Randi Berkowitz, MD;    Hebrew Senior Life;   "A Rehospitalization Reduction Program on a Geriatric Skilled Nursing Unit" (project description)
Alice Bonner, PhD, RN;    Massachusetts Senior Care Foundation;   "A Statewide Program to Improve Care Transitions and Reduce Avoidable Rehospitalizations from Skilled Nursing Facilities" (project description)
Audrey Chun, MD;    Mount Sinai School of Medicine;   "Geriatrics Patient Centered Medical Home" (project description)
Sandee Ferguson, RN, BBA, MS;    Area Agency on Aging, 10B Inc.;   "Community-based Long Term Care High Risk Care Management" (project description)
Sharon Foerster, LCSW;    Elder Independence of Maine/SeniorsPlus;   "Enhancing Care Management Practice for HCBS Consumers: A Proactive Approach to Identifying Risk Factors and Connecting to the Physician" (project description)
Eileen M. Koons, MSW, ACSW;    Huntington Hospital;   "Diabetes Care Program for Older Adults" (project description)
Janis McGillick, MA(SW), LNHA;    Alzheimer's Association, St. Louis Chapter;   "Dementia Friendly Hospital Initiative" (project description)
Kate T. Queen, MD;    Haywood Regional Medical Center;   "Beyond Bone Mass Measurements: Integrating Fall and Fracture Prevention in Osteoporosis Management" (project description)
Caroline Ryan, MA(SW);    Aging Care Connections;   "Safe Discharge Home: A Community Response to Rapid Re-integration of Observation Patients" (project description)
Gail Silver, RN, NP;    Visiting Nurse Service of New York;   "Develop a Patient Centric Geriatric Home Care Management Model" (project description)

Randi Berkowitz, MD
"A Rehospitalization Reduction Program on a Geriatric Skilled Nursing Unit"
Hebrew Senior Life
Boston, MA

Dr. Randi Berkowitz is a geriatrician in Boston and medical director of the subacute units at the Hebrew Rehabilitation Center and Orchard Cove Continuing Retirement Care Community at Hebrew Senior Life. She graduated from Barnard College and University of Chicago Pritzker School of Medicine. She received her training in internal medicine at Beth Israel Hospital in Boston, and her training in geriatrics at the Harvard Medical School Geriatrics Fellowship program. She has worked in a PACE program, home visit practice, and in the hospital and subacute settings. She is a certified medical director and a member of the American Medical Directors Association. Dr. Berkowitz serves on the medical advisory board for the Massachusetts Department of Motor Vehicles.
Dr. Berkowitz has developed programs to help the multidisciplinary team work more cohesively to increase patient safety and provide more patient centered care. The goal of her fellowship project is to decrease unplanned discharges from the subacute unit back to the hospital. Dr. Berkowitz will study why patients are readmitted to the hospital, and will develop a continuous improvement plan to decrease these readmissions. She will also work with the Institute for Healthcare Improvement to improve communication from the hospital to the rehabilitation center.
Alice Bonner, PhD, RN
"A Statewide Program to Improve Care Transitions and Reduce Avoidable Rehospitalizations from Skilled Nursing Facilities"
Massachusetts Senior Care Foundation
Westborough, MA
Alice Bonner has been a gerontological nurse practitioner for the past 20 years. From 1997-2005 she was the Clinical Director of Long Term Care and Geriatrics at the Fallon Clinic in Worcester, Massachusetts. Currently, Dr. Bonner is Executive Director at the Massachusetts Senior Care Foundation, an organization that works to improve the lives of older adults and persons with disabilities through research, education and quality improvement programs across all settings. She is also an Assistant Professor at the Graduate School of Nursing, University of Massachusetts in Worcester, MA. Dr. Bonner maintains a geriatric practice in a long term care facility in Worcester, MA. Her research interests include falls prevention, medication safety and care transitions.
Audrey Chun, MD
"Geriatrics Patient Centered Medical Home"
Mount Sinai School of Medicine
New York, NY

