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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Am Geriatr Soc. Author manuscript; available in PMC Mar 5, 2013.
Published in final edited form as:
PMCID: PMC3588568
NIHMSID: NIHMS445642

Sustaining Clinical Programs During Difficult Economic Times: A Case Series from the Hospital Elder Life Program

Abstract

OBJECTIVES

To explore strategies used by clinical programs to justify operations to decision-makers using the example of the Hospital Elder Life Program (HELP), an evidence-based, cost-effective program to improve care for hospitalized older adults.

DESIGN

Qualitative study design utilizing 62 in-depth, semi-structured interviews conducted with HELP staff members and hospital administrators between September 2008 and August 2009.

SETTING

19 HELP sites in hospitals across the U.S. and Canada that had been recruiting patients for at least 6 months.

PARTICIPANTS and MEASUREMENTS

HELP staff and hospital administrator experiences sustaining the program in the face of actual or perceived financial threats, with a focus on factors they believe are effective in justifying the program to decision-makers in the hospital or health system.

RESULTS

Using the constant comparative method, a standard qualitative analysis technique, three major themes were identified across interviews. Each focuses on a strategy for successfully justifying the program and securing funds for continued operations: 1) interact meaningfully with decision-makers, including formal presentations that showcase operational successes, and also informal means that highlight the benefits of HELP to the hospital or health system; 2) document day-to-day, operational successes in metrics that resonate with decision-maker priorities; and 3) garner support from influential hospital staff that feed into administrative decision-making, particularly nurses and physicians.

CONCLUSION

As clinical programs face financially challenging times, it is important to find effective ways to justify their operations to decision-makers. Strategies described here may help clinically-effective and cost-effective programs sustain themselves, and thus may help improve care in their institutions.

Keywords: Hospital Elder Life Program, cost-effectiveness, sustaining programs, hospital administration, clinical innovations, quality of care, delirium prevention, acute care, geriatrics

INTRODUCTION

Past research suggests it is difficult to sustain new clinical programs, especially in geriatrics, where interventions are often multi-faceted and require change across multiple care processes.1,2,3 In difficult economic times, new clinical programs may face even greater challenges, including increased scrutiny from hospital administrators and other decision-makers as they look for opportunities to cut costs.

The medical literature has little to guide clinical programs in sustaining themselves, with even less focused on the particular issue of ensuring long-term support from hospital administrators.3 Studies on clinical innovations have largely focused on the issue of innovation adoption, rather than sustainability,4,5,6,7 with a very limited discussion of “human technologies” (defined by Bradley as “innovations that are multifaceted, require coordination across disciplines and are not traceable to a specific new technology, and involve substantial attitudinal shifts among staff”3). The quality of care improvement literature has a greater focus on human technologies, but is similarly focused on adoption rather than sustainability.8 Further, while the research identifies organizational characteristics associated with the adoption of improvements even in the field of geriatrics,9,10,11 the process by which these characteristics lead to the adoption or continuation of a program is largely a black box, with little information to shed light on the processes involved.12 Thus, there is very little evidence-based, practical information to guide the clinician in steps to improve the likelihood that a program will survive on a long-term basis. Available information speaks more to accounting details of the process rather than the staff and organizational issues.13

This article addresses this gap in the literature by examining staff and operational strategies that clinical programs utilize to justify a program’s operations and budget to decision-makers. To provide a practical and detailed view, it utilizes a case study approach focused on the Hospital Elder Life Program (HELP). HELP is an innovative, hospital-based program to prevent delirium and functional decline in hospitalized older adults, and it is currently operating in approximately 100 hospitals in the United States and 7 countries worldwide. HELP utilizes a multi-disciplinary team and trained lay volunteers to deliver a series of interventions to older patients. These interventions include: daily visits and orienting communication, therapeutic activities, assistance with mobilization, assistance with feeding and hydration, monitoring and correction of vision and hearing deficits, and assistance with sleep. HELP serves as an excellent model for such a study because it has several characteristics that are likely to be attractive to decision-makers. For example, it has been shown to be both clinically effective and cost-effective, saving approximately $800 per enrolled patient and diminishing costs of long-term care.14,15,16,17 The program has also been shown to improve nursing satisfaction as well as patient and family satisfaction.18 Moreover, HELP is useful for prevention of Medicare no-pay conditions.19 At the same time, HELP staff cannot rely exclusively on this literature to justify operations because each program is adapted to a unique clinical setting where decision-maker priorities may vary.3 Thus, as with new programs in many settings, each site must explicitly or implicitly justify their unique program to local decision-makers.

