My Birth Preferences: An Evidence-Informed, Patient-Centered Decision Aid To Reduce Bias and Promote Equity in Perinatal Care

There is an urgent need to improve the quality of care for Black birthing people, yet providers often lack sufficient tools and training to engage expectant families in person-centered decision-making. This project seeks to center the voices of marginalized birthing people by developing and testing a patient decision aid, My Birth Preferences, which explains evidence-based labor and birth options and gathers preferences prior to hospital admission.

Kari Radoff, MSN, CNM, FACNM, Boston Medical Center, Department of Obstetrics and Gynecology

Community-Partnered Engagement to Improve Violence Among Youth of Color

Establishing Safe Cultures (ESC) is a coalition of grassroots organizations that provides a youth-based, holistic violence prevention program in North Carolina. For this project, ESC will partner with Black adolescents, parents and/or caregivers, community partners, and the nurse scientists of Duke University’s HEEAT (Health disparities through Engagement, Equity, Advocacy and Trust) Research Lab to optimize ESC’s existing violence prevention programming for broader scaling efforts.

Schenita Davis Randolph, PhD, MPH, RN, FAAN, Duke University, School of Nursing

Disrupting Intergenerational Family Violence Using a Family-Centered, Technology-Enhanced, and Trauma-Informed Program

Black women and children are disproportionately affected by domestic violence and abuse (DVA) from their partner or father. These same men have a high rate of dropping out of DVA rehabilitation programs. This project will investigate what factors lead Black families to seek help and will develop the FatherlyACT trauma-informed model of care. Led by male nurses, FatherlyACT consists of a mix of virtual and in-person sessions for each family member designed to enhance parenting skills, promote healthy relationships, and involve the family in the intervention.

Chuka Emezue, PhD, MPH, MPA, CHES, Rush University

Integrating Chatbot Technology with Augmented Reality to Promote HIV Testing Among Black MSM in the Southern United States

Mobile health (mHealth) interventions can be effective at increasing the uptake of preventive measures and testing for HIV, but such programs require a degree of human oversight that is hard to operationalize and sustain. This project will address these challenges by using cutting-edge innovations—artificial intelligence chatbots trained on theory and culturally-tailored strategies, along with augmented reality technology—to make mHealth more accessible for high-risk Black men who have sex with men (MSM) in the southern U.S., the epicenter of the HIV epidemic in the country.

Zhao Ni, PhD, BMed, RN, FAAN, Yale University, School of Nursing

‍‍Developing a Model of Care for Victims of Law Enforcement Violence

There are limited healthcare interventions specifically designed to meet the needs of people affected by law enforcement violence. Led by forensic nurses who are also experts in social justice and health equity, this project will test the feasibility of a new care model through a pilot program, outline a research agenda for implementation, and investigate policy opportunities to expand program access for victims of police violence.

Maija Anderson, DNP, APRN, FNE-A/P, and Jacqueline Callari-Robinson, RN, BSN, SANE-A, SANE- P, D-F IAFN, Morgan State University

Delivering Peer-to-Peer Trauma Support for Black Women Experiencing Homelessness

Black women experiencing homelessness are disproportionately impacted by traumatic stress, yet few trauma-focused programs are tailored for this population. This intervention, which leverages a peer-led model that centers the shared lived experiences of unhoused Black women, provides trustworthy guidance towards improved mental health and housing outcomes.

Kirsten Dickins Aryee, PhD, AM, APRN, FNP-C, Rush University

Deploying Peer Navigators for People with Developmental Disabilities

People with developmental disabilities have difficulty communicating their healthcare needs, while clinicians lack training for how to treat this population. This bold intervention, which trains peer patient navigators to assist other neurodiverse patients to navigate the health system, holds promise to ensure that differently-abled groups receive the care and attention they deserve.

Daniel Wilkenfeld, PhD, University of Pittsburgh

Promoting Positive Parenting Skills in Unhoused Women

Parenting is challenging for unhoused women, particularly those who also experience interpersonal violence. This nurse-designed intervention combines trauma-informed counseling with guidance in play and learning strategies to improve the parenting skills of mothers and the wellbeing of their children.

Doncy Eapen, PhD, MSN, APRN, FNP-BC, University of Texas Health Science Center at Houston

Using Telehealth to Improve Access to PrEP for Women Sex Workers

PrEP utilization is alarmingly low among women sex workers, who are at especially high risk for HIV infection. Designed by a multidisciplinary team, this intervention will use a community-based telehealth system to improve sex worker access to this highly effective daily medication that reduces HIV infection.

Jessica Zemlak, PhD, MSN, RN, FNP-BC, PMHNP-BC, Marquette University

Centering the Voices of Sexual Assault Survivors in Reducing Secondary Victimization

Survivors of sexual assault, particularly Indigenous and Black women, are often retraumatized when seeking healthcare. This study aims to better understand the experience of secondary victimization as a means of designing more effective care for Indigenous and Black women who have been sexually assaulted.

Ashley Ruiz, PhD, RN, Arizona State University

Enhancing Sexual Health Awareness Among Rural Youth

Many schools in rural communities lack sexual education resources to support the health and wellbeing of adolescents. This program will engage and center rural youth in the creation of a virtual adolescent sexual health training course for school staff while simultaneously empowering young people to act as advocates among their peers.

Elizabeth Dickson, PhD, RN, University of New Mexico

Improving Heart Health of Appalachian Caregivers Through Physical Activity

Caregivers in rural Appalachia are at heightened risk for cardiovascular disease. This project will pilot and test the real-world efficacy of a novel intervention to decrease cardiovascular disease risk among rural Appalachian caregivers.

Jennifer Smith, PhD, RN and Debra Moser, PhD, RN, FAHA, FAAN, University of Tennessee

Promoting Self-Care of Older Women Experiencing Homelessness

Middle-aged and older women experiencing homelessness face a constellation of traumatic life events and manage multiple physical and mental health conditions. This grant supports a feasibility study of an enhanced, trauma-informed, chronic disease self-care program designed to meet the complex needs of this population.

Benissa Salem, PhD, RN, MSN, PHN, CNL, University of California at Los Angeles

Increasing PrEP Utilization by Black Women Through AI

Black cisgender women are disproportionately underrepresented among patients using PrEP for HIV prevention. Combining the holistic approach of nurse practitioners with AI technology, this interdisciplinary initiative will deliver personalized, culturally-tailored healthcare communication to augment HIV prevention strategies.

Chen Zhang, MPH, PhD and Mitchell Wharton, PhD, RN, FNP-BC, CNS, ACRN, AAHIVE, University of Rochester

Optimizing Opioid Use Disorder Services Across the Jail-to-Community Continuum

Opioid-related overdose deaths are skyrocketing in Washington State and more than half of its people who regularly use opioids are incarcerated annually. Harnessing the expertise of frontline providers, this nurse-led, scalable intervention has the potential to radically improve the continuity and effectiveness of overdose prevention care for people transitioning from jail to community settings.

Sarah Gimbel, PhD, MPH, RN, FAAN, University of Washington

Development and Testing of Healthcare-Team Focused Implementation Strategies to Improve Latinx Teens’ Engagement in Depression Treatment

Latinx teenagers are more likely to experience depression but less likely to seek and receive treatment than their peers. This project will address inequities in depression treatment among Latinx adolescents by elevating the role of interpreters as trusted members of the patient-provider team.

Allison Stafford, PhD, RN, Duke University

A Digital Storytelling Intervention to Promote the Health of African American Family Caregivers

African Americans (AA) experience a higher burden of family caregiving and worse physical health than their white counterparts, yet are often underrepresented in studies on caregiver health. This project will implement and evaluate a digital storytelling intervention, in which healthy behaviors among AA caregivers are promoted through the creation and sharing of life stories.

