Duration of Program: July 1 2017-June 30, 2018

Program description for geriatric medicine

University of Illinois at Chicago

Program director: Tanjeev Kaur, MD

table of contents

  1. educational philosophy
  2. Implementation of Core ACGME Competencies
  1. Curriculum for the inpatient hospital units
  1. Consulting services
  1. Outpatient clinics
  1. Long term care
  1. Hospital based primary care
  1. Hospice and palliative care
  1. Geropsychiatry
  1. Didactic training in geriatric medicine
  1. What to read first, second, and then third in geriatrics
  1. Elective time

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Tanjeev Kaur, MD Date

Program Director

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University of Illinois at Chicago

Section of Geriatric Medicine

Curriculum for Geriatric Medicine Fellows 2017-2018

I.educational philosophy

The faculty of the Section of Geriatric Medicine has compiled this curriculum in conformation to the standards of the Accreditation Council for Graduate Medical Education. It also reflects the Section’s educational philosophy. This written curriculum discusses the goals, objectives, methodology of teaching, and evaluation of the fellows for the clinical sites in which you will rotate and also describes the approach to the didactic portion of the Program. The curriculum reflects a competencies-based approach to teaching and measuring performance.

At the level of Geriatric Medicine Fellows, you are in the process of making a transition between following a curriculum that others have devised for you and development of your own curriculum, which you will face in the years following your training as fellows. Therefore, this is a time of transition in which you will be expected to become more independent in designing and implementing a curriculum for yourselves. The Geriatric Medicine faculty stand willing to help you in whatever way to provide you with educational resources in terms of our reading of the wide range of textbooks and literature in geriatrics and gerontology and in finding persons and facilities which may be of further resource to you. We will meet periodically with you to review you progress in developing you individualized curriculum.

We also recognize that all Geriatric Medicine fellows have special areas of interest. Therefore, the process of evaluating geriatric medicine fellows is not so much against an absolute standard. Rather, as a result of participating in the development of a curriculum for yourselves, you enter into the area of self-evaluation. Here you are asked to evaluate your performance in relation to your own expectations as well as having the faculty comment on your performance in the various areas. In addition, there is a competencies-based core curriculum and evaluation.

Implementation of Core ACGME Competencies for Geriatric Medicine

The Section of Geriatric Medicine takes an innovative approach to implementing a curriculum that assists fellows and faculty in pursuit of the core ACGME competencies for all physicians. Through previous collaborations with the Institute for Healthcare Improvement, the section merged a Chronic Disease Model of Care with a Quality Improvement Program to create a mechanism for fellows and faculty to acquire and refine their core ACGME competencies. The Chronic Disease Model of Care is based on a design by E. Wagner, MD from the MacColl Institute. This model applies evidence – based medicine towards different chronic conditions with the purpose of improving the quality of healthcare while reducing overall costs. The objective is to enhance patient self-management as well as community resources while improving the delivery of healthcare by increasing physician resources, collaborations and changes in the system. Measurable outcomes, such as hospitalization rates, emergency room use, and adherence to best practice guidelines are tracked for the geriatric practice group in addition to individual physician profiles. The clinical outcomes are analyzed by faculty and fellows relative to quality improvement projects that embrace Plan  Do  Study  Act cycles of change.

Implementation

  1. Fellows are firstly introduced to the concept and constructsof Chronic Disease Management. For purposes of this curriculum, we have chosen the chronic condition of Heart Failure in Elderly as our focus because this condition contributes to the highest hospitalization rate for elderly. Information about the Chronic Disease Model of Care is provided through lectures, readings and discussion at weekly meetings held specifically for the curriculum.
  2. Expectations of Fellows and the healthcare team (nurses, pharm Ds, kinesiologists, nutritionalists, and info technologist) are reviewed in the beginning of fellowship. Emphasis is placed on how the model of care entails a collaboration between Geriatric Medicine and Cardiology.
  3. Each fellow longitudinally follows a panel (n = 8 – 10) of heart failure patients 75 years old and older who are frail as defined by NYHA classification III or IV and have at least one functional impairment (ADL). These patients will be seen 1:1 as well as in groups. The fellows are responsible for periodic (6 month), interdisciplinary assessments of their patients to determine any changes in functional status. Problems with patient adherence or changes in function are discussed with the entire team weekly, and collective solutions are sought.
  4. To keep at the cutting edge of treatment, Fellows review the medical literature and distill the results for the CHF team.
  5. Fellows meet weekly with the team to discuss current literature, systems-based barriers to healthcare and strategies to improve health outcomes, e.g., fewer acute care admissions, increased exercise capacity.
  6. Monthly reports on clinical outcomes are generated for the team, tracking the hospitalization rate for the heart failure patients and ER usage. Additional data includes the percentage of patients taking appropriate medications and the percentage of those pursuing self – management such as exercise and daily weights. These data are collected for the whole patient group and are broken down into physician – specific panels. The data are discussed monthly, trends are noted, and projects are planned to improve outcomes. For example, the trainees organize patient group meetings to educate them about heart failure, nutrition, exercise, self-management, and medications.
  7. The fellows also create Plan  Do  Study  Act cycles as part of quality improvement within the geriatric heart failure project. Fellows present small projects that involve 6 -10 patients and test the applicability of the intervention to this small group of patients before deciding to apply the change to the entire patient population.

