Download Care of the Elderly Residency Program Goals and Objectives

Care of the Elderly Residency Program
Goals and Objectives
Inpatient Acute Care Geriatric Consultation Service rotation
GOALS
This rotation will provide the Resident the opportunity to provide inpatient consultation service to
various medical and surgical services in the acute care setting. There is also opportunity to provide
consultation service to patients in the emergency department on request by the admitting service.
Residents will learn comprehensive and clinical assessment skills of the frail elderly, including assessment
of mental function. Residents will become familiar with the atypical presentation of illness in an acute
care environment and the management of common geriatric and psychogeriatric problems. They will
also obtain experience in management of post-operative complications in the geriatric population such
as acute delirium, functional and cognitive decline. Residents will expand their clinical and
administrative skills, knowledge and leadership abilities to effectively interact with interprofessional
team members.
Residents will become familiar with the problems of the hospitalized elderly patient and develop the
knowledge, skills and attitudes to provide appropriate care to these patients. The Resident will
acquire the following competencies through graded responsibility.
MEDICAL EXPERT
Physicians are skilled clinicians who provide comprehensive, continuing care to patients and their
families within a relationship of trust. Care of the elderly physicians apply and integrate medical
knowledge, clinical skills and professional attitudes in their provision of care. Their expertise includes
knowledge of their patients and families in the context of their communities, and their ability to use
patient centered clinical methods effectively. As family medicine experts they integrate all the
CanMEDS-Family Medicine (CanMEDS-FM) roles in their daily work.
Key and enabling competencies; Family Physicians with enhanced skills in Care of the elderly are able
to...
1. Integrate all CanMEDS-FM roles in order to function effectively with a focused practice in Care of the
Elderly
1.1. Utilize relevant competencies contained within the CanMEDS-FM roles when approaching
clinical situations with older patients
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1.1.1. Demonstrate skill in the assessment and management of geriatric syndromes ( Delirium,
Dementia, immobility and falls, polypharmacy, atypical presentation of disease)
1.1.2. Demonstrate skill in the assessment and acute management of medical conditions
relevant to this population
1.1.3. Demonstrate knowledge of preventative care issues such as infectious disease, delirium,
medication safety and falls.
1.2. Residents will be able to identify and participate in efforts to reduce the potential hazards of
hospitalization such as delirium, falls, pressures ulcers, malnutrition, medication related adverse
events, indwelling Foley catheters, incontinence and immobility.
2. Establish and maintain clinical knowledge, skills and attitudes required to meet the needs of the
practice to the care of older adults.
2.1. Apply knowledge, skills and attitudes in the Care of the elderly to daily practice.
2.1.1. Demonstrate the ability to recognize atypical presentation of common diseases in the
elderly
2.1.2. Provide in patient consultation services that will address issues related to cognition,
functional decline, delirium, dementia, discharge planning, potential for rehabilitation,
medication related problems and driving.
2.1.3. Demonstrate understanding of cognitive impairment in the acute care setting and how
this impacts decision making and provision of care.
2.1.4. Define and distinguish between the clinical presentations of delirium, dementia and
depression
2.1.5. Describe the indications, risks, alternatives and contraindications for physical and
chemical restraints.
2.1.6. Recognize and manage common issues in Dementia care
2.1.7. Evaluate baseline and current functional abilities using reliable sources of information
including standardized assessment tools
2.2. Demonstrate an understanding of the basic principles of aging including the biologic,
psychologic and social aspects
2.3. Apply the basic principles of geriatric pharmacology and be able to practice appropriate
prescribing. Identify medications that are most likely to cause adverse events in an older patient
2.4. Recognize personal limits in knowledge, skills and attitudes
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2.5.
3. Demonstrate proficient assessment and management of older adults using the patient centered
clinical method
3.1. Describe the components of the patient centered clinical method
3.2. Residents will be able to diagnose delirium, formulate a differential diagnosis, develop and
implement plans for evaluation and management.
3.3. Demonstrate the ability to utilize a community oriented patient centered approach in
assessment and management of clinical problems in the elderly including partnering with
patients, their family, caregivers, substitute decision makers and interprofessional team
members.
