This initiative creates a paradigm shift from the traditional perception of primary care as a visit to a doctor to one in which primary care is woven throughout a continuum of locations that extends into the community where care plans can be enhanced to attain better health outcomes through non-traditional interventions.

Dr. Tara A. Cortes
Dr. Tara A. Cortes, PhD , RN, FAAN

Services Will be Provided at Montefiore Health System and Regional Aid for Interim Needs (R.A.I.N.) in the Bronx

New York University College of Nursing’s Tara Cortes, PhD, RN, FAAN, professor of geriatric nursing and executive director of the Hartford Institute for Geriatric Nursing, has been awarded a 3-year $2.55 million Health Resources and Services Administration (HRSA) grant through the Geriatrics Workforce Enhancement Program (GWEP), entitled, “Community/Clinical Primary Care of Older Adults Program (CC-PCOA).”  GWEP supports the development of a health care workforce that improves health outcomes for older adults by integrating geriatrics with primary care and community resources to maximize patient and family engagement better manage chronic disease and promote optimum function in older adults.

“This initiative creates a paradigm shift from the traditional perception of primary care as a visit to a doctor to one in which primary care is woven throughout a continuum of locations that extends into the community where care plans can be enhanced to attain better health outcomes through non-traditional interventions,” said Dr. Cortes.

Dr. Cortes and her team at the Hartford Institute for Geriatric Nursing will be partnering with Montefiore Health System and Regional Aid for Interim Needs, Inc. (R.A.I.N.), a community organization in the Bronx, to implement an interprofessional, multi-modal educational intervention aimed at creating a culture that values the health of our aging population.

Montefiore was chosen as a partner because of its advanced research and specialized services for patients with Alzheimer’s disease and other dementia-related conditions, and because of its extensive primary care network serving many older, frail and vulnerable patients and large medical resident training program. Montefiore also stands out for its leadership in the Pioneer Accountable Care Organization program for Medicare fee-for-service beneficiaries.

R.A.I.N., the community based partner in the grant, is a large not-for profit, multi-service organization that operates multiple senior centers and provides a menu of senior support services in the Bronx and upper Manhattan. R.A.I.N. will provide its expertise through programs that promote overall wellness and provide nutritional, transportation, and care management services to seniors.  R.A.I.N. employees and a corps of volunteer community health workers will be trained in geriatric care so that patients and their caregivers can be better supported in the community.  This will include a program on caring for patients with dementia targeted at home health aides.

The CC-PCOA will build the capacity of the primary care workforce in clinical and community settings to address health care gaps for older adults and maximize patient and family engagement. The program is designed to meet the National Prevention Strategy’s goal of increasing the number of Americans who are healthy at every stage of life through a multidisciplinary educational intervention.

The specific objectives are to:

  • Provide educational resources to increase age-sensitive knowledge and skills of primary care professionals and promote team-based patient- and family-centered, evidence-based care that is responsive to the needs of older adults;
  • Educate primary care clinical providers and community based networks to be coordinating partners focused on promoting health and self-management of disease at the individual, community and population levels;
  • Utilize community resources to educate and support older adults, families and caregivers, to promote healthy aging and manage chronic diseases; and
  • Provide a comprehensive Alzheimer’s Disease and Related Dementias (ADRD) program to address the needs of providers, patients, families and caregivers through community support networks and educational materials and resources.

“The education will focus on interprofessional geriatric-specific care, care coordination and the promotion of wellness through the Medicare Annual Wellness Visit and managing chronic disease – specifically heart failure and diabetes,” said Dr. Cortes. “Community resources will support wellness behavior and chronic disease management.”

The project will be implemented in five (5) of Montefiore Medical Group’s Patient Centered Medical Homes, the Montefiore Einstein Center for the Aging Brain, and numerous community sites in R.A.I.N.’s network throughout the Bronx, NY.

“Being able to collaborate with primary care physicians, subspecialists and caregivers allows us to create comprehensive care plans and resources for geriatric patients and their families,” said Joe Verghese, M.B.B.S., director, Montefiore Einstein Center for the Aging Brain, chief, Integrated Divisions of Cognitive & Motor Aging (Neurology) and Geriatrics (Medicine) at Montefiore and Einstein and professor in the Saul R. Korey Department of Neurology and of Medicine at Einstein. “We are pleased to participate in this important project which will draw upon the expertise of clinicians in the fields of geriatrics, neurology, rehabilitative medicine and psychiatry to inform unmet needs and enable us to strengthen care services for many of our most vulnerable patients.”

