Pioneering an Enhanced Geriatric Curriculum Russell Blackwelder, MD, MDiv Scott Bragg, PharmD, BDPS Melissa Hortman, MEd

Disclosures We have no conflicts of interest in relation to this program/presentation.

Objectives At the end of this presentation, active participants will: Modify your own curriculum by developing more engaging didactics Apply negotiating skills learned for generating buy-in at your own institution Create your own successful geriatric curriculum to meet the needs of your organization

What problems do you have in your own programs?

Background /5 of U.S. Population >65 years old /5 of >85 years old in S.C. will live near Charleston TMC/MUSC postgraduate survey –Largest demographic of patients is Geriatrics 2015 Match for Geriatric Fellowships –99 programs unfilled (most) –43% of total positions filled (least)

Minimum Geriatric Competencies IM/FM Working Group in competencies in 7 domains –Transitions of Care; –Hospital Patient Safety; –Cognitive, Affective, and Behavioral Health –Complex or Chronic Illnesses; –Medication Management; –Ambulatory Care –Palliative and End of Life Care

Geriatric Requirement IV.A.6.d) –Residents must have at least 100 hours (or one month) or 125 patient encounters dedicated to the care of the older patient IV.A.6.d).(1) –The experience must include functional assessment, disease prevention and health promotion, and management of patients with multiple chronic diseases IV.A.6.d).(2) –The experience should incorporate care of older patients across a continuum of sites

Longitudinal Requirement IV.A.6.a).(3) –Resident must be primarily responsible for a panel of continuity patients, integrating each patient’s care across all settings, including the home, long-term care facilities, the FMP site, specialty care facilities, & inpatient care facilities IV.A.6.a).(3a) –Long term care experience must occur over a minimum of 24 months

Geriatric Curriculum Development (1) 2012/13: –Used AAFP’s Philosophy/Attitude/Knowledge/Skills on Geriatric Medicine –2 Home Visits –Nursing Home Visits (4 per year/8 total over 2 years) –2 Half Days per week over 2.5 weeks –Set Noon Conference schedule

Geriatric Curriculum Development (2) 2014/15: –Rotation with nearby Nursing Home PGY2: 2-half days per week (2.5 week rotation), 4 Nursing Home visits per year PGY3: 4 Nursing Home visits per year –AAFP readings

Geriatric Curriculum Development (3) 2015/16: –Rotation with nearby Nursing Home PGY2: 5-half days for 5 week long rotation, monthly visits to Nursing Home PGY3 - monthly visits to Nursing Home PGY2/3: Elective Experiences –AAFP readings and quiz –Morning Reports –Pharmacotherapy quizzes –Pre-post rotation self-assessment

270pts

Geriatric Core Rotation (PGY2) The resident will recognize the variability of presentation of illness and disease processes and the unique pharmacologic challenges of the geriatric patient which are frequently present in a general family medicine practice and may be further referred to specialists for evaluation and treatment. (PC, MK, SBP) The resident will be able to perform comprehensive, standardized geriatric assessments and develop short- and long-term treatment plans. (PC, MK) The resident will develop empathy and compassion towards the elderly and assisting them to cope with inevitable decline and loss. (PC, PROF, C) The resident will coordinate a range of services appropriate to the patient's needs and support systems. (PC, SBP, PBLI, PROF, C)

Geriatric Longitudinal Experience Goals –The resident will gain an understanding of the variability of presentation of illness and disease processes and the unique pharmacologic challenges of the geriatric patient (PC, MK, SBP) –The resident will become aware of the importance of his/her own experiences and attitudes towards aging, disability and end of life issues and how these may impact his/her health care delivery and multidisciplinary team approach in the care of the older adult (PC, MK, PBLI, PROF, C)

Geriatric Longitudinal Experience Lectures and Skills at The Village at Summerville (9 per year/ 2 year rotation) Year B Orientation & Meeting of Resident Pairings Screening and Life Expectancy Vaccines and the Elderly Managing Pain in the Elderly Urinary Issues and Aging Services for the Elderly Skin Ulcer Prevention and Treatment Vision Impairment and Aging Growing Old at (Some) Home Year A Overview of the Program and Meeting of Resident Pairings Movement Disorders Sleep and Aging Establishing Capacity Preparing for the End Falls and Fall Assessment Dementia Delirium Beers List and Polypharmacy

Geriatrics Longitudinal Experience Dementia Medical Resident (N=15) –8 PGY2, 7 PGY3 Village Resident (N=20) Most helpful: –“Going through the scenarios with the Village Residents and learning with them, teaching them and learning from them, seeing and hearing their perspective.” –“Working with geriatric patients while reviewing this material allowed me better insight into their through process/perspective on their issues.”