Abiola Keller, PhD, MPH, PA-C and Kristin Haglund, PhD, RN, PNP, FNP, APRN, Marquette University

AI-Enhanced Nursing Intervention Platform for Latino Family Caregivers

Latinx children with chronic conditions are more susceptible to higher morbidity rates than their peers, leading to disproportionate physical, mental, and financial caregiving burdens for their families. This project will tailor an existing artificial intelligence platform – Caring for Caregivers Online – to provide culturally-congruent support to Latinx caregivers.

Weichao Yuwen, PhD, RN and Maggie Ramirez, PhD, University of Washington

Yurok NET Wellness: A Culturally Congruent, Nursing-Driven, Village Centered Model to Treat Trauma for Wellness Court Clients

Historical trauma, racism, and marginalization have led to increased psychosocial risk, morbidity, and mortality in the Yurok Tribe of Northern California, the state’s largest surviving federally recognized tribe. In this project, tribal members will pilot a culturally-centered intervention that directly treats the underlying individual and intergenerational trauma contributing to poor health in the community.

Kylea Liese, RN, CNM, PhD, University of Illinois at Chicago

Designing a Trauma Informed Community Health Worker Intervention to Address American Indian Social Invisibility and Health Inequities

Serious health disparities persist among American Indian communities in South Dakota and beyond. This project aims to identify the healthcare priorities and needs of the Lakota community, and to collaboratively develop a culturally responsive, trauma-informed program to train and support community health workers.

Mary Isaacson, PhD, RN, CHPN and Tiara Ruff, DNP, RN, MBA, South Dakota State University

A Palliative Care Intervention in Primary Care Clinics for Vulnerable Populations with High-Risk Diabetes

Nurses are often successful “interpreters” of complex medical information. To improve outcomes for high-risk patients with poorly controlled diabetes at this safety net hospital, palliative care nurses will train primary care nurses to run group visits and provide diabetes case management. Community health workers who already work with this patient population—which includes many undocumented, poor, non-English speakers who may not understand the details or the seriousness of their condition—will offer advance care planning counseling, encouraging conversations and the completion of advance directive documents.

Abisola Odujinrin, RN and Carin van Zyl, MD, Section Head of Palliative Medicin;, Los Angeles County and University of Southern California Medical Center

A Technology-Assisted Program for Long-Term Care of Traumatic Injuries Among Low-Income Urban Populations

Through the use of wearable devices like wrist monitors and a web-based platform called Way to Health (WTH), which uses the tech devices many people already have (e.g., cell phones and computers), this program will redefine the scope of conventional trauma care and allow nurses to follow recovery metrics like physical activity and sleep patterns, and develop referral mechanisms and incentivize recovery-promoting behaviors.

Sara Jacoby, PhD, MPH, RN, Assistant Professor and Center Investigator at the Penn Injury Science Center; University of Pennsylvania School of Nursing

Parents ASSIST: A Program to Help Gay, Bisexual, and Queer (GBQ) Teen Boys Avoid HIV and Other STIs

Parents ASSIST will offer skill-building techniques for parents and help them overcome perceived impediments to communication with their sons. This program is the first project to present GBQ topics and communication modelling skills for parents through a dedicated website.

Dennis Flores, PhD, ACRN, Postdoctoral Fellow; University of Pennsylvania School of Nursing

A Smartphone Application to Prevent Intimate Partner Violence (IPV) Among Young Adult Latino Immigrants

Latino immigrants in the U.S. are disproportionately affected by IPV, defined as physical, sexual, or psychological violence between current or former romantic partners. The app, Culturaciόn: Cultura y Relaciones Intimás (Culture and Intimate Relationships), addresses the risks and protective factors for IPV among Latino immigrants between the ages of 18-29, including adverse childhood experiences, acculturation stress, cultural norms influencing relationship power and communication, fewer help-seeking behaviors, and lack of access to culturally-specific health services. Participants will also learn healthy and practical ways to manage stressors in their intimate relationships. A key partner will be the National Latin@ Network for Healthy Families at Casa de Esperanza.

Rosa M. Gonzalez-Guarda, PhD, MPH, RN, FAAN, Associate Professor; Duke University School of Nursing

Promoting Father-Son Health Communication and Healthy Sexual Behaviors Among Black Male Adolescents Through a Nurse-Driven Mobile App

HIV infection rates among black males ages 13 to 17 account for more than half of all HIV infections in this age group and are eight times higher than those of white male youth. The proposed Cutting E.D.G.E (Empowering Dads to Guide and Educate) mobile app aims to help black fathers better communicate and promote healthy sexual behaviors to their sons. This initiative, the first of its kind, represents a bold first step towards addressing an overlooked health disparity.

Schenita D. Randolph, PhD, MPH, RN, CNE; Duke University School of Nursing

Peer Mentoring Middle School Youth in Appalachia to Improve Lifestyle Behaviors and Health Outcomes

Young people in rural Appalachia suffer from worse health outcomes and practice fewer positive health behaviors than their counterparts elsewhere in the U.S. Leveraging the power of peer group dynamics and social networking, this nurse-designed initiative trains 10th grade mentors to help guide middle school students towards lifelong healthy behaviors and improved health outcomes.

Laureen Smith, PhD, RN, FAAN; Ohio State University

Turning Sick Care into Well Care for Homebound Older Adults and Their Pets

Pets are highly valued companions and can be especially helpful in improving health outcomes in homebound elderly populations who may otherwise be isolated. POP (Pet Owner and Pet) Care creates an inter-professional team consisting of a nurse practitioner, a veterinarian, and a social worker to address the healthcare needs of homebound older adults and their pets. The expectation is that the improved health of the person-pet dyad will correlate with better health and well-being outcomes for the pet owner.

Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN, Ohio State University

Keto Prescribed: Translating Ketogenic Research into Clinical Practice

This nurse practitioner-led health coaching program incorporates ketogenic eating and culturally competent mental/physical health interventions to reduce cardiovascular disease risk and increase quality of life for adult African American women.

Barbara Jones Warren, PhD, RN, APRN-CNS, FNAP, FAAN, The Ohio State University

Nursing in the Fields: Vector-borne Illness Prevention and Detection among Migrant and Seasonal Farmworkers

Among migrant populations in high-risk agricultural jobs, the dangers of vector-borne illnesses like Lyme disease are largely unrecognized. This project uses nurses as educators and data collectors, distributing and compiling information that will be used to influence both policy and practice.

Sarah Maxwell, PhD, MA, University of Texas at Dallas

MHISTREET Youth Initiative

Using storytelling, peer-mentoring, and community engagement as primary tools, this people-centered intervention seeks to improve the mental health of African American youth in Southeast Washington, DC by de-stigmatizing mental illness and increasing mental health literacy.

Erin Athey, DNP, FNP, BSN, George Washington University

“Centering” and Empowerment: The Road to Reducing HIV and STIs in Chicago’s Sex Worker Community

With a team comprised of sex workers, clinicians, public health scientists, and community stakeholders, this project will assess the feasibility and acceptability of adapting a community empowered group care model (Centering Healthcare) to address the HIV and sexually transmitted infection (STI) prevention needs of sex workers in Chicago.

Randi Singer, PhD, MSN, MEd, CNM, RN, University of Illinois at Chicago College of Nursing; in collaboration with Sex Worker Outreach Project-Chicago

App to Enhance Sexual Communication Between African American Mothers and Daughters

In '17, nearly 75% of new HIV cases in girls aged 13-19 occurred among African American (AA) girls. This study aims to develop a culturally tailored, interactive, avatar-based intervention that will enhance sexual communication between adolescent AA girls and their mothers.

