Initiatives

Faculty Lead: Ali-Asghar Ali, M.D.

Challenges: In the United States, the prevalence of dementia continues to rise. Currently 5.7 million Americans have Alzheimer's, with only 50 percent of individuals meeting the criteria being formally diagnosed.

Unmet education and training needs: Health professionals, interprofessional trainees, direct care workers, and primary care providers face a training gap in addressing the needs of patients with ADRD and their families. This education gap results in primary care providers and the interprofessional team feeling unprepared to diagnose dementia and manage behavioral disturbances (which impact 60 percent of community-dwelling individuals with dementia).

Unmet health need: Older adults with ADRD and their families face difficulty receiving an accurate dementia diagnosis, appropriate treatment of associated behaviors, and caregiver support. Caregivers in return feel that they don’t receive adequate counseling to help care for their loved ones with ADRD. In addition, those from the LGBT community experience additional challenges around healthcare access and stigma.

Initiative vision: Education regarding dementia diagnosis and management, with a particular focus on appropriate management of dementia-associated behavioral issues and caregiver support, will meet these unmet needs.

Partners:

• Mental Illness Research, Education and Clinical Centers
• Baylor College of Medicine
• Michael E. DeBakey VA Medical Center
• University of Houston Colleges of Medicine, Social Work, and Pharmacy
• UT Cizik School of Nursing
• Baylor St. Luke’s Primary Care Network
• BakerRipley Senior Services
• Montrose Center
• Lone Star Circle of Care

Faculty lead: Mark Kunik, M.D.

Challenges: Depression, generalized anxiety, and increased rates of pain leading to opioid use and associated complications are common in the geriatric population. There are very few geriatric psychiatry practitioners in the United States resulting in high levels of unmet needs in primary care, particularly in medically underserved areas.

Unmet health needs: Less than 50% of mental health issues in older adults, including depression, anxiety, and opioid use disorders, are addressed. Older adults, particularly those in rural areas, often lack access to integrated care that can improved outcomes.

Unmet education and training needs: Primary care providers, who provide the majority of mental health care, and interprofessional trainees require specialized training to expand their knowledge in common geriatric mental health issues.

Initiative Vision: We will partner with The Veterans Affairs–affiliated South Central Mental Illness Research, Education, and Clinical Center (SC MIRECC) and University of Houston College of Pharmacy to improve recognition of depression, anxiety, and opioid misuse. We will utilize telehealth technology to train community primary care providers to improve their care of older adults with mental health needs and increase workforce capacity by training them as local experts in these topics.

Partners:

• Baylor College of Medicine
• University of Houston Colleges of Pharmacy
• Lone Star Circle of Care
• South Central Mental Illness Research, Education, and Clinical Center
• Texas Woman's University
• Hope Clinic
• Mental Illness Research, Education and Clinical Centers
• Michael E. DeBakey VA Medical Center

Faculty lead: Aanand Naik, M.D.

Challenges: Care for older adults with chronic conditions is often poorly coordinated, limited by a focus on single-disease guidelines, and inconsistent with what matters most (i.e., patient priorities). Despite recognizing the importance of advance care planning, only one in four older adults has discussed this issue with their provider.

Unmet health needs: Fragmented, single-disease guidelines–based healthcare often results in burdensome care while also exposing older adults to harm care that is unnecessary or inconsistent with patient priorities.

Unmet education and training needs: Providers and interprofessional trainees in primary care require training in clarifying patient priorities and appropriately aligning care based on what matters most. Providers and trainees often have discomfort due to lack of preparedness in addressing care planning and palliative care.

Initiative Vision: The SETx-GWEP will educate health professions in Patient Priorities Care (PPC), a structured process to identify and align patient priorities with current and advanced care planning, which can reduce treatment burden and enhance patients’ sense of personal and community integration. Furthermore, education about implementing advance care planning conversations into primary care encounters will improve provider comfort and increase the feasibility of completing appropriate Medicare-defined care plan documentation.

