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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 August 2015 1 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 August 2015 2 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 August 2015 3 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. August 2015 4 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. August 2015 5 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. August 2015 6 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. June 2015 7 3.9 Respect team ethics, including confidentiality, resource allocation and professionalism. 3.10 When appropriate, demonstrate leadership in a healthcare team. 2 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. June 2015 8 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 June 2015 9 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 June 2015 10 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 June 2015 11 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 June 2015 12 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 June 2015 13 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. June 2015 14