METHODS

Design and Data Collection

Data utilized in this analysis come from a qualitative study of 19 active HELP sites in hospitals and health systems in the United States and Canada that volunteered to participate. Eligible sites for this study included those with a formal HELP contract, an identified liaison, and actively enrolling patients for at least 6 months by the time of the first interview.

Because budgetary decision-making processes in hospitals are often diffuse and complex,20 researchers interviewed people involved with HELP in a range of capacities, including administrators, physicians and nursing staff, to provide multiple perspectives on efforts to justify the program to decision-makers. To identify participants, researchers used a “snowball” recruiting methodology , which is a particularly appropriate approach for the study of small populations such as this one.18 For the “snowball” method, the first step was to recruit the main contact person, or HELP liaison, at each site, who then recommended up to 3 additional people at the site to complete an interview. At the close of each subsequent interview, participants were asked to identify others who would be appropriate for interviewing and so on. Interviews continued at each of the sites until all persons identified through this process had been contacted.

Researchers trained in qualitative interviewing techniques conducted semi-structured, in-depth interviews with each participant over the telephone. The interviewing process was based on standardized techniques considered to enhance the quality and comparability of qualitative research efforts.22,23 The interview guide was developed principally with open-ended questions addressing the major topics, and then follow-up questions and probing techniques were used to round out the responses from participants. Through these interviews, participants described their experiences in HELP with a particular focus on the challenges they faced, as well as the strategies that helped them address these challenges, in trying to justify the program to key decision-makers, defined generally as those with funding-related authorities for staff or resources. Participants commented on their own activities, as well as those of other HELP staff and hospital or health system administrators.

Interviews lasted between 45 and 75 minutes, and in one case a participant requested a second interview that extended the discussion another 30 minutes. Where possible, interviews were audiotaped and then transcribed by an independent, professional transcription team with subsequent review by a research team member for accuracy. All participants provided oral consent before beginning the interview. The institutional review boards (IRB) at Hebrew SeniorLife and the Harvard School of Public Health approved all research procedures.

Data Analysis

Analysis of these data relied on the constant comparative method, a standard qualitative analytic technique,24,25 through which researchers developed a systematic synthesis of thematic elements in the interviews that described the primary strategies through which HELP sites justify their programs to key decision-makers. Researchers utilized a sample of approximately 15 interviews to develop an initial code list, and then refined this code list through multiple iterations until they reached thematic saturation as they continued to review interviews. The full research team reviewed the codebook to ensure logic and comprehensiveness. Decisions about the codebook were achieved through consensus of the primary coders and project director. Utilizing the finalized codebook, two members of the research team coded all of the interviews in Atlas-ti (ATLAS.ti GmbH, Berlin, Germany). This state-of-the art software is designed explicitly for qualitative research and facilitates not only the constant comparative method during codebook development, but also the identification of related themes and relevant quotations. Coding resulted in 24 interrelated themes that were organized into three major areas. During the initial stages of analysis, it was apparent that data from participants in different roles were consistent with each other, and thus, all data were analyzed together.

RESULTS

Sample Characteristics

Of the 23 eligible sites, 21 participated in the study. One site did not qualify (i.e., had not been recruiting patients for at least 6 months) and one refused to participate due to time constraints on staff. Thus, 96% of the qualified and identifiable sites participated. During the course of the study, two HELP sites that initially agreed to participate were closed and could no longer participate. The final list of 19 study sites included those located in hospitals and health systems that vary with respect to size, geography, ownership status and teaching status. (See Table 1). Programs had been enrolling patients for 4.5 years on average (range of 1.2 to 7.5 years) at the time of their interviews, and all the sites received some funds from the hospital where they were located. Typically, the hospital covered the cost of staff salary and benefits, while donations, grants and other fundraising supported the program materials, including hearing amplifiers and games, for example.

Table 1
Characteristics of Study Hospitals

Researchers attempted to conduct interviews with 72 people across sites. Three people had left the program; one declined to participate because he did not feel he had sufficient experience with HELP; one refused due to time constraints; and five never replied to multiple invitations by email and phone. Thus, 62 completed an interview, which is a 91% response rate among qualified participants still involved in HELP programs. Interviews included a range of 2-5 staff members at each site who were grouped into 2 overarching categories (See Table 2). There were 20 people (32%) at 15 sites who were considered “influencers” because of direct or indirect involvement in the decision-making relevant to the HELP budget and who typically had closer relationships to the senior administrative team, such as the president or Chief Executive Officer (CEO). Participants in the category of “influencers” included administrators and managers serving in roles such as the Chief Nursing Officer or the Director of Rehabilitation, as well as physicians who had managerial responsibilities and served in roles such as Department Chair, Program Chief, or Medical Staff Director. There were 43 participants (68%) at all 19 sites who fell into the second category, which we call “frontline staff.” These included people serving in roles such as the Elder Life Specialist or Elder Life Nurse Specialist (typically an advance practice geriatric nurse). Individuals in this latter category had little direct involvement in the budgetary decision-making process, but frequently indicated that managers, administrators and physicians they worked with had discussed the decision-making process with them explicitly.

Table 2
Interviewees by Category

Influencers typically had more in-depth information about the strategic priorities of senior administrators, materials they would find most compelling when considering whether or not to fund the HELP program, and the nature of meetings with senior administration about the HELP program. By contrast, frontline staff typically had more in-depth information about how HELP staff supported influencers’ efforts to reach administrators through day-to-day operations, such as report preparation, data collection and interaction with other staff. However, the comments of these two categories of participants were complementary, and in some cases they also overlapped considerably. Influencers described what frontline staff did and frontline staff also described what influencers did and what they learned about the views of senior administrators. Thus, data from both of these populations are presented together in order to give readers a broad perspective on the strategies HELP programs used to reach decision-makers (Table 3).

Table 3
Select Quotations from “Influencers” and Frontline Staff

Major Themes Related to Justifying the Program

Analysis revealed three major themes related to what participants reported as effective efforts to justify the program to key decision-makers. First, sites interact meaningfully with decision-makers, not only formally through presentations that showcase operational successes, but also informally in ways that highlight the benefits of HELP to the hospital or health system. Second, sites document their day-to-day, operational successes and estimate their impact in terms of metrics that resonate with decision-makers. Third, sites garner support from staff who are critical to administrative decision-making, particularly nursing staff and physicians. Each of these themes and activities is described below. In addition, Table 3 presents further practical strategies to address each of the themes.

Interacting Meaningfully with Decision-makers

HELP program staff make use of multiple means for interacting with decision-makers. For example, HELP program staff sometimes present formally to decision-makers, with prepared materials in PowerPoint or written text form during regularly scheduled and highly-structured meetings, such as annual departmental or program reviews. Performing well in these high-visibility meetings is critical. Factors that facilitate effective performance include: adhering to formal guidelines (e.g., number of slides); keeping it brief as a general rule; and presenting data that is compelling to administrators and non-clinical hospital leaders.

Much of the success in formal settings derives from earlier, informal connections with decision-makers. These not only help staff know how to present materials in the formal setting, but also make broader connections. Examples of informal connections include meetings about other topics such as committee meetings, in which HELP staff or supporters are able to bring up the issue of HELP, but also able to garner feedback from decision-makers about their general priorities and about their views of HELP’s benefits to the hospital or health system. Participants felt that interactions went far beyond formal presentations to include true relationship building and require vigilance to ensure the relationships maintain even during difficult times. While “influencers” were generally more likely to be focused on relationship-building, frontline staff were nonetheless involved in meetings with persons who would be indirectly involved with the most senior decision-makers, such as quality improvement committees or geriatric service committees, in order to enhance visibility through these channels as well.

Often, senior HELP staff or “champions” of the program participate in informal meetings with the most senior decision-makers, and the champion’s position facilitates the interactions. This person may know the senior decision-makers so well that she or he can even anticipate their needs or speak to them in the most casual settings that allow them to make a stronger case for maintaining HELP. For this reason, having a reporting structure in which HELP staff report to senior administration directly can be helpful.

In addition to direct interactions with senior decision-makers, HELP programs may bolster their relationships with more traditional public relations techniques to reinforce the idea that the HELP program is successful, well-received within the hospital/health system, and reflecting well on the hospital or health system to outsiders and competitors. They may do this on their own, or rely on the public relations group at the hospital or health system. Aside from publishing their own newsletter or writing stories for the hospital newsletter, there are less traditional approaches as well, including internal publicity events like health fairs or conferences and the presentation of data. Sometimes sites also benefit from traditional press coverage of hospital and program events such as fundraisers

Documenting Successes in Metrics that Resonate with Decision-Makers

Determining which data to collect is, in part, influenced by practical necessities such as what data is feasible to collect. It is also a strategic choice because successful HELP programs collect data to document their achievements in terms of outcomes that are meaningful to decision-makers. They determine which metrics will resonate through interactions with the decision-makers as described above, but also with more generalized views of what is likely to be important based on the hospital or health-system’s broader priorities. The factors most generally documented with quantifiable data fell into two categories: 1) Metrics that document the extent of care or services provided by the HELP program, including the protocols they provide, the number of patients they see, and how long they provide services to them; 2) Metrics that demonstrate the impact of this care or services on a) health outcomes (e.g., Did we reduce delirium? Did we reduce falls?); b) the impact on costs (e.g., Did HELP reduce costs or factors that indicate costs, like length of stay?); c) the impact on patient satisfaction or staff satisfaction (e.g., Did HELP improve satisfaction?)

While there may not be an explicit invitation to submit such data, successful programs consider such reporting a top priority. Many assume that formal documentation is required, even if it is not explicitly stated, and others note that they collect the data or even submit it even if such information is not requested for the current year.

Further, even if senior decision-makers have asked for general information, HELP staff may include financial measures because financial goals are often an implicit priority.

Documenting these measures requires more time or expertise than staff typically have, and although it can be part of HELP staff job descriptions, this is not uniform. Extra staff hours are pulled in through volunteers, students, interns, and some unpaid hours. Several sites have developed ongoing relationships with nearby universities in order to ensure a steadier supply of students and interns. Gathering data that is housed in other places, such as ‘length of stay’ or financial data, often requires assistance of other persons that may work in other departments, including quality management, information technology, or finance. Champions can be helpful in getting their involvement. Analysis of the data typically involves someone with more statistical or data management skills than staff may have, so staff may rely on persons in these other departments or they may turn to students or interns, or even some untraditional partnerships with volunteers who have these skills. Alternatively, if staff have the data skills themselves, they may pull in interns to take on other responsibilities while they focus on the data.

In addition to quantifiable data, HELP programs also collect anecdotal evidence of their success. Descriptions of the ways that staff or volunteers support patient care, or excerpts from patient or family letters of thanks help decision-makers understand the value of HELP in human terms. They put the quantifiable data in context that may better articulate how the HELP program supports the hospital or health system’s larger goals. Such information can also be important in making a stronger case to senior decision-makers, especially those with clinical backgrounds, because it can showcase the compassionate aspect of the program.

Finally, HELP staff also show that HELP supports other important hospital goals, including 1) sustaining the hospital or health system mission and 2) strategically positioning the hospital or health system in the competitive arena of other area providers. Situating HELP inside this package makes clear to decision-makers that the HELP program benefits the hospital or health system. For this reason, having a hospital that has a focus on geriatrics either as a mission or as a strategic positioning against competitors makes the job easier for HELP sites.

Garnering Support from Influential Hospital Staff

Successful HELP programs garner support from influential hospital staff aside from decision-makers in order to ensure that senior staff or clinicians know about the program and its positive impact, to preempt any unforeseen obstacles to long-term program survival, and to create a positive “feel” about the program that can reach decision-makers indirectly.

Reaching out to nurses is a priority for successful HELP sites. Strategies for doing so include not only having discussions with the head nurse for a department or relevant shift nurses, but also providing true services to the nursing team as a whole. This may include training sessions on geriatric care for new hires, for example. The frontline staff, who are often nurses themselves, use frequent one-on-one discussions to ensure that their services are seen as helping nurses rather than overriding them or adding to their workload.

In some cases, HELP programs have gone so far as to operate parallel programs that do not officially enroll HELP patients. In these cases, the program provides the “friendly visits” and other pieces of the HELP protocols that assist nurses with their workload and reassure them that their patients are receiving compassionate care, even when they are busy.

Reaching out to physicians is also important insofar as some of the physicians have a more direct connection with key decision-makers, and hospital decision-makers may be interested more generally in physician perceptions of hospital programs. HELP staff and supporters provide some formal services, including presentations at grand rounds and training sessions for medical students/trainees or for sitters/companions in HELP principles and geriatric care, but they also emphasize the importance of individualized interactions with doctors to ensure that the physicians do not feel the program is overstepping its bounds or being critical of existing care practices. The physician on the HELP staff has a particularly important role to play here.

HELP staff and supporters maintain positive relationships with ancillary staff to ensure effective operation of the program, but these relationships play a lesser role in connecting with key decision-makers at some institutions. Nonetheless, formal trainings as well as interdisciplinary meetings provide key opportunities to garner ancillary staff support and generate broader support for the program.