Partners:

• Texas Southern University - Houston
• Baylor College of Medicine
• University of Houston Colleges of Medicine, Social Work, and Pharmacy
• UT Cizik School of Nursing
• Baylor St. Luke’s Primary Care Network
• BakerRipley Senior Services
• Lone Star Circle of Care
• Hope Clinic
• Michael E. DeBakey VA Medical Center

Faculty Lead: Kathryn Agarwal, M.D.
Faculty Member: Mahveen Sohail, M.D.

Challenges: Transitions between one care setting and another, such as the transition from the hospital back home, are critical periods that impact function and mobility of older adults.

Unmet clinical need: Care transitions, a period of increased vulnerability for older adults, are especially high-risk in Houston and surrounding areas given high underinsurance and poor access to primary care. Lack of an identified primary care provider and the absence of timely intervention can lead to functional decline, mobility impairment, and other harms, prompting ED visits and avoidable hospital readmissions, which can result in greater functional decline.

Unmet education and training need: Primary care providers and interprofessional trainees have little education on falls, function screening, and recovery after care transitions.

Initiative vision: Through our partnerships, SETx-GWEP will intervene on three levels. On the population level, data from Baylor St. Luke’s Primary Care Network (BSLPCN) will be used to identify primary care providers for older adults ensuring timely post discharge follow-up. Patients without a primary care provider will receive community-based follow-up with Harris Health House Calls Program. Interprofessional trainees rotating with the house calls team will receive educational regarding successful care transitions. On an individual level, BSLPCN providers will receive training on screening for falls to document individual fall risks in patient medical records.

Partners:

• HHS House Calls Program
• Baylor St. Luke’s Primary Care Network
• Baylor College of Medicine

Faculty lead: Shalizeh Patel, DDS

Challenges: One in eight older adults in Texas is endentulous, and overall oral health outcomes in the Houston region are poorer than those in other Texas urban areas, contributing to dental pain, malnutrition, took loss, chronic disease destabilization, and decreased quality of life.

Unmet health needs: Unmet oral health needs are common in Houston and surrounding areas because dental care is not covered by Medicare, standard Medicaid coverage, or many other insurance offerings. 

Unmet education and training needs: Despite the importance of oral health in wellbeing, oral health education is lacking for health professions trainees outside dentistry and dental trainees receive minimal geriatrics education.

Initiative Vision: Education of dental and interprofessional health trainees will address these education gaps. As an initial clinical intervention, primary care trainees will implement the Kayser-Jones Brief Oral Health Status Examination. Caregivers will also receive education about dental health at community health centers.

Partners:

• UT School of Dentistry
• UT Cizik School of Nursing
• Michael E. DeBakey VA Medical Center
• Baylor College of Medicine
• BakerRipley Senior Services
• University of Houston Colleges of Medicine and Pharmacy

Faculty lead: Sabrina Pickens, Ph.D., GN

Challenges: Elder abuse, neglect, and financial exploitation impact 1 in 10 Americans who are 60 years or older. However, many providers lack knowledge and skills to recognize and intervene on elder abuse and neglect. Meals on Wheels volunteers are an important front line in identifying potential abuse and neglect cases, but typically receive no training in this area.

Unmet clinical needs: Many elders experiencing abuse and neglect, including self-neglect, may not present to medical attention and therefore go unrecognized.

Unmet education and training needs: While there is a robust, well-respected clinical and educational elder abuse and neglect program at UT-Health, other health professions trainees and individuals who come into contact with at-risk adults in the community, such as Meals on Wheels volunteers, receive little training recognize warning signs and appropriate response.

Initiative Vision: Educate interprofessional trainees and Meals on Wheels volunteers to recognize abuse, neglect, and financial exploitation and intervene appropriately, especially in the rural population.

Reference: Center for Disease Control and Prevention - Elder Abuse

Partners:

• Baylor College of Medicine
• Mental Illness Research, Education and Clinical Centers
• Meals on Wheels
• UT Cizik School of Nursing
• University of St. Thomas- Houston Peavy School of Nursing
• Michael E. DeBakey Veteran Affairs Medical Center
• University of Houston College of Medicine, Social Work, and Pharmacy