Needs Assessment of the Curriculum of Interdisciplinary Geriatric Care at PACE

Curriculum Design of Interdisciplinary Geriatric care for rotation at PACE (Program of All Inclusive Care for Elderly) for Geriatric Medicine fellows

Abstract:PACE (Program of All-Inclusive Care for Elderly) provides a very unique learning environment for Geriatric Medicine Fellows and other learners with an interest in Geriatrics. Learners are exposed to a population of frail, nursing home eligible older adults that continue to dwell in the community with the support of an integrated medico-social model of care. Learners can gain valuable insight on the functioning of a highly effective interdisciplinary team and learn about PACE and similar models of care.

Geriatric medicine fellows at Virginia Commonwealth University currently spend one month at the PACE site in Richmond, Virginia. A new PACE curriculum was designed with the overarching goal of creating a significant learning experience. The first step was a “general needs assessment “with analysis of the difference between the current approach and an ideal approach. This was followed by a “targeted needs assessment “ of the current and past learners as well as their learning environment. Goals and objectives were then developed, and feedback and assessment methods were determined for each objective. The learning strategies were then assigned to each objective to develop an integrated course design.

Needs assessment of the Curriculum of Interdisciplinary Geriatric care at PACE:

For the purpose of developing a curriculum for the PACE rotation, a detailed general as well as specific needs assessment was done. The information collected from this assessment helped shape the subsequent steps in developing a curriculum for the rotation.

General Needs Assessment

Problem identification: The population of older Americans is expected to increase from 35 million in 2000 to 69.4 million in 2030. The health care needs of this age group are disproportionately high, accounting for 40% of hospital stays and 49% of all days of care in hospitals in 1995. It is expected that more elderly will require long-term care assistance and services because of chronic illness or disabling conditions that limit their ability to perform basic activities1.In 2005, national spending on long-term care totaled $207 billion with most spending for nursing home care2.As a response to these economic concerns and to address the desire of most people to age in place, the Program of All-inclusive Care for the Elderly (PACE) was first founded3.

PACE programs are comprehensive community-based care models for frail, chronically ill older adults whose significant functional and cognitive impairments make them nursing home eligible4.

Practice innovations in PACE include the use of an interdisciplinary team, consisting of many professionals, including physicians, nurse practitioners, social workers, nutritionists, therapists, as well as health and transportation workers. This team collaborates for coordinated medical and social services across the acute and long-term settings, including priority access to primary care.

The PACE model’s interdisciplinary approach fosters a less hierarchical and more collaborative approach to care across disciplines. This presents a fertile environment to teach interdisciplinary care. Didactic modules as well as experiential learning modules can be implemented. Didactic modules can provide students with a background in interdisciplinary geriatric care, basic principles of geriatric assessment, complex care management, and the PACE program. The experiential modules can provide students with the opportunity to work as part of an interdisciplinary team with community based frail elder population5.

Current approach: At present there are more than 93 PACE programs operating in 30 states. These sites provide an ideal environment to educate Geriatric medicine fellows on interdisciplinary care of frail older adults. Geriatric medicine fellows get very limited exposure to such settings and only a few programs across the country have access to a PACE site.

Currently, a rotation for residents and fellows at PACE sites is being offered by several institutions such as Johns Hopkins division of Geriatrics and Gerontology, Division of Geriatrics medicine at University of Pittsburg, University of Rochester Medical Center, Oregon Health and Science University Geriatrics program and Division of Geriatrics at Virginia Commonwealth University Health system. Concordia Care- Cleveland’s PACE site offers this to Internal medicine PGY II and PGY III residents.

A curriculum development guide for training health professionals in interdisciplinary geriatrics care at rural PACE sites was developed by Department of Health and Human Services and Health Resources and Services Administration in 2007.These principles of gaining a holistic view of the bio-psychosocial needs of the patient by working closely with a team of experts are immensely valuable and can be applied in any setting by a Geriatrician.

To gain additional information on current curricula used by other PACE sites, questions were posted on the list-serve of PACE physicians across the country about the use of curriculum for learners at PACE sites. A response was obtained from the Chief Medical Officer of Center for Elder's Independence in Oakland, CA who reported no formal curriculum for learners.

Ideal approach: As the numbers of PACE sites across the country continue to increase and the need for integrated care of complex medical care continues to expand, it would be very important to train future geriatricians on these concepts at sites like PACE.

