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Acute Care of the Elderly (ACE) Curriculum at The University of North Carolina March 2013 The aim of the ACE curriculum is to ensure that Internal Medicine and Family Medicine residents will be able to provide quality, safe, and comprehensive care to acutely ill older adults, maintaining a focus on cognitive and functional status, caring for patients both in the hospital setting and during the transition out of the hospital. Rationale for Development of the ACE Curriculum: Over a third of all hospitalized patients in the United States are over the age of 65.1 Despite the ACGME requirement for a geriatrics medicine curriculum for all Internal Medicine and Family Medicine residency programs, there is still concern that graduating residents will not be adequately trained to care for the growing number of older patients.2,3 In response to this, the American Geriatrics Society outlined essential geriatric competencies for all Internal and Family Medicine residents in a 2010 position statement. These competencies outline the specific expectations for residents that enable the provision of quality care for older adults. A resident must be able to screen for delirium, depression, and dementia. A resident must be able to recognize and manage delirium as an emergency. A resident is expected to be able to discuss and document advanced care planning. Specific to hospital based care, residents must evaluate all older patients for falls risk, immobility, pressure ulcers, nutrition, pain, new urinary incontinence, constipation, inappropriate medication prescribing, and inappropriate bladder catheter usage. Emphasizing patient safety in transitions of care, a resident must be able to create a discharge summary that reflects the special needs of this population. This summary must include not only the clinical course, but also reconciled discharge medications, current cognitive and functional status, advance directives, plan of care and scheduled follow up.4 Despite these expectations, residents report the need for better training in the assessment of an older patient for hospital discharge and safe transitions of care.5 There have been several studies looking at the impact of various geriatric rotations and curricula on resident knowledge and attitudes. Most of these studies show improved scores after such experiences, but less is known about the sustainability of these effects and actual impact upon patient care.6-8 In a review of best practices for geriatrics education and integration into residency programs, the three essential elements of a sustainable and valued curriculum include the provision of model geriatric care, the focus on patient care across transitions, and the reliance on interdisciplinary teamwork.9 Emphasizing quality improvement, a requirement for all residents, is one potential strategy to teach the curriculum and translate knowledge into practice. 10-12 This curriculum will therefore focus on the inpatient care of older adults by residents in Internal Medicine, will begin with the competencies in geriatric medicine established by the AGS as essential to resident training, and will rely upon quality improvement strategies to reinforce knowledge and translate what is learned into patterns of sustainable behavior. ACE Curriculum Committee: The ACE curriculum development, implementation, and maintenance will be guided by the Program Director for the Geriatric Fellowship. The committee will include one clinical faculty member from Geriatrics, one faculty member with a PhD in education, two advanced Geriatric Fellows, and a current Geriatric Fellow in training. Two resident members of the AGS Resident Chapter at UNC will serve as resident representatives. Learners, Instructors, Context Learners: Target audience: The ACE curriculum is focused primarily upon the resident in Internal Medicine who is on a clinical rotation that centers upon the care of acutely ill older patients in the hospital setting (the Acute Care of the Elderly service). Prerequisites for learners: Residents on the service have all completed medical school training, have a Medical Degree, and have either a training or full state license to practice medicine in North Carolina Instructors: Prerequisites for Instructors: Instructors must have trained in either Family or Internal Medicine, be board certified in Geriatric Medicine, and have an appointment through the Division of Geriatric Medicine as clinical and teaching faculty. All instructors meet regularly as part of the Division of Geriatric Medicine, receive faculty development for teaching, and will receive all curricular goals and objectives prior to teaching. Context, Structure, and Organization for the ACE Curriculum: Context: Residents on the ACE inpatient service are the primary target learners for the curriculum. The rotation is a month long block for residents that is required by the IM residency program. This rotation may be done at any point in a resident’s training, therefore some learners will be exposed to the curriculum early in their first year of training and others not until later years. Structure: The curriculum will be taught as part of a clinical rotation. Teaching activities need to be flexible and fit within the structure of an interdisciplinary team with the primary goal of caring for acutely ill hospitalized elders. The team also consists of third and fourth