I’m Chris LangstonThe program director at the John A. Hartford Foundation
But first to review our goals for today – ApproachI will get us started with an overview our grantmaking approach and of the program overall and how it all comes together. ReviewThen each of the program officers will with their three slides review the strategies within their areas, show how grants connect to these strategies, and look at how currently approved funds are going to be spent over the next few years. Each will also report on the progress we are making towards our indicators. We will not be talking about individual grants, but rather trying to look up to how the effects of the individual grants add up to broader change. We have taken great pains to try to present a relatively simple model of what we are doing, using only three slides each - So if you think something is missing it probably is, but we are trying very hard to create a model that clarifies more than it confuses, one that stimulates thought.As you know measuring progress in our work is actually remarkably difficult. It is easy to measure and track the outputs of our grants, how many scholars, how many sites, and so on. However, it is harder and much more expensive to find out if those pieces are really adding up to change in whole fields of education and practice the way we want. So this summer we used pretty much all the available time of our summer intern as well as some of Marcus’ time and the program officers to do some detective work, and measure some things that we thought would tell us something about how geriatrics is positioned in the field. Our intern, Steve Strickland, did most of this work on-line reviewing faculty rosters for medical nursing and social work schools. Reading on-line course catalogs and requirements. For the most part this is new information, only a few weeks old and is different from most other information in the field which is based on voluntary and often relatively low rates of response to surveys. Of course this approach is highly dependent upon the dedication with which schools keep their websites up to date. No data is perfect and throughout this work, we have tried to have the attitude: let’s measure something and see what we can learn.Finally we do want to propose to you a minor adjustment in the allocation among sub areas of the program, that would be used to guide future grantmaking in 2012 as we start to regrow our program once again.We will leave plenty of time for questions and comments.
Grant spending’10 - $24.2’11 - $20.2’12 - $18.7’13 - $19.2’14 - $19.6We are highly strategic, internally directed (as opposed to reactive) funders. We make relatively large long-term grants to large accademic, professional, and practice organizations with the intent of making large scale national change. We have a bit over 100 grants and falling as we try to live within our means and we close the individual Centers of Excellence award. Our median grant size is almost $900k over 4-5 years and yet our grants represent relatively small proportion of our grantees’ budgets given their size. We have an expert program staff who are each deeply engaged in their areas and as such we are all committed to making change using all the tools available to us, not limiting ourselves to making grants alone. This includes developing partnerships, communicating to a variety of audiences, and providing non-financial support to grantees as you’ve heard in yesterday’s updates.In the panel of the right, you see the resource bottom line we are working with. Although the effects of the fall in the endowment were cushioned by the change in payout to the three year average, we are still in the declining payout phase, with a further reduction to our payout targets of 20% expected next year before we hit bottom in 2012 and then begin to rise up again.
Our mission is of course better health of older adults and this diagram shows how we think we will get there.Older adults are in the center of course and the broad environment is out here. Clearly this includes a fair amount of general problems in health care quality coupled with some special problems in ignorance and ageism that make are jobs that much harder. In here are the 4 parts of our program, MDs, RNs, MSWs, and Services.The problems of geriatric care are notable in that they demand interdisciplinary care that considers the biological, psychological, and social aspects of aging. Producing better health outcomes for older people requires change in at least these four areas.We therefore need skilled physicians, nurses, and social workers (and others as well). We also need the places where they work to enable them to use their skills, so we need to support redesign of practice. It is only through changes in practice that we can hope to have changes in the health outcomes of people.Finally the thin “other” work hovering overhead, represents important efforts like our communications work, the IOM, and others which serve to push this effort along.So before turning the floor over to Amy – I just want to say again that I think we are doing well, pursuing a critical mission, and that we feel proud and privileged to be able to say that we work at the John A. Hartford Foundation.*******************************************************************As we all know time is both on our side and one of our biggest problems. Since the start of the aging and health program in 1982, the public and stakeholders have becoming more and more aware of the importance and the defects in care of older americans. I think pretty much every policy makers knows at this point that the majority of health care spending is on those with multiple chronic illnesses, and most realize that those people are older adults.We saw significant attention to aging issues in PPACA, if not as much as we would have liked.We are seeing significant funding in aging being added from both private sources and public ones. While we are all concerned about some of our larger partners like Reynolds and Atlantic spending down, we are still 5 to 10 years away and in both cases they are supporting important parts of the puzzle. We are also seeing many new funders interested in aging or at least in issues like chronic care and hospital readmissions that lead inevitably to aging.Nevertheless, if we are going to have an opportunity to really improve health and health care for older people we need to make progress within the next 10 to 15 years BEFORE the demographic problems become insurmountable and the slow nature of change in the health care workforce and and delivery delay improvements even further.
