Faculty Chair:
Leandrita Ortega/Stephanie Benson
Assistant Faculty Chairs:
- Patrick Leung
- Davena Norris
- Danielle Fitzsimmons-Pattison
- Daubney Boland
- Erika Gergerich
Required Experiences:
This rotation will consist of longitudinal components as well as a 4 week rotation done either during the PGY-2 or PGY-3 training year. Longitudinal components include the requirement for all residents to participate in the care of patients in the skilled nursing facility as measured by care provided to at least 2 patients within the nursing facility over 3 years. It will also include Participation in at least 2 home visits for elder patients over the 3 years of training. Descriptions of the individual components of education during the 4 week block are outlined below.
During the 4 week rotation residents will attend and participate in:
- A pharmacy clinic focused on geriatric population.
- A weekly half day experience visiting one of the SNF’s in town and reviewing the care of our patients in that facility with attention to medication review, behavioral assessments, and addressing of acute medical issues. A member of the behavioral and pharmacy team will accompany the resident. One SNF will be visited per week so that each SNF is reviewed by the end of the 4 week block.
- A half day per week working with PT to learn and perform functional assessments of the elderly
- A half day per week working with the behavioral team learning and performing neuro-cognitive and behavioral assessments of the elderly
- A full day per week learning end of life care with a preceptor at Mesilla Valley Hospice.
- A team based comprehensive assessment and discussion of the elderly patient of their choice.
Optional Experiences:
Additional experiences may be available as additional electives, for example in hospice care, or during the 4 week block and may include such things as additional hospice training, participation in senior adult community education, and work alongside the hospital chaplain at Memorial Medical Center.
Suggested Weekly schedule:
| Monday | Tuesday | Wednesday | Thursday | Friday | |
| AM | Clinic | Clinic | PT evaluations | Hospice | Clinic |
| PM | Pharmacy Clinic | Behavioral Assessments | Didactics | Hospice | SNF Visits |
Requirements:
AOA
Geriatrics
The program must provide at least 100 hours or 1 month of training in the care of the geriatric patient. This is in addition to training that occurs in the continuity of care site or general internal medicine rotations.
At a minimum this shall include:
- Physiological changes of aging.
- Pharmacokinetics in the elderly.
- Functional assessment of the elderly.
- ECF management.
- Hospice.
- Home care.
ACGME
Residents must have at least 100 hours (or one month) or 125 patient encounters dedicated to the care of the older patient. (Core)
The experience must include functional assessment, disease prevention and health promotion, and management of patients with multiple chronic diseases. (Detail)
The experience should incorporate care of older patients across a continuum of sites. (Detail)
Description of Rotation or Educational Experience:
The percentage and number of older adults in our society is steadily increasing. Elderly persons occupy a large number of acute-care hospital beds, comprise the largest percentage of nursing home residents, and make more visits to physicians’ offices than any other segment of the population. The acquisition of age-appropriate skills and knowledge in taking a patient’s history, performing a physical examination, making clinical and psychosocial diagnoses, and managing a patient’s condition must be an integral part of residency training. Yet, the American health care system has become more focused on acute and episodic care rather than preventative, chronic, and comprehensive care.
Although people do not suddenly acquire different characteristics at an arbitrarily predetermined age, there are many subtle, yet significant, differences in the diagnosis and management of older adults when compared with younger patients. The philosophy of providing comprehensive, continuing care includes the belief that a patient’s health in his or her later years is vitally affected by lifestyle and health care patterns established earlier in life. One goal of family medicine is to prepare younger adult and middle-aged patients for changes that occur with aging. Another goal is to assist elderly persons to function independently with self-respect, preserving their lifestyles as much as possible. This curriculum applies a comprehensive approach to the psychosocial and economic factors affecting aging patients and their families.
Expectations:
Residents:
Residents are expected to arrive to the preceptor’s office and continuity clinics on time and to dress and act in a professional manner. It is expected that while at the preceptors’ office the residents will be respectful of the office space and personnel. The resident is responsible for maintaining a procedure log as well as completing assigned readings. The resident is also responsible for identifying one of their geriatric continuity patients for the team based care portion of the rotation at the beginning of the rotation. The resident then must notify the Faculty Advisor, Pharmacist Faculty, and Behavioral Faculty and choose a date towards the end of the rotation for a team based care case review. Residents are also expected to complete the end of the rotation quiz and turn it into the Faculty Advisor.
Faculty:
Family medicine faculty will provide precepting of geriatric cases and procedures as seen in resident continuity clinics, SNF encounters, and home visits. The Family medicine faculty, Pharmacy Faculty, Behavioral faculty as well as additional hospice and PT preceptors will provide precepting during the focused Geriatric rotation. The faculty and preceptors are expected to allow the resident to participate in active patient care and procedures when appropriate. The Faculty team will also arrange a time with the resident towards the end of the 4 week rotation for a 1 hour Team based care conference for comprehensive review of the care of the resident’s chosen patient. The faculty will complete the end of the rotation evaluation in a timely manner and the Faculty Advisor will return the graded end of the rotation quiz to the resident for feedback.
