Inpatient Geriatric Evaluation and Management Units (GEMs) in the Veterans Health System: Diamonds in the Rough?

Transcription

1 Journal ofgerontologv: MEDICAL SCIENCES 1994, Vol. 49, No. 5,'M195-M200 In the Public Domain Inpatient Geriatric Evaluation and Management Units (GEMs) in the Veterans Health System: Diamonds in the Rough? Darryl Wieland, 1 Laurence Z. Rubenstein, 1 Susan C. Hedrick, 2 David B. Reuben, 3 and David M. Buchner 2 'GRECC, Sepulveda, California, VA Medical Center, and Multicampus Program in Geriatric Medicine and Gerontology, University of California at Los Angeles. 2 Health Services Research and Development Field Program, Seattle VA Medical Center, and Department of Health Services, University of Washington. 3 UCLA Medical Center and Multicampus Program in Geriatric Medicine and Gerontology. Background. Research suggests that inpatient geriatric evaluation and management units (GEMs), which undertake interdisciplinary diagnosis to improve the health of frail elderly patients, are effective. The Department of Veterans Affairs (VA) helped pioneer U.S. GEMs and mandates that every facility shall have a GEM by We conducted a population survey of VA GEMs in 1991 to assess their dissemination. Methods. Various organizational and performance characteristics of GEMs were entered in a data base derived from a piloted questionnaire and administrative records. Basic criteria from consensus reports were used to classify and compare "standard" and "nonstandard" GEMs. The criteria covered performance of assessment, team structure, patient selection, GEM location, and treatment functions. We analyzed the effect of GEM type and other factors on length of stay and placement. Reasons for closure of GEMs inactive in 1991 were recovered, and GEMs active in 1991 but later closed are described. Results. As of 1991, 41 of 73 GEMs were classified as standard, and 32 nonstandard. Standard compared to nonstandard GEMs had shorter stays (25.4 vs 69.9 days; p <.001), higher home discharge rates (63.4% vs 40%; p <.001), and lower nursing home placement rates (19.1% vs40.3%;p <.001). Eleven hospitals had closed their programs by By 1993, 6 additional GEMs had closed; all were nonstandard in Conclusions. Most VA GEMs are organized according to basic consensus standards, and appear to be discharging most patients back to the community after reasonably short stays. However, various resource constraints are common, apparently reflected in nonstandard organization and GEM closure. Additional work is needed to monitor GEM proliferation, implementation, and performance in and out of the VA system. COMPREHENSIVE geriatric assessment is an interdisciplinary diagnostic process intended to determine a frail elderly person's medical, psychosocial, and functional capabilities and limitations in order to develop an overall plan for treatment and long-term follow-up (1-5). It has become a fundamental part of geriatric care and is regularly performed in settings as diverse as hospitals, offices, patient homes, and nursing homes. Hospital-based inpatient geriatric evaluation and management units (GEMs) are particularly concerned with selecting patients with benefit potential, improving patient function, successful home discharge, and the cost-effectiveness of health services over the longer term. The research record on the efficacy of inpatient GEM units in improving patient outcomes continues to expand and is generally positive (2,6-9). Studies have detected physical, cognitive, and emotional improvement (10-13), as well as increased diagnostic accuracy and reductions in medications, hospital readmissions and days, rates of discharge to nursing homes (NHs), and NH days (10-15). A recent metaanalysis of controlled trials determined that, compared to usual care at end of follow-up, inpatient GEMs lowered mortality risk by 25%, and increased the likelihood of living at home by 66% and of improving in physical and cognitive function by 72% and 100%, respectively (16). In view of the research, the Department of Veterans Affairs (VA) decided that each of its 171 facilities should have some type of geriatric assessment program by 1996 (17). To facilitate expansion and enhance existing programs, it began in 1985 to provide competitive supplemental funding to individual hospitals in support of GEM team positions. Of the various U.S. health-care sectors, the VA has the most widely disseminated network of GEMs, and accounts for a large proportion of all U.S. units (18,19). Despite the VA's commitment, little formal evaluation of its network of units has been undertaken. Several consensus conference proceedings, and the VA's own manual, outline basic standards for hospital inpatient units (1,4,5,20). The most general specify that inpatient GEMs should (a) perform comprehensive geriatric assessment; (b) have a specifically designated or core interdisciplinary team (minimally comprising a geriatrician, nurse, social worker) meeting weekly; (c) selectively admit patients M195

