driven innovations that promote

equitable, person-centered,

and trustworthy care.

Our grantees are reimagining health

and healthcare 

for all.

Photo by Karen Kasmauski
Photo Credits


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Our grantees – from a variety of backgrounds, care settings, and communities – bring extraordinary vision and a shared commitment to creating a more effective, just, and equitable healthcare system. We’re proud to be a part of bringing that vision to life.

→ Hillman Emergent Innovation Grantees→ Hillman Emergent Innovation:
       Serious Illness and End of Life Grantees
→ Hillman Innovations in Care Grantees→ Hillman Innovation Dissemination Grantees→ Catalyst Award Grantees

Hillman Emergent Innovation Grantees

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


Hillman Emergent Innovation:
Serious Illness and End of Life Grantees

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


Hillman Innovations in Care Grantees


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)

Hillman Innovation Dissemination Grantees

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


Catalyst Awards

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


Privacy Notice

To help us in the evaluation and analysis of projects, all proposals, documents, communications, and associated materials submitted to The Rita and Alex Hillman Foundation (collectively, “Submission Materials”) will become the property of the Foundation and will be shared with other members of the Advisory Committee, Board of Directors, and other funding partners or potential funding partners. We will report publicly on the number of applications received.

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