3.4. Demonstrate the ability to conduct a comprehensive geriatric assessment that is relevant,
concise, accurate and appropriate including an evaluation of cognition, functional ability, mood
and behavior using standardized, valid and reliable instruments.
3.5. Demonstrate the ability to assess and manage common conditions of older adults, including:
Dementia, delirium, depression, falls, nutritional disorders, incontinence, osteoporosis and
fractures, pain and chronic disease management.
3.6. Demonstrate the ability to assess and manage the multiple interactive problems of the frail
elderly that affect cognition and function.
3.7. Develop skill in performing medication reviews with recommendations, after considering
indications, evidence of benefit, side effects, pharmacokinetics, drug- drug and drug – disease
interactions.
3.8. Explore both the disease and the patient’s personal experience of illness
3.9. Demonstrate an understanding of the whole person: the life history, personal and
developmental issues as well as their context.
3.10.
Find common ground with the patient in regard to defining problems and priorities,
setting goals of treatment and re-evaluating these goals as appropriate.
3.11.
Recognize the roles of the older adult patient and care of the elderly physician in dealing
with medico legal issues including capacity assessments
3.12.
Incorporate disease prevention and health promotion of older adults into the
clinical encounter.
3.13.
Consciously enhance the patient-physician relationship recognizing characteristics of the
therapeutic and caring relationship
3.14.
Manage time and resources effectively.
4. Provide comprehensive and continuing care to older adults incorporating appropriate preventative,
diagnostic and therapeutic interventions
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4.1. Provide comprehensive assessment to the frail elderly patient in the acute care setting through
the spectrum of health promotion, risk identification, clarification of diagnoses, and
identification of reversibility, disease prevention, and supportive care.
4.2. Provide preventative care application of current standards relevant to older hospital inpatients.
4.3. Utilize available evidence for diagnostic and therapeutic interventions in the elderly patient,
balancing risks, benefits and costs.
5. Attend effectively to complex clinical situations in the care of the older adults
5.1. Through clinical reasoning strategies, adapt the scope of clinical evaluation to the particular
context in a selective manner in order to appropriately assess each patient.
5.2. Demonstrate an ability to assess pain , fluid intake, continence issues, functional status and
nutrition in the elderly patient, especially when there is cognitive impairment
5.3. Demonstrate the ability to address multiple often undiagnosed clinical issues, both acute and
chronic, to provide continuity and collaboration in assessment and management, often in a
context of uncertainty.
5.4. Demonstrate an understanding of loss of functional reserve in older patients resulting in greater
vulnerability to lose function with even minor illnesses and to present with atypical
presentations of illness.
5.5. Demonstrate an understanding of how individual older adults function in the family, the home
and the community
5.6. Develop diagnostic hypotheses informed by prevalence, community incidence and consideration
of urgent treatable problems.
5.7. Identify relevant priorities for management, based on the patient’s perspective, medical urgency
and context.
5.8. Be able to make clinical decisions informed by best available evidence, past experience and the
patient’s perspective.
5.9. Recognize and respond to the ethical dimensions in clinical decision- making.
6. Demonstrate Proficient and evidence-based use of screening and diagnostic tools.
6.1. Demonstrate proficient and evidence based use of screening and diagnostic tools and
performance measures relevant to acute care consultations
6.1.1. Ability to use the acceptable validated tools
6.1.2. Utilize the Canadian consensus on Dementia to decide on assessment and investigations
of patients with Dementia.
6.2. Demonstrate an awareness of the strengths and weakness of these tools, as well as their
sensitivities, specificities and positive and negative predictive values.
6.3. Appropriately document assessments performed, reflective of interprofessional practice, goals
of care and their outcomes, and ensure adequate follow up.
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Communicator
As communicators, Family physicians with enhanced skills in care of the elderly will facilitate the doctor
patient relationship and the dynamic exchanges that occur before, during and after the medical
encounter.
Key enabling competencies: Care of the elderly physicians use the patient centered clinical method, and…
1. Develop rapport, trust and ethical therapeutic relationships with older patients, their family,
caregivers and substitute decision makers.
