so that all first time chemotheray for geriatric patients (65 and older) will be seen by oncology nurse for education session prior to starting treatment within next 6 months.	To access the learning needs of the oncology nurse staff on Geriatric/Oncology by providing a staff survey. Based on the identified needs, we will have regular on-going educational topics presented at our monthly staff meetings within next 12 months.
Oncology Nursing Society	Pittsburgh, PA	Pamela Ginex (pginex@ons.org)	Assess current ONS resources to identify which are specific to older adults or which would apply to older adults. Identify gaps in resources and find opportunities to fill these gaps within 6 months.	Explore developing an "older adult" specific web page to have the resources from Goal 1 on the ONS website within 9 months.	Conduct a review of the literature and a review of existing resources related to older adult patient provider communication. Summarize this information and disseminate either online, in a presentation or in a publication within 12 months.
PCR Oncology	Arroyo Grande, CA	Alphea D. Bonds-Castro (phea@pcroncology.com)	RN will select and implement a geriatric assessment on 6 new patients within 3 months.	RN will implement to use TUAG with new patients to assess functional status within 6 months.	Implement use of BMI to survivorship care plan on breast cancer pts 65 and older in 12 months.
Ronald Regan UCLA	Los Angeles, CA	Stephanie Jackson (stjackson@mednet.ucla.edu) Joecelyn Densing (jdensing@mednet.ucla.edu) Sarah Hoskins ()	To conduct a needs assessment among inpatient heme/transplant nursing staff for two weeks to assess their knowledge of the geriatric populatioin by August 1, 2019.	To provide quarterly targeted education through online modules based on the results of the needs assessment by February 1, 2020.	Establish a multidisciplinary team to create a proactive mobility plan, and perform weekly mobility screenings on patients 65 and older to reduce the monthly prevalence of falls and cost by August 1, 2020.
Sidney Kimmel Cancer Center	Philadelphia, PA	Michelle Lasota (michelle.lasota@jefferson.edu) Samantha Asher (samantha.asher@jefferson.edu) Anne Henner (anne.henner@jefferson.edu)	We will streamline and develop process for our geriatric oncology clinic referrals by implementing clinic wide G8 assessments. Assessment will be completed by patient's 65 and older. Completion of goal by May 2019.	To create bi-monthly clinic-wide case reviews for patient 65 years and older. All disciplines will be present. Will also include bereavement session in regards to employee/staff burnout and compassion fatigue. The sessions will be implemented by August 2019.	To create a series of mini-education sessions for staff on gerontology adult care. Upon completion will create program for staff nurses to provide education and shadowing for nursing students within our health organization. Anticipated implementation by February 2020.
St. Luke's Cancer Institute	Kansas City, MO	Heather Edwards (heaedwards1@saint-lukes.org ) Kimmie Blankenship (kblankenship@saint-lukes.org ) Ashley Parkhurst (aparkhurst@saint-lukes.org)	Disseminate education from conference regarding geriatric assessment, management, symptoms, and differences to administrative staff, medical assistants, and RN staff for over the next year.	Collaborate with physical therapy to develop a home exercise program for nursing to disseminate the patient's over the age of 65. Education to include criteria when patients would need to seek further assistance. Program to be instituted in 1 year.	Evaluate clinic from geriatric perspective for geriatric friendliness and implement changes as needed over the next year.
Swedish Cancer Institute	Seattle, WA	Amy Christian (amy.christian@swedish.org) Anna Canoy (anna.canoy@swedish.org) Ana Boekenoogen (ana.boekenoogen@swedish.org)	Update supportive care referral for older adults by May 2019. (E.G. Referral for social work, nutrition, naturopathy, art therapy, financial advocate, and psychiatry, etc.)	Provide a one-time education event for the multidisciplinary clinic team by October 2019 to educate on updated supportive care referral tool for older adults.	Focus on nutritional needs of the older adult: Meet with the dietitian to collaborate on care and educate clinic caregivers on gaps. Referral to Nutrition for all patients over the age of 65. Measure the number of referrals to the dietitian at baseline, 6 Months, 12 Months, and 18 Months.
Sylvester Comprehensive Cancer Ctr Team 1	Miami, FL	Pamela Dudkiewicz (pdudkiewicz@med.miami.edu ) Yamila Melendez (y.melendez@med.miami.edu ) Michelle Sapp (msapp@med.miami.edu)	Assess all new patients greater than equal to 70 years old using a geriatric assessment tool by phone 2 weeks or less prior to the first appointment in order to identify high risk patients requiring further assessment and/or referral to be initiated within 6 months.	Identify interdisciplinary geriatric champions–pharmacy, geriatrician, social worker, PT, nutritionist, etc within 6 months.	Amended the facility website to show case available resources for our aging adults with an 18 months contingent on the above goals being met.
