Individualized Care for At Risk Older Adults

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For the foreseeable future, addressing the complex health and social needs of the growing population of older adults with multiple chronic conditions (MCCs) and supporting their family caregivers, especially during frequent transitions in health, is a societal priority. This T32, Individualized Care for At-Risk Older Adults, based at the University of Pennsylvania School of Nursing (SON) where expertise in aging and transitional care research are hallmarks of our faculty, is uniquely designed to prepare nurse scholars who will address this challenge. Since 2007, this program has successfully prepared 15 PhD graduates and 13 postdoctoral fellows who are now pursuing successful scholarly careers and advancing science related to health and health care transitions of older adults. This proposed renewal, led by two highly experienced nurse scientists is supported by nine additional core and eight associated faculty in the SON with complementary programs of research. Our emphasis on team science is actualized with co-mentored training from 25 interprofessional Penn faculty external to nursing. Guided by the AHRQ Multiple Chronic Conditions Research Network's conceptual model, our training program will prepare four predoctoral and four postdoctoral nurse scientists appointed annually with the skills and knowledge to: 1) advance science related to the impact of frequent and complex transitions in health and health care on older adults with MCCs and their family caregivers, with particular emphasis on the role of nurses; 2) conduct research with the highest standards of rigor and integrity, using a team science approach, and employing contemporary and emerging research designs and methodologies; and 3) perform synthesis, dissemination, implementation and translation of research findings designed to inform and improve health care practices and policies. This renewal builds on our success and is responsive to dynamic population, research, and health care system changes through innovative program modifications. Specifically, this renewal expands the program's emphasis on care of chronically ill older adults to focus on the complex health and social needs of the growing population of older adults with multiple chronic conditions and their family caregivers. Further, we emphasize the longitudinal care of diverse and vulnerable subgroups of older adults with MCCs throughout multiple health transitions. We enhance our current training in research methods to include: (a) a broader range of designs with enhanced translational potential; (b) advanced data science; (c) sophisticated qualitative and mixed methods; and, (d) rigorous measurement of outcomes. Current attention to dissemination of individual study findings extends to a more robust focus on knowledge synthesis, implementation, and translation. The rich scientific base, resources and networks contributed by committed faculty mentors provide an excellent foundation and environment for this training grant. Building on our prior success, we will produce nurse scientists and leaders prepared to contribute scientific advances designed to have a major, positive impact on the care and outcomes of older adults with MCCs and their family caregivers.