1.1 Recognize that being a good communicator is a core clinical skill for physicians, and that
physician–patient communication can foster patient satisfaction, physician satisfaction,
adherence and improved clinical outcomes.
1.2 Establish positive therapeutic relationships with the older patients, their family, caregivers and
substitute decision makers that are characterized by understanding, trust, respect, honesty and
empathy.
1.3 Respect patient confidentiality, privacy and autonomy.
1.4 Use both general and active Listening skills to facilitate communication.
1.5 Demonstrate effective use of strategies to enhance communication such as an awareness of and
responsiveness to non- verbal cues.
1.6 Demonstrate effective use of communication skills in the setting of cultural diversity, cognitive
and hearing impairment.
1.7 Facilitate a structured clinical encounter.
1.8 Respect boundaries in the doctor-patient relationship.
2. Accurately elicit and synthesize information from, and perspectives of, older patients, their family,
caregivers, substitute decision makers, colleagues and other professionals.
2.1 Gather information about the patient’s belief’s, concerns and expectations about the presenting
illness. Integrate the older patient’s beliefs and value structure in the development of a
treatment plan.
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2.2 Explore the patient’s psychosocial context.
2.3 Conduct an interview with multiple participants such as the patient’s family, caregivers and
other professionals to gather information about factors affecting the patient.
3. Accurately convey needed information and explanations to older patients, their family, caregivers,
substitute decision makers, colleagues and other professionals.
3.1 Deliver information to older patients, their family, colleagues and other professionals in a
humane manner and in such a way that it is understandable and encourages discussion and
participation in decision making.
3.2 Demonstrate effective communication strategies in challenging situations including the ability to
convey bad news in a sensitive, flexible, understanding and balanced manner or during risk
assessment.
3.3 Disclose error/ adverse events in an effective manner.
4. Develop a common understanding on issues, problems and plans with the older patients, their
family, caregivers, substitute decision makers, colleagues and other professionals to develop,
provide and follow-up on a shared plan of care.
4.1 Respect diversity and difference, including but not limited to the impact of gender, religion and
cultural beliefs on decision making
4.2 Encourage discussions, questions and interaction in the encounter.
4.3 Develop an integrated plan of care by engaging older patients, their family, caregivers,
substitute decision makers and relevant health professionals in shared decision making.
4.4 Communicate effectively as a member or leader of the health care team or other professional
group.
4.5 Provide follow up contact with patient and family using a form of communication that will
achieve the best outcome for the patient and family.
4.6 Effectively address challenging communication issues such as motivating behavioral change,
delivering bad news and addressing anger or dependency.
4.7 Provide therapeutic interventions through supportive and other counseling techniques used in
primary care.
4.8 When appropriate, communicate utilizing an interpreter.
5. Convey effective oral and written communication
5.1 Demonstrate the ability to maintain clear, accurate and appropriate records (e.g. verbal, written
and proficiency with the use of technology) to enhance communication of clinical encounters
and plans.
5.2 Demonstrate effective communication between older patients, their family, caregivers,
substitute decision makers, members of the interprofessional team and peers.
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5.3 Demonstrate an ability to work with older patients and others who present significant
communication challenges because of confusion, sensory impairments, behavioral problems or
an ethno-cultural background different from the Resident.
5.4 Demonstrate effective oral and written communication in individual encounters, referral, and
collaborative care as well as within team meetings.
5.5 Demonstrate effective consultation skills by presenting well documented assessments of older
patients with clearly justified recommendations in written and verbal reports of clinical
encounters and plans.
5.6 Communicate appropriately using electronic mail and other electronic means, while maintaining
patient confidentiality.
COLLABORATOR
As collaborators, Family physicians with enhanced skills in Care of the Elderly work within a health care
team to achieve optimal patient care.
Key and Enabling Competencies: Care of the Elderly physicians are able to…
1. Provide coordination of patient care including collaboration and consultation with other health
professionals and caregivers.
1.1 Coordinate the care of older patients with interprofessional care providers and teams of
providers.