year medical students as well as students and residents from other departments such as Clinical Pharmacy, Physical Medicine and Rehabilitation, and Emergency Medicine. The team is led by, and the curriculum taught by, a Clinician Educator with the Division of Geriatric Medicine. Fellows in Geriatric Medicine are also on the service and will provide a primarily educational role in the curricular activities. Organization: The Division of Geriatric Medicine within the Department of Internal Medicine will primarily be responsible for the development and implementation of the ACE curriculum. All curricula for IM residents must ultimately be reviewed, approved, and disseminated through the IM residency program. National Guidelines: The ACGME requires all IM residency programs to have geriatric curriculum that is ultimately developed and managed by faculty with expertise in geriatrics. In addition, the foundation of this curriculum is based upon a standard of core competencies set by the American Geriatrics Society for all residents in IM and FM. Institutional, Social and Community context: This curriculum meets the demand for improved care for older adults by community and social leaders as well as the ACGME and AGS. The focus on quality indicators, evidence based medicine, communication skills, and improvement in practice fits nicely with many of the ACGME core competencies as well as the requirements being established for the Next Accreditation System (NAS). UNC ACE Curriculum core competencies (based upon ACGME core competencies) 1. Patient Care: Residents will provide comprehensive, quality and evidence based care to acutely ill older patients during hospitalization and discharge. 2. Knowledge: Residents will understand the core AGS competencies expected in the care of older patients and will be able to identify common hospital problems for the elderly, assess cognitive and functional status, and review medications. 3. Communication: Residents will work with interdisciplinary teams, patients and families in the care of older hospitalized patients, and will effectively communicate the hospital course and needs at the time of transfer out of the hospital setting. 4. Systems Based Practice: Residents will understand the quality standards identified for the safe discharge of an older patient, appreciate potential safety problems during transitions in care, and ensure improved communication with the goal of improving patient safety during hospitalization and discharge. 5. Practice Based Learning and Improvement: Residents will be able to identify core components required for quality care of older adults during hospitalization and discharge, review their current practice, and utilize quality improvement strategies to provide for more safe and standardized care to all older patients. 6. Professionalism: Residents will respect each older adult as an individual, appreciate the impact that medical illness and functional decline can have upon older adults and caregivers, and strive to provide patient and family centered care. Aim: Internal Medicine residents will be able to provide quality, safe, and comprehensive care to acutely ill older adults, maintaining a focus on cognitive and functional status, caring for patients both in the hospital setting and during the transition out of the hospital. Learning Outcomes for the ACE Curriculum: This curriculum will use the AGS core competencies (see Appendix 1) as Learning Outcomes for internal medicine residents to achieve with a focus on the care of acutely ill older adults in the hospital setting. During the rotation on the ACE service, the internal medicine resident will develop the skills needed for appropriate prescribing, cognitive and functional assessment, caring for the individual with a focus on goals of care, and patient safety during hospitalization and transitions of care. Appropriate Prescribing: The resident will be able to: 1. Appropriately prescribe drugs, considering age related changes, side effects, and drug-drug interactions and if prescribing high risk drugs, discuss and document the rationale for their use, alternatives, and ways to decrease side effects 2. Review medications with the patient and/or caregiver, assess for adherence, and consider adverse medication reactions in the differential of new symptoms Cognitive and Functional Assessment: The resident will be able to: 3. Identify and understand how to use and interpret at least one tool each for the assessment of delirium, dementia, depression and substance abuse 4. Recognize delirium as a medical urgency and evaluate and manage patients with changes in affect, cognition, and behavior 5. Perform and document standard assessments of cognitive and functional status 6. Identify barriers to communication (hearing, speech, health literacy, cognition) 7. Determine whether an older adult has capacity 8. Assess, document, and manage fall risk, immobility, pressure ulcers, adequacy of oral intake, pain, new urinary incontinence, and constipation Caring for the individual older patient, understanding complexities of aging and focusing on goals of care: The resident will be able to: 9. In evaluating acute ill older adults, generate differential diagnoses that include diseases that present atypically in older adults and demonstrate understanding of the major age related changes in physical and laboratory findings 10. Individualize standard recommendations