During Dr. Liebel's 15-year research career at the SON she has worked conscientiously to conduct a program of research focused on the use of innovative nurse models of care management designed to improve the quality of life and health outcomes of older persons experiencing multiple chronic conditions (MCC), depression, and disability. This research is a natural outgrowth of Liebel’s initial work as a project manager for the "Medicare Primary and Consumer-Directed Care Medicare Demonstration" (MCPC), an RCT trial conducted across 3 states, providing comprehensive care management to community-dwelling older Medicare beneficiaries (n=1600)who had an existing disability and prior use of healthcare (e.g. hospitalizations).  Liebel was a member of the core research team, responsible for the implementation and management of all phases of the research project including the implementation of nurses' intervention arm (e.g., health promotion, disease management, coaching/empowerment, goal setting/behavioral change) as well as joint visits with nurses, PCP,s, and patients. Outcome evaluation of the Medicare Demonstration showed favorable health outcomes among participants (e.g., less disability worsening) as well as a reduction in healthcare cost and use (le.g., less NH use). Notably, this trial was one of only six studies to achieve less disability among these older persons who were experiencing high levels of health complexity. Liebel also conducted and published results from a process evaluation of the nurse intervention, finding good fidelity and participant engagement as well as identifying the select nurse activities instrumental in achieving the beneficial disability outcomes (i.e., disease/medication self-management, goal setting showed ting, family conference visits, and visit dose). During her tenure as a Post-Doc Fellow in Geriatrics and Geronotlooigy (T-32) and faculty roles, she continued to conduct multiple analyses and evaluations of the MCDC trial data (i.e., BMI, individual IADL/ADL, and personal care use). The evaluation results were disseminated in a series of publications and presentations,  providing considerable evidence to support Liebel's research agenda- to promote the use of integrated care management (ICM) nurse interventions in acute Medicare home healthcare settings.  

Simultaneously, Dr. Liebel developed an academic partnership with the SON and the University of Rochester Medical Home Care (URMHC) agency to conduct a series of qualitative and quantitative descriptive research studies with agency nurses exploring the delivery of ICM (e.g., depression care management (DCM); disability care management) during episodes of care. A chart review (N=100) determined that when nurses used depression care plans depression was less, Qualitative analyses of data from nurses' interviews and focus groups showed that agency nurses were not confident in providing ICM or DCM. Thus, Dr. Liebel designed, developed, and tested evidence-based strategies and educational tools/courses for HHC nurses to use based on best practices in DCM as well as her own research findings. Subsequently, after conducting observation visits in the home, she saw the need to develop a therapeutic communication curriculum that nurses could use to more efficiently address health complexity. Liebel also presented and published about how the nurse-patient relationships were the primary mechanism for the effective delivery of ICM leading to improved health outcomes (e.g. delaying or slowing patients’ physical decline) and community-level outcomes. Next, Liebel used the results from the evaluation of the tools to develop a new ICM intervention named NSPIRE (Interactive Nursing Support to Promote Integrated care for elders REceiving HHC). She has applied for funding to NIH and other funding sources to test and evaluate the intervention in a Medicare setting.

In addition, she has continued to augment her education and expertise in population health on a national and international level. For example, she was invited to attend the International Summer Institute on Integrated Care (Oxford, England) and completed an Integrated Care Management certification course (developed by CMSA). Liebel also teaches multiple courses in her faculty role such as Population Health, Program Evaluation, Research, and Population Health and Care Management

Overall, these enhanced skills have enabled her to act as an effective interface between the HHC system, nursing students, older persons, and communities.


Current Focus

I have worked conscientiously to conduct a program of research, improve my teaching practice, and engage in professional activities related to comprehensive care management of aging populations. My program of research explicitly targets improving the quality of life among older persons with multiple chronic conditions (MCC), depression, and disability in the following ways. First, by conducting community-based exploratory research to illuminate the substantial health disparities experienced by this population. Second, by designing, implementing, and evaluating the effectiveness of nurse-led models of integrated care management (ICM) designed to improve disability and depression outcomes for persons receiving home health care (HHC) services. Third, I have established a track record of peer-reviewed (i.e., first and second authored) publications, about this understudied sub-population of vulnerable older persons. Fourth, I provide clinical expertise about principles of population-based approaches to healthcare, including health promotion, community health, integrated care, and evidence-based programs (e.g., health prevention programs;