Again our goal is for all physicians to be competent in the care of older adults. We know that fewer than 7,000 and falling of the roughly 800,000 MDs in the US specialize in geriatrics and traditionally most physicians have little or no exposure to geriatrics in their training. Finally, as in the other professions, geriatric care is not a small issue at the margins, but rather the core business of health care so we need at least basic competence from all if we are to provide high quality care.Since its beginning in 1982, the Foundations work with physicians has used these two main strategies: faculty development and curricular change. You might remember that our very first formal aging and health grant was the Hartford Faculty Scholars program which retrained physician faculty from other disciplines of medicine in geriatrics and which got David Reuben started in his career in geriatric medicine.In faculty development we try to help those interested in geriatrics per se or in the aging aspects of other specialties get off to a good start and position themselves for influence in their careers. Because we still have so many scholars programs in medicine this graphic breaks them out as a separate echelon in the back. Collectively these scholars programs have supported almost 700 people at the faculty level as well as over 1000 medical students of whom several hundred have focused their careers in aging. One of the characteristics of our programs at this point in time, but in medicine especially, is the potential power of their alumni given the large number and time to move into positions of influence they have had. As an example, just last week Harlan Krumholz a 2nd cohort Beeson scholar at Yale was profiled in Forbes as the most important doctor you have never heard about for his comparative effectiveness work in cardiology. In Curricular change, shown here by our ADGAP Chief Resident program, the surgical specialists initiative, and the internal medicine specialists initiative , we try to influence training standards, develop training materials, and have them spread. It is here that we are working for the big win that nursing has already had – a really effective requirement for minimum competency in caring for older adults in medicine.Of course these two strategies work together as faculty do the direct teaching of future practitioners, lead curricular change efforts, and eventually are positioned to support them from positions of leadership.Last, while we have spent more money and have done most of the initial work, because of their size and scope, I also wanted to mention the work in aging and health of the Donald W. Reynolds Foundation. Over the last 10 years they have spent almost $100M on their grants to 40 medical schools and 4 faculty development centers. We understand that they are very likely to award another $10M later this year for geriatric training of surgical specialists and for MDs to be better team members. However, they are very unpredictable in the short term and spending down in the long-term. Atlantic is pretty much off all of these boards with its current focus on public policy and consumer advocacy. They still have some residual monies in all of these games, but it is running out and they are not attending to any of their investments.