1.2 Apply the competencies of the Collaborator role in team- based interprofessional care
2. Incorporate the family, caregivers, substitute decision makers, and other care givers appropriately in
the care of the older patients, while abiding by the ethical standards of patient autonomy and consent.
3. Participate in collaborative interprofessional model in the care of older adults.
3.1 Clearly describe the care of the elderly physician’s roles and responsibilities to the other
professionals.
3.2 Identify the roles and responsibilities of other professionals within the health care team and
describe the expertise and limitations of the members of this core team, including but not
limited to, clinical nutrition, nursing, occupational therapy, pharmacy, physiotherapy, social
work and speech language pathology.
3.3 Recognize and respect the diversity of roles, responsibilities and competencies of other
professionals in relation to their own and the impacts on team functioning.
3.4 Demonstrate an understanding that Care of the elderly must be collaborative and coordinated
with team members relying on the special skills and knowledge of each individual care provider
on the team.
3.5 Participate effectively in interprofessional team meetings and family conferences.
3.6 Enter into interdependent relationships with other professions for the provision of quality care.
3.7 Utilize the principles of team dynamics to enhance team performance
3.8 When needed, work with others to assess, plan, provide and review non-clinical tasks, such as
research problems, educational work, program review or administrative responsibilities.
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3.9 Respect team ethics, including confidentiality, resource allocation and professionalism.
3.10
When appropriate, demonstrate leadership in a healthcare team.
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Maintain a positive work environment with consulting health professionals, team care members and
community agencies.
2.1. Respect differences, misunderstandings and limitations in other professionals and employ
collaborative negotiation to resolve conflicts.
2.2. Recognize one’s own differences, misunderstanding and limitations that may contribute to
interprofessional tensions and demonstrate a willingness to receive and act upon both positive
and negative feedback from colleagues, other healthcare workers, older patients, their family,
caregivers and substitute decision makers.
2.3. Reflect on the basic principles of team dynamics and the problems which may occur in a
multidisciplinary / interprofessional team in a distributed environment. This includes the
common causes for team dysfunction, different types of team management, and common
causes of conflict within a team, case management principles, and division of labour and
individual responsibility in a team.
3. Engage and facilitate older adults their family, caregivers and substitute decision makers as active
participants in their care.
3.1. Find common ground on the identification of problems, priorities of interventions and on the
methods and goals of treatment.
3.2. Work to establish the respective roles of the family physician with enhanced skills in Care of the
elderly.
3.3. Demonstrate the ability to collaborate with older patients, their family, caregivers, substitute
decision makers and health care team to provide patient centered care.
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MANAGER
As managers, Family physicians with enhanced skills in Care of the Elderly are central to the primary
health care of the elderly and integral participants in healthcare organizations. They use resources wisely
and organize practices which are a resource to their population to sustain and improve health,
coordinating care within the other members of the health care system.
Key and enabling competencies: Care of the Elderly physicians are able to…
1. Participate in activities that contribute to the effectiveness of their own practice, health care
organizations and systems.
1.1. Demonstrate an awareness of the role of the focus practice in Care of the Elderly physician in
situations other than patient care, such as participation in geriatric health care management,
policy development and planning.
1.2. Describe the role of the focused practice of the Care of the Elderly physician in the health care
system and their relationships with other health care professionals and community
organizations.
1.3. Understand the concept of capacity building as it relates to care of Seniors
1.4. Work collaboratively with other health care professionals and community organizations to
provide coordinated care for older patients
1.5. Participate in systemic quality process evaluation and improvement such as patient safety
initiatives
1.6. Participate in continuous quality improvement activities within their own practice environment ,
such as practice audit
1.7. Demonstrate an understanding of the structure and function of the current health care system as
it pertains to older adults (hospital based, community based and specialized geriatric systems
including rural and remote communities)
2. Manage their practice and career effectively
2.1. Prioritize Professional duties when faced with multiple competing demands
2.2. Demonstrate an understanding of how to function effectively in a focused practice care of the
Elderly, which includes setting priorities and managing time to balance energy and resources
effectively in older patient care, learning needs, outside activities and personal life
2.3. Manage a practice including finances and human resources and implement processes to ensure
continuous quality improvement within a practice
2.4. Utilize information technology, including electronic medical records to plan appropriately for
patient care
3. Allocate finite healthcare resources appropriately
3.1. Recognize the importance of appropriate allocation of healthcare resources to older adults,
including referral to other healthcare professionals and community resources, balancing
effectiveness, efficiency and access with optimal patient care
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3.2. Apply evidence and management processes for cost-appropriate care, consideration of
alternative strategies and the analysis of performance
3.3. Judiciously manage access to scarce community resources and referral sources
3.4. Integrate knowledge of the structure of the health care system and demonstrate an
understanding of the regulations and administrative issues within Long term care as it relates to
patient care.