2 M196 WIELAND ET AL. with potential to benefit from GEM units in terms of health status or placement (i.e., "target" admissions); (d) be situated on hospital acute- or intermediate-care services; and (e) provide either inpatient treatment and rehabilitation or outpatient follow-up. In early 1991, we undertook a survey of VA hospitals in order to describe the implementation of inpatient GEMs in the system. We determined the conformity of GEMs to the five above-stated standards, and compiled information concerning host hospitals and other data on GEM structure, process, and outcomes. Our objectives here are to contrast "standard" with "nonstandard" GEMs in order to understand (a) how hospital, GEM organizational, and patient admission variables are associated with GEM type, and (b) how GEM type, together with other factors, is associated with length of stay, and placement at discharge (home vs nursing home). Further, using additional information on GEMs active in 1993, we describe closings of GEMs in the VA system. Table 1. Characteristics of Hospitals With GEMs, by GEM Type METHODS A questionnaire was piloted in 1990, and, in April 1991, mailed to inpatient GEM unit directors. We included questions on unit organization, types and time commitments of GEM personnel, length-of-stay and discharge locations. GEMs were identified on acute or intermediate medical wards, or both ("mixed" units), psychiatry services, or in NH beds. (Intermediate medicine in this system consists of subacute, step-down care, with 24-hour skilled nursing, and a 60-day stay limit.) Respondents reported annual rates of direct admission from outpatient clinic or home, transfer from acute-care wards, NHs, or other institutional-care settings, as well as readmission, admission of patients with moderate-to-severe dementia, and those having substantial functional dependency (i.e., more than three Katz ADL dependencies). We also obtained rates of discharge to home, board-and-care, NHs, acute-care wards, and unit mortality. For suspended units, and GEMs providing incomplete responses, supplemental information was collected by telephone in May and June All data were at the unit or hospital level. Central administrative records updated in early 1991 supplied confirmatory as well as additional data, including GEM start-up dates, inpatient-unit functions, targeting criteria for patient selection, and annual patient volume. The VA's Summary of Medical Programs (21) provided information on host hospitals, including total annual patient volume, and the proportion of hospital beds in psychiatry services. Central records from April 1993 were reviewed for GEMs opening and closing since the earlier survey date. Data from the survey questionnaire, central records, and telephone follow-up were primarily analyzed using descriptive statistics. Standard and nonstandard GEMs were contrasted using r-tests and ANOVAs for continuous data, and nonparametric statistics for categorical measures. To relate GEM type and other factors (e.g., GEM structural, patient admission, and hospital resource factors) to placement and length of stay, multiple linear regression was employed. Log transforms were used where necessary to meet normality assumptions of bi- and multivariate parametric tests. RESULTS Information on GEM hospitals, coexisting geriatrics programs, GEM bed service, size, and functions were available for all GEMs operating for at least one year (n = 73) in May 1991 (Table 1). Usable responses on unit performance (e.g., proportion of admissions by source, problems at admission) were obtained from 65 GEMs (89%). More nonstandard than standard GEMs did not provide complete performance information (8 vs 1). Compared to both standard GEMs and nonstandard responders, the nonstandard, nonresponding GEMs were significantly more likely to be in the southern and less likely to be in the northeastern regions. Further, they had significantly more beds (30.6 ±4.8) and longer mean stays (147.6 ± 34.4 days) than either standard or responding nonstandard GEMs (Table 2). No other differences were apparent. Of the 73 GEMS, most conformed to the identified stan- Standard GEMs (n = 41) Nonstandard GEMs (n = 32) Hospitals (FY 1990) with GEMs, Mean ± SD Total patient admissions Beds in psychiatric sections Region [Number (Percent of GEM Type)] Northeast Midwest South West Coexisting Geriatrics/Long-Term Care Programs Nursing home care units Hospital-based home care Respite care Adult day health care Geriatric Research, Education and Clinical Centers Interdisciplinary team training programs *p <.05 (chi-squared test). 4,161 ± ± 2.7% 13(32%) 11 (27%) 10(24%) 9 (22%) 37 (90%) 28 (68%) 29(71%) 16(39%) 8 (20%) 10(24%) 3,624 ± ± 3.0% 14(42%) 10(31%) 4(13%) 6(19%) 24 (75%) 18(56%) 14(44%)* 15(47%) 5(16%) 1 (3%)*

3 GEMS IN THE VA HEALTH SYSTEM M197 Table 2. GEM Characteristics, by Type GEM Size and Function (Mean ± SD) Bedst Admissions in prior yeart Length of stayt Patients screened per 1 admittedt Location: Intermediate medicine wards Acute medicine wards Both acute and intermediate-care NH/Psychiatry units! Consultation/Outreach Functions: Both inpatient consultation and outpatient assessment services Outpatient clinics only Inpatient consultation only Neither function Source of Admissions! Readmissions (as proportion of admissions) Transferred from acute care Direct from community Direct from nursing home Patient Problems at Admission Moderately/severely demented Dependent (> 3/6 Katz ADL dependencies) Placement at Discharge! Home Nursing home Board-and-Care/Domiciliary Hospital Died tstatistical comparison performed using log-transformed data. tnursing-home and psychiatry-based GEMs were by rule classified as "nonstandard. *p <.05; **p <.01; ***p <.001 by ANOVA or Fisher's Exact Tests. dard organizational features for these units: 93% (68) routinely performed comprehensive geriatric assessment; 75% (55) were staffed by a specifically assigned team of physician, nurse, and social worker; 82% (60) employed targeting criteria in admitting patients; 82% (60) were based on acute and/or intermediate medical wards; and 92% (67) provided active management in terms of inpatient restorative care or outpatient follow-up. In defining standard GEMs as those compliant with all the standards, 41 (56%) VA GEMs are so classified, leaving 32 (44%) nonstandard GEMs that fail to meet at least one standard. Compliance with these standards tended to be correlated. Tables 1 and 2 display associations between GEM type (i.e., standard and nonstandard) and hospital, GEM organizational and patient admission characteristics. Hospitals with standard GEMs were essentially similar to nonstandard GEM hospitals in total patient volume, psychiatric mix, and regional distribution. Compared to nonstandard GEMs, standard GEMs tended to operate alongside other specialized geriatric clinical or educational programs: the differences were significant with respect to coexistence of respite care (71% vs 44%) and team training programs (24% vs 3%). While standard and nonstandard GEMs were approximately the same size (12.7 vs 15.4 beds), standard GEMs admitted more than twice as many patients as nonstandard Standard GEMs (n = 41) 13.7 ± ± 25.4 ± 2.3 ± 17(41%) 13(32%) 11 (27%) Nonstandard GEMs (n = 32) 15.4 ± ± 13.4*** 69.9 ± 98.8*** 2.0 ± 1.1 [Number (Percent of GEM Type) ] 11 (34%) 5(16%) 3 (9%) 13(41%) 29(71%) 11 (34%)** 10(24%) 7 (22%) 0 6(19%)** 2 (5%) 8 (25%)* (Mean ± SD of Percent of Total Admissions) 13.5 ± 2.5% 11.0 ±3.2% 46.0 ± 4.9% 30.8 ± 6.4% 34.8 ± 4.7% 42.4 ± 6.1% 11.8 ±2.9% 22.2 ± 3.8%* 36.7 ± 3.8% 52.5 ± 4.9%* 54.4 ± 3.7% 61.8 ±5.0% (Mean ± SD of Percent of Total Discharges) 63.4 ± 15.0% 40.0 ± 24.5%*** 19.1 ± 11.0% 40.3 ± 22.2%*** 8.6 ± 7.3% 11.2 ± 14.0% 4.8 ± 4.1% 5.8 ± 11.4% 3.8 ± 3.9% 3.0 ± 3.5% units. Thus, mean length of stay (LOS) on standard units was significantly shorter, at just over 3 weeks compared to well over 2 months. Standard GEMs did not screen significantly more patients per admission. Standard GEMs by definition were those on acute and/or intermediate care; among nonstandard units, only 59% were on these bed sections. Excluding 13 nonstandard GEMs in psychiatry or NH wards, there is no significant difference between GEM types in allocation to acute, intermediate, or mixed locations. Standard GEMs were significantly more likely to support inpatient consultation and outpatient assessment and follow-up programs. While standard GEMs tended to admit more of their patients stepping down from acute care, this difference was not significant. However, compared to standard GEM admissions, significantly more of nonstandard GEMs' patients were admitted from nursing homes. Over half of the patients admitted to both GEM types were substantially dependent in basic ADLs, and significantly more admissions to nonstandard GEMs were moderately-to-severely demented (53% vs 37%). Standard units discharged more of their patients home (63% vs 40%) and fewer to NHs (19% vs 40%) than nonstandard unit; other dispositions (to board-and-care, hospital, and units mortality) totalled 17% and 20% of discharges for standard and nonstandard units (Table 2).