Professional Experience
Associate Professor of Clinical Nursing, University of Rochester (Nursing), Rochester, NY, US. 2020 - Current

Instructor, University of Rochester (Comprehensive Gerontological Care: A Holistic Approach to Caring for the Older Adult), Rochester, NY, US. 2012 - Current

Instructor, University of Rochester (Intervention Administration and Data Collection in Clinical Practice), Rochester, NY, US. 2012 - Current

Teacher's Assistant, University of Rochester (Principles and Applications of Evidence for Nursing Practice), Rochester, NY, US. 2005 - Current

Instructor, University of Rochester (Population Health), Rochester, NY, US. 2011 - 2012

Post Doctoral Fellow, School of Nursing University of Rochester, Rochester, NY, US. 2009 - 2012

Instructor, University of Rochester (Research Principles for Evidence Based Advanced Practice), Rochester, NY, US. 2010 - 2011

Post Doctoral Fellowship, University of Rochester School of Nursing (Geriatrics and Gerontology (T32)), Rochester, NY, US. 2007 - 2009

Post Doctoral Fellow, None (T32 Training in Geriatrics and Gerontology), US. 2007 - 2009

Teaching Assistant, University of Rochester School of Nursing (Undergraduate Nursing Courses), Rochester, NY, US. 2005 - 2006

Co-Investigator, Medicare Demonstration (MCDC) (Depression in Primary Care: Testing a Consumer Directed Care Model), US. 2003 - 2004

Co- Principle Investigator, Medicare Demonstration (MCDC) (Health Promotion Nurse Model for Chronic Disease Self-Management in Rural Areas), NY, US. 2002 - 2003

Intervention Nurse Supervisor, Monroe County Long Term Care Program (Randomized Control Trial of Primary and Consumer Directed Care for people With Chronic Illness), Rochester, NY, US. 1998 - 2003

Nurse Health Educator/Counselor, University of Rochester (Weight Management), Rochester, NY, US. 1997 - 1999

Nurse Health Educator/Counselor, Johnson and Johnson Clinical Diagnostics (Healthy Weights Program), US. 1995 - 1996

Charge and Staff Nurse, Strong Memorial Hospital, Highland Hospital, Allentown and Bethlehem Hospital, Dudley Elementary School., (Nursing), US. 1978 - 1990

Who’s Who in the World and Lifetime Achievement
Marquis Whos Who, 2018

Integrated Care in Theory and Practice
Wolfson College, University of Oxford, 2016

Terry Family Research Fund Award,
University of Rochester, 2016

Who’s Who in America
Marquis Whos Who, 2015

Nominee Nurse of the Year, Education/Research,
March of Dimes, Rochester, NY, 2015

Elaine Hubbard Research Award
University of Rochester, 2014

Carole Brink Geriatric Research Fund Award
University of Rochester, 2013

Most Promising New Investigator,
University of Rochester, 2013

Geriatric Nursing Research Scholar
John A. Hartford Institute for Geriatric Nursing, 2011

Jill Thayer Dissertation Award
University of Rochester , 2006

Scholars Day Masters Thesis Award
SUNY Brockport , 1998

The medical director/role with a facility ID in developing a quality assurance and performance improvement program
Annual Meeting, American Geriatrics Society, 2014
Orlando, Florida

The Meliora traineeship: Preparing adult gerontological nurse practitioners for interprofessional team work and leadership in quality improvement
Annual Meeting, American Geriatrics Society, 2014
Orlando, Florida

The Supported Living Research Network (SLRN): A Community/ Academic Partnership for Assessing and Meeting the Needs of Older Adults
The Gerontological Society of America Annual Scientific Meeting on Optimal Aging Through Research, 2014
New Orleans, Louisiana

Effect of an HVN Intervention of Individual ADLs
Academy of Health, 2011

Structure and Process Components Associated with Disability Maintenance/Improvement of a Primary Care Affiliated Home Visiting Nurse Intervention
66 th Annual Scientific Meeting of the Gerontological Society of America, Gerontological Society of America, 2011
Boston, Massachusetts