4. Serve in administration and leadership roles, as appropriate
4.1. Chair or participate effectively in committees and meetings
4.2. Demonstrate leadership within the individual health care team and or system as it relates to
Care of the Elderly which may include implementing a change in health care practice.
4.3. Contribute to policy development related to systems of health care as it relates to the older
patient.
4.4. Participate in relevant administrative roles related to clinical care.
HEALTH ADVOCATE
As Health Advocates, Family physicians with enhanced skills in care of the Elderly responsibly use their
expertise and influence to advance the health and wellbeing of individual patients, communities and
populations.
Key and enabling competencies: Care of the Elderly physicians are able to…
1. Respond to individual patient health needs and issues as part of patient care
1.1. Identify the health needs of the individual older patient.
1.2. Identify opportunities for advocacy, health promotion and disease prevention for the individuals
to whom they provide care.
1.3. Demonstrate the ability to give quality care to older adults despite cognitive and functional
decline, providing dignity to the frail older patients in a variety of community and institutional
settings.
2. Respond to the health care needs of the communities that they serve
2.1. Describe the practice communities that they serve
2.2. Identify gaps in health care delivery for seniors in a distributed practice and recognize
opportunities for advocacy, health promotion and disease prevention for seniors care in the
communities that they serve and respond appropriately.
2.3. Appreciate the possibility of competing interests between the communities served and other
populations.
3. Identify the determinants of health within their communities
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3.1. Identify the determinants of health care in the geriatric population, including barriers to access
to care and resources, and apply this understanding to common problems and conditions in
Health Care of the Elderly.
3.2. Identify the at risk groups within the elderly population such as the frail older adult, cognitively
impaired and restricted mobility, and apply the available knowledge about prevention and
health maintenance to this group.
4. Promote the health of individual older patients , communities and populations
4.1. Describe an approach to implementing a change in a determinant of health in the older patient
population
4.2. Describe how public policy , healthcare delivery and healthcare financing impact access to care
and health care financing impact access to care and health of the older adult
4.2.1. Identify current policies that affect health care of the elderly, either positively or
negatively including but not limited to Dementia, fall, Transitions of Care, Home care
services/ community resources and Care of the Elderly patient in acute care and
community settings.
4.3. Strive to promote health and wellness to prevent functional decline
4.4. Identify points of influence in the healthcare system and its structure
4.5. Describe the ethical and professional issues inherent in health care advocacy, including altruism,
social justice, autonomy, integrity and idealism
4.6. Appreciate the possibility of conflict inherent in the role the role of health advocate for a patient
or community with that of manager or gate keeper.
4.7. Describe the role of the medical profession in advocating collectively for health and patient
safety.
SCHOLAR
As scholars, Family physicians with enhanced skills in Care of the Elderly demonstrate a lifelong
commitment to reflective learning as well as the creation, dissemination, application and translation of
knowledge.
Key and enabling Competencies: Care of the Elderly Physicians are able to…
1. Apply the lifelong learning skills to the Scholar Role to implement a personal learning
program in response to the diversity of the primary care practice with a focused care of the
Elderly patient population.