Call:
There are no specific call requirements for this rotation. The resident may choose to take call as an optional experience with the Chaplain or Hospice provider.
Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:
Competencies
- Be able to perform comprehensive, standardized medical, functional and behavioral geriatric assessments and develop short- and long-term treatment plans. (Patient Care, Medical Knowledge)
- Recognize his or her own practice limitations and seek consultation with other health care providers when necessary to provide optimal care. (Patient Care)
Objectives
In the appropriate setting, the resident should demonstrate the ability to independently perform:
- A comprehensive history and mental status examination in the office, hospital, and nursing facility, utilizing all available sources of information
- Psychological screening examinations of the geriatric patient for each of the following problem areas: anxiety, insomnia, depression, suicidal ideation and intent
- Functional assessments to include evaluation of mobility, gait, and balance
- Functional status including activities of daily living (ADL) and instrumental activities of daily living (IADL
- Neuro-cognitive assessment of the older adult including the administration and proper interpretation of a Montreal Cognitive Assessment (MOCA), a Folstein Mini-Mental Status
- Evaluation of the appropriate use of assistive devices (e.g.canes,walkers,wheel or power chairs)
- Appropriate selection, interpretation, and performance of diagnostic procedures, including recognition of appropriate and inappropriate screening to be done at this stage of life.
- Appropriate house calls and coordination of home care
- Counseling of patients about age-related psychological, social, and physical stresses and changes of the normal life cycle of aging, dying, and death
- Facilitated discussions with the patients and family re: advance directives, decision-making capacity, and palliative and end-of-life care
These objectives will be measured through direct observation recorded by an end of the rotation evaluation At least one patient record documenting the proper administration and interpretation of the MOCA, Folstein Mini-Mental Status exam, to include a neurologic exam will be submitted at the end of the rotation for review by the behavioral faculty. Knowledge of psychological screening exams will be measured by the submission of at least one patient record documenting the proper administration and interpretation of each of the above for review by the behavioral faculty.
These objectives will be taught through guided patient care, supervised by Faculty, including designated rotation time for education from PT re: functional assessments and behavioral health Faculty re: neurocognitive and mental status assessments.
Medical Knowledge
Goal
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:
Competencies
Objective:
The resident should demonstrate the ability to apply knowledge of:
- Physiologic changes of aging in the various body system
- Age-related pharmacokinetic and pharmacodynamics changes in the elderly
- Age related neurocognitive changes
- Normal psychological, social, and environmental changes of aging
- Reactions to common stresses such as retirement, bereavement, relocation, and ill health
- Changes in family relationships that affect healthcare of the elderly
- Unique modes of presentation for care, including atypical presentations of specific diseases in elderly patients
- Immobilization and its consequences including and understanding of pressure ulcer prevention
- Screening for and identification of elder abuse and neglect
- Routine screening guidelines and immunization recommendations for those over the age of 65
- Indications and benefits of the house call in the assessment and management of elderly patient
- Characteristics of the various types of long-term care facilities and alternative housing available to the elderly
- Specific regulations for patient care in long-term facilities
- Understanding local, state, and federal programs that assist the elderly to finance the cost of their health care
- Community resources, including those used to help patients maintain independence
- Evaluation of the functional status of the elderly patient
- An understanding of end of life care
- Causes of and evaluation of altered mental status in the elderly
- Causes diagnosis and treatment of delirium
- Causes diagnosis and treatment of dementia, including vascular and Alzheimer’s type
- Medication management in the elderly with attention to:
- Identification and correction of inappropriate medication therapy (dose, dosage form, duration, schedule, route of administration, method of administration)
- Adverse drug or device-related events or potential for such events
- Clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test interactions or potential for such interactions
- Interference of medical therapy by social, recreational, nonprescription, or nontraditional drug use by the patient or others
- Psychosocial causes of medication non-adherence
- Avoidance of and prevention of polypharmacy and therapeutic duplication
- The START/STOPP criteria and Beer’s list to recognize appropriate and inappropriate medication prescribing
These objectives will be measured by direct observation, an end of the rotation evaluation, and completion of assigned readings and an end of the rotation quiz.
These objectives will be taught by assigned readings and guided supervised patient care including resident continuity clinic, SNF encounters, home visits, geriatric pharmacy clinic, behavioral assessments, and functional assessments with PT.
Practice Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Residents are expected to develop skills and habits to be able to:
Competencies
- Be able to recognize his or her own practice limitations and seek consultation with other health care providers to provide optimal care.
Objectives
- Complete assigned reading topics and apply learned material in the clinical setting as well as complete the end of rotation quiz
- Demonstrate ability to identify limitations in own knowledge and take steps to fill these gaps.
System Based Practice
Goal
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:
Competencies.
- Coordinate ambulatory, in-patient and institutional care across health care providers, institutions and governmental agencies.
