Since launched in 2007, Individualized Care for At-Risk Older Adults, a National Institute of Nursing Research (NINR)-funded institutional NRSA training program based at the University of Pennsylvania School of Nursing (Penn Nursing) has successfully prepared a cadre of new nurse scientists (six PhD graduates and 10 postdoctoral research fellows) who now are actively pursuing scholarly careers and advancing science related to transitions and aging. An additional seven students are expected to complete their doctoral degrees in nursing within the next two years. The primary goal of this renewal application is to train additional highly qualified nurse scientists who will generate, disseminat and translate new knowledge with a unique focus on improving the care experience, health and quality of life outcomes of a growing population of chronically ill older adults as they experienc common and difficult transitions in health and healthcare. In addition to preparing scholars to address the significant human and economic challenges associated with assisting this increasingly diverse and vulnerable population to achieve their health goals, this renewal will: capitalize on the strong foundation in science contributed by program faculty members, build upon an established collaboration between faculty members in two of Penn Nursing's research centers (the New Courtland Center for Transitions and Health and the Center for Integrative Science in Aging), employ innovative inter-professional mentorship and training models that engage preeminent scholars throughout Penn, offer trainees unparalleled opportunities to learn sophisticated and emerging research methods, and place a new emphasis in preparing future scholars who can rigorously translate science to have an impact on clinical practice and health policy. During this five year renewal, four pre-doctoral students and four postdoctoral research fellows will be appointed annually. The goals of the proposed training program align with each of NINR's strategic priorities as well as the Department of Health and Human Services'strategic goal of optimizing the health and quality of life for individuals with multiple chronic conditions

Public Health Relevance

As a society, the conditions are set for a perfect storm: a projected increase in the number and diversity of older adults coping with multiple complex chronic conditions, limitations in current clinical practices and healthcare policies, and rising health care costs are coalescing to create an untenable future for older Americans. These conditions create an urgent need to build on the advances in knowledge generated from faculty and trainees from the first five years of our National Institute of Nursing-funded training program Individualized Care for At-Risk Older Adults. This renewal seeks to continue to prepare nurse scholars whose advanced skills in interdisciplinary science will chart a better path for this population and their family caregivers throughout vulnerable transitions in health and healthcare.

National Institute of Health (NIH)
Institutional National Research Service Award (T32)
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Study Section
Special Emphasis Panel (ZNR1)
Program Officer
Banks, David
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University of Pennsylvania
Other Health Professions
Schools of Nursing
United States
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Tang, Hsin-Yi; Vitiello, Michael V; Perlis, Michael et al. (2014) A pilot study of audio-visual stimulation as a self-care treatment for insomnia in adults with insomnia and chronic pain. Appl Psychophysiol Biofeedback 39:219-25
Lorenz, Rebecca Ann; Budhathoki, Chakra B; Kalra, Gurpreet K et al. (2014) The relationship between sleep and physical function in community-dwelling adults: a pilot study. Fam Community Health 37:298-306
Stawnychy, Michael; Masterson Creber, Ruth; Riegel, Barbara (2014) Using brief motivational interviewing to address the complex needs of a challenging patient with heart failure. J Cardiovasc Nurs 29:E1-6
Bowles, Kathryn H; Hanlon, Alexandra; Holland, Diane et al. (2014) Impact of discharge planning decision support on time to readmission among older adult medical patients. Prof Case Manag 19:29-38
Masterson Creber, Ruth; Lee, Christopher S; Lennie, Terry A et al. (2014) Using growth mixture modeling to identify classes of sodium adherence in adults with heart failure. J Cardiovasc Nurs 29:209-17
O'Connor, Melissa; Hanlon, Alexandra; Bowles, Kathryn H (2014) Impact of frontloading of skilled nursing visits on the incidence of 30-day hospital readmission. Geriatr Nurs 35:S37-44
Toles, Mark; Anderson, Ruth A; Massing, Mark et al. (2014) Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge. J Am Geriatr Soc 62:79-85
O'Connor, Melissa; Bowles, Kathryn H; Feldman, Penny H et al. (2014) Frontloading and intensity of skilled home health visits: a state of the science. Home Health Care Serv Q 33:159-75
Radhakrishnan, Kavita; Bowles, Kathryn; Hanlon, Alexandra et al. (2013) A retrospective study on patient characteristics and telehealth alerts indicative of key medical events for heart failure patients at a home health agency. Telemed J E Health 19:664-70
Van Cleave, Janet H; Trotta, Rebecca L; Lysaght, Susan et al. (2013) Comorbidities in the context of care transitions. ANS Adv Nurs Sci 36:E1-E13

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