Development of Inter-Professional Geriatric and Palliative Care Clinic In your own PCMH Residency Clinic Janel Kam-Magruder MD FAAFP FAAHPM

Outline the process of Development of a Geriatric and Palliative Care clinic within a Residency Based Patient Centered Medical Home Clinic Review Logistics of the Visit (Who is teaching?, Who is learning? What is being taught?, How does it run?) Introduce Supplementary Curriculum Tools in the STFM Resource Library Objectives

Identification of need Resident driven Focus on training providers to care for full spectrum family medicine particularly in rural Alaska. Identification of need Curriculum Evaluation of Alaska Family Medicine Residency revealed resident request for a geriatric specialty clinic and palliative care specialty clinic training.

Identification of key players Resident Identification of key players Faculty Learners Family medicine faculty with geriatric training (CAQ or other specialty experience) Family medicine residents PGY1-3 Medical Students Faculty Pharmacist Pharmacy student interns Faculty Behavioral Health Specialist Behavioral Health Interns Palliative Care Family Medicine Faculty with palliative care training (CAQ in Hospice and Palliative Medicine) and Fellow Home Visiting Faculty Clinic Faculty (Clinic Director, Medical Assistants, Nurse Case Managers) Social Work Faculty Social Work Interns First steps included identification of key inter-professional teaching faculty and targeted learners

Development of an Inter-professional Teaching Curriculum Guidelines Entrustable Professional Activities (Geriatric and Palliative Care) Family Medicine ACGME Requirements Family Medicine Milestones and Competencies Behavioral Health Competencies Inter-professional Competencies See STFM Resource Library for Teaching Tools by Competencies See STFM Resource Library for Competencies by Profession Development of an Inter-professional Teaching Curriculum Guidelines

Identification of the Teaching Resources and Tools Based on Faculty Literature Review Teaching with available areas of expertise and identified clinic need See STFM Library for supplement on Teaching tools by Profession Identification of the Teaching Resources and Tools

Logistics of Pilot phase Initial teams built separately focused on geriatrics and palliative care and rotated between two simultaneous patients Geriatric team- resident, FM faculty, behavioral health and pharmacy Palliative care team- resident, FM faculty or palliative care fellow Logistics of Pilot phase Sample schedule for residents, teams, and patients 8-9 Shared didactic with IPT 9-10 am shared review of patients Patient 1 with resident 1 and geriatrics team Patient 2 with resident 2 and palliative care team Patient 1 with resident 2 and palliative care team Patient 2 with resident2 and geriatrics team Patient 3 with resident 1 and geriatrics team Patient 4 with resident 2 and palliative care team Patient 3 with resident 2 and palliative care team Patient 4 with resident 1 and geriatrics team

Resident suggestion to remain with patient and faculty for improved continuity and less change for the patient Review of didactic content to incorporate more review of assessment and tools for the clinic Pilot phase review

Logistics of the Didactic and Clinic Session- Schedule Resident 1 Schedule Resident 2 Schedule 8-9 am Shared Didactic 9-10 am IDT Review of Patients Clinic Visit with Patient 1 Clinic Visit with Patient 2 Clinic Visit with Patient 3 Clinic Visit with Patient 4

Logistics of the Didactic and Clinic Session- Didactic Content Didactic by the Inter-professional Team (including hospital ethicist) Review of the tools – For R1’s demonstration of tools such as gait evaluation with expectation of R3’s as ability to teach the tools Review of resident selected topic with possible resource or journal article such as for gait evaluation a resource on assistive devices Didactic lead by rotating learners and faculty: examples pharmacy review of medication interactions, behavioral health review of geriatric depression intervention, social review of local resources, palliative care review of symptom management etc. Logistics of the Didactic and Clinic Session- Didactic Content

Attended by Inter-Professional Team (with additional Hospital Chaplain and Ethicist) Facilitated by Resident learners initial PGY1 with aide of faculty with expectation of PGY3 to independently lead discussion. Residents receive and email with an explanation and facilitation guide for preparing and leading IPT (See STFM library for Resident IPT Discussion Facilitation Guide) At the conclusion of the IPT patient discussion, the resident should be able to identify aspects of need and assign an the “Top 3” areas of assessment and treatment to approach during the clinic visit. Example- Need for cognitive assessment, gait evaluation, and discussion of goals. Consider symptom evaluation or functional evaluation for an additional visit. Logistics of the Didactic and Clinic Session- Inter-professional Team Discussion

Logistics of the Didactic and Clinic Session- the Clinic Visit Each patient is seen by a core Inter-professional Team and often by adjunctive providers as based on their need (identified during IPT or during visit. Example- Social work for increased Personal Care Services Providers such as pharmacy or behavioral health may rotate between patients depending on how many patients and providers are available while family medicine resident and faculty will be present for the entire visit. Logistics of the Didactic and Clinic Session- the Clinic Visit Inter-professional Providers Adjunctive Provider Family Medicine Resident Social Work Interns Family Medicine Faculty or Palliative Care Fellow Nurse Case Managers Behavioral health Intern and faculty (rotating) Home Visiting Faculty Pharmacy Intern and faculty (rotating) Clinical Medical Assistant Social work interns and faculty are often pulled into the visit to address issues of resource. Nurse Case Managers often address medication education and financial resources (prescription drug plans), and Home Visiting Faculty may be present to meet patients and introduce home visit services if a patient is found to be transitioning towards this type of care.

Logistics Inter-professional providers during the Clinic Visit MH Mental Health Provider Pharmacist FM Faculty * FM Resident Geriatrics and Palliative Care Patient Logistics Inter-professional providers during the Clinic Visit Caregivers are encouraged to be with patient *FM Faculty with focus in Geriatrics or Palliative Care Adjunctive providers include Social work and nurse case managers 2 patients each are seen FM resident and faculty Mental health and pharmacy providers see each patient sometimes in rotating fashion.

Evaluations and Feedback End of Session Wrap Up is conducted with Inter-Professional Team Providers Resident Self Evaluations completed pre and post experience on confidence and knowledge in domains of Geriatrics and Palliative Care. