STUDENT ORIENTATION

HOME VISIT PROGRAM

AMALGAMATED-PARK RESERVOIR COOPERATIVE

2003

GERIATRIC MEDICINE PROGRAM

INTRODUCTION TO CLINICAL MEDICINE ALBERT EINSTEIN COLLEGE OF MEDICINE


Background:

This is a pilot program for first year- medical students who are enrolled in the Geriatric Medicine Program- Introduction to Clinical Medicine. The goal is to allow students to have a continuity experience with a community dwelling older adult. The student will have the opportunity to complete an in-depth medical and psychosocial history. Each student will make four home visits over the course of five months. All the older adults are residents of the Amalgamated –Park Reservoir Cooperative in the Bronx. This housing cooperative, which is located minutes from Montefiore, has 1,800 residents and is defined as a NORC (Naturally Occurring Retirement Community). A NORC is a group of buildings, apartment complexes, or neighborhoods, not originally planned for older people, where over time the majority of the residents have aged in place and become elderly. Within the NORC there are a variety of social services and educational activities coordinated by multiple community agencies. The Geriatric Ambulatory Practice (GAP) at Montefiore provides primary medical care for patients within the Bronx, including persons residing in the Amalgamated Cooperative. The older persons selected for this program are all patients of Montefiore Geriatric Ambulatory Practice and students will be expected to communicate directly with the patient’s primary physicians after their final visit.

Scheduling:

Introductory First Visit: October 13 or October 20

  • Debra Greenberg, MSW will accompany all students on the first visit. The students will have the opportunity to have a brief tour of the Amalgamated Cooperative and meet the social service staff. The students will have a brief introductory meeting with the older person and confirm future appointments.
  • Students will take a cab arranged through the ICM office.
  • October 13 Students: n/a
  • October 20 Students: n/a
  • The preceptors at your primary site have all been sent information and the dates of this new program. However, please review the schedule with the preceptor so they do not expect to see you on the dates you are making a home visit.

Second Visit: November 10

Third Visit: December 15

Fourth Visit: February 2

  • The older adults have all been given the schedule of visits. If they need to change the time of the visit, they have been asked to communicate with Debra Greenberg, MSW and not contact the medical student directly. We would like the students to call the participant the week before you plan to visit and confirm the appointment. If you need to reschedule, because of a conflict, please notify Debra Greenberg as well as the preceptor at your site.

Reception at AECOM: February 23

  • All older adults who participated in the program will be invited to a reception and tour of AECOM with the students and staff of the Geriatric Medicine Program.

Transportation:

  • Taxis will be arranged through the ICM office and will go to the Amalgamated Cooperative on the above dates. If you need to change the date of your visit, please speak to the ICM office to arrange your transportation.

Guide Lines for a Home Visit:

  • Try to arrive on time. If you are going to be more than a few minutes late, please call the older person directly. In general visits should be limited to 60 –90 minutes or shorter depending on the patient’s comfort.
  • Reintroduce yourself, and greet all family members who are present.
  • Follow the patient’s lead in where you should sit.
  • “Touch base” with the patient about their understanding of the interviews and address any concerns.
  • You may need to reassure the patient that you are bound by professional confidentiality and that you will not discuss the case outside of professional settings.
  • Refrain from offering any medical advice. Explain that you are a medical student and direct them to discuss concerns with their physicians.
  • If you are concerned about an urgent medical question or situation, direct your patient to contact their physician.

Write Up:

  • After each home visit a brief 5-10 sentence summary of the visit should be e-mailed to Dr. Amy Ehrlich ( and D. Greenberg, MSW ().
  • At the end of the four visits students should write a one-page summary of pertinent medical and psychosocial history. After review by Dr. Ehrlich and D. Greenberg, MSW this will be forwarded to their primary physician.

Curriculum for Home Visits 2-4:

Visit Two

During this visit the students will obtain a complete medical and psychosocial history of the older person, which will include questions about:

  • Current and past medical history
  • Current medications, allergies
  • Pain inventory
  • Educational, family, personal history

Open-ended questions may include:

What are your major medical problems?

Can you tell me about your medications, and why they were prescribed?

How do your symptoms affect the quality of your life?

Are you satisfied with your care?

Where are you from?

Tell me about your parents, siblings, and school experience, work history

What do you remember about the Great Depression?

How did World War II impact you?

Tell me about your family now? Who is your oldest friend?

Thank the older adult for their time and confirm the next visit.

Visit Three

During this visit the student will conduct a geriatric screen andfunctional assessment of the older person to include:

  • Observation of the neighborhood and environment
  • Motor and sensory function
  • Functional status and its impact on daily activities and relationships
  • Home environment
  • Geriatric review of systems (falls, depression, incontinence, sleep, nutrition, memory loss)

Use of assessment tools is encouraged. (See Appendix.)

Open-ended questions may include:

Can you tell me what the nature of the relationship you have had with the health care system?

Could you share your earliest memories of doctors and medicine

What are the qualities you look for in a good doctor?

Do you have difficulty with your vision, hearing, and taste?

Do you use assistive devices (cane, hearing aide, glasses)?

Does the use of these devices feel helpful or burdensome?

Do you have safety concerns in your home/environment?

What community-based services do you participate in?

Recommendations for being a good doctor

Thank the older adult for their time and confirm the next visit.

Visit Four

The purpose of the final visit will be to discuss the older person’s values and advanced directives including:

  • Family dynamics and relationships
  • Cultural and social supports
  • Caregiver issues
  • Political perspectives
  • Religious/spiritual beliefs
  • Health care preferences and directives
  • Elicit hardest part of the aging process
  • Hopes and fears for the future

Open-ended questions may include:

Have their been new issues in your family since you/ your spouse became ill?

What has helped you cope with your illness?

Who in the family helps when you need assistance?

Is there anyone outside the family that helps you at home?

Do you get help from social, religious or other community agencies?

How important are your political values to you?

Do you consider yourself a religious or spiritual person?

What makes live most worth living for you?

How do you experience the quality of your life right now?

How do you want to be remembered?

Do you have a health care proxy or living will to state your wishes and values?

Thank the older adult for their time and confirm participation in the end of program reception.

APPENDIX

Activities of Daily Living (ADL)

Independent Activities of Daily Living (IADL)

Mini-Mental State Examination (MMSE)

Geriatric Depression Scale (G.D.S.)

Geriatric Depression Scale-Short Form

1