for screening tests and chemoprophylaxis based on life expectancy, functional status, patient preference, and goals of care 11. Demonstrate respect for each older patient as an individual, avoiding stereotypes, and understanding the core concept of function 12. Discuss and document advance care planning and goals of care with all patients 13. Develop a treatment plan that incorporates the patient’s and family’s goals of care, preserves function, and relieves symptoms and in patients with life threatening illness, assess pain and other distressing symptoms, institute appropriate treatment based upon goals of care, and transition to comfort care when appropriate Patient Safety during hospitalization and transition of care: The resident will be able to: 14. In patients with a bladder catheter, discontinue or document indication for use 15. Before using or renewing physical or chemical restraints, assess for and treat reversible causes of agitation and consider alternatives to restraints 16. Identify older persons at high safety risk, including unsafe driving or elder abuse/neglect, and develop a plan for assessment and referral 17. When transferring a patient from the hospital, work with an interdisciplinary team to create a plan of care with a written summary of the hospital course that is transmitted to the patient and/or family caregivers as well as the receiving health care providers. This summary should also communicate clinical status, discharge medications, current cognitive and functional status, advance directives, plan of care, scheduled or needed follow up, and hospital physician contact information. Performance Indicators for the UNC ACE Curriculum: At the end of the rotation on the Inpatient Geriatric (ACE) service, the resident will specifically be able to do the following skills needed for: Appropriate Prescribing: 1. Identify medications that are high risk for older adults, including commonly used medications such as insulin, oral hypoglycemic agents, and warfarin 2. Document risks of potentially inappropriate medications and polypharmacy in admission notes for older patients Cognitive and Functional Assessment: 1. Use and interpret the Mini-Cog as a basic screening tool for cognitive assessment and document the results in the discharge summary 2. Assess a patient for capacity and document specific concerns 3. Use and interpret the Confusion Assessment Method (CAM) to screen for delirium at the time of admission and again at discharge, documenting results for appropriate transfer of care 4. Perform and interpret a Get Up and Go screening test for gaits and falls assessment on all patients, documenting assessment in the discharge summary 5. Perform and interpret a depression screen in an older patient (PHQ2 or PHQ9 or Geriatric Depression Screen) 6. Create hospital progress notes that document fall risk, immobility, pressure ulcers, adequacy of oral intake, pain, new urinary incontinence, and constipation Caring for the individual older patient, understanding the complexities of aging and focusing on goals of care: 1. Demonstrate clinical reasoning in oral presentations as well as written admission notes of newly admitted patients that includes an understanding of atypical presentations of common diseases in the elderly and common changes of aging 2. Demonstrate respect for the individual in oral presentations and communications with team members, students, and other clinicians in the care of older adults 3. Describe to the team and include in the admission note patient and/or caregiver goals of care for the hospitalization of an older patient 4. Perform and document an advanced care planning discussion with a patient and/or caregiver, going beyond standard “Do Not Resuscitate” discussions Patient Safety during hospitalization and transition of care: 1. Document the presence of any bladder catheter, physical or chemical restraints, identify any indications for continued use or document discontinued use, and identify alternatives when appropriate 2. Appropriately review medications in older adults at the time of discharge, evaluating for and managing inappropriate prescribing, and document a medication review and reconciliation (including new medications, stopped medications, and final medication list) in the final discharge summary 3. Utilize a discharge template that includes quality indicators for care of older adults who are transferring out of the hospital setting that accurately and concisely communicates evaluation and management, clinical status, discharge medications, current cognitive and functional status, advance directives, plan of care, scheduled or needed follow up, and hospital physician contact information. Primary Domains for Learning Outcomes (AGS competencies for residents) and relationship to ACGME core competencies •Appropriate Prescribing •Caring for the Individual with a focus on goals of care •Cognitive and Functional assessment SBP Knowledge PBLI Knowledge Patient Care Communication professionalism PBLI SBP Knowledge communication •Pateint safetfy during hospitalization and discharge Instructional Design: Week 1: Sessions 1-5, Laying the Foundation Session Learning Performance Outcome, the Indicator, the resident will be resident will: able to: 1: Generate Demonstrate Orientation: differential clinical overview of diagnoses that reasoning in learning include diseases oral and outcomes that present written and atypically