Teri Aronowitz, PhD, APRN, FNP-BC, FAAN, University of Massachusetts Boston

Precision Matching of Nurses with Vulnerable Patients in Low-Resource Settings for Optimal Outcomes

Evidence-based nurse-patient matching software helps reduce adverse events and avoidable costs for minority patients (who disproportionately suffer bad outcomes) and where nursing resources are scarce (such as rural and safety net hospitals).

Andrew Dierkes, PhD, RN, Nursing Analytics, University of Pennsylvania School of Nursing

Expanding Primary Care for People with Disabilities through Nurse-Led Telehealth

A telehealth program to provide primary and specialty care for an underserved population of people with intellectual disabilities and autism in community-based group home settings.

Tine Hansen-Turton FAAN, Woods Services Inc.

Adapting the NFP Model to Include an Interdisciplinary Approach and Skilled Nursing Care to Reduce Pregnancy-Related Morbidity and Mortality in African American Women

Due to implicit bias, structural racism, and frequent comorbidities, African American mothers-to-be face an elevated risk of death regardless of their socioeconomic status. The new model includes outreach, education, and nurse home visits.

Nastassia Davis, DNP, MSN, RN, IBCLC, Montclair State University

A Youth-Centered Intimate Partner Violence Prevention Program for Immigrant Communities

This initiative seeks to prevent intimate partner violence in the Arab community by involving Arab youth in promoting early intervention, mobilizing community change, and promoting healthy relationships.

Sarah Abboud, PhD, RN, University of Illinois at Chicago

Promoting Health in African American Populations through Partnership with Barbershops and Wearable Activity Trackers

This barbershop-based initiative brings together nurses, community partners and wearable devices to promote the self-management of lifelong healthy behaviors.

Lisa Anne Bove, DNP, RN-BC, University of North Carolina Wilmington School of Nursing

Mental Health Challenges in the Asian American Community Beyond COVID-19

This program will identify new, more effective ways of reducing stigma and increasing utilization of mental health services in the Asian American community.

Shu-Hua Wang, MD, MPH&TM, PharmD, FIDSA, The Ohio State University, Global One Health Initiative

Melanated Maternity Community Care

This team of nurse scientists and nurse-midwives will develop training for Black certified nursing assistants and provide three key services: assessing postpartum warning signs of major complications; linking to wraparound services and referrals; and providing basic support and education for postpartum recovery to Black women in their homes.

Karie Stewart, APN, MSN, MPH, CNM, University of Illinois at Chicago College of Nursing

Closing the Breastfeeding Gap: Using Telelactation to Provide Equitable Breastfeeding Support to African American Mothers

Addressing a national shortage of African American lactation professionals and low rates of breastfeeding among African American women, this project will provide peer counselors for immediate support in the hospital and Zoom-based telelactation consultation in the post-partum period as needed.

Karen Robinson, PhD, RN, CNM, Marquette University College of Nursing

ADVANCED-Comfort: Improving Dementia Care in the Chinese American Community

Chinese Americans with advanced dementia are at risk for unwanted and invasive end of life procedures due to cultural and family-based decision-making preferences. This project aims to enhance dementia care in the Chinese American community by developing a culturally tailored ADVANCED-Comfort program, designed to improve access to personalized comfort care and empower families to make comfort-focused care decisions through education and guided planning.

Ruth Palan Lopez, PhD, MGH Institute of Health Professions

Supporting the Needs of Bereaved Siblings in School: A Crowdsourced Approach

Children who lose a sibling are at high risk for emotional, behavioral, and social difficulties, and there are very few supports for them. This project will use insights crowdsourced from interdisciplinary healthcare professionals, community support groups, and parent advocates to identify the needs of bereaved siblings, develop resources and guidance, and explore schools as a setting for support.

Sarah Wawrzynski, PhD, CCRN, Nemours Children’s Hospital

Empowering Nurses to Initiate and Lead “Advance Care Planning for All” in Primary Care Settings

Advance Care Planning (ACP) in primary care settings is not conducted equitably and clinicians often feel uncomfortable having these conversations with patients from diverse backgrounds. To address these gaps in care, this project will train nurses to lead a systematic and interprofessional approach to ACP practice in a Federally Qualified Health Center (FQHC) primary care clinic.

Eriko Onishi, MD, Oregon Health and Science University

Post-Acute Transition to Home with Supportive Care (PATHS): An NP-Led Telehealth Intervention for Black & Latinx Patients & Families at End of Life

For Black and Latinx people with cancer who have declined further treatment and hospice, the transition from hospital to home is one of the most difficult periods, with extreme risk for preventable suffering, overwhelming caregiver burden, and hospital readmission. This project will test an adapted version of the Post-Acute Transitions from Hospital to Home with Supportive Care (PATHS) — a nurse-led intervention to reduce patient and family distress while encouraging hospice enrollment for home-based supportive care.

William Rosa, PhD, MBE, APRN, FAANP, FPCN, FAAN and Judith Nelson, MD, JD, Memorial Sloan Kettering Cancer Center

Supporting Coping Efforts for Black Mothers After Stillbirth

Stillbirths are twice as common for Black mothers as for White mothers, and there are few interventions to support them after this experience. Collaborating with healthcare professionals and Black mothers with lived experience, this project seeks to develop a new culturally sensitive and needed intervention to facilitate adaptive coping for Black women after stillbirth.

Carrie Henry, PhD, CNM, RN, The University of Alabama

Community-Based Serious Illness Support: A Grassroots Network

Older adults in rural counties lack or have limited access to palliative care. This project further develops the Oregon Network for Community-Based Serious Illness Support, which is inspired by the Compassionate Communities model of care in which all community members have a role to play in supporting each other during times of illness, grief, and loss. Through a public health approach to providing palliative care and engaging community members, this project seeks to improve quality of life for those with serious illness and improve rural health equity.

Erin Collins, MN, RN, CHPN and Elizabeth Johnson, MA, The Peaceful Presence Project

Breaking Barriers, Honoring Wishes: Advancing End of Life Care in Marginalized Communities

Advance care planning for older adults can be difficult, disjointed, and inaccessible, particularly for minority populations, which can result in futile life-saving measures, late hospice referrals, delayed comfort, caregiver strain, and inadequate grief support. This project will develop a holistic approach to end of life (EOL) conversations and increase planning for disadvantaged populations through a hybrid clinic that partners with health, law, and faith ministry professionals to educate clients about options and document their preferences.

Amanda Kirkpatrick, PhD, RN, FAAN, FNAP and Meghan Potthoff, PhD, APRN-NP, PPCNP-BC, CPNP-AC, Creighton University, College of Nursing

Unheard Voices: Partnering with Spanish-Speaking Parents and Interpreters to Guide a Nurse-Led Approach to Reduce End of Life Suffering

Language can be an obstacle in ensuring that all children nearing end of life (EOL) receive high quality care. Families who speak languages other than English are also often excluded from pediatric EOL research. This project will work with Spanish-speaking parents and medical interpreters to identify processes to help nurses tailor EOL care to families’ needs across language barriers and build infrastructure to include linguistically diverse families in future intervention development.

Elizabeth Broden, PhD, RN, Yale University School of Medicine

Perinatal Palliative Care: Supporting Parents Through Life-Limiting Fetal Diagnosis

The current standard of care for a life-limiting fetal condition (LLFC) is limited to clinical care for mother and infant and does not address the continued, complex needs of parents following the death of their child. Building on a successful pilot study of an intervention to address the holistic healthcare of these parents, this project seeks to broaden its reach to marginalized groups, including BIPOC and LGBTQ+ populations and people whose access to healthcare is limited by location or transportation challenges.

