Stanford University Geriatric Education Resource Center  

HP5: Guide to Geriatric Training across the Continuum of Care

Table of Contents.

Introduction 4
Acute Geriatrics Teaching Program 6
Post Acute / Rehabilitation Teaching Program 10
Ambulatory Geriatrics Teaching Program 14
Elder Housecall Teaching Program 19
Appendix A - Sample Weekly Schedules 24

Introduction

Teaching geriatric medicine across the continuum of care requires at least three key ingredients: 1) direct clinical experience with frail elderly patients, 2) physician, nurse, and other professional role models who can teach principles of geriatric care and 3) clear curricula that are appropriate for each clinical setting. This guide to geriatric training across the continuum summarizes the key teaching elements and curricula that are used in four different clinical settings to support a comprehensive geriatric training program for primary care residents. The curricula for each clinical setting are not mutually exclusive. Some topics, such as functional assessment and polypharmacy, are emphasized in every clinical setting. The purpose of this guide is to provide a general outline for geriatrics training that encourages flexibility at individual residency sites.

The primary goal is to educate residents about caring for elderly patients at many stages of medical illness and functional status. Current components of the Johns Hopkins clinical geriatrics system include: an acute geriatrics service; a sub-acute transitional care unit; a rehabilitation unit; a chronic hospital unit; a physician housecall program; a skilled care nursing facility; a PACE Program (Program for All-Inclusive Care of Elderly); two large continuing care retirement communities (CCRC); and ambulatory clinics in primary care, comprehensive geriatric assessment, urinary continence, gerorheumatology, and metabolic bone disease.

Experience in every sector of such a clinical system is not required to learn geriatrics well. Each clinical setting can, however, offer important opportunities for teaching specific aspects of geriatric medicine. This guide outlines the structure of teaching programs in the following clinical settings:

  1. Acute geriatrics
  2. Post-acute/rehabilitation care
  3. Ambulatory geriatrics
  4. An elder housecall program

Each clinical module described includes a description of the patient population, key teaching elements, and curricula that are used to encourage an effective training experience. Appendix A includes sample weekly schedules for teaching programs in the four clinical settings.

All residency programs have the elderly patients, dedicated generalist teachers, and curious trainees that are the critical ingredients for successful geriatrics training. We hope this guide can assist in developing or strengthening the geriatrics training at your institution.

This guide is meant as only one example of a teaching program in geriatric medicine. The implementation of a geriatric teaching program at other residency sites may require significant adaptation to the programs described herein. The faculty in geriatric medicine at Johns Hopkins are interested in offering consultation on how to adapt these guidelines to your institution.

Evaluation.
The evaluation of the geriatric teaching programs described here is accomplished in three ways. The first measure we use is to identify the number of residents who actually choose to enter the field of geriatric medicine after a broad exposure to geriatrics. The second measure is a subjective questionnaire where residents comment on each rotation's value for enhancing their skills in geriatrics. These skills include:

The residents have consistently expressed positive comments about seeing the breadth of care in geriatrics. For example, one resident noted "getting a sense of the breadth of geriatric medicine was one of the strengths" and another added that the primary benefit of the "ambulatory" rotation was "plenty of exposure to geriatric patients along the whole spectrum."

Residents identified several experiences as particularly important; these included some exposure to elder housecall care, outpatient evaluation of dementia, and specialty training in rheumatology, urinary incontinence, and osteoporosis.

The third measure of evaluation that we use is a geriatric knowledge base assessment test that was developed by several geriatric centers and supported by the John A. Hartford Foundation. This survey is completed by residents at each year of training to examine the level of residents' geriatric skills derived from their overall training experience.

I. Acute Geriatrics Teaching Program

In the acute care setting, an effective geriatrics teaching program involves residents in an interdisciplinary team, provides close mentorship from attending physicians with expertise in geriatrics, and includes daily case-based teaching sessions. Recent changes in health care, however, have transformed acute medical wards into rapid turnover care settings for the evaluation and initial treatment of patients who are then transferred into less costly alternative care sites such as nursing homes, sub-acute units, or the outpatient setting. These health care delivery changes can cause substantial discontinuity for both residents' learning and patients' care that pose great challenges to teaching geriatrics in the acute care setting. Patients often leave the hospital before a precise diagnosis is made or before the course of illness become evident in elderly patients, for whom response to treatment and recovery are slow processes. These changes in the acute care environment make it very important that training programs link acute care teaching with training in other settings along the continuum of care.

In the acute care setting, residents may care for many elderly patients but this does not always translate into effective learning of geriatrics principles. Such learning requires the direct involvement of residents within an interdisciplinary team. This focuses a high priority on a patient's social and functional status and on the careful transfer plans that determine the success of elderly patients' care as they move rapidly across a clinical system. The acute geriatrics teaching program described below can be generalized to any medical unit that cares for frail elderly patients with an interdisciplinary team approach. See Appendix A for a sample weekly teaching schedule.

A. Key Elements of an Acute Geriatrics Teaching Program

This section outlines the personnel and structural components of an acute geriatrics teaching program. This outline can be adapted to match the needs of the local residency environment.

B. Acute Geriatrics Curriculum

An acute geriatrics curriculum requires a different paradigm from the traditional teaching of ward medicine. This paradigm recognizes that hospitalized elderly patients often present with unusual symptoms that challenge normal diagnostic methods, experience a high rate of iatrogenic illness, and face serious risk of functional decline and personal indignity while in the hospital. Primary teaching goals therefore, are to understand the interaction of acute hospitalization with the physiologic changes of aging, to make accurate diagnosis of atypical symptoms, and to implement care that prevents iatrogenic illness and preserves functional status.

User Comments

I like the detailed schedules for rotations, clear learning objectives.

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