Geriatrics Longitudinal Experience Dementia More knowledgeable –MR: Average= 4.73 (out of 5) –VR: Average= 4.45 (out of 5) Helpful to learn resources –MR: Average= 4.73 (out of 5) –VR: Average= 4.4 (out of 5) Better prevent –MR: Average= 4.6 (out of 5) –VR: Average= 3.94 (out of 5) Better treat –MR: Average= 4.6 (out of 5)

Geriatrics Longitudinal Experience Falls and Fall Prevention Medical Resident (N=11) –6 PGY2, 5 PGY3 Village Resident (N=6) Most helpful: –“Helpful learning more about what PT/OT do.” –“Good practice tests to asses fall risk.”

Geriatrics Longitudinal Experience Falls and Fall Prevention More knowledgeable –MR: Average= 5 (out of 5) –VR: Average= 5 (out of 5) Helpful to learn resources –MR: Average= 4.91 (out of 5) –VR: Average= 4.91 (out of 5) Better prevent –MR: Average= 5 (out of 5) –VR: Average= 5 (out of 5) Better treat –MR: Average= 4.8 (out of 5)

Group Activity Pair up with a partner Discuss your biggest curriculum problem (4 minutes) Brainstorm ideas to solve you problems (4 minutes) Discuss solutions as a group (8 minutes)

Curriculum Development Ralph Tyler (1949) –What educational purposes should the institution seek to attain? (Objectives) –What educational experiences are likely to attain these objectives? (Instructional strategies and content) –How can these educational experiences be organized effectively? (Organization of learning experiences) –How can we determine whether these purposes are being attained? (Assessment and evaluation)

Tyler Model of Curriculum Development Nature and structure of knowledge Needs of the learner Needs of the community /society

Nature and Needs Think of your own –Needs of your learners –Needs of your community –Nature and structure of knowledge Selection of topics covered Organization of topics Approaches to topics Nature and structure of knowledge Needs of the learner Needs of the communit y/society

Innovative Teaching Hosting content in Moodle –Pre/post survey –AAFP reading quiz –Pharmacotherapy quizzes –Morning Report –Additional resources

Geriatrics Self-Assessment Taken by resident on geriatric rotation (PGY2) –Taken before the rotation –Taken at the end of the rotation Statements cover PBLI, SBP, C, PROF, PC, & MK

Significant Changes in Comfortability (3) Explain the therapeutic capabilities and financing of care at different sites (eg, hospitals, subacute care, rehabilitation units, nursing homes, assisted living, hospice, ambulatory care, and patients' homes.) (2) Explain the public policy and economic implications of an aging society. (1) Accurately assess and recommend level of care needs, incorporating information from family, caregivers, and therapists. (3) Describe the current sociodemographic profile of older adults in the United States. (3) Enumerate the major considerations that affect your assessment of a patient's level of care needs and how you may direct patients/families to obtain needed resources. Over a 14% increase in comfortability

Average difference pre-post = Most significant change: Accurately assess and recommend level of care needs, incorporating information from family, caregivers, and therapists.

Readings and Quizzes Advantages: objective assessments for each topic area, knowledge clearly assessed across cohorts, emersion in literature, building habits for reading

AAFP Readings Done during the Geriatric rotation –Functional Decline in Older Adults (2013) –Reducing the Risk of Adverse Drug Events in Older Adults (2013) –House Calls (2011) –Management of Falls in Older Persons: A Prescription for Prevention (2011) –Nursing Home Care: Part I. Principles and Pitfalls of Practice (2010) –Nursing Home Care: Part II. Clinical Aspects (2010)

AAFP Quiz Contains questions from readings (N=16) –80% or higher on quiz to pass –Unlimited attempts Average overall grade = 88 –Taken by: 7 PGY2 –Reattempted twice by 1 PGY2 (83 to 100)

Example (Attempt=56%)

Pharmacotherapy Quizzes Wound Care Management –Q=6 –N=10 (1 PGY3, 8 PGY2, 1 PGY1) –Average grade of first attempts: 72.50% –Average grade of last attempts: 92.50%

Pharmacotherapy Quizzes Dementia –Q=7 –N=7 (7 PGY2) –Average grade of first attempts: 82.65% –Average grade of last attempts: 93.88%

Pharmacotherapy Quizzes Parkinson’s Disease –Q=10 –N=8 (7 PGY2, 1 PGY1) –Average grade of first attempts: 54.38% –Average grade of last attempts: 96.25%

Morning Report Resident on Geriatrics rotation leads Geriatric focused Morning Report during this rotation –Collaborate with faculty advisor to develop and present lecture

Additional Resources American Geriatrics Society: Vitaltalk.org Palliative Care electives and didactics Additional Pharmacotherapy resources and videos

References Denham, T. (2002). Comparison of the two curriculum instructional design models: Ralph Tyler and Siena College accounting class. Siena College, New York.

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