- Coordinate care among multiple members of the health care team
- Be able to optimize treatment plans based on knowledge of local geriatric care resources, including local, state, and federal agencies. (Systems-based Practice, Practice-based Learning and Improvement)state, and federal agencies. (Systems-based Practice, Practice-based Learning and Improvement)
Objectives
- Make appropriate referrals to and coordinate care with specialists and other members of the healthcare team when appropriate
- Demonstrate cost effective care and diagnostic testing
- Lead and coordinate a multidisciplinary team to perform a Comprehensive Geriatric Assessment (CGA) in as measured by participating faculty/team members evaluation
These objectives will be measured by an end of rotation evaluation.
These objectives will be taught by supervised direct patient care and participation in and leadership of a multidisciplinary care team.
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:
Competencies
- Compassion, integrity, and respect for others
- Responsiveness to patient needs that supersedes self-interest
- Respect for patient privacy and autonomy
Objectives
- Display sensitivity for patient privacy and autonomy during exams and procedures
- Engage in interviewing techniques which demonstrate cultural and social sensitivity
These objectives will be measured by direct observation and an end of the rotation evaluation.
These objectives will be taught by role modeling, supervised patient care, and assigned readings.
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:
Competencies
- Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
- Act in a consultative role to other physicians and health professionals
- Demonstrate the ability to communicate effectively with the patient, as well as the patient’s family and caregivers, to ensure the diagnosis is clearly understood and the treatment plan is developed collaboratively. (Interpersonal and Communication Skills)
Objectives
- Communicate with patients and their families in a respectful and concise manner with attention to adjustment of communication style to the appropriate level of education and health care literacy
- Communicate with the patient and/or caregivers the proposed investigation and treatment plans in a way that promotes understanding and adherence
- Provide patient and family education and facilitate discussion of end of life issues including advance directives and hospice care.
These will be measured by direct observation and an end of rotation quiz.
These objectives will be taught by role modeling, supervised patient care, and assigned readings.
Teaching Methods
Residents will provide medical care to patients under the direct supervision of the attending physician. They will be supervised on all procedures performed. They will participate in weekly conferences. Residents will be assigned specific reading topics to be completed by the end of their month on the service. See above section on required experiences for a detailed description of individual experiences.
Assessment Method (residents)
Direct observation with an ongoing global assessment with New Innovation Shift Cards. There will be review of documentation by family medicine preceptors as part of continuity clinic supervision. All procedures will be recorded on New Innovations and independence for each procedure assessed using the Shift Cards. Residents will be evaluated by an end of the rotation evaluation to be completed by the faculty team. The end of the rotation quiz will be graded by the Faculty Chair and returned to the resident for feedback. A score of 80% is required on the end of the rotation quiz for successful completion of the rotation. See each competency section above for additional details for assessment of each competency.
Assessment Method (Program Evaluation)
Residents will be provided with an evaluation of their experiences and given the opportunity to provide feedback of the rotation during their quarterly IEP assessments.
Level of Supervision
The resident is directly supervised by the attending physician during all procedures performed. An Attending will be available the entire time the resident is on the rotation. An Attending will be available at all times during continuity clinic visits.
Educational Resources
Readings:
Week 1
Week 2
Week 3
Week 4
Resources
1. American Academy of Hospice and Palliative Medicine. Primer of Palliative Care. 5th ed. Glenview, Il: American Academy of Hospice and Palliative Medicine; 2010
2. Arenson C, Busby-Whitehead J, Brummel-Smith K, et al, eds. Reichel’s Care of the Elderly: Clinical Aspects of Aging. 6th ed. New York, NY: Cambridge University Press; 2009.
3. Beck JC. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 6th ed. New York, NY: American Geriatrics Society; 2006.
4. Ham RJ, Sloane PD, Warshaw GA, et al, eds. Primary Care Geriatrics: A Case-Based Approach. 5th ed. St. Louis, Mo: Mosby; 2006.
5. Reuben DB. Geriatrics at Your Fingertips.13th ed. New York, NY: American Geriatrics Society; 2011.
6. Handbook of the Psychology of Aging, Seventh Edition (Handbooks of Aging) Paperback – November 16, 2010 by K Warner Schaie (Editor), Sherry L. Willis (Editor) New York: Elsevier. ISBN-13: 978-0123808820 ISBN-10: 0123808820 Edition: 7th
7. Handbook of the Biology of Aging, Seventh Edition (Handbooks of Aging) Paperback – November 30, 2010 by Edward J. Masoro (Editor), Steven N. Austad (Editor) New York: Elsevier. ISBN-13: 978-0123786388 ISBN-10: 012378638X Edition: 7th
8. Handbook of Aging and the Social Sciences, Seventh Edition (Handbooks of Aging) Paperback – November 16, 2010 by Linda George (Editor) New York: Elsevier.ISBN-13: 978-0123808806 ISBN-10: 0123808804 Edition: 7th
Web Sites
The American Geriatrics Society. http://www.americangeriatrics.org.
The American Geriatrics Society. Clinical Geriatrics. http://www.clinicalgeriatrics.com.
British Geriatrics Society. http://www.bgs.org.uk.
Geriatrics & Aging. http://www.geriatricsandaging.com.
Geriatrics journal. http://www.geri.com.
The University of Iowa. Iowa Geriatric Education Center. http://www.medicine.uiowa.edu/igec/.
SNMFMRP Curriculum 