An ideal curriculum would help geriatric medicine fellows develop knowledge, skills and attitude to effectively care for community based frail older adults with limited resources. Major areas of knowledge would include physiology of aging, common geriatric syndromes, rehabilitation and health policy. Key skills would include interdisciplinary teamwork, effective patient communication, and cognitive assessment by different tools based on level of impairment, evaluation and scoring of depressive symptoms, fall assessment and care transitions across various settings.

An ideal PACE curriculum would address all 6 ACGME core competencies of Patient care, Medical Knowledge, Practice based learning and improvement, Interpersonal and communication skills, Professionalism and System Based practice7.

Targeted Needs Assessment

Targeted Learners: Geriatric medicine Fellows from Virginia Commonwealth University health systems who spend 1 month at PACE.

Content about Targeted learners: Geriatric medicine fellows have a high level of interest in the PACE rotation given the unique multi-disciplinary setting but have limited previous training or experience of working in or observing similar settings. Fellows need practice in working within a team setting and providing a medical perspective in what would seem like a“social issue”. Fellows need to gain knowledge on PACE and similar medical-social models of care. PACE setting would provide them an opportunity to develop leadership skills and thus will have an impact on their future career plans.

Targeted learning environment: Fellows spend 1 month at the Riverside PACE Mactavishsite in Richmond, Virginia. PACE rotation provides a good environment for active learning but currently does not have a structured format of providing education.

Active learning takes place during daily interdisciplinary team meetings (8:30-9:30 am) and patient encounters during clinic visits (10am -2pm). However the patient encounters have to happen in the first half of the day at PACE as patients do not stay beyond 2 pm and new medication orders have to be entered by 11:30 am. This can mean that learners having to attend PACE only in the afternoons would miss out several important elements.

Currently there is only 1 teaching faculty member at the PACE site so the learners can miss valuable time in the event of absence due to other commitments of this faculty member. There is a need to establish independent self-guided activities that the student can engage in during such times. Participation Passport could be used as large portions of the course can be experiential in nature.

Also, other faculty members who may be covering at times need more education on teaching about PACE model of care.

Riverside PACE Mactavish site is equipped with sufficient conference room space for didactics, structured sessions and family meetings however there is only 1 computer available for use for online learning or access to additional resources.

METHODS: As this curriculum developer is new to the institution and PACE rotation has only been available for the last 3 years, we focused on obtaining in-depth qualitative data from a small sample of learners and faculty. Informal interview with current fellows and fellows from past year were conducted over the phone. Three prominent faculty members were interviewed over the phone or sent questionnaires via email.

The questions that were presented to the fellows were very open ended to assess the perceived learning needs and preferences. They included the following:

1) What are your opinions regarding the adequacy of courses taken during Geriatric fellowship training to prepare you for Geriatric interdisciplinary care?

2) What were the most useful elements of the PACE rotation?

3) What did you find most challenging about the rotation?

4) What part of the rotation seemed redundant?

5) What were some topics that were not covered that would have been helpful?

6) What is your preferred modality to learn about interdisciplinary geriatric care: lectures/ reading, e-modules, case based discussions?

7) How could we improve your experience?

Questions presented to faculty members and program directors

1) What is your opinion about the current rotation offered at PACE

2) What is your idea of an ideal curriculum?

Findings:

2 current fellows and 3 past fellows were interviewed individually in a phone discussion. Setting was informal and length of interview varied from 25 minutes to 44 minutes. The themes that were noted on discussion with the past and current Geriatrics Fellows:

1) Adequacy of training in Interdisciplinary Geriatric care prior to rotation: Most fellows noted that they had very limited exposure to interdisciplinary teams prior to PACE rotation. Most noted that prior exposure was more passive where they were observers and they had not taken an active part in decision making in prior situations. 1 fellow noted that she was inquisitive about the concept and read about PACE prior to her rotation but being a part of the PACE experience was completely different.

2) Most useful elements of PACE rotation: All Fellows found the rotation to be beneficial and noted that the morning IDT (Interdisciplinary team) meetings were very unique. They had limited exposure to a similar model of integrated care elsewhere and 2 fellows noted that this model demonstrated a scenario of “Ideal Medicine” to them. The 2 current fellows mentioned that they really gained a lot of insight on environmental management of difficult behaviors in elderly by spending time with the Recreation Therapist who has immense training and experience in Gerontology. Another fellow mentioned she enjoyed observing the Social Work manager perform her assessment and conduct family meetings. She admired the Social Worker Manager's demeanor and other forms of nonverbal communication which demonstrated concern and empathy. This fellow mentioned that the experience has made her very aware of its impact on family members and she uses this insight on a daily basis during her patient encounters. A past fellow mentioned she enjoyed the longitudinal care of an individual across all settings- she gave an example of having seeing a patient in clinic, then following this patient as he went to an emergency room, then hospital for 1 week , skilled nursing facility for another week and then back home. She learned about successful transitions across settings and the planning and forecasting that it involved.