in older presentations performance adults and indicators for demonstrate Demonstrate entire understanding of respect for the rotation major age related individual in changes in physical oral and lab findings presentations and Demonstrate communication respect for each with team older patient as an members, individual, students and avoiding other clinicians stereotypes, and understanding core concepts of function 2. Use and interpret Use and Introduction at least one tool for interpret the to Cognitive assessment of Mini cog as a and delirium and basic screening Functional dementia tool for Assessment cognitive Perform and assessment and document standard document in assessments of d/c summary cognitive and functional status in Use and all older adults interpret the CAM to screen Recognize delirium for delirium at as an emergency admission and discharge and Determine whether document at Activity (all small group activities) Assessment Introduction to functional status: watch video http://www.nyti mes.com/2009/ 08/24/health/24 nursing.html?pag ewanted=all&_r= 0 Clinical evaluation by faculty at mid and end points (resident meeting ACGME core competencies of communication, professionalism , PBLI and SBP) Overview, AGS competencies, ACE curriculum, expectations, Geriatric Tracker Discussion: self assessment: what is geriatrics, interdisciplinary care? Discussion: What is the minicog? What is the CAM? How do you know if someone has capacity? How do you document these assessments? Case examples: capacity Geriatric fellow to demonstrate assessment tools Self assessment as part of GeriTracker Geri-Tracker to document use of Mini-Cog, CAM, Get Up and Go Chart reviews by attending on daily basis (as part of process in which attendings have to sign off on all patient notes) Chart reviews by fellow on 3. Appropriate Prescribing an older adult has capacity time of transfer of care Assess, document, and manage fall risk Assess a patient for capacity, document concerns in the medical record Appropriately prescribe drugs, considering age related changes, common side effects, and if using high risk medications discuss and document reason for use Review medications, consider drug side effects in differential of any new symptom 4. Goals of Discuss and care and document advance advanced care planning and care planning goals of care with patient/surrogate Develop treatment plan that incorporates goals of care, preserves function, and relieves symptoms; Perform and interpret a get up and go for gait and falls, document in d/c summary Identify medications that are high risk for older adults, including commonly used drugs (warfarin, insulin) Document risks of potentially inappropriate meds and polypharmacy in admission notes Describe to the team and include in the admission note goals of care for hospitalization Perform and document an advanced care planning discussion with with group Distribute and review Teaching Cards (Mini-Cog, CAM, Get up and Go) service at the beginning, midpoint, and end of rotation Introduction of the Discharge Template Reading materials: Revised Beers List from the AGS 2012 Presentation: Weighing risks and benefits of medications (15 minutes) Problem Based Learning (PBL) exercise: Review of sample medication lists Small group discussion: experience with advance care planning discussions, communication, prognosis Group exercise: Chart audit – how many have Daily review of notes by attending Chart audits by fellow at beginning, midpoint, and end of each rotation (as part of the discharge summary chart review) Geri-Tracker 5. Hospital Discharge and Transitions of Care assess pain and distressing symptoms, treat based on goals, and transition to comfort care when appropriate a patient and/or caregiver, going beyond the standard “DNR” discussions and orders Work with an interdisciplinary team when transferring a patient out of the hospital Appropriately review meds in older adults at d/c, evaluating for inappropriate prescribing, document med review and reconciliation (new meds, stopped meds, final list) in the final d/c summary Create d/c summary that is transmitted to patient/caregiver as well as receiving health care team that communicates evaluation and treatment, clinical status, d/c meds, cog and functional status, advance directives, plan of care, f/u, physician contact information advance care planning documented? Are goals of care discussed? How many have DNR order but no documentation of discussion? PBL medication reconciliation exercise with practice discharge summary Review medication reconciliation process Chart audits by fellows (review of d/c summaries) in beginning, midpoint, and end of rotation Review d/c summary template and quality Utilize d/c indicators: template that Clinical summary includes quality Med review, indicators for Cognitive status care of older Functional status adults who are Advance transferring out directives of hospital Follow up, contact Week 2: Sessions 6-10, Hospital Complications and Patient Safety Session 6. Catheters and restraints Learning Outcome: The resident will be able to …. In patients with bladder catheter, Performance indicator: the resident will…. Document presence of any bladder Activity Assessment Small group exercise with chart audits: Does your patient have a Geri-tracker discontinue or document Before using or renewing restraints, assess for and treat reversible causes of agitation and consider