DISCUSSION

Staff and administrators at 19 successful HELP programs in the United States and Canada have identified three interrelated processes that they believe help them justify, and therefore sustain, the program to key decision-makers: 1) interact meaningfully with decision-makers both formally and informally; 2) document day-to-day, operational successes and estimate program impact in terms that resonate with decision-makers; and 3) garner support from hospital staff who are influential in administrative decision-making.

The processes outlined in this research are not easy to undertake, and they require investment of staff time and resources. For example, reaching out to supportive clinicians through training sessions, or running an informal program to address specific nursing needs, can require substantial staff time. Programs may need to anticipate ways to support staff who feel they are doing ‘extra’ work for such efforts. Data collection is also a time-consuming task, but perhaps more importantly, requires somewhat sophisticated analytic and computer skills. Staff who have such skills are an asset for programs; programs that do not have these resources in their own staff may need to look at creative partnerships, including relationships with other hospital departments or nearby universities, in order to build this capacity.

The processes outlined in this research also requirelong-term commitment and perseverance, given the nature of data collection and relationship development. For example, although setting up data collection may have to happen early in the process, small programs may need to collect data for several months or longer, in order to show impact. In addition, it may take many meetings before the new program regularly appears on the agenda, such as of departmental meetings. The processes identified here are consistent with the approaches successful programs may take during implementation, even if they require programs to take additional steps after that phase in order to cycle through the justification process. 4,5 Nonetheless, planning for later stage efforts even during the implementation phase may be wise. Thinking ahead in this way is consistent with theoretical work in the area of implementing clinical programs.26

A theme underlying the description of each of these steps is the idea that justifying the program to decision-makers may also take a shift in mindset – from daily operations to longer-term, strategic planning. Programs cannot simply collect data they believe is important, but must also try to anticipate the current and future needs of the hospital from the eyes of decision-makers. In a similar vein, they cannot provide only the services or care they believe are important, but instead must try to understand unmet clinical needs locally, and then make sure the program addresses them.

There are limitations to this study, given that it is based on an extended case study of a single hospital-based model of care. The findings may not be applicable to other healthcare settings, particularly those with very different decision-making structures and processes, such as outpatient or institutional care. Further, the study did not include decision-makers at all of the sites, so it laid emphasis on what the frontline staff and physicians believed was important. However, the perspectives of these front-line staff proved quite useful in contributing to practical recommendations for future sites. In addition, all of the sites had maintained funding for long enough to recruit patients (which can take several years), so their ideas had engendered some success. We did not see any substantial differences in approach between those programs that were newer and those more established.

Despite these limitations, the findings from this study may help similar, hospital-based programs be successful over time. Importantly, this study fills a key gap in the literature. To date, very little research has been done on sustaining programs in general, or in the current difficult economic times. Thus, this study provides vital and practical information to assist program developers and clinical innovators with strategies that have face validity and that will likely be generalizable across programs and settings. Future research may be beneficial to examine areas not addressed in this effort, including the experiences of sites that have closed. Such research may shed light on additional issues that influence site success, including funding source and amount as well as the broader hospital environment.

Table 4
Tasks That Successful Programs Undertake to Justify Operations to Key Decision-Makers

ACKNOWLEDGMENTS

Additional coauthors who are members of the HELP Dissemination sites are indicated below:

Abington Memorial Hospital (Abington, PA): Rita Leinheiser, MA

Crouse Hospital (Syracuse, NY): Sharon Martin, RN, BSN

Fletcher Allen Healthcare (Burlington, VT): Suzanne Goetschius, RN, CNS

Hamilton Health Sciences (Hamilton, Ontario): Anne Pizzacalla, RN, MHSc, ACNP

Hamilton Health Sciences (McMaster site, Hamilton, Ontario): Erin Stirling BA, BSW, MSW

Inova Fairfax Hospital (Falls Church, VA): Susan Heisey, MSW, LCSW

Joseph Brant Memorial Hospital (Burlington, Ontario): Trish Corbett RN, BN, MSN, GNC(c)

Kingston General Hospital (Kingston, Ontario): Jeanette Suurdt, BScN, MSc

Maine Medical Center (Portland, ME): Heidi R. Wierman, MD

MetroHealth Medical Center (Cleveland, OH): Cheryl Bradas RN, MSN, GCNS-BC

Moses Taylor Hospital (Scranton, PA): Sonia Sandhaus, NP

New York-Presbyterian/Weill Cornell Medical Center (New York, NY): Deborah Cooke, MS