3) Most Challenging aspect of the rotation: All 5 fellows mentioned that timing of the rotation was challenging as most patients leave the PACE center to go back home by 2 pm. Hence on the days they had morning continuity clinic outside of PACE, they felt they “missed out on all the action”. 1 fellow mentioned that the duration 1 month was insufficient and that she wished it was longer.

All fellows mentioned lack of structure as a concern. One fellow mentioned that a structured curriculum would have helped ensure that she got adequate exposure to all disciplines at PACE during her rotation. She said there were times when she wanted to be at 2 places at one time and had to make a choice. It always left her with a sense that she was “Missing out on all the good stuff”. On similar lines, another fellow mentioned that she was hoping to shadow the Chaplain doing a life review with a patient but missed the opportunity as she had clinical duties outside of PACE. She was appreciative of the PACE teams flexibility but would have benefited from knowing “where to be when” as she was navigating the new system.

4) Elements of the rotation that seemed redundant: No part of the didactic or experiential curriculum seemed redundant to 3 out of 5 fellows. 2 fellows mentioned that the online modules on dementia diagnosis seemed too basic and these topics have been covered several times on previous rotations.

5) Topics not covered at PACE but would be beneficial: One fellow mentioned that she had some difficulty getting a better understanding of DME (Durable medical Equipment) and services the patients are entitled to in terms of medical necessity. She gave an example of dentures and its medical necessity and said she continues to struggle with this even in settings outside of PACE. She said she tried to piece this information together during different IDT sessions but wishes she had some formal didactic sessions on this. Another fellow wishes she had a better understanding of community resources and wishes she could have spent more time with the social worker.

6) Modalities of learning: All fellows enjoyed the case based discussions. Most fellows enjoyed the interactive nature of the formal didactic lectures as they were always one on one. All fellows were open to e-modules and doing patient life reviews with the Chaplain.

7) Elements that would improve experience: Structure to curriculum and timing of teaching sessions stood out as a theme in discussions with all fellows.

Themes noted with discussion with faculty members: 4 faculty members were interviewed informally over the phone. Discussions lasted 12-25 minutes. Of these 1 faculty member was a previous MCV Fellow and had completed her PACE rotation last year. Hence she was asked questions from the fellow as well as faculty perspective.

1) Opinion on current rotation at PACE: 2 of the 4 faculty members had a basic understanding of the working of PACE but were not aware of the details of the rotation. Both these faculty members mentioned that from their interaction with the current and past fellows they had received a very positive feedback on the rotation and saw significant benefit of fellows electing to spend a month at PACE. 1 faculty member has worked at PACE for a few days in the year. He had interacted with learners during this brief time, but noted that the learners were PGY I Internal medicine residents who spend 1 week at PACE and not geriatric medicine fellows. He commented on how the learner was not able to describe the financial aspects of the PACE model when questioned. He felt the need for more structured didactics to address this issue.

The one faculty member who was a previous fellow mentioned that she learned more about the finer details of the PACE model only after working at PACE as an attending but did not pick on these as a fellow- she provided examples of details such as “Who is a good PACE candidate?”, “What are the community resources available to patients?” and “What can be managed by PACE physician vs. When to refer to a specialist?”

2) Ideas about an Ideal PACE rotation: One faculty member pointed out that PACE rotation should offer the opportunity for fellows to follow 1 patient all day as he is assessed by various disciplines (Initial, Semi- annual or annual assessment) . The fellow should then present the medical perspective on this patient during IDT meeting the next morning. This would give the fellow a complete perspective on management of this patient. He pointed out that while didactic sessions and other form of learning can occur at most rotations , fellows should be offered elements education at PACE that are not available in other settings- interdisciplinary care under 1 roof. 2 faculty members mentioned they would like to see didactic sessions addressing health policy, information on PACE and functioning of interdisciplinary teams in healthcare.

Summary of findings:

1) PACE is an excellent model of interdisciplinary Geriatrics care and very few geriatrics fellows in this country are fortunate to get exposure to this unique model.

2) Geriatric fellows may not work in a setting like PACE in their future but the principles of integrated care practiced at PACE can be applied in any setting.

3) Ideal PACE curriculum should have a didactic component as well as experiential component to address all 6 ACGME competencies.