2. Contribute to the enhancement of quality of care in their practice, integrating the available
and best evidence and best practices of geriatric medicine
3. Maintain and enhance professional activities through ongoing self-directed learning based on
reflective practice
3.1. Describe the principles in maintaining professional competence and implementing a personal
knowledge management system
3.2. Recognize and reflect on a learning issue in Health Care of the Elderly
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3.3. Formulate an appropriate learning question as it relates to Health Care of the Elderly
3.4. Integrate new learning into practice
3.4.1. Demonstrate knowledge of new advances in the management of Geriatric disorders
including but not limited to diagnosis and treatment of Dementia, including early and
preclinical stages, diagnosis and management of neuropsychiatric symptoms of
Dementia, Screening tools for depression and pain assessment in patients with
Dementia.
3.5. Evaluate the impact of any change in practice
3.6. Document the learning process.
4. Critically evaluate medical information, its sources and its relevance to their practice and apply this
information to the practice decision.
4.1. Describe the principles of critical appraisal
4.2. Critically appraise retrieved evidence in order to address a clinical question
4.3. Integrate critical appraisal conclusions into clinical care.
4.3.1. Describe and critically appraise recent landmark articles that impact current practice in
Geriatrics.
5. Facilitate the education of Older patients, families, trainees, other health professionals, colleagues,
and the public, as appropriate
5.1. Describe the principles of learning relevant to medical education
5.2. Identify collaboratively the learning needs and desired learning outcomes of others in health
Care of the Elderly.
5.3. Discuss the benefits of collaborative learning
5.4. Deliver a learner centered approach to teaching Care of the Elderly
5.5. Assess and reflect on a teaching encounter
5.6. Provide effective feedback
5.7. Describe the principles of ethics with respect to teaching
6. Contribute to the development, dissemination, application , and translation of new knowledge and
practices
6.1. Judge the relevance, validity, and applicability of geriatric research findings to their own practice
and individual patients.
6.2. Pose a scholarly question
6.3. Conduct a systematic search for evidence
6.4. Select and apply appropriate methods to address the question
6.5. Appropriately disseminate the findings of a study.
PROFESSIONAL
As Professionals, Family physicians with enhanced skills in Care of the Elderly are committed to the
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health and well- being of individuals and society through ethical practice, profession led regulation and
high personal standards of behavior.
Key and Enabling Competencies: Care of the Elderly physicians are able to…
1. Consider issues of older patient safety and ethical dimensions in the provisions of care and other
professional responsibilities.
2. Demonstrate a commitment to their patients, profession and society through ethical practice.
2.1. Exhibit professional behaviors in practice, including honesty, integrity, reliability,
compassion, respect, altruism, and commitment to patient well- being.
2.2. Demonstrate a commitment to delivering the highest quality of care and maintenance of
competence.
2.3. Understand and apply relevant legislation that relates to the health care system in order to
guide clinical practice (e.g. Advance Care Planning, Adult/ Guardianship and Trusteeship
act).
2.4. Demonstrate respect for colleagues and team members
2.5. Appropriately manage conflicts of interest.
2.6. Recognize the principles and limits of patient confidentiality as defined by professional
practice standards and the law
2.7. Maintain appropriate professional boundaries.
2.8. Speak directly and respectfully to colleagues whose behavior may put patients or others at
risk.
3. Demonstrate a commitment to their patients , profession and society through participation in
profession led regulation
3.1. Appreciate the professional, legal and ethical codes of practice, including knowledge of the
CMA and CPSA code of ethics, the roles of the CMPA, CCFP, AMA and ACFP
3.2. Fulfill the regulatory and legal obligations required of current practice
3.3. Demonstrate accountability to professional regulatory bodies
3.4. Recognize and respond to other’s unprofessional behaviors in practice
4. Demonstrate a commitment to physician health and sustainable practice
4.1. Balance personal and professional priorities to ensure personal and a sustainable practice
4.2. Strive to heighten a personal and professional awareness and insight
4.3. Recognize and respond to other professionals in need.
5. Demonstrate a commitment to reflective practice
5.1. Demonstrate the ability to gather information about personal performance, know one’s
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own limits, and seek help appropriately
5.2. Demonstrate an awareness of self and an understanding of how one’s attitudes and feelings
impact their practice.
5.3. Reflect on practice events, especially critical incidents, to deepen self knowledge.
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