The James Comprehensive Cancer Center	Columbus, OH	Carla L. Grieshop (Carla.grieshop@osumc.edu) Jessica Ruple (jessica.ruple@osumc.edu) Megan Jackson (megan.jackson@osumc.edu)	Within 6 months, we will select screening tools and educational materials to assess and promote functional status in patients 70 years of age and older.	Within 12 months, we will promote/provide education to nursing staff on how to use screening tools and educational materials in clinic for new patient 70 years of age and older.	Within 18 months, we will begin screening new patient 70 years of age and older for functional status and provide education, PT/OT referrals when appropriate in the clinic setting. We will reassess every 2-3 months, and assess changes over time.
UCSF	San Francisco, CA	Amanda Ernzer (amanda.ernzer@ucsf.edu) Sharyn Boissevain Chen (Sharyn.BoissevainChen@ucsf.edu) Stephany L. Rodriguez (StephanyL.Rodriguez@ucsf.edu) Cami Lenett (Cami.Lenett@ucsf.edu)	By 9/1/2019, recruit speakers, create contact for and complete 2 rounds of a 3-4 Care of Older Adults with Cancer class, offering CEU's to inpatient and outpatient RNs.	By 12/1/2019, training group of 10 inpatient and 5 outpatient RN's to conduct and document the MOSS and IADL functional assessments and allo recipient ages 50 years and older upon admission, and at days 30, 90, and 180 post transplant.	By 5/1/2019, prepare 2 years worth of "myths of aging" or care tips to be included in the outpatient monthly and inpatient weekly staff email update. Create a recognizable landing spot for this content.
UCSF-Comprehensive Cancer Center	San Francisco, CA	Natalie Olsen (Natalie.Olsen@ucsf.edu)	Within 3 months, New Pt. NP will implement process to identify new Geri-Onc on patients with a dx of anxiety/depression. This data will be obtained from new patient chart and post consult chart review and through ICD-9 search and patient assessment. Education will be provided to staff and how to assess for distress.	Within 3 months of ID of Geri-Onc patients with anxiety/depression will be referred to appropriate referrals.	Within 4 months of referral to psychiatric support will reassess patient distress/anxiety levels.
VA Long Beach	Long Beach, CA	Shindy Garcia () Ishita Kothari () Nimian Bauder (nimian.bauder@va.gov)	Will increase compliance of oral care by 50% to 60% among residents greater than 65 years old by July–October 2019.	Will provide oral care compliance education for healthcare providers in 2 units (East and West) and to residents greater than 65 years old on the importance of oral care and hand hygiene by May 2019.	We will decrease social isolation of residents greater than 65 years old in 2 units (East and West) to 0% by engaging them in various activities of their preference in collaboration with recreational therapy and restorative nursing assistants.
VAGLAHCS Westwood	Los Angeles CA	Elisabetta Jackson (Elisabetta.Jackson@va.gov) Tracy Loc (Tracy.Loc@va.gov) Mano Hovasapyan (Mano.Hovasapyan@va.gov)	Follow-up (4 North) discharge (3 South) packet on education-will be given to patients greater than or equal to 65 old, font will be 14 or larger, it would be age friendly. We want to improve early identification of S/S of chemotoxicity readmission 2/2 symptoms managment Pt involvement. Goal: within 6 months.	Educate staff members about gerontological oncology issues/we will have biweekly classes on ageism, resources and multiple topics (30 minutes). We want to improve ANCC gerontology certification by 100%. Goal: in 12 months.	Provide articles to "Nursing Infusion" (quarterly journal in WLA-VA) that explore the gerontological and oncological side of our patients. Improve education throughout the medical center on gerontological issues. Goal: in 6 months.
Washington Univ School of Medicine	St. Louis, MO	Kelly Terrell (kellyterrell@wustl.edu) Angela Vickroy (vickroya@wustl.edu ) Stephanie Bauer (sbauer@wustl.edu)	Implement baseline geriatric assessments for BMT patients ≥65 and develop a referral strategy for patients at moderate to high risk in order to determine geriatric needs or resources which could be provided (ex: Rehab, nutrition, pharmacy, etc.) Using G8 and TUG tools.	Implement screening process for cognitive impairment with BMT patients ≥ 65 prior to transplant admission and with each milestone office visit post transplant in order to identify cognitive decline.	Develop a chemotherapy toxicity and polypharmacy review program in which BMT patients ≥ 65 at moderate to high risk for adverse drug events receive a pharmacist review of medications to identify interactions, duplications, and appropriateness using Beers Criteria and Chemothery Toxicity Prediction Tool.
West Cancer Center	Germantown, TN	Bernie Crook (bcrook@westclinic.com) Angie O'Kelly (aokelly@westclinic.com) Jill Clarke (jclarke@westclinic.com)	To increase awareness among the clinical staff members about the Geriatric Cancer patients' needs, both physical and psychological by producing a short electronic newsletter quarterly using the pretest, posttest format, and possible survey to assess practice change. 6 months.	To implement a specific focused intervention such as increasing the font and type on patient education material making it easier to read for the geriatric patient. Use an elderly panel to assess benefit of changes made. 9 months.	Create a list of comp community resource for our geriatric patients/find local resources already in place and disperse information on paper as well as post on website. 12 months.

Last Updated on November 27, 2020