Denise Côté-Arsenault, PhD, RN, CPCLC, FNAP, FAAN, Saint Louis University

Improving Serious Illness Care for Neurodiverse Individuals

People with intellectual or developmental disabilities experience many barriers to equitable care. This bold project will tailor an evidence-based intervention, Serious Illness Conversation Guide, to inform care consistent with the needs and values of neurodiverse people who are seriously ill.

Jane Tobias, DNP, CRNP, CPNP-PC and Caitlyn Moore, DNP, MS, CRNP, ACHPN, Thomas Jefferson University

Preparing Doulas to Care for Seriously Ill LGBTQ+ People

Older LGBTQ+ people often confront discrimination when they seek care for serious illness. This community-based, nurse-led intervention will develop a culturally concordant, end-of-life doula model to increase social support and improve care for seriously ill LGBTQ+ patients.

Raeann LeBlanc, PhD, DNP, AGPCNP-BC, CHPN and Susan Shaw, PhD, University of Massachusetts at Amherst

Fostering Socialization Among Hemodialysis Patients Using Virtual Reality

Loneliness, boredom, and anxiety too often prompt patients with end-stage kidney disease to skip hemodialysis. This project, which will have a disproportionate impact on marginalized communities, will explore a new nurse-moderated, social virtual reality experience to decrease isolation and increase health literacy and adherence to treatment.

Lea Ann Matura, PhD, RN, FAAN, University of Pennsylvania

Promoting Conversations About Sex with Seriously Ill LGBTQ+ People

Sex is important even in the last days of life, but clinicians rarely address the topic with seriously ill patients. The goal of this innovative project is to deliver an LGBTQ+- inclusive intervention that facilitates conversations between clinicians and advanced cancer patients about sexual pleasure.

Kimberly Acquaviva, PhD, MSW, CSE, FNAP and Bethany Payne Giesel, MSN, RN, ACNP-BC, University of Virginia

Implementing Algorithms to Increase Advanced Care Planning

Two in three Americans, disproportionately from marginalized communities, do not have an advanced directive or any documented end-of-life wishes. This project will use tailored algorithms to identify patients who lack advance directives or surrogates and provide targeted nursing care to engage them in advance care planning.

Bevin Cohen, PhD, MPH, MS, RN, Icahn School of Medicine at Mount Sinai

Developing Palliative Solutions to Ease Pain in Black Adults with Heart Failure

Pain is often unaddressed in Black adults with heart failure, creating the need for nonpharmacologic treatment. This study will develop and refine a community-based, nurse-led and navigator-coached palliative care pain intervention to reduce pain disparities in older Black adults with heart failure.

Rachel Wells, PhD, MSN, RN, CNL and Shena Gazaway, PhD, RN, University of Alabama at Birmingham

Supporting the BIPOC Bereaved Through Poetic Medicine

BIPOC communities have limited access to care for the bereaved. In the wake of inequities laid bare by the COVID-19 pandemic, this bold project will tailor an internationally successful intervention, Poetic Medicine, to help reduce the emotional suffering of BIPOC populations and their healthcare providers who experience complicated grief.

Michael Rabow, MD and Judith Redwing Keyssar, RN, University of California at San Francisco

Cultivating Financial Self-Advocacy Among Rural Cancer Patients

Rural cancer patients are at high risk of financial hardship. In this project, clinicians, patients, and caregivers will co-create a culturally tailored, nurse navigator intervention to increase the financial self-advocacy of rural cancer patients and their families.

Djin Tay, PhD, RN, University of Utah

Promoting Peer-to-Peer End of Life Care for Aging Incarcerated People

The prison population is aging and the need for compassionate end-of-life care is great. This innovative project trains incarcerated individuals to provide care and companionship to their aging and dying peers, and aims to share this model across state prisons in California and elsewhere.

Lisa Deal, ScD, MSc, MPH, MN, BSN, Humane Prison Hospice Project in collaboration with the California Department of Corrections

Investigating EMS as an Untapped Resource for Rural POLST Education

Advance care planning lags in rural America, even though its population is sicker, more impoverished and has less access to healthcare than their urban counterparts. This project seeks to use emergency medical services personnel – often trusted and familiar community members – to educate rural Virginians and Hawaiians about the benefits of completing Portable Medical Orders (POLST) forms, which clarify wishes about receiving life-sustaining treatment.

Kim Callanan, MA, National POLST

Adapting the Serious Illness Conversation Guide for Older Adults Experiencing Homelessness

The population of homeless older people continues to grow rapidly, and their physical and mental burdens, combined with challenges in receiving adequate care, contribute to shorter life expectancies than their housing-secure peers. This study seeks to adapt the Serious Illness Conversation Guide, which is primarily used to drive values-based conversations between caregivers and oncology patients, for use with older adults experiencing homelessness to recognize and meet their serious illness needs.

Abigail Latimer, MSW, PhD, LCSW and Debra Moser, PhD, RN, FAHA, FAAN, University of Kentucky Research Foundation

Motivational Advance Care Planning: End-of-Life Preparation for Severe Mental Illness and Life Threatening Co-Morbidities

Life-threatening co-morbidities correlate with serious mental illness (SMI), yet care planning is underutilized by individuals with SMI at the end of life. The goal of this project is to develop a motivational interviewing strategy that nurses can use to boost the completion of advance directives for the seriously mentally ill.

Christina Steward-Tiesworth, BSN, RN, PMH-BC, CCM, Hope Network

A Culturally Centered Complicated Grief Group Therapy Intervention for Black Americans

Bereaving Black communities are at heightened risk of Complicated Grief because of historical trauma, systemic racism, mistrust in the healthcare system, and a frequent reluctance to seek mental health care. This project will investigate the experience of Black grievers and use those findings to modify an existing intervention, Complicated Grief Group Therapy, into a culturally centered psychotherapeutic intervention.

Siobhan Aaron, PhD, MBA, RN, FNP-BC, Case Western Reserve University

A Community-Based, Collaboratively Designed Communication Guide for Clinicians Working with Refugees with Serious Illness

Seriously ill refugees are at an especially high risk for negative health outcomes, in part because clinicians do not often share their cultures, languages or communication norms. In this project, clinicians and refugees will collaborate to develop a communication guide that will help assure that care delivery aligns with these patients’ goals and values.

Katherine Doyon, PhD, MEd, RN, CHPN, Boise State University

Project SUNDAYS: Engaging Rural African American Religious and Spiritual Leaders on Advance Care Planning

Advance Care Planning (ACP) is complex and challenging for older African Americans (AA) with serious illness in rural communities. This project will explore a new model for developing care conversations with seriously-ill AA adults in South Carolina that utilizes trusted local clergy to provide elements of religion and spirituality in ACP.

Tracy Fasolino, PhD, FNP-BC, ACHPN, Clemson University

A Novel Poetic Dignity Therapy Application to Enhance Meaning and Purpose for Sexual and Gender Minority Patients at End of Life

Sexual and gender minority (SGM) patients are at increased risk for discrimination, stigma, mistreatment, and low-quality care that compromises dignity at the end-of-life. This innovative, nurse-led adaptation of Dignity Therapy will utilize a poetic approach to enhance meaning and purpose among SGM-identified hospice patients.

William Rosa, PhD, MBE, NP, FAANP, FAAN, Memorial Sloan Kettering Cancer Center and Rachel Hadler, MD, University of Iowa

PALL-HEART, a Telehealth Palliative Care Pilot Project for Rural Heart Failure Patients

Heart failure patients who live in rural areas are especially vulnerable to suffering and often experience barriers to specialized palliative care, symptom management, and physical activity programs that could improve symptoms and quality of life and decrease hospitalization rates. PALL-HEART is a tablet-based symptom management program for rural patients with heart failure that is delivered in the home.