Measurement of competency: Both the team and individuals are measured by health outcomes of the heart failure patients. These consist of one – page reports that indicate CHF hospitalization rate, All causes hospitalization rate, ER usage, ER usage for CHF, medication compliance, self – management compliance, and exercise adherence. In the first half of the year, only the team report is presented and once the fellows are familiar with the project, individual reports of physician performance are provided to each fellow. Geriatric fellows have the option of participating in the UIC Department of Medicine Graduate Medical Education Core Curriculum Modules which for subspecialties are 4 modules per year unless they have previously completed them at UIC or can produce documentation of a similar curriculum at another institution. Fellows also have the option of taking a Core Curriculum Competencies test at the end of their fellowship. All fellows participate in the geriatric/heart failure outcomes assessments designed by the section chief and program director. Fellows are also strongly encouraged to attend Department of Medicine conferences that are designated as "meeting ACGME Competencies" on the e-mailed and posted weekly fliers.

The description of activities during their geriatric heart failure clinic and other activities by competency is provided below.

Patient Care
Geriatric fellows are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, treatment of disease and at the end of life.
Gather essential information from all sources, including medical interviews, physical examination, medical records and diagnostic/therapeutic procedures.
Make informed recommendations about preventive, diagnostic. and therapeutic options and interventions that are based on clinical judgment, scientific evidence and patient preferences.

Develop, negotiate and implement effective patient management plans and integration of patient care.

Perform competent diagnostic and therapeutic procedures considered essential to the practice of geriatric medicine.
Recognize when patients are terminally ill and at the end of life and, in these instances. Strive to implement a palliative plan of care.
Curriculum
Many of the above objectives are addressed as part of the daily clinical curriculum and monitored by faculty on the fellow evaluation form. The outpatient geriatric heart failure clinic is staffed by interdisciplinary team whose primary objective is to render care to fragile older adults with multiple medical problems and complications associated with deconditioning. Critical to designing care plans for these patients is the identification of social support, acknowledgement of the suffering and stress experienced by caregivers and the effective utilization of community-based resources. Recognizing when patients are terminally ill, planning for end of life care, and implementing a palliative plan of care are important elements of geriatric training and are addressed in conference, as well as, clinical settings.

Participation in a weekly Geriatric heart failure meeting is required. This meeting instructs fellows in the basic concepts of clinical epidemiology, evaluation of the medical literature, and evidence-based medicine.
Outcomes Assessment
1.The ABIM Competency-Based Evaluation Form is utilized to evaluate trainees on the geriatric heart failure clinic.

2. Fellows complete a test (short-essay exercise) addressing this competency during each year of training. This exercise poses a hypothetical situation that requires the fellows to articulate the knowledge and skills they have acquired specific to geriatric medicine and to apply this knowledge to address a specific clinical problem. See Core Curriculum competencies test.

3.Individual outcome measurements from the Heart failure clinic: All-cause hospitalizations rates, CHF hospitalization rates, CHF emergency room usage rate, all cause emergency usage rate, compliance with medication guidelines.
Medical Knowledge
Geriatric fellows are expected to be able to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and demonstrate the application of their knowledge to patient care and education of others.
Apply an open-minded and analytical approach to acquiring new knowledge.
Access and critically evaluate current medical information and scientific evidence.
Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of internal medicine and geriatric medicine.
Apply this knowledge to clinical problem solving, clinical decision-making, and critical thinking.
Curriculum

In addition to these objectives being addressed and evaluated as part of the daily clinical curriculum in both the inpatient and outpatient setting, formal conferences play a major role in the fulfillment of these objectives. The Geriatric Medicine Core Curriculum includes regular presentations that address concepts of geriatric assessment, activities of daily living, mental status testing, dementia evaluation and assessment of competency in decision-making. Specific didactic presentations in pharmacology in geriatric patients focus on enhancing medication usage, simplifying medication regimens and titrating dosages of drugs for older persons.
The importance of teaching by the geriatric fellows is emphasized throughout the course of the training period. Internal medicine residents and medical students are part of the geriatric patient care teams, as are Pharm D”s, nurses and social workers. It is the role of the geriatric fellow to teach these members of the team on a daily basis. In addition, geriatric fellows present a series of lectures to the Obstetrics and Gynecology residents on the management of common medical problems in elderly patients. All incoming fellows participate in a Teaching How to Teach workshop conducted by Graduate Medical Education.

Outcomes Assessment
1.The ABIM Competency-Based Evaluation Form is utilized to evaluate trainees on all rotations.
2.Fellows complete a short-essay exercise addressing this competency during each year of training. This exercise poses a hypothetical situation that requires the fellows to articulate the knowledge and skills they have acquired specific to geriatric medicine and to apply this knowledge to address a specific clinical problem.