Dr. Audrey Chun completed her residency in Internal Medicine at Baylor College of Medicine in Houston, Texas. She then finished her fellowship in geriatrics at the Mount Sinai School of Medicine where she also served as Chief Fellow. As a recipient of a Health Professions Health Resources and Services Administration (HRSA) funded Geriatric Academic Career Award (GACA), she is able to pursue her clinical interests that include geriatric assessment, medical education, and delivery of care models in the outpatient setting. She is active in the educational programs of Geriatrics and Palliative Care and regularly participates in the education of medical students, residents, geriatrics fellows and colleagues at her home institution and nationally. She has been featured in the Frontline documentary "Living Old" and has participated in numerous panel discussions on aging in America and its implications. Currently, she is the Director of the Martha Stewart Center for Living at the Mount Sinai Medical Center.
Sandee Ferguson, RN, BBA, MS
"Community-based Long Term Care High Risk Care Management"
Area Agency on Aging, 10B Inc.
Akron, OH

Sandee Ferguson is the Senior Vice President of Area Agency on Aging 10B, Inc. in Akron, Ohio. She is a licensed Registered Nurse and holds a Masters Degree in Science (Human Resource Leadership and Management) and a Bachelors Degree in Business Management from Mount Vernon University, Ohio. Sandee has spent over 20 years in the community long term care service with the elderly population. At her present position with the Area Agency on Aging, she is responsible for the overall operation of the Managed Long Term Care Division that employs 105 professional staff.
Sandee spent 10 years as an Administrator with the Ohio Department of Aging and three years as a Section Chief with the Ohio Department of Job and Family Services. She was responsible for the development of clinical practice and provider administrative code rules and standards for Ohio's elderly waiver, PASSPORT. Sandee's previous professional experience includes three years as a Director of Hospice, 8 years as a supervisor at an Ohio County General Health District and 11 years of acute and emergency hospital care. Sandee has given numerous national and regional presentations.
Sharon Foerster, LCSW
"Enhancing Care Management Practice for HCBS Consumers: A Proactive Approach to Identifying Risk Factors and Connecting to the Physician"
Elder Independence of Maine/SeniorsPlus
Lewiston, ME

Sharon currently serves as Director of Elder Independence of Maine (EIM), a home care coordinating agency, contracted with Maine's Office of Elder Services and a division of SeniorsPlus, Area Agency on Aging. She received her masters in clinical social work from the Boston University School of Social Work where she was first introduced to home medical training. Her interest in gerontology began as an undergraduate at the College of the Holy Cross. Early in her career, she focused on mental health clinical assessment and treatment of older people in the community. She has since applied her formal clinical training and lessons learned from clients, clients' family members and colleagues to inform administrative and policy work in order to keep the client at the center of the work. In her current role, she has had the opportunity to lead the EIM social worker and nurse care managers who met the challenge to change practice and successfully carry out the evidence-based Healthy IDEAS program. With the incredible opportunity of the PCF grant, she hopes to build upon such practice change success and apply it to community-based consumers in order to add value, and ultimately quality of life, to the services the clients currently receive. Sharon is a member of the National Association of Social Workers, the National Institute of Community-based Long Term Care (through NCOA) and the Society for Social Work Leadership in Health Care, Maine.
Eileen M. Koons, MSW, ACSW
"Diabetes Care Program for Older Adults"
Huntington Hospital
Pasadena, CA

Eileen Koons has dedicated her 20 year career to providing, developing and overseeing high quality health and social services for older adults. Currently she manages Huntington Senior Care Network and directs its government programs. Senior Care Network is an arm of Huntington Hospital, created in 1984 and which has received national and statewide recognition in fulfilling its mission to maximize the wellness and independence of adults in the community. The department provides case management, community outreach, education and information to community-dwelling frail and functionally-impaired individuals and family caregivers, funded with Medicaid home and community based service (HCBS) waiver funds, along with other federal, state, and local sources.
Ms. Koons serves in leadership and advocacy roles statewide and locally, and in 2008 was appointed to the advisory committee of California Community Choices, the state's federal Real Choice Systems Change grant to increase access to HCBS services and decrease unnecessary nursing home placement. She previously oversaw program planning and development for the Los Angeles County Area Agency on Aging, and began her career as a medical social worker. In 1995 she graduated from the California State University, Long Beach Master of Social Work program's older adults and families concentration.
Janis McGillick, MA(SW), LNHA
"Dementia Friendly Hospital Initiative"
Alzheimer's Association, St. Louis Chapter
St. Louis, MO