alternatives Session 7. Assess, Hospital document, and complications manage pressure ulcers, nutritional status, new urinary incontinence, and constipation Session 8. Identify and Barriers to assess barriers communication to communication in the hospital setting Session 9. Depression and substance abuse Session 10. Safety outside the hospital— screening for Identify and understand how to use and interpret at least one tool for delirium, dementia, depression, substance abuse Identify older persons at high safety risk, including catheter and discontinue or document indication Identify chemical and physical restraints, discontinue or document indication Create notes that document assessment of fall risk, immobility, pressure ulcers, oral intake, UI, constipation Identify and assess for hearing loss, speech problems, health literacy, cognitive disorders Perform and interpret depression screen (PHQ 2, PHQ 9, geriatric depression scale), screen for substance abuse Assess for driving safety Assess for bladder catheter? Oxygen tubing? Compression stockings? Telemetry leads? How can these be restraints? Attending review of daily progress notes Discussion/presentation: what are restraints? what are chemical restraints? What are problems with antipsychotics? 20 minute presentation: Geri-tracker pressure ulcers, nutrition, new UI, Attending constipation review of daily notes Hands on review of pressure ulcers with Nurse Practitioner Watch Health Literacy video GeriTracker Small group presentation: hearing, sight, speech Clinical evaluations Small group discussion: What challenges so far? Presentation/ Discussion: Depression, Dementia Delirium and substance abuse GeriTracker Review screening with fellow role play Presentation/discussion: GeriEM, driving assessments Tracker (how do we think of safety screening in elder mistreatment and unsafe driving unsafe driving elder or elder mistreatment abuse/neglect, and develop a plan for assessment and referral young adults -seatbelt use, drug use, etc-and children -smoking in the home, IPV in the home, carseat-: Although EM and driving seem separate, think “safety” Week 3, Sessions 11 and 12: Caring for the Individual patient, understanding the complexities of aging Session Learning Performance Activity Assessment outcome, the Indicator, the resident will be resident will…. able to…. 11. Individualize Practice shared Small group Geri-Tracker Understanding recommendations decision making, discussion the Medicare for screening based upon life centered Annual based on life expectancy, goals around Wellness Visit expectancy, of care, Medicare functional status, functional status Wellness Visit patient preference, and patient guidelines and goals of care preference 12. Risks and Individualize Practice shared Presentation Geri-tracker benefits of recommendations decision making and discussion: treatment based on life with knowledge risks and expectancy, of risks and benefits functional status, benefits patient preference, Sessions 13-18: Special topics that are common to the ACE service: These topics can be taught at any point in the rotation. Presentation materials are available on the website for faculty to use, and should be done when appropriate cases are admitted to the hospital that can serve as examples (case based learning). 1. Hyponatremia and hypernatremia 2. Care of the patient with a hip fracture 3. Congestive Heart Failure: systolic and diastolic heart failure in older adults 4. Pneumonia, including aspiration pneumonia and feeding tubes 5. Tremors and movement disorders 6. Urinary incontinence Sessions 19-20: 1. Final chart audit with the team to review their own progress 2. Meetings with individual residents and students for feedback and evaluations Resources for Curricular Activities: 1.Video at orientation: http://www.nytimes.com/2009/08/24/health/24nursing.html?pagewanted=all&_r=0 2. Video for health literacy 3. Readings: Geriatric At Your Fingertips (6 copies available to team on service) 4. Pocket Teaching Cards: Mini-Cog, CAM, Get Up and Go, Reconciliation, D/C template 5. Sample medication list for PBL exercise 6. Sample discharge summary for PBL exercise 7. Presentations : available on Geriatric website, link to website on IM Resident home page 8. Geri-Tracker (Appendix 2) 9. Discharge Summary Chart Audit Rubric Learner Assessment and Evaluation Summative Evaluation: The evaluation of IM residents on the ACE service will be done with the UNC resident evaluation form that is organized by ACGME competency with associated milestones (appendix 4), but with a specific focus on the care of the older hospitalized patient. Evaluations of resident performance are based upon observations of clinical care, sign off of clinical notes and documentation, and review of the Geri-Tracker by the faculty. Residents will need to demonstrate proficiency in core competencies as follows: 1. Patient Care: Residents will provide comprehensive, quality and evidence based care to acutely ill older patients during hospitalization and discharge. 2. Knowledge: Residents will understand the core AGS competencies expected in the care of older patients and will be able to identify common hospital problems for the elderly, assess cognitive and functional status, and review medications. 