SO this chart shows some indicators of progress medicine in year 2 of our 5 year plan.Indicators of Impact Geriatrics Divisions Increase Faculty Size by 20%50% of Medical Schools Adopt New Geriatric Competencies 50% of Residencies, Specialties, & Subspecialties Adopt Specific Geriatric Training Standards (Currently ~ 30%)So down here we would show current measures of our impact - Size of Divisions, % of schools adopting competencies, and % of residencies Faculty growth - Some good news and some bad newsOf those institutions with formal geriatrics academic units (divisions or departments) the average number of physician faculty is 16 – however, only 60% of medical schools have a division or better of geriatrics that we could find and when they do not, while they no doubt have some geriatrics faculty, the number is undoubtedly less.30% of medical schools have explicit geriatric requirements for Medical Students57% of Internal medicine residencies have some geriatrics requirements in their training programs
The Integrating and Improving Services grants aim to improve health of older adults at the bedside and the kitchen table. They build upon the Foundation’s previous work in Health Care Cost & Quality that led to outcomes such as the development of PACE, the program for all-inclusive care of the elderly, begun at On Lok under the leadership of Jenny Chin Hansen, which continues to be replicated today. Our Services grants aim to redesign services to be effective and affordable, and to meet the needs of older adults. We accomplish the redesign through three main strategies that you see in this slide. 1) First, we develop and test of innovative models of care AND2) Second, we create Agents of Change within practice settings to implement proven innovations. 3) Together these foster our third strategy, dissemination of the Foundation’s efforts.The Foundation focuses on areas that are truly important to the health of older adults such as medication management and improving care transitions. Our efforts cross a wide range of health care settings from the hospital to primary care to home care. For example, the Center to Advance Palliative Care led by Diane Meier, is expanding the availability of hospital-based palliative care programs. Our CHAMP Program through the Visiting Nurse Service of NY is improving how medications, pain, and other geriatric issues are handled in home care agencies around the country. These efforts are high risk and high reward. And we have achieved significant impact through these investments as I will show you in a moment.
Hartford models are in health care setting in all 50 states including Alaska and Hawaii. Our active grants today have trained more than 5300 physicians, nurses and social workers in new models of care. Over 3700 hospitals, home care agencies and primary care practices have adopted our models.And we have created 68 leaders to serve as change agents in 27 states who are leading geriatric services redesign in practice settings. Next, let’s look at our indicators of impact, what we hope to achieve through these investments.Outputs (AB)Model development, testing & dissemination: Models adopted in 50 states at 3764 sites 5372 providers trained in new modelsAgents of change: 68 leaders in 27 states trained to lead geriatric services redesign in practice settings========================Models in testing phase: Guided Care, AARP Professional Partners Supporting Family Caregivers, SHM BOOST (3)Models in dissemination phase: IMPACT, CTI, CMP, PICF (4) [Resources in dissemination phase: CHAMP, CAPC ]========================Somewhat different kinds of indicators. Here we want to develop new ideas and get them spread. Our indicators are taking two models to the point of proven benefit and feasibility and getting four models to the point of self-sustaining spread.In our strategy of model development, we have also refined our strategy. We have specialized more and more in late stage model testing and development, refining and proving benefit in areas where there is already substantial evidence of what can and should be done. While this is still risky work, it is much less risky at this late stage of the development process than at earlier stages.We are also becoming more and more expert in issues of dissemination, as Amy mentioned we will be convening our most accomplished grantees to focus on what is known about this work in December. But we know now how important it is to market and offer training – to actively push (there are no better mouse traps that just fly off the shelf here. We know that business case, marketing, branding, and channels of information are very important.And lastly part of dissemination but also a new strategy that Amy has developed is the recognition that in the process of changing clinical care, human capital is also essential but that the agents of this change are not necessarily academics but may need capacity building to be effective. Our new grant to Sigma Theta Tau to training practicing nurses with administrative roles to lead change within their institutions is a good example of this strategy.