Shore Memorial Hospital (Nassawadox, VA): Susan Scheuring, RN

University of Michigan Hospital (Ann Arbor, MI): Alene Blomquist, BA, MA, LCSW

University of Pittsburgh Medical Center Shadyside Hospital (Shadyside, PA): Fred Rubin, MD

Wheaton Franciscan-St. Joseph (Milwaukee, WI): Cathleen Hoffman, RN, BSN

Wheaton Franciscan Healthcare-Elmbrook (Brookfield, WI): Mary Beth Trentadue, RN, MS

Wheaton Franciscan Healthcare-St. Francis (Milwaukee, WI): Linda Fridlington, MSN, RN

York Central Hospital (Richmond Hill, Ontario): Angela Gulizia, RN, GNC(c)

The authors gratefully acknowledge the patients, families, and staff who participated in the programs and the many volunteers who devoted countless hours to serve HELP patients and improve hospital care for older persons. The authors acknowledge the following individuals by site: Grace Wert, MSN,RN, Sharonrose Wieckowski, MSN, RN, Sarah Maus (Abington Memorial Hospital), Patricia Calvert, MSN, RN (Caritas Norwood Hospital), Cynthia J. Nigolian, GCNS-BC, Christina Pavetto Bond, MS, FACHE (Crouse Hospital), Jeanne Hutchins, MA, Shelly Barton, RN, BSN (Fletcher Allen Healthcare), Angela John, BA, BSW, RSW, Tamara Babinaeu, RN, BScN, Cathy Reis, RN, BSN, MSc(T) (Hamilton Health Sciences), Mary Dixon, RN MSN NEA-BC, Deirdre M. Carolan Doerflinger, CGNP, CANP, PhD , Gwen Kinney, RN, MSN (Inova Fairfax Hospital), Cathy Morgan (Joseph Brant Memorial Hospital), Erin Meisner, BA, SSW, EPC (Kingston General Hospital), Stacey Farrington, MS, RN, Cara Chasse (Maine Medical Center), Coletta Hazel, RN, MSN, Donna Leech, RN, Diane Schuerger, RN (MetroHealth Medical Center), Donna Valenti, RNC, Marilee Manganiello, RN, MSN, Ulyana Arzamasova (Moses Taylor Hospital), Barry Gaillison, MSN, APRN, Eugenia Siegler, MD (New York-Presbytherian Hospital), Terris Kennedy, RN, PhD (Shore Memorial Hospital), Karen E. Hall, MD, PhD, Kimberly Hickey, MSN, APRN, BC (University of Michigan Hospital), Kelly Neal, MSN, CRNP, Eileen Mozolak, Jenna Williams (University of Pittsburgh Medical Center Shadyside Hospital), Debby Korpela, Ellen S. Danto-Nocton, MD (Wheaton Franciscan-St. Joseph), Richard London, MD, Diane Lozano (Wheaton Franciscan Healthcare-St. Francis), Lori Geary, BA, Tatiana Diamond, RN, BScN, GNC(c) (York Central Hospital).

Sponsor’s Role: The sponsor did not have any role in the design, methods, subject recruitment, data collections, analysis or preparation of paper.

Funding sources Supported in part by grants #2007-225 from the Retirement Research Foundation (SKI), #IIRG-08-88738 from the Alzheimer’s Association (SKI), #K24AG000949 (SKI) from the National Institute on Aging, and the HELP Dissemination Program, Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife. Dr. Inouye holds the Milton and Shirley F. Levy Family Chair.

Footnotes

Financial or Personal Disclosure: None – please see COI checklists

Conflict of Interest Disclosures:

Elements of
Financial/Personal
Conflicts
*Gillian K.
SteelFisher
Lauren A. MartinSarah L. DowalSharon K. Inouye
YesNoYesNoYesNoYesNo
Employment or AffiliationXXXX
Grants/FundsXXXX
HonorariaXXXX
Speaker ForumXXXX
ConsultantXXXX
StocksXXXX
RoyaltiesXXXX
Expert TestimonyXXXX
Board MemberXXXX
PatentsXXXX
Personal RelationshipXXXX

Author Contributions: Gillian K. SteelFisher - 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; ; and 3) final approval of the version to be published

Lauren A. Martin - 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content

Sarah L. Dowal - 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content

Sharon K. Inouye - 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; 3) final approval of the version to be published; 4) obtaining funding and administrative support.

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