Jill Esquivel, PhD, AC/FNP-BC, FAHA, University of Virginia

Training Geriatric Nurse Practitioners to Provide Quality Primary Palliative Care in Nursing Homes

This project will develop, implement, and evaluate a primary palliative care training program for Skilled Nursing Facility-based nurse practitioners to increase the number of advance directives completed and ultimately improve the quality of care received. Its design leverages an academic-practice partnership between the University of Pennsylvania School of Nursing and Acts Retirement-Life Communities.

Joan Carpenter, PhD, CRNP, ACHPN, University of Pennsylvania

Complicated Grief Group Therapy for Persons with Serious Persistent Mental Illness

Unlike normal grief, complicated grief is characterized by maladaptive thoughts, feelings, and behaviors that obstruct the difficult but natural progression of grief. Unresolved grief following a traumatic death is highly associated with complicated grief and both contributes to and sustains persistent mental illness in adulthood. This study will examine the efficacy, feasibility, and impact of community implementation of complicated grief therapy for low-income, uninsured persons with persistent mental illness.

Katherine Supiano, PhD, LCSW, University of Utah

Advance Care Planning and Goals of Care for Unrepresented Older Prisoners

This project will improve the provision of advance directives for use in prison populations and identify best practices for medical decision-making among unrepresented incarcerated persons. The work will support prisoners’ autonomy and access to advance care planning, which is essential to allowing incarcerated individuals the right to die with dignity. This effort also aims to shift increasingly scarce prison healthcare resources toward care that is desired and away from procedures that are unwanted and costly.

John Song, MD, MPH, MAT, University of Minnesota

Improving Palliative Care in the ICU for Black Populations: A Nurse-Led Approach

This project will address care disparities at the end of life for black populations who often receive inferior health care and have greater unmet care needs. Using an experience-based co-design methodology, the project will collaborate with the African American communities being served to develop, implement, and evaluate a palliative care intervention in the intensive care unit to improve goals of care conversations and help patients transition back into the community.

Rebecca Wright, PhD, BSc (Hons), Johns Hopkins University

Nurses Leading Change in Palliative Care for the Houseless with Serious Mental Illness

This effort aims to embed a palliative care model into an existing nurse-managed primary care clinic to more effectively address the needs of the seriously mentally ill houseless population.

Casey R. Shillam, PhD, RN, University of Portland

A Nurse-Led, Mobile Health-Enabled Program to Improve Communication and Support for Home Hospice Family Caregivers

A technology-driven, nurse-led support program that aims to better address unmet family caregiver needs in hospice and increase communication for marginalized, isolated home hospice caregivers across the country.

Susan Lysaght Hurley, PhD, RN, Care Dimensions Inc.

Exploring the Role of Nurses in Driving Health Equity Through Serious Illness Conversations

This study will evaluate the quality and impact of serious illness conversations (SIC) led by nurses (compared to those facilitated by other health professionals) and will explore patients’ experiences of SIC through the lens of socio/cultural diversity to promote equity in serious illness care.

Seiko Izumi, PhD, RN, FPCN, Oregon Health & Science University

Nurse-Led Advance Care Planning using PREPARE in a VA Oncology Infusion Center and Dialysis Clinic

A pilot study to demonstrate the effectiveness and feasibility of using a licensed vocational nurse to conduct advance care planning in a diverse population of veterans who are receiving dialysis and oncology infusion services.

Rebecca Liddicoat Yamarik, MD, MPH, FAAHPM, HMDBC, The Tibor Rubin Long Beach Veterans Affairs Medical Center

Planting the Seeds: A Community-based Palliative Care Model for Latinos with Advanced Cancer

Early access to palliative care has been shown to improve quality of life at the end of life, but disparities persist for Latinos with cancer. A community-based Latino Lay Health Advisor program will address the critical issue of access to advanced cancer care for Latinos in three rural counties in North Carolina.

Lee Ann Johnson, PhD, MSN, East Carolina University

A Nurse-Led Storytelling Intervention for Rural Pediatric Palliative Care Populations

Legacy-making activities, such as digital storytelling, can help decrease suffering for children with life-threatening conditions and for their caregivers. This program will test the intervention for the first time in a rural setting.

Terrah Foster Akard, PhD, RN, CPNP, FAAN, Vanderbilt University

A Nurse-Led Intervention for Fear of Progression in Advanced Cancer

Up to 70% of patients with advanced cancer fear that their disease will progress or return. This study will test a nurse-led videoconferencing intervention for patients with advanced gynecologic or lung cancer, including in an under-resourced community.

Anne Reb, PhD, City of Hope

Photovoice: An Intervention for Aligning Goals of Care within Seriously Ill African American Dyads

Photovoice uses photographs and narrative recording methods to help people living with serious illness and their family caregivers understand and communicate what is important during this time of life.

Susan DeSanto-Madeya, PhD, APRN-CNS, FAAN, University of Rhode Island College of Nursing

A Nurse-Led, Home-Based Palliative Care Pilot to Improve the Quality of Life for Patients with Advanced Dementia in Rural Populations

Through nurse and social worker-led assessments, interventions, and conversation, people living with dementia and their families will better understand the disease and complete Advanced Care Planning directives in an effort to reduce caregiver burden and prevent avoidable emergency department visits and hospitalizations.

Lori Scoville, MSN, RN, CHPN, Snowline Hospice​​

Using COVID Lessons to Increase Access to POLST in Rural Communities

The goal of this program is to improve the provision of telehealth-based, advance care planning for resource-strapped rural communities hard hit by the COVID-19 pandemic.

Amy Vandenbroucke, JD, National POLST (a program of Tides Center)

A Telehealth Guide for e-Empathy in Goals of Care Conversations for African American/Black Kidney Patients

This project will establish a culturally tailored approach to help clinicians communicate empathy more effectively when working with Black patients with kidney disease in a virtual/telehealth environment.

Adriana Glenn, PhD, MA, MN, RN, FNP-BC, George Washington University School of Nursing

A Primary Palliative Care Model for Pediatric Cardiac Patients

This nursing-driven model for young Latinx cardiac patients will enable intensive care unit nurses and their interprofessional colleagues to deliver culturally-informed primary palliative care as part of routine clinical services.

Sarah Green, DNP, CPNP-AC, RN, Children’s Hospital Los Angeles

Primary Palliative Care for Urban-Dwelling African Americans with Chronic Lung Disease

This project will test a novel, nursing-driven and telehealth-enabled collaborative model of palliative care (PC), specifically designed to increase uptake and impact of PC among marginalized patients with advanced lung disease.

Carrie Stricker, PhD, RN, ANP-BC, Thomas Jefferson University

Innovating for ImPACT: Nurse-led Telehealth for Pediatric Palliative Care Patients

This program will design, implement, and evaluate a nurse-led telehealth intervention that provides home-based, culturally congruent palliative care to diverse pediatric patients and caregivers.

Jane Bragg, MSN, ARNP, MBA, PMHNP-BC, CPON, NEA-BC and Danielle Altares Sarik, PhD, APRN, CPNP-PC, Nicklaus Children's Hospital

Early Palliative Care Intervention for American Indian and Rural Patients with Advanced Cancer

Cancer burden among American Indians (AI) in South Dakota is profound and inequitable, with mortality rates 26.2% higher than Whites’. This intervention seeks to increase access to culturally congruent, early palliative care for American Indian and rural patients living with advanced cancer.