4 M198 WIELAND ET AL. Table 3 displays the effects of standard GEM type in multiple linear regression models for home and NH discharge rates treated as separate outcome (dependent) variables. Standard GEM organization was strongly associated with higher home and lower NH placement rates, explaining 14% and 32% of the rate variances. Home discharge from GEMs was also positively associated with higher volume hospitals, and negatively associated with high psychiatric mix facilities. Overall, GEMs readmitting larger proportions of patients tended to place fewer patients home at discharge. NH placement, strongly associated with nonstandard GEM type, was predicted by only one other factor availability of NHs on site. Finally, nonstandard GEMs had significantly longer average LOS (nearly 70 vs 24.5 days, p <.001). GEM type remained an important predictor of LOS in multiple regression analysis (Table 3). LOS was also negatively associated with hospital patient volume, and positively associated with hospitals having NHs, intermediate-care GEMs, number of GEM beds, and GEM readmissions. Rates of patient problems at admission (e.g., percent functionally dependent or demented) were not predictive of any outcome. In May 1991, we identified 11 hospitals in which GEMs had been suspended or closed, in addition to the 73 open units. Several reasons were given for unit closure. In four cases, GEM beds had over time become occupied with longstay patients lacking community or other institutional placement alternatives, and these units were officially converted to long-term care wards. For the remainder, unavailability of key personnel was reported as the deciding factor: in three instances, the geriatricians running the units retired without replacement; in three other cases, competing demands of other geriatrics/long-term care programs on physician time were cited; in two cases, GEMs were closed due to a lack of Independent Variable GEM type (Standard vs Nonstandard) GEM on intermediate care ward Number of GEM beds Hospital has NH care unit Percent of hospital beds in psychiatric sections Total hospital patients (FY90) other critical team personnel; and one facility cited both competing demands on the geriatrician and lack of other personnel. In April 1993, the number of active VA GEMs grew from 73 to 105. These comprised 67 existing GEMs, 35 new units, and 3 programs that had been closed during the 1991 survey but since reactivated. The number of inactive or closed units rose from 11 in 1991 to 14. These included 8 that were closed in 1991 and 6 that subsequently became inactive. All 6 closures occurred in GEMs classified in 1991 as nonstandard, and 4 were units not providing 1991 performance information. The 1991 LOS of these closed units averaged over 150 days. DISCUSSION The VA appears to be progressing toward its goal of having GEMs in all facilities by However, program variability and closure have emerged as problems. We classified 32 of 73 nominal units active in 1991 (44%) as nonstandard with reference to basic consensus criteria. The criteria were (a) performance of comprehensive geriatric assessment, (b) by an interdisciplinary team, (c) which selectively admitted patients to the unit, (d) based in a hospital acute and/or intermediate service, and (e) providing, minimally, inpatient rehabilitation or outpatient followup services (1,4,5,20). This classification appears to have validity: standard and nonstandard units were found to differ significantly in organization and performance, with standard GEMs placing significantly more patients home (and fewer to NHs), after significantly shorter stays. Thus, these units would appear more oriented to the recognized goal of GEM programs to obviate Table 3. GEM Type and Other Factors Associated With Patient Placement and Length-of-Stay Readmissions (proportion of former patients among admissions) Regression model: Model F r 1 (adjusted r 2 ) Length of Stay (days) (n = 72) _ 41** (.15) +.33** (.03) +.33** (.17) +.28* ( 10) -.29* (.07) +.36** (.06) 8.6**.58 (.52) Dependent Variablest Proportion of Patients Discharged Home («= 65) +.39** (.14) -.33* (.10) +.30* (.24) -.26* (.04) 9.6**.52 (.46) Proportion Placed in NHs {n = 65) -.60** (.32) +.45** (.06) 9.8**.38 (.34) tstandardized (3 coefficient with significance level, (r 2 change). Positive (negative) sign for (3 coefficient indicates an increase (decrease) in the value of the dependent variable. Adjusted r 2 for regression model attempts to remove effect of small sample sizes in estimate of overall model value. *p<.05;**p<.01.