3. Communication: Residents will work with interdisciplinary teams, patients and families in the care of older hospitalized patients, and will effectively communicate the hospital course and needs at the time of transfer out of the hospital setting. a. Milestone 20: Communicates effectively with patients and caregivers b. Milestone 21: Communicates effectively in inter-professional teams c. Milestone 22: Appropriate utilization and completion of health records 4. Systems Based Practice: Residents will understand the quality standards identified for the safe discharge of an older patient, appreciate potential safety problems during transitions in care, and ensure improved communication with the goal of improving patient safety during hospitalization and discharge. a. Milestone 8: Works effectively within an inter-professional team b. Milestone 11: Transitions patients effectively within and across health care delivery systems 5. Practice Based Learning and Improvement: Residents will be able to identify core components required for quality care of older adults during hospitalization and discharge, review their current practice, and utilize quality improvement strategies to provide for more safe and standardized care to all older patients. a. Milestone 12: Monitors practice with a goal for improvement b. Milestone 13: Learns and improves via performance audit c. Milestone 14: Learns and improves via feedback 6. Professionalism: Residents will respect each older adult as an individual, appreciate the impact that medical illness and functional decline can have upon older adults and caregivers, and strive to provide patient and family centered care. a. Milestone 16: Has professional and respectful interactions with patients, caregivers, and members of the inter-professional team b. Milestone 18: Responds to each patient’s unique characteristics and needs Learner Assessment Tools: Faculty will use the following tools to assess the knowledge, attitudes and skills that the resident has acquired during the rotation in order to gather data for the summative evaluation Outcome PerforInstrument Description ComReSchedule Domain mance pleted ports Indicator by: go to: Appropri- Identify Resident Faculty obResident Faculty Weekly ate Prehigh risk tracker serves and facreview of scribing medications ulty tracker Cognitive and functional assessment Document risks of medications Resident tracker Faculty observes Resident and faculty Faculty Weekly review of tracker Use MiniCog Resident tracker Faculty observes and checks off tracker Resident and faculty Faculty Weekly review of tracker Assess Capacity Resident Tracker Resident and faculty Faculty Weekly review of tracker Use CAM Resident Tracker Resident and faculty Faculty Weekly review of tracker Use Get up and Go Resident Tracker Resident and faculty Faculty Weekly review of tracker Use depres- Resident Faculty observes and checks off tracker Faculty observes and checks off tracker Faculty observes and checks off tracker Faculty ob- Resident Faculty Weekly Outcome Domain Caring for the individual, focusing on goals of care Performance Indicator sion screen Instrument Description Tracker Document fall risk, immobility, ulcers, nutrition, pain, UI, constipation Review of clinical notes (performance audit) Demonstrate clinical reasoning for complex older adults Clinical observations of oral presentations and written notes Clinical observation of oral presentations and written notes Clinical observation serves and checks off tracker Faculty reviews all notes written by residents, review appropriate documentation Clinical observations Demonstrate respect Describe goals of care for a patient Discuss advance care planning Patient Safety Document lines, catheters, restraints Perform medication reconciliation Clinical observation and resident tracker Review of clinical notes Resident tracker Resident tracker Review of Completed by: and faculty Reports go to: Schedule faculty faculty Daily review of notes required for co-signature Faculty Faculty Daily Clinical observations Faculty Faculty Daily Clinical observations Faculty Faculty Daily Clinical observation, review of tracker Clinical observations, review of tracker, review of daily notes Faculty and resident Faculty Weekly review of tracker Faculty and resident Faculty Daily Review of resident tracker, review of dis- Faculty and resident Faculty Daily review of discharge summar- review of tracker Outcome Domain Performance Indicator Use d/c template with quality indicators Instrument Description discharge summaries charge summaries prior to co-sign Resident tracker Resident tracker, review of discharge summaries prior to co-sign Review of discharge summaries Completed by: Faculty and resident Reports go to: Faculty Schedule ies, Weekly review of tracker Daily review of summaries, weekly review of tracker Geriatrics Curriculum Program Evaluation: Component Instrument Improvement Performance in care of Audits (chart older adults audits/reviews) by residents (meeting AGS competencies) Evaluation of rotation (teaching conferences, curriculum, tracker system) Rotation evaluation form Evaluation of faculty teachers Resident tracker Standard evaluations of teaching faculty Review of resident trackers Description Review of charts focusing on AGS competency/ quality indicators o before and after rotation o before and after curriculum started for the year Standard rotation evaluation forms; includes evaluation of teaching conferences and other learning activities Standard faculty evaluations within eValue Review of resident trackers: were