Jan is Education Director/Director of the Alzheimer's Association Education Institute at the St. Louis Alzheimer's Association, serving a 38-county, bi-state region. She received her Social Work degree from the University of Missouri and MA (SW) from University of Chicago. Jan is also a licensed nursing home administrator. As her career reflects, Jan's lifelong passion is to advocate with and for older adults. During her 18 years with the Association, she's developed numerous award-winning programs addressing all stages of Alzheimer's disease, for caregivers and professionals. She educates hundreds of health care professionals annually, and is active in culture change movements in Illinois and Missouri. The Older Women's League (OWL) St. Louis honored Jan with a Woman of Worth award. In conjunction with many committed professionals, Jan has most recently developed and delivered a curriculum for hospital staff aimed at systems and practice changes that result in "dementia friendly care" in hospitals. She is an active field instructor for social work interns, university instructor in long- term care management, lecturer and collaborator with academic institutions, community based organizations and other Alzheimer's Association Chapters. Jan is particularly grateful for the opportunity to interact and learn from her Practice Change Fellow peers.
Kate T. Queen, MD
"Beyond Bone Mass Measurements: Integrating Fall and Fracture Prevention in Osteoporosis Management"
Haywood Regional Medical Center
Clyde, NC

Dr. Queen is the director of a regional Osteoporosis Center at Haywood Regional Medical Center, a program she developed 17 years ago with grant support. This center provides bone density testing and serves as a regional resource for continuing medical education and community education/awareness. From its inception, the center has been committed to providing a spectrum of rehabilitation services focused on fall and fracture prevention. Dr. Queen also developed an Osteoporosis Outreach Program with private foundation support 13 years ago, which continues to provide mobile bone density testing to rural clinics and hospitals in the mountains of western NC. Dr. Queen serves as a board member for the NC Osteoporosis Foundation, and is on the Public Policy Committee of the International Society for Clinical Densitometry and the NC Falls Coalition. She is a Fellow of the American College of Rheumatology and a member of the N.C Rheumatology Association. Dr. Queen obtained a BS in nursing from University of Michigan, worked as a public health nurse and then attended medical school at UNC - Chapel Hill where she obtained her MD degree and her training in Internal Medicine. Following her fellowship in Rheumatology at Duke, she returned to western NC where she continues to practice as a rheumatologist in a multispecialty internal medicine group.
Caroline Ryan, MA(SW)
"Safe Discharge Home: A Community Response to Rapid Re-integration of Observation Patients"
Aging Care Connections
La Grange, IL

Caroline is the Program Manager of the Aging Resource Center program at Aging Care Connections in La Grange, Illinois. Aging Care Connections is a not-for-profit, community-based service provider which serves as the point of entry for aging services for 22 communities. Caroline is currently implementing and evaluating a community-based service model that supports older adults and their families as they transition home from Adventist La Grange Memorial Hospital and three local skilled nursing facilities. Caroline was previously employed by the Department of Psychiatry at Washington University in St. Louis, and has more than eight years of research experience. Caroline also has previous program development and direct practice experience from Older Adult Programs at RUSH University Medical Center and PLOWS Council on Aging, a community-based service provider. She received her undergraduate degree from Washington University in St. Louis and her Master's degree and Certificate in Health Administration and Policy from The University of Chicago School of Social Service Administration where she was selected as a Hartford Geriatric Leadership Fellow and awarded the Sonia G. Berz Award for outstanding work and promise in the field of aging.

Gail Silver, RN, NP
"Develop a Patient Centric Geriatric Home Care Management Model"
Visiting Nurse Service of New York
New York, NY

Gail Silver joined Visiting Nurse Service of New York (VNSNY) in March 2008 as the Administrator of the Long Term Home Healthcare Program (LTHHCP) and Visiting MD Program. Ms. Silver is a board certified Nurse Practitioner in Gerontology. She received her BS/RN and MS/NP degrees from the University of New York at Stony Brook. With over 30 years as a healthcare professional she has broad based experience as a Senior Executive and Nurse Practitioner. Ms. Silver successfully implemented health services and provider network start-up programs in the managed care arena. In her previous role, Ms. Silver directed the Evercare NP model in New York and New Jersey.
Her current responsibilities include overall operations, planning, implementing and managing multidisciplinary staff, including the oversight of the HIV-AIDS LTHHCP and Visiting MD acute care programs. Under Ms. Silver's direction, VNSNY's LTHHCP has achieved 15% total growth in patient census. In collaboration with senior management, her role has focused around strategic development to support and grow the organizational business plan to serve the long-term care patients of the future.