5 GEMS IN THE VA HEALTH SYSTEM M199 patients' need for NH placement after relatively short stays for assessment, treatment, and rehabilitation. Aside from several units providing short-term acute care to elderly patients, nonstandard GEMs appeared to consist chiefly of low turnover, long-stay wards with low home and high NH placement rates. Closure or redesignation as extended-care programs occurred in some GEMs with nonstandard organization. On telephone follow-up, the 11 closures in 1991 were related to personnel resources insufficient to maintain GEM staffing and lack of institutional placement alternatives. Similarly, new 1993 closures occurred only in nonstandard GEMs having long stays in Several limitations of this study must be considered. First, data pertaining to GEMs, both from the questionnaire and central records, were self-reported, raising reliability and validity concerns. The questionnaire was piloted, and completed by knowledgeable respondents (GEM directors) who were consistent in their answers on telephone follow-up. Further, the questionnaire contained items (e.g., GEM beds, functions, staffing, LOS) also included in the contemporaneous administrative survey, with which there was close agreement in paired responses. Second, while almost complete response was obtained from active standard GEMs, onequarter of active nonstandard units provided no information on admission source and mix, and placement rates. Skewed nonresponse may affect the results of GEM-type comparisons for these variables and analysis of GEM-type and cofactor relationships to placement. However, it seems implausible that information on these rates for the 8 nonstandard, nonrespondent GEMs would have decreased the observed differences in placement between GEM types: the nonstandard, nonrespondents were larger, low turnover units with longer stays than either standard or nonstandard respondents. Patient-level data were unavailable, which prevented exploration of the (probably substantial) impact of problem mix, and mix of patient-specific treatment goals, on LOS, placement, and closure. In addition, the study was not specifically designed to determine reasons for GEM closures. However, exploration of 1991 and 1993 closings suggests that deactivated units went through a period of nonstandard organization prior to closing. Finally, our population survey was exclusively of VA units. It may be argued that the VA system is relatively closed and our findings concerning the proliferation of GEMs and relationships between unit organization and performance may not apply outside. However, in a health sector regarded as especially conducive to GEM development and support (18,22), the findings suggest dissemination problems for VA GEMs similar to those recently observed elsewhere: in fact, a sample survey of all U.S. GEMs by Lavizzo-Mourey et al. found that VA units had a higher closure rate than others (19). Further, she observed that physician staffing was a particularly important problem for the maintenance of VA GEMs. In support, we found that physician retirement or reassignment was cited as the reason for over half of closures of VA GEMs detected in The high organizational variability we found among VA units is also characteristic of non-va GEMs in Lavizzo- Mourey 's report, which had a mean of 38.0 ± 66.4 beds, and average LOS of ± days. This variability led these authors to observe that... GEMs have not been standardized in terms of staffing ratios, mandatory services or required assessments.... The marked variation in LOS and bed size... suggests that some units being called 'GEMs' may actually be NHs or hospital-based NH units (19). Our study, which provided a standardization using basic organizational criteria, largely supports this conclusion for VA units. Our five criteria for standard GEM organization were straightforwardly drawn from published consensus reports on comprehensive geriatric assessment and the VA's GEM manual. Still, it may be objected that both the high rate of nonstandard units and the associations between GEM type and performance result from a too restrictive organizational standard. To address this, we performed sensitivity analyses of the relationship of GEM type to performance. Standard and nonstandard GEMs were defined after successively subtracting the least met criterion, until only two criteria remained (and the smallest testable nonstandard group). While successively less restrictive definitions raised the number and proportion of standard GEMs (to 57 GEMs [78%] classified as meeting standards), our findings were unaltered. In conclusion, despite evidence that GEM programs are beneficial in the health care of frail elderly inpatients, dissemination of effective GEM models has been shown to present substantial challenges even within a health-care environment committed to their support and development. The VA differs from the predominant fee-for-service sector in functioning as a prepaid, comprehensive care provider to the veteran population. Thus, the financing and reimbursement barriers are not as directly at issue in GEM development as in the private sector (22). Still, like other units, VA GEMs are affected by the geriatrics workforce crisis and the increasingly constricted availability of long-term institutional care resources. While hospitals interested in opening and maintaining GEMs should be encouraged to take guidance from consensus standards for their organization, considerable room remains for adaptation and innovation. Of particular interest for health-care research is the optimal structure and role of hospital-based geriatric assessment programs as care continues to shift to the ambulatory arena, and hospital-based geriatrics defines its position among evolving long-term services. ACKNOWLEDGMENTS This research was supported in part by the Health Services Research and Development Service and Cooperative Studies in Health Services Programs of the Department of Veterans Affairs. Address correspondence to Dr. Darryl Wieland, GRECC (HE), Sepulveda VA Medical Center, Plummer Street, Sepulveda, CA REFERENCES 1. Consensus Development Panel. National Institutes of Health Consensus Conference Statement: Geriatric assessment methods for clinical decision-making. J AmGeriatrSoc 1988;36: Rubenstein LZ, Campbell LJ, Kane RL, eds. Geriatric assessment. ClinGeriatrMedl987;3(l).