goals met? Completed by: Geriatric supervising faculty on curricular committee Reports Schedule to: Supervisor Monthly of Curriculum Academic year Geriatric PD Resident IM program director then to Geriatric PD Resident IM PD and Monthly geriatric PD Geriatric Monthly PD and curriculum Resident Monthly Component Instrument Description Survey of resi- Survey dents (repeat needs assessment survey) Survey of fac- Survey ulty Survey used in needs assessment repeated Geriatric knowledge before and after Review geriatric component performance by residents on ITE In training exam Survey of geriatric faculty Completed Reports by: to: committee Resident Geriatric PD and curriculum committee Faculty Geriatric PD and curriculum committee Residents IM PD and to IM PD geriatric fellowship director Schedule Yearly Yearly Yearly Bibliography: 1. Russo CA, Elixhauser A. Hospitalizations in the Elderly Population, 2003: Statistical Brief #6. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD)2006. 2. Bragg EJ, Warshaw GA. ACGME requirements for geriatrics medicine curricula in medical specialties: progress made and progress needed. Academic medicine : journal of the Association of American Medical Colleges. Mar 2005;80(3):279-285. 3. Warshaw GA, Bragg EJ, Thomas DC, Ho ML, Brewer DE, Association of Directors of Geriatric Academic P. Are internal medicine residency programs adequately preparing physicians to care for the baby boomers? A national survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study. Journal of the American Geriatrics Society. Oct 2006;54(10):16031609. 4. Williams BC, Warshaw G, Fabiny AR, et al. Medicine in the 21st century: recommended essential geriatrics competencies for internal medicine and family medicine residents. Journal of graduate medical education. Sep 2010;2(3):373-383. 5. Drickamer MA, Levy B, Irwin KS, Rohrbaugh RM. Perceived needs for geriatric education by medical students, internal medicine residents and faculty. Journal of general internal medicine. Dec 2006;21(12):1230-1234. 6. Lindberg MC, Sullivan GM. Effects of an inpatient geriatrics rotation on internal medicine residents' knowledge and attitudes. Journal of general internal medicine. Jul 1996;11(7):397-400. 7. Jellinek SP, Cohen V, Nelson M, Likourezos A, Goldman W, Paris B. A before and after study of medical students' and house staff members' knowledge of ACOVE quality of pharmacologic care standards on an acute care for elders unit. The American journal of geriatric pharmacotherapy. Jun 2008;6(2):82-90. 8. 9. 10. 11. 12. Duthie EH, Jr., Gambert SR. The impact of a geriatric medicine rotation on internal medicine resident knowledge of aging. Gerontology & geriatrics education. Spring 1983;3(3):233-236. Thomas DC, Leipzig RM, Smith LG, Dunn K, Sullivan G, Callahan E. Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions. Annals of internal medicine. Oct 7 2003;139(7):628-634. Litvin CB, Davis KS, Moran WP, Iverson PJ, Zhao Y, Zapka J. The use of clinical decision-support tools to facilitate geriatric education. Journal of the American Geriatrics Society. Jun 2012;60(6):1145-1149. Moran WP, Zapka J, Iverson PJ, et al. Aging Q3: an initiative to improve internal medicine residents' geriatrics knowledge, skills, and clinical performance. Academic medicine : journal of the Association of American Medical Colleges. May 2012;87(5):635-642. Smith KL, Ashburn S, Rule E, Jervis R. Residents contributing to inpatient quality: blending learning and improvement. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. Feb 2012;7(2):148-153. Appendix 1: AGS guidelines for the core competencies for IM and FM residents caring for older adults in the hospital setting: Residents caring for older adults are expected to be able to: 1. Prescribe appropriate drugs/ dosages considering: age-related changes, body composition, and CNS sensitivity; common side effects in light of patient’s comorbidities, functional status, other medications; and drug-drug interactions 2. When prescribing drugs which present high risk for adverse events and interactions (such as coumadin, NSAID’s, opioids, digoxin, insulin, strongly anticholinergic drugs, and psychotropic drugs), discuss and document the rationale for their use, alternatives, and ways to decrease side effects. 3. Periodically review patient’s medications (including meds prescribed by other physicians, OTC and CAM) with the patient and/or caregiver to assess adherence, eliminate ineffective, duplicate and unnecessary medications, and assure that all medically indicated pharmacotherapy is prescribed. 4. Appropriately administer and interpret the results of at least one validated screening tool for each of the following: delirium, dementia, depression, and substance abuse. 5. Recognize delirium as a medical urgency, promptly evaluate and treat underlying problem. 6. Evaluate and formulate a differential diagnosis and workup for patients with changes in affect, cognition, and behavior (agitation, psychosis, anxiety, apathy). 7. In patients with dementia and/or depression, initiate treatment and/or refer as appropriate. 8. Identify and assess barriers to communication such as hearing and/or sight impairments, speech difficulties, aphasia, limited health literacy, and cognitive disorders. When present, demonstrate ability to use adaptive equipment and alternative methods to communicate (e.g., with the aid of family/friend, caregiver). 