Sarah Mollman, PhD, MSN, RN, South Dakota State University College of Nursing

Black Churches and Access to Hospice and Palliative Care in Arkansas

Leveraging the influence of trusted local institutions like churches and town councils, this intervention seeks to expand acceptance and understanding of hospice and palliative care among rural Black communities.

Deanna May, RN, Arkansas Hospice, Inc.

The Development of ACCESS-Care: A Community Care Model to Enhance Supportive Services for Caregivers of Black Women with Metastatic Breast Cancer

The goal of this study is to develop a community-based, palliative care intervention to mitigate disparities in distress and pain in Black patients with metastatic cancer.

Melissa Mazor, PhD, MS, RN, Mount Sinai School of Medicine

Screening Linked to Care: A School-Based Suicide Prevention Program for Students in Grades 6-12

Adolescent mental health has deteriorated over the last decade, and those living in rural regions face the greatest burden due to poor access to mental health care. To address these challenges, the Rural Behavioral Health Institute (RBHI) developed Screening Linked to Care (SLTC), an innovative suicide prevention and mental health promotion program for 6th- to 12th-grade students that is delivered in schools. SLTC includes free universal mental health screening, same-day care for students with suicidality, and follow-up care. Following a successful pilot and initial scaling effort in Montana, RBHI plans to use Hillman funding to expand the program to all eligible students in Montana and six other states where rural adolescents face similar barriers to care.

Janet Lindow, PhD, and Amelia David, PMHNP, RN, MSN, Rural Behavioral Health Institute

TeamBirth: A Solution to Improve Community-Based Postpartum Care Through Structured Teamwork and Communication

One in five pregnant people in the U.S. experience mistreatment during childbirth, and up to 40 percent of Black and multiracial patients report discrimination while receiving maternity care. HIC funding will support the adaptation and testing of a new, community-based version of TeamBirth–a patient-centered care model designed to improve communication, teamwork, and shared decision-making throughout the birthing process–in Federally Qualified Health Centers (FQHCs). FQHCs are deeply connected to underserved communities, making this an ideal partnership for developing a cost-effective innovation, decreasing inequities, and improving the quality of postpartum care.

Amber Weiseth, DNP, MSN, RN, and Wanda Montalvo, PhD, RN, FAAN, FADLN, Ariadne Labs in partnership with Harvard University

A Model for Supporting Preschool Children's Mental Health in Head Start

Families from low-income and under-served communities face myriad challenges accessing resources that can enhance parenting skills and support the mental health of their young children. Fewer than 15 percent of children from low-income families who are in need of mental health services receive the behavioral health care they require. With HIC funding, the Chicago Parent Program for individual families (CPPi) seeks to address these inequities by making parenting and mental health resources more readily available. An adaptation of the group-based Chicago Parent Program (CPP) – the first evidence-based parenting program developed with and for a racially and economically diverse community of parents – CPPi will be implemented by nurses via telehealth, dramatically eliminating a multitude of barriers that many families face in accessing in-person child mental health services. A community-based partnership with trusted local Head Start sites will help CPPi engage families in need and lay the groundwork for a potential national scaling effort.

Deborah Gross, DNSC, MS, BSN, RN, FAAN, Johns Hopkins University

Supporting the Well-Being of LGBTQ+ Adolescents and Their Families

At a time when LGBTQ+ youth are challenged by both disproportionately high rates of negative mental health outcomes and an increasingly hostile legislative environment that threatens their access to health services, it is imperative that families are provided with skill sets enabling them to effectively communicate support to their LGBTQ+ children. Many families are unable to benefit from vetted educational resources due to lack of availability, understanding, cultural taboos, and limited, if any, contact with a trusted healthcare provider. HIC funding will expand Parents ASSIST (Advancing Supportive and Sexuality Inclusive Sex Talks), a nurse-driven, community- informed, digitally accessible intervention that offers parents the practical knowledge they need to fully support LGBTQ+ children as they navigate adolescence and a turbulent world. By breaking down longstanding silos within LGBTQ+ science (e.g., separate programming for sexual minority vs. gender diverse youth) and recognizing the power that parents have to improve the lives of their LGBTQ+ children, this consolidated intervention is poised to make a significant impact on the health and well-being of all families with LGBTQ+ youth.

Dalmacio Dennis Flores, PhD, ACRN, FAAN, University of Pennsylvania

Sexual Assault Forensic Examination Telehealth (SAFE-T) Nurse-Led Model of Care

Sexual assault rates are higher in rural communities than in cities, yet those living in rural areas rarely have access to specially trained sexual assault nurse examiners (SANEs). A team from Penn State’s Sexual Assault Forensic Examination Telehealth (SAFE-T) Center will leverage its network of SANEs and its nurse-designed, proprietary technology to deliver secure, trauma-informed sexual assault care in 10 rural hospitals. With the support of HIC funding, this project will generate evidence that could position the SAFE-T Center’s system as an effective solution for providing care to sexual assault victims in a wide range of under-resourced settings.

Sheridan Miyamoto, PhD, FNP, RN, FAAN, Penn State University

Changing the Prescription: Leveraging Strategic Partnerships Between Nurses and Planners to Achieve Health Equity through Housing Policy

The link between housing and health is well established. Building on earlier work funded by a previous Hillman Catalyst Award, a multi-disciplinary research team – combining nurses and urban planners with officials from housing, public health, and environmental agencies – will harness big data and community knowledge to rethink, and potentially reshape, a key federal housing program. This visionary project from the University of Pennsylvania will utilize HIC funding to show how integrating health-affecting neighborhood characteristics into the distribution criteria of housing subsidy programs can contribute to better health for low-income families.

Sara Jacoby, PhD, MPH, MSN, RN, University of Pennsylvania, in collaboration with the Housing Initiative at Penn

Team-Based Home Care and Home Repair Services Help Older Adults Remain in their Communities.

MiCAPABLE provides team-based home care and home repair services to help older adults remain in their homes and communities. Program participants receive 12 weeks of home visits from a team that includes a registered nurse, an occupational therapist, and a handyman to ensure that health, safety and quality of life needs are met. Hillman funding will be used to train clinicians and provide MiCAPABLE to 270 patients.

Sandra Spoelstra, PhD, RN, Grand Valley State University; Sarah Szanton, PhD, RN/ANP, Michigan State University

Integrating Nurse Practitioner-Led Clinics With Head Start Sites.

This new clinic model provides early childhood education programs and services to families in at-risk communities. The initial pilot clinic has already provided services to over 300 children and has increased vaccination rates from 50% to 100%. Grant funding allowed the team to add sites, more than triple the number of children and families that are served, and expand services to include nutrition counseling and mental and behavioral health.

Julie C. Novak, DNSc, RN, CPNP, FAANP, FAAN, Sharp Health Care Foundation; in collaboration with UTHSC Houston and UTHSC San Antonio

A Public Health Nursing/Legal Partnership Serving Low-Income Mothers and Babies.

This project integrates two highly-successful models – Nurse-Family Partnership and Medical-Legal Partnership – to create a broad based network of services. In this new model, a staff of 40 public health nurses work alongside lawyers to provide seamless health, legal and social services to more than 650 new mothers per year. The team addresses unmet legal needs, identifies and pursues policy issues affecting client health, and improves program efficiency by freeing up time previously spent by nurses on case management.

Katherine Kinsey, PhD, RN, FAAN, National Nursing Centers Consortium (NNCC) Philadelphia Nurse-Family Partnership

Transitional Care for Homeless Populations.

The Durham Medical Respite Program is a nurse-led, community based initiative, that addresses a pressing unmet need to offer safe discharge options for homeless persons who are too sick for the streets or a shelter, but not sick enough to qualify for continued hospitalization. Hillman funds help to broaden the role of nurse care coordinators and community health workers who help connect patients to health care for chronic and acute conditions, and navigate access to housing and other benefits.