Impact of Disease Management-Health Promotion on Total Healthcare Expenditures
Academy of Health, 2010

Further Analyses of a Process Evaluation of a Nurse Home Visiting Intervention
The Honor Society of Nursing: Sigma Theta Tau International, 2010

Weathering the Storm: Nurse Home Visiting to Older Adults with Existing Disability
State Society of Aging, 2009
New York

Weathering the Storm: Qualitative analysis of nurse home visiting to older adults with existing disability
The American Geriatric Society, 2009

Patient satisfaction, Empowerment, and Health and Disability Status Effects of a Disease Management-Health Promotion Nurse Intervention among Medicare Beneficiaries with Disabilities
Academy of Health, 2009

Weathering the Storm: Qualitative analysis of nurse home visiting to older adults with existing disability
Gerontological Society of America, 2008

Results of a Process Evaluation of Nurse Home Visiting that Postponed Disability Worsening in Older Adults
American Geriatric Society, 2008

Process Evaluation of a Nurse Home Visiting Intervention that Postponed Disability Worsening in Order Adults
American Public Health Association (Gerontological Health Section), 2007

Results of a Process Evaluation of a Nurse Home Visiting Intervention that Postponed Disability Worsening in Order Adults
American Public Health Association (Gerontological Health Section), 2007

Results of a Process Evaluation in Rural Elders Participating in a Nurse Home Visiting Program
American Public Health Association (Gerontological Health Section), 2007

Chronic Disease- The Big Picture and Innovative Strategies for Patients
University of Rochester Symposium/Seminar, Department of Community and Preventative Medicine, 2006
Rochester, New York

Outcomes of Functionally Impaired Older Adults (best practices and tools)
Presentation to the NY State Office of the Aging Directors, Finger Lakes Geriatric Center, 2002
Finger Lakes, New York

Case Studies of Functionally Impaired Older Adults with High Medicare Utilization
American Public Health Association (Gerontology Health Section), 2002

Comprehensive Senior Assessment Using Problem Knowledge Coupler Technology in a Nursing Intervention
Comprehensive Senior Assessment Using Problem Knowledge Coupler Technology in a Nursing Intervention, Monroe Country Hospital, 2000
Rochester, New York

Geriatrics and Managed Care
Rural Initiatives/ innovations in Comprehensive Senior Assessment and Treatment Plans, Fingerlakes Geriatric Education Center & Community for Long Term Care, 1999
Rochester, New York

Coping with the Long QT Syndrome
SUNY Brockport, 1997
Brockport, New York

Wang, J., Liebel, D. V., Yu, F., Caprio, T. V., & Shang, J. (2018). Inverse dose-response relationship between home health care services and rehospitalization in older adults. Journal of the American Medical Directors Association. PMID: 30579919 DOI: 10.1016/j.jamda.2018.10.021

Miner, S., Liebel, D.V., Wilde, M.H., Carroll, J.K., Omar, S. (2018). Somali older adults' and their families' perceptions of adult home health services. Journal of Immigrant and Minority Health, 20 (5), 1215-1221. PMID: 28929315 DOI: 10.1007/s10903-017-0658-5

Miner, S; Liebel, DV; Wilde, MH; Carroll, J; Omar, S (2017). Using a Clinical Outreach Project to Foster a Community-Engaged Research Partnership With Somali Families. Progress in Community Health Partnerships: Research, Education, and Action, 11 (1), 53-59.

Miner, S., Liebel, D.V., Wilde, M.H., Carroll, J.K., Omar, S. (2017). Somali Older Adults' with Their Families' Perceptions of Adult Home Health Services. J Immigr Minor Health. PMID: 28929315 DOI: 10.1007/s10903-017-0658-5

Lowey S, Liebel D (2016). Factors that influence care transitions of end-stage heart failure patients to palliative home care. Journal of Hospice & Palliative Nursing, 18 (6), 572-578.