9. Determine whether an older patient has sufficient capacity to give an accurate history, make decisions and participate in developing the plan of care. 10. In evaluating adults with undifferentiated illness, generate differential diagnoses that include diseases that often present atypically in older adults (e.g., acute coronary syndromes, the acute abdomen, urinary tract infection, and pneumonia). 11. Consider adverse reactions to medication in the differential diagnosis of new symptoms or geriatric syndromes (e.g., cognitive impairment, constipation, falls, incontinence). 12. Demonstrate understanding of the major age-related changes in physical and laboratory findings during diagnostic reasoning (e.g., S4 does not reflect CHF, pulse increase less common with orthostasis, pO2 declines with age, abdominal pain may be less severe). 13. Discuss and document advance care planning and goals of care with all patients with chronic or complex illness, and/or their surrogates. 14. Develop a treatment plan that incorporates the patient’s and family’s goals of care, preserves function, and relieves symptoms. 15. In patients with life limiting or severe chronic illness, assess pain and distressing nonpain symptoms (dyspnea, nausea, vomiting, fatigue) at regular intervals and institute appropriate treatment based on their goals of care. 16. In patients with life limiting or severe chronic illness, identify with the patient, family and care team when goals of care and management should transition to comfort care. 17. As part of the daily physical exam of all hospitalized older patients, assess and document whether delirium is present. 18. In hospitalized medical and surgical patients, evaluate - on admission and on a regular basis - for fall risk, immobility, pressure ulcers, adequacy of oral intake, pain, new urinary incontinence, constipation, and inappropriate medication prescribing, and institute appropriate corrective measures. 19. In hospitalized patients with an indwelling bladder catheter, discontinue or document indication for use. 20. Before using or renewing physical or chemical restraints on geriatric patients, assess for and treat reversible causes of agitation (e.g., use of irritating tethers [including monitor leads, blood pressure cuff, pulse oximeter, intravenous lines and in-dwelling bladder catheters], untreated pain, alcohol withdrawal, delirium, ambient noise). Consider alternatives to restraints such as additional staffing, environmental modifications, and presence of family members. 21. In planning hospital discharge, work in conjunction with other health care providers (e.g., social work, case management, nursing, physical therapy) to recommend appropriate services based on: the clinical needs, personal values and social and financial resources of the patients and their families (e.g., symptom and functional goals in the context of prognosis, care directives, home circumstances and financial resources); and the patient’s eligibility for community-based services (e.g., home health care, day care, assisted living, nursing home, rehabilitation, or hospice). 22. In transfers between the hospital and skilled nursing or extended care facilities, ensure that: for transfers to the hospital: the caretaking team has correct information on the acute events necessitating transfer, goals of transfer, medical history, medications, allergies, baseline cognitive and functional status, advance care plan and responsible PCP; and for transfers from the hospital: a written summary of hospital course be completed and transmitted to the patient and/or family caregivers as well as the receiving health care providers that accurately and concisely communicates evaluation and management, clinical status, discharge medications, current cognitive and functional status, advance directives, plan of care, scheduled or needed follow-up, and hospital physician contact information. 23. Yearly screen all ambulatory elders for falls or fear of falling. If positive, assess gait and balance instability, evaluate for potentially precipitating causes (medications, neuromuscular conditions, and medical illness), and implement interventions to decrease risk of falling. 24. Detect, evaluate and initiate management of bowel and bladder dysfunction in community dwelling older adults. 25. Identify older persons at high safety risk, including unsafe driving or elder abuse/neglect, and develop a plan for assessment or referral. 26. Individualize recommendations for screening and chemoprophylaxis in older patients based on life expectancy, functional status, patient preference and goals of care.4 Appendix 2: Geri-Tracker: Keeping track of your experiences on the ACE service at UNC Resident: Attending: Dates: Goals for the rotation: 1. 2. 3. Please check off and have your attending or fellow sign off when you have done the following activities (you may complete these in any order, and at any point during the month long rotation) Activity Resident Check Faculty/Fellow Resident notes Faculty/fellow Check comments Self assessment: What is geriatrics? What are AGS competencies Mini-Cog Assess Capacity CAM Depression screen Get Up and Go Medication review Medication Reconciliation Lead advance care/goals of care discussion Review restraint use Utilize discharge template Assess pressure ulcer with Nurse Practitioner Assess for elder mistreatment Assess driving safety Discuss Medicare Wellness visit guidelines