6 M200 WIELAND ET AL. 3. Rubenstein LZ, Rubenstein LV. Multidimensional assessment of the elderly. Adv Intern Med 1991 ;36: Brocklehurst JC, Williams TF. Multidisciplinary health assessment of the elderly a summary. In: Brocklehurst JC, Williams TF, eds., Multidisciplinary health assessment of the elderly: proceedings of an international conference. Dan Med Bull Special Gerontology Supplement no. 7, 1989: Deyo R, Applegate WB, Kramer A, et al., eds. The future of geriatric assessment: research recommendations. Special issue of J Am Geriatr Soc 1991;39, Part Kane RA, Kane RL, Rubenstein LZ. Comprehensive assessment of the elderly patient. In: Peterson MD, White DL, eds. Health care of the elderly. Newbury Park, CA: Sage Publications, Wieland D. Geriatric assessment: a guide and review of the literature. Dan Med Bull Special Gerontology Supplement no. 7, 1989:7. 8. Rubenstein LZ, Wieland D. Comprehensive geriatric assessment. Ann Rev Gerontol Geriatr 1989,9: Rubenstein LZ, Stuck AE, Siu AL, et al. Impacts of geriatric assessment programs on defined outcomes: overview of the evidence. J Am Geriatr Soc 1991; 39(9) Part 2: Rubenstein LZ, Josephson KR, Wieland D, et al. Effectiveness of a geriatric evaluation unit: a randomized clinical trial. N Engl J Med 1984;311: Lefton E, Bonstelle S, Frengley JD. Success with an inpatient geriatric unit: a controlled study. J Am Geriatr Soc 1983;31: Collard AF, Bachman SS, Beatrice DF. Acute care delivery for the geriatric patient: an innovative approach. QRB 1985;(June): Applegate WB, Miller ST,Graney MJ,etal. A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital. N Engl J Med 199O;322: Popplewell RY, Henscke PJ. What is the value of a geriatric assessment unit in a teaching hospital? A comparative study. Aust Health Rev l983;6: Gilchrist WJ, Newman RJ, Hamblen DL, et al. Prospective randomized study of an orthopaedic geriatric inpatient service. Br Med J 1988;297: Stuck AE, Siu AL, Wieland D, et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1990;342: Department of Veterans Affairs. Policy Memorandum Circular to VA Medical Centers/Outpatient Clinics, 1985, rev Epstein AM, Hall JA, Besdine R, et al. The emergence of geriatric assessment units: the "new technology of geriatrics." Ann Intern Med 1987:106: Lavizzo-Mourey RJ, Hillman AL, Diserens D, et al. Hospitals' motivations in establishing or closing geriatric evaluation and management units: diffusion of a new patient-care technology in a changing health care environment. J Gerontol Med Sci 1993;48:M78-M Department of Veterans Affairs. Geriatric evaluation and management program: guidelines for development and operation. Washington, DC: Veterans Health Services and Research Administration, 1991 (revision). 21. Department of Veterans Affairs. Summary of medical programs, September Washington, DC: Assistant Secretary for Information and Analysis, Office of Information and Analysis Rubenstein LZ, Wieland D. Geriatric assessment and prospective payment systems. In Romeis JC, Coe RM, eds., Quality and cost containment in care of the elderly. New York: Springer, 1991: Received February 24, 1993 Accepted September 17, 1993 Internist/Gerontologist University of Maryland and Baltimore VA Medical Center GRECC The VA Medical Center is seeking a physician with training in gerontology for a tenure track faculty position in the Division of Gerontology at the University of Maryland at Baltimore. The successful candidate should have clinical and research training in endocrinology-metabolism, nutrition, and exercise physiology research in aging. There are opportunities for research related to epidemiology, preventive medicine, health services research, and musculoskeletal epidemiology. The position provides an opportunity to collaborate with a productive group of gerontological researcners within the Division of Gerontology in the Departments of Medicine, Epidemiology, and Preventive Medicine at the School of Medicine. Clinical activities include geriatric assessment, rehabilitation medicine, primary care, and consultative services in gerontology. Rank and salary commensurate with experience. The VA Medical Center and the University of Maryland at Baltimore are AA/EEO/ADA Employers. Submit statement of career goals, curriculum vitae and names of three academic references to Andrew P. Goldberg, MD, Geriatrics Service GRECC (18), Baltimore VA Medical Center, 10 North Greene St., Baltimore, MD