Miner S, Liebel D, Wilde M, Carroll J, Zicari E, Chalupa S (2015). Meeting the Needs of Older Adult Refugee Populations with Home Health Services. Journal of Transcultural Nursing. PMID: 26711884 DOI: 10.1177/1043659615623327

Gillespie, S., Olsan, T., Liebel, D. Cai, X., Stewart, R., Katz, P.R., & Karuza, J (2015). Pioneering a nursing home quality improvement learning collaborative: A case study of method and lessons learned. Journal of the American Medical Directors Association. PMID: 26420494 DOI: 10.1016/j.jamda.2015.08.014

Liebel, DV; Friedman, B; Conwell, Y; Powers, BA (2015). Evaluation of Geriatric Home Healthcare Depression Assessment and Care Management: Are OASIS-C Depression Requirements Enough?. AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY, 23 (8), 794-806.

Friedman B, Santos EJ, Liebel DV, Russ AJ, Conwell Y (2015). Longitudinal prevalence and correlates of elder mistreatment among older adults receiving home visiting nursing. J Elder Abuse Negl, 27 (1), 34-64.

Liebel DV, Powers BA, Hauenstein EJ. (2015). Home health care nurse interactions with homebound geriatric patients with depression and disability. Res Gerontol Nurs, 8 (3), 130-9. PMID: 26042245 DOI: 10.3928/19404921-20150105-01

Friedman, B., Yanen, L., Liebel, D., & Powers, B. (2014). Effects of a home visiting nurse intervention versus care as usual on individual activities of daily living: a secondary analysis of a randomized controlled trail. BMC Geriatrics, 14 (24).

Li, Y., Liebel, D.V., & Friedman, B. (2013). An Investigation into which individual Instrumental Activities of Daily Living are Affected by a Homo Visiting Nurse Intervention. Age Ageing, 42 (1), 27-33. PMID: 23034558 PMCID: PMC3577044 DOI: 10.101093/ageing/afs151

Liebel, D., Friedman, B., Watson, N., Powers, B. (2012). Which components of a primary care affiliated home visiting program are associated with disability maintenance/improvement?. Home Healthcare Services Quarterly.

Liebel, D., Powers, B., Watson, N., Friedman, B. (2011). Barriers and facilitators to optimize function and prevent disability worsening: A content analysis of a home visit nurse intervention. Journal of Advanced Nursing, 68 (1), 80-93. PMID: 21645046 DOI: 10.1111/j.1365-2648.2011.05717.x

Meng, H., Liebel, D. Wamsley, B. R. (2011). Body Mass Index and the impact of a health promotion intervention on health services use and expenditures. Journal of Aging and Health, 23 (4), 743-763. PMID: 21311047 DOI: 10.1177/0898264310395755

Meng, H., Liebel, D. Wamsley, B. (2011). Health Promotion intervention, Body Mass Index, and health care expenditures among Medicare beneficiaries with disabilities. Journal of Aging and Health, 23 (4), 743-763.

Friedman, B., Wamsley, B., Liebel, D., Saad, Z., Eggert, G. (2009). Patient satisfaction, empowerment, and health and disability status effects of a disease management-health promotion nurse intervention among Medicare beneficiaries with disabilities. The Gerontologist, 49, 778-792. PMID: 19587109 DOI: 10.1093/geront/gnp090

Liebel, D., Friedman, B., Watson, N., Powers, B. (2009). Nursing home visiting interventions for community dwelling older persons with existing disability. Medical Care Research and Review, 66 (2), 119-146.

Liebel, D. & Watson, N. (2009). Consolidating medication passes: It can lead to more time with patients. American Journal of Nursing, 105 (12), 63-64.

Meng, H., Wamsley, B., Friedman, B., Liebel, D., Dixon, D., Gao, S., et al. (2009). Impact of body mass index on the effectiveness of a disease management-health promotion intervention on disability status.. American Journal of Health Promotion, 24 (3), 214-222. PMID: 20073389 DOI: 10.4278/ajhp.081216-QUAN-306

Meng, H., Wamsley, B., Liebel, D., Dixon, D., Eggert, G., Van Nostrand, J. (2009). Urban-Rural differences in the effect of a Medicare health promotion and disease self-management program on physical function and healthcare expenditures. The Gerontologist, 49 (3), 407-417.

Meng, H.; Wamsley, B., Friedman, B., Liebel, D., Eggert, D. (2009). Personal Assistance (PA) ue and expenditures among high-risk Medicare beneficiaries. Home Health Care Services Quarterly, 28 (4), 113-129.