D. Clay Ackerly, MD, MSc

Project: "Skilled Nursing Facility Network Development for High-Risk Patients"
Massachusetts General Hospital
Massachusetts

Randi Berkowitz, MD

Project: "Skilled Nursing Facility Network Increase Days at Home (SNIDH Intervention)"
Commonwealth Care Alliance
Massachusetts

Stephanie R. Bruce, MD

Project: "Total Elder Care"
Medstar Washington Hospital Center
Washington DC

Jennifer DeCubellis, LPC

Project: "Hennepin Health"
Hennepin County
Minnesota

Christian Davis Furman, MD, MSPH

Project: "Advance Care Planning: Ensuring Patients’ Wishes are Honored"
University of Louisville School of Medicine
Kentucky

Corita Grudzen, MD, MSHS

Project: "Triggered Palliative Care Consultation for Older Adults Transferred to the ED from Long-Term Care"
Mount Sinai Medical Center
New York

Suzanne E. Landis, MD, MPH

Project: "Enhanced Primary Care in a Retirement Community"
Mountain Area Health Education Center, Inc.
North Carolina

Stephen K. Liu, M.D., MPH

Project: "Re-engineering the Geriatric Inpatient Stay and Transition Home (REGISTRY)"
Trustees of Dartmouth College
New Hampshire

Margaret Namie, RN, BSN, MPH, CPHQ

Project: "Care Transitions from Hospital to Home"
Mercy Health
Ohio

Nancy Roberts, RN, MSN

Project: "A Transitional Care Model (from hospital to home to the community) for Patients with Heart Failure"
Kent County Visiting Nurse Association d/b/a VNA of Care New England
Rhode Island