3.Individual outcome measurements from the Heart failure clinic: All-cause hospitalizations rates, CHF hospitalization rates, CHF emergency room usage rate, all cause emergency usage rate, compliance with medication guidelines.
Practice-Based Learning and Improvement
Geriatric fellows are expected to be able to use scientific evidence and methods to investigate, evaluate and improve patient care practices.
Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care.
Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient care.
Develop and maintain a willingness to learn from and use errors to improve the systems or processes of care.
Use information technology or other avai/able methodologies to access and manage information, support patient care decisions and enhance both patient and physician education.
Curriculum
Didactic conferences and clinical experiences address the applicability of practice guidelines and routinely recommended preventive measures for older persons. Fellows learn about the areas of continued controversy regarding screening practices and treatment strategies. A particularly important area of instruction is the impact of health literacy in the effective care of older persons. Finally, errors frequently occur during the transfer of care between different clinical settings. Fellows' panels are routinely assessed to ensure that all necessary measures are employed to ensure the accurate transfer of information between inpatient hospital units, outpatient clinics, long-term care facilities and hospice care.
The Clinical Research Core Curriculum is designed specifically to provide trainees with the research skills to critically analyze scientific evidence in the field of geriatric medicine. These conferences allow the trainee to learn about methods used to investigate and evaluate patient care practices. Under the guidance of faculty, clinical experiences ensure that fellows have opportunities to apply these principles to investigate, evaluate and improve patient care.
Outcomes Assessment
1.The ABIM Competency-Based Evaluation Form is utilized to evaluate trainees on all rotations. .
2.Fellows complete a short-essay exercise addressing this competency during each year of training. This exercise poses ahypothetical situation that requires the fellows to articulate the knowledge and skills they have acquired specific to geriatric medicine and to apply this knowledge to address a specific clinical problem.

3.Individual outcome measurements from the Heart failure clinic: All-cause hospitalizations rates, CHF hospitalization rates, CHF emergency room usage rate, all cause emergency usage rate, compliance with medication guidelines.
Interpersonal and Communication Skills
Geriatric fellows are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.
Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients their families and colleagues.
Use effective listening, nonverbal, questioning, and narrative skills to communicate with patients andfamilies.
Interact with consultants in a respectful, appropriate manner.
Maintain comprehensive, timely and legible medical records.
Curriculum
These objectives are addressed as part of the daily clinical curriculum in both the outpatient and inpatient settings and monitored by faculty on monthly evaluation forms. In both of these settings fellows are observed taking histories, performing physical examinations and providing counseling to patients and their families. Through multidisciplinary conferences, fellows are observed to negotiate treatments plans with other care providers, including nurses, dieticians, PharmDs and geriatric social workers. Fellows routinely conduct meetings with family members and other caretakers of older persons and frequently need to communicate exclusively with caretakers to collect data on an incapacitated older person. Communicating bad news to patients and families is
The use of the computer-based medical record is required at both the University ofIllinois Hospital and the West Side Veteran's AdministrationHospital. Fellows are expected to enter their initial and follow-up notes into these systems in a timely manner. Faculty monitor the content of these communications on a daily basis.
Outcomes Assessment
1.The ABIM Competency-Based Evaluation Form is utilized to evaluate trainees on all rotations.
2.Fellows complete a short-essay exercise addressing this competency during each year of training. This exercise poses a hypothetical situation that requires the fellows to articulate the knowledge and skills they have acquired specific to geriatric medicine and to apply this knowledge to address a specific clinical problem.
3.During academic year nursing staff will be interview to fellows' performance in interpersonal and communication skills. This will emphasize interpersonal and communication skills.

Professionalism
Geriatric fellows are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.
Demonstrate respect, compassion, integrity, trustworthiness, and altruism in relationships with patients, families and colleagues.
Demonstrate continuing commitment to excellence, sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues.
Adhere to high ethical and moral standards and principles of confidentiality, scientific and academic integrity, and informed consent.
Exercise accountability to self and peers, responsibility to profession, and contribution to review of practice and standard setting.
Curriculum
These objectives are addressed as part of the daily clinical curriculum in both the inpatient and outpatient settings and are monitored by faculty using the fellow evaluation form. In all clinical settings, fellows are observed interacting with patients, families and colleagues. They also work with diverse interdisciplinary teams and are expected at all times to respect the opinions of others and conduct themselves for the benefit of patient care.
Ethical issues in the care of geriatric patients arise frequently and are discussed with attending faculty and consulting ethicists. Frequently encountered topics include the ethical aspects of balancing autonomy and beneficence, addressing suspected elder abuse, and determining plans for end of life care.
All fellows participate in a College of Medicine-wide Clinical Research Core Curriculum that is offered yearly. This conference includes three lectures addressing ethical issues: Ethical Controversies in Clinical Medicine, Integrity in Scientific Research and Ethics in Research.