Medical Society Fundraising Presentation
Medical Society Fundraising NetworkWorking with Foundations Winter 2011
Goal for Today:Working Effectively with FoundationsOutline• Background and Trends in Foundation Sector• A Little about JAHF• Working with Foundations• Questions and Some Answers
Background• 75,000 Grantmaking Foundations• $42.9 Billion in Giving 2009• $30.8 Billion from Independents vs. Corporate ($4.4B) or Community ($4.1B)
Background• 32,000 hold ≥ $1,000,000 or payout ≥ $100,000• 64% of these are < 20 years old• Assets Concentrated : 80-20 rule
Background• Health and Education Are Top Areas• Dwarfed by Individual Charitable Giving ($229B, ~$22B to health organizations)
General Trends• Increasing Prominence• New Approaches• Increased Scrutiny/Criticism
Financial Trends• Effects of the Crash –Giving reduced 2009 and 2010, but only to 2006/2007 levels –Intergenerational Wealth Transfer, slowed but still $6-$25T (e.g., Margaret A. Cargill Foundation)
Financial Trends• Fundamental Issues –Sustainability –Partnerships –Role of “Social Capital”
2010 Summit Fundraising “Booster” Webinar, June 2010: Donor Engagement
“To know one foundation is to know one foundation” Corinne H. Rieder, EdD Executive Director John A. Hartford Foundation
Hartford Foundation: Mission Improve the health and well being of older Americans through better education of health professionals and better designed health care delivery.
Hartford Foundation: Rationale• In 2011, those born in 1946 will begin to turn 65• By 2030, 71 million Americans will be 65 or over, double the number in 2005
Hartford Foundation: RationaleOlder Americans are the CoreBusiness of Health Care ~43% of hospital bed/days ~35-70% of outpatient visits ~70% home health cases ~85% of hospice cases ~90% of nursing home occupancy
Hartford Foundation: RationaleOlder Americans Get Poor Care –30% of indicated care provided for “geriatric conditions” (vs. 55% more generally) –60% of unnecessary hospitalizations –19% of hospitalizations of OAs lead preventable harm (vs. 13% <65)
Grantmaking Approach Projected Payout ($ millions)• Only national funder 30 focused on aging and 25 health mission 24.2 20 20.2• Highly strategy driven 18.7 19.2 19.6• Expert staff, engaged 15 in the field 10• Creating change, not 5 grants alone 0 2010 2011 2012 2013 2014
Aging and Health Program: Overview Better Health of Older Adults
Medicine:Portfolio Centers of Excellence MSTAR Faculty Development ADGAP – Leadership BeesonAllPhysicians Scholars Reynolds ProgramsCompetent Foundation Williamsto Care for ProgramsOlder Adults ADGAP – Chief Residents Jahnigen Curricular Change Surgeons Initiative Internal Medicine Specialist Initiative
Medicine:Indicators of Impact* % Aca. Medical Centers with Divisions of Geriatrics Average MD faculty = 16 % Medical Schools with geriatric requirements % IM Residencies with some geriatrics requirements 0% 20% 40% 60% 80% 100% Goal Current*Original Indicators of Impact: Faculty in Divisions of Geriatric Medicine Grow by 20% Medical Schools Adopting AAMC Geriatric Competencies Residencies, Specialties, & Subspecialties Adopting Geriatric Training Standards
Integrating & Improving Services: Portfolio PHI – Coaching OHSU – Care Supervision Management + Model AARP –Caregiver Partners in Care – Development Support Medication Mgmt. and TestingHealth Care Guided Care U. of Washington –Delivery IMPACTRedesignedfor Older VNSNY – Dissemination of Proven Ideas CHAMPAdults U. Colorado – Sigma Theta Tau – Care Transitions Leadership Agents of Academy Mount Sinai – Change Palliative Care Practice Change Fellows SHM – BOOST Care Transitions
Integrating & Improving Services:Grant Outputs • Models Adopted in 50 States • 3,764 Clinical Sites • 5,372 Providers Trained
Foundation Activities• Manage existing grant programs• Find and develop new programs• Create networks• Broker resources & knowledge• Communicate• Convene stakeholders• Partner with other foundations
The Dos and Don’ts of Grant Seeking1. Learn about a foundation’s mission, goals, and objectives2. Learn about the foundation’s culture3. Understand the internal processes of grantmaking4. Understand the foundation perspective5. Know when to bring in content/project experts6. Don’t be dismissive or condescending of foundation staff7. Know when and how to revise a proposal8. Cast net widely for funds