“R.A.I.N. is elated to be a partner in this important collaboration.  With the increased life expectancy of New York City’s population and the coming of age of the “baby boom” population, the goals of this initiative are paramount.  R.A.I.N. is pleased to bring its extensive integrated community-based geriatric experience and expertise to facilitate enhanced health outcomes and expand primary care among the aging population,” said Dr. Torres, CEO of R.A.I.N.

The project’s interprofessional advisory team and core leadership will oversee the review of all educational resources already available through the partners, and develop a strategy to educate professionals, patients, families, caregivers and direct care workers in the clinical and community partnership.

ADRD activities will be carried out in the Montefiore Einstein Center for the Aging Brain under a physician, social worker and nurse. Cognitive function screening will be a goal for all primary care practices and the Center will develop an interprofessional pathway with community service referrals for caretaker support.


About New York University College of Nursing

NYU College of Nursing is a global leader in nursing education, research, and practice. It offers a Bachelor of Science with major in Nursing, a Master of Science and Post-Master’s Certificate Programs, a Doctor of Nursing Practice degree and a Doctor of Philosophy in Research Theory and Development. For more information, visit

About Hartford Institute for Geriatric Nursing (HIGN)

HIGN seeks to shape the quality of health care that older Americans receive by promoting the highest level of geriatric competency in all nurses who deliver care. By raising the standards of nursing care, HIGN aims to ensure that people age in comfort and dignity. Its initiatives include education, practice, research, and policy. For more information, visit

About Montefiore Health System

Montefiore is a premier academic health system and the University Hospital for Albert Einstein College of Medicine. Combining nationally-recognized clinical excellence with a population health perspective that focuses on the comprehensive needs of the communities it serves, Montefiore delivers coordinated, compassionate, science-driven care where, when and how patients need it most. Montefiore consists of eight hospitals and an extended care facility with a total of 2,747 beds, a School of Nursing, and state-of-the-art primary and specialty care provided through a network of more than 150 locations across the region, including the largest school health program in the nation and a home health program.  The Children's Hospital at Montefiore is consistently named in U.S. News' "America's Best Children's Hospitals."  Montefiore's partnership with Einstein advances clinical and translational research to accelerate the pace at which new discoveries become the treatments and therapies that benefit patients. The health system derives its inspiration for excellence from its patients and community, and continues to be on the frontlines of developing innovative approaches to care.  For more information please visit  

About R.A.I.N.

Regional Aid for Interim Needs (R.A.I.N.) Inc. aims to enhance the well-being and quality of life for all New Yorkers by meeting the interim needs of people of all ages.  R.A.I.N. is a multi-service community organization specializing in providing quality services and programs to meet the interim needs of New York City’s older population. Established in 1964 R.A.I.N. provides a continuum of care and range of services that allows individuals to maintain their dignity and age in place. R.A.I.N. maintains a commitment to the provision of culturally and linguistically competent service delivery and quality care to the elderly population of The Bronx. Currently, R.A.I.N. is the largest provider of social services for seniors in the Bronx. With eleven senior center service sites throughout the Bronx and one in upper Manhattan, it offers a comprehensive continuum of services to help seniors live safely and independently in their homes.  With over 1,300 employees, R.A.I.N. serves an estimated 30,000 individuals annually through its programs.  It has one of the largest home attendant and personal care services for homebound persons in the City known as R.A.I.N. Home Health Care, in addition to a home-delivered meal program serving 1600 meals daily, case management services, R.A.I.N. One Stop, transportation services, Cucina Dolores serving 325 daily meals to the homeless and hungry, elder abuse services and two housing developments with over 156 units for low-income seniors; one HUD sponsored and the other a tax credit complex.  R.A.I.N. Home Health Care is licensed to provide services in the five Boroughs of NYC, but has a primary focus in the Bronx at this time. For more information please visit

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Christopher James
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