Julia Gamble, MPH, NP and Donna J. Biederman, DrPH, MN, RN, Project Access of Durham County (PADC)

Empowering Seriously Ill African Americans with Resources to Meet Their Spiritual, Social, and Advanced Care Planning Needs.

Hillman funds will help to expand, evaluate, and sustain the Advanced Illness Care Program (AICP), a highly creative, faith-based, nursing-driven intervention that trains and places care navigators in African-American church communities in Oakland, California. These specially trained care navigators provide referrals, physical and spiritual care, and advanced care planning services to congregants, caregivers, and persons with advanced illness in the community.

Janice Bell, RN, MN, MPH, PhD, University of California, Davis – Betty Irene Moore School of Nursing; Rev. Cynthia Carter-Perrilliat, MPA, Alameda County Care Alliance

A Nurse-Driven Telehospice Program for Underserved Rural Populations.

The HIC grant will leverage Four Seasons’ federally funded tele-palliative care model to develop a program providing remote, in-home hospice services to low-income, rural communities in western North Carolina. Specially trained nurses will seek to efficiently and cost effectively provide hospice care by remotely addressing symptom and pain management, medication adherence, advance care planning, and spiritual and psychosocial needs.

Michelle Webb, MSN, RN, CHPCA, Four Seasons Compassion for Life

The National Launch of a Newly Developed Mental Health Innovation (MHI), as Part of Nurse-Family Partnership

This will be the first U.S. home-visiting program with an integrated mechanism for mental health care, and will help low-income, first-time mothers with debilitating levels of depression and anxiety. Hillman funds will support implementation and evaluation to enable Nurse-Family Partnership to integrate much-needed behavioral health care throughout its nationwide network of more than 264 implementing agencies.

Linda Beeber, PhD, PMHCNS-BC, University of North Carolina at Chapel Hill School of Nursing

Expansion of the Nightingale Perinatal Assistance and Treatment Home (PATHway) Program

To improve care for new and expectant mothers with opioid dependence and their children through the first two years of life, this person- and family-centered program will use a web-based training program for nurse facilitators and expand existing perinatal addiction and peer support services. Hillman will support expansion of the program, first locally in Kentucky, then nationally, to increase access and improve health outcomes for pregnant women and their infants.

Kristin Ashford, PhD, WHNP-BC, FAAN, University of Kentucky College of Nursing

Women-Inspired Neighborhood (WIN) Network: Detroit

Through a bold approach that integrates an evidence-based group prenatal care program led by certified nurse midwives (CNMs) with community health workers as key system change agents addressing social determinants, this model demonstrates strong potential to reduce preterm and low birth weight deliveries amongst low-income African-American women.

Cathy Collins-Fulea, MSN, CNM, FACNM and Kimberlydawn Wisdom, MD, MS, Henry Ford Health System

Optimizing Nursing Practice to Improve Childbirth Outcomes: An Audit and Feedback Intervention

This project aims to codify how the engagement and empowerment of nurses – through a well-established audit and feedback (A&F) intervention – is a successful mechanism to improve maternal health outcomes. This study will determine how nurse-led audit committees can best use these data to inform system-level improvement efforts. The interdisciplinary team’s unparalleled combination of expertise, partnerships and infrastructure will help to position this nursing-driven intervention for rapid scaling and national replicability.

Joyce K. Edmonds, PhD, MPH, RN, Boston University; Amber Weiseth, DNP, MSN, RNC-OB, Ariadne Labs, Harvard University

Huntsman at Home- A Nursing-driven Model of Care for Rural Dwelling Cancer Patients and Their Families

Cancer patients living in rural areas are particularly underserved and most models of cancer care do not extend to the home setting, yet this is where many patients experience significant symptoms and distress, and where family caregivers often struggle. Huntsman at Home provides intensive, hospital-quality clinical care that allows rural patients to be discharged from the hospital sooner and receive follow-up care at home, including acute care, post-surgical care, palliative care, physical therapy, caregiver support, and hospice care.

Kathi Mooney, PhD, RN, FAAN, Huntsman Cancer Institute at the University of Utah

Promoting the Postpartum Health and Well-being of Families Experiencing Racism

Community of Hope and Georgetown University will partner to expand an innovative maternal health program that dramatically reimagines postpartum care. Challenging conventional services that offer a single visit at 6-8 weeks post-delivery, Community of Hope offers a 12-month comprehensive plan that incorporates racially and culturally congruent care, home visitation, case management, and family focus groups for birthing people of color living in Washington, D.C.

Ebony Marcelle, PhD, MS, RN, CNM, FAANM, Community of Hope; Christina Marea, PhD, MA, MSN, RN, CNM, School of Nursing and Health Studies, Georgetown University

Supporting Native American Youth Mental Health Well-being

The Lumbee Tribe of North Carolina and local education officials will work with Native American nurse scientists to implement the Talking Circle intervention throughout all of Robeson County’s 36 schools. Rooted in indigenous traditions, the Talking Circle has the potential to transform how educational institutions address the impact of historical trauma, racism, and marginalization on the mental health of Native American and other BIPOC students.

John Lowe, PhD, RN, FAAN, The University of Texas at Austin School of Nursing (Cherokee); in collaboration with Jada Brooks, PhD, MPSH, RN, FAAN (Lumbee); and Eugenia Millender, PhD, RN, PMHNP-BC, CDE (Kuna)

Sustaining and Scaling Rural Huntsman at Home

Adapted from the hospital at home concept, Rural Huntsman at Home (RHH) provides a suite of hospital-quality clinical services for cancer symptom monitoring and management directly to patients in their homes in low-resource, remote communities. Among its many evidence-based benefits, Rural Huntsman at Home improves quality of life for patients and families, shortens patients’ hospital stays after treatment, reduces emergency room visits, and lowers health care costs. With growing demand from neighboring states and an expanding evidence base, the Hillman Innovation Dissemination grant will enable RHH to develop a value-based reimbursement model, along with a business plan and scaling playbook to accelerate scaling efforts in Utah, Nevada, Idaho, Wyoming, and Montana.

Kathi Mooney, PhD, RN, FAAN, Huntsman Cancer Institute, University of Utah

TeamBirth: Shared Decision-Making in Maternity Care

Developed by Ariadne Labs, TeamBirth is a care process innovation that ensures people giving birth and the clinicians who are caring for them have shared input and understanding into decisions during labor and delivery. Using such easy-to-implement components as team huddles and a patient-facing white board, patients and clinicians alike have credited TeamBirth with making the labor and delivery process more person-centered and, most importantly, safer. With growing demand and an expanding evidence base, the Hillman Innovation Dissemination grant will enable Ariadne Labs to pursue innovative strategies for maximizing the reach and impact of TeamBirth.

Amber Weiseth, DNP, MSN, RN, Ariadne Labs

Alameda County Care Alliance Advanced Illness Care Program for Seriously Ill African Americans

The Alameda County Care Alliance Advanced Illness Care Program™ (ACCA-AICP) is a faith- and community-based initiative providing care navigation services to people with advanced illness and their families and caregivers. The ACCA-AICP works with more than 42 denominationally diverse African American churches in the San Francisco Bay area and has piloted projects with two healthcare systems. This Hillman Innovation Dissemination grant will enable the ACCA-AICP to expand its innovative model to more communities throughout the country.

Rev. Cynthia Carter Perrilliat, MPA, Alameda County Care Alliance; and Janice F. Bell, PhD, MPH, MN, FAAN, Betty Irene Moore School of Nursing at the University of California Davis

Expansion of the Community Aging in Place—Advancing Better Living for Elders (CAPABLE)

CAPABLE combines handyman services with nursing and occupational therapy to improve mobility, reduce disability, and decrease healthcare costs to help older people “age in place.” With a gold-standard evidence base and the growing significance of community-based care and home health, CAPABLE is poised for rapid expansion. This grant will help Dr. Szanton to develop and implement the infrastructure necessary to allow CAPABLE to scale effectively

Sarah L. Szanton, PhD, ANP, FAAN, Johns Hopkins University School of Nursing

The Chicago Parent Program: Improving the Lives of Young Children in Poverty

The Chicago Parent Program (CPP) was created in partnership with African American and Latino parents from different economic backgrounds to help improve parenting skills. CPP, recognized by the American Academy of Nursing as an Edge Runner initiative, is the only evidence-based program designed with and for parents raising young children in low-income communities, particularly families of color. Research has shown that the CPP is relatively inexpensive to deliver, costing about $37 per child per session, with a potential social return on investment exceeding 900%.

Deborah Gross, DNSc, RN, FAAN, Johns Hopkins University

Nursing-Driven, Home-Based Primary, Hospice and Palliative Care for Vulnerable Populations

The nursing-driven Housecall Providers model delivers interdisciplinary home-based primary care, hospice care, and palliative care services in the Portland, Oregon area. It is the only safety net health plan program in the country that serves people dually eligible for Medicare and Medicaid while focusing on advanced illness. This grant enables the creation of a digital toolkit as well as an online learning community to help disseminate knowledge and best practices with other organizations seeking to replicate this innovative model.

William Kennedy, DO, CareOregon and Housecall Providers

Farm Dinner Theater: Stage Two Expansion of the Didactic Farm Reader’s Theater

Farm Dinner Theater helps farm communities adopt and embrace behavior changes that improve the health and well-being of farmers and their families. Each production is personalized for the location, with local farmers supplying real-life stories, performing on stage, and managing logistics. A nurse-facilitator turns the stories into short scripts which portray the cultural, physical, and spiritual struggles of farming. A nurse facilitator leads a focused discussion so the audience can personalize the story and verbalize possible solutions for the challenges identified in the play.

Deborah Reed PhD, MSPH, RN, FAAOHN, FAAN, University of Kentucky

Neighborhood Nursing

Building on public health successes in the UK and Costa Rica, Neighborhood Nursing will be the first effort of its kind in the United States to pair every resident of a specified geographic area with a nurse-led healthcare team. Anchored in CAPABLE’s principles and methodology, and bolstered by strong local and state institutional support, this bold intervention offers a rare opportunity to pilot a radical new approach to care, at scale.

Sarah Szanton, PhD, ANP, FAAN, Johns Hopkins University

Expanding and Evaluating the THRIVE Transitional Care Support Program for Economically Disadvantaged Individuals

THRIVE is a novel, equity-centered approach that provides whole-person care to Medicaid patients transitioning from hospital to home. Developed by a nurse-led interdisciplinary team at the University of Pennsylvania, results from an early pilot demonstrated a range of positive outcomes including reduced rehospitalizations. A $300,000 Hillman Catalyst Award will allow THRIVE, in partnership with Penn Medicine at Home and Pennsylvania Hospital, to expand to a second site and generate new evidence that could help to establish the intervention as a standard for delivering comprehensive transitional care to Medicaid patients and their families.

J. Margo Brooks Carthon, PhD, RN, FAAN, University of Pennsylvania

Building Inclusivity into Psychedelic Treatment for Historically Oppressed Clinicians and Patients

A primary concern undergirding this research is that people of color experience higher rates of mental health issues and are greatly underrepresented in psychedelic studies. The purpose of this effort, therefore, is to build inclusivity and culturally concordant care into psychedelic-assisted psychotherapy for nurses, physicians and patients from historically oppressed populations. A key outcome of this work will be to build research and clinical teams inclusive of Black, Indigenous and people of color.

Anthony Back, MD, and Ladybird Morgan, RN, MSW, University of Washington

Changing the Prescription: Strategic Partnerships Between Nurses and Planners to Dismantle Structural Racism and Achieve Health Equity Through Housing Policy

This proposal aims to establish an unprecedented partnership between nurses, urban planners, and community health leaders in Philadelphia, PA to design and test an intervention that advances health equity through housing policy. This initiative will leverage existing policy mechanisms to expand housing opportunities for low-income BIPOC households in health-promoting, high-opportunity neighborhoods. This will be piloted locally in Philadelphia with the intent of developing a framework for national dissemination.

Sara Jacoby, PhD, MPH, MSN and Vincent Reina, PhD, MBA, MSC, BS, University of Pennsylvania

Systems Analysis and Improvement to Optimize Health Outcomes for Incarcerated Youth in Washington State

The Systems Analysis and Improvement Approach (SAIA) is an evidence-based implementation strategy, designed by and for nurses (and other frontline health workers) that uses systems engineering tools to improve understanding of low-cost workflow modifications that translate into better health outcomes. SAIA will be adapted and piloted in health clinics in Juvenile Detention Centers in Washington State to improve the quality, equity and efficiency of health service delivery.

Sarah Gimbel, BA, MA, BSN, MPH, PhD, University of Washington

UCSF Street Nursing: Chronic Illness Management among San Francisco and Oakland’s Houseless Population

UCSF Street Nursing, in partnership with a local mobile hygiene service, provides health care to clients who are houseless. UCSF Street Nursing will expand its innovative nursing-driven delivery model to improve care transitions by working in partnership with the UCSF Emergency Department’s Information Exchange program. This collaboration uniquely positions the Street Nursing team to support the daily health needs of a community at risk of rapidly deteriorating health.

Laura Wagner, PhD, GNP and Heather Leutwyler, RN, PhD, NP, UCSF, University of California at San Francisco

Bridging the Health and Housing Divide

A convening of Habitat for Humanity specialists and health care practitioners will develop a toolkit for replicating the CAPABLE program at Habitat sites across the country. The toolkit, tailored for Habitat construction teams with valuable insight from healthcare professionals, will be produced and disseminated to share best practices, clear guidelines and essential resources.

Carol Gregory, BA, MA, Habitat for Humanity

Improving the Health and Well-Being of Rural Family Caregivers of Older Adults Living with Dementia

This project will position a successful nursing-driven model –Serving the Unique needs of older adults in the Community by providing Caregiver Enhanced Support Services (SUCCESS) – for broader replication at the state and national level. A multidisciplinary team will work closely with community partners and rural family caregivers to refine and improve the intervention.

Angela Norman, MSN, FAAN, Arkansas for Medical Sciences Reynolds Institute on Aging

​​Adaptation of Talking Circle for Adult Indigenous Populations at Risk for Substance Use, Trauma and Depression

This project will support the adaptation, implementation, and evaluation of the Talking Circle intervention developed by a Native American nurse-scientist for use with Native American young adults (ages 18-24) who are at high-risk for substance use disorders. The intervention, which is rooted in indigenous traditions, has thus far only been utilized for youth, ages 10-17. It is endorsed as an evidenced-based program by the United States Department of Justice.

John Lowe, RN, PhD, FAAN, Professor, Florida State University

A Nurse-driven Model of Health Care for the Department of Corrections

In this innovative model, nurse practitioners and nursing students will provide health care, health education and, most notably, a seamless transition to post-release primary care to individuals in the Illinois correctional system. As nurses provide the majority of care to incarcerated individuals throughout the United States, this education and practice model could serve as an exemplar for bridging correctional health with community care.

Susan Corbridge, PhD, APN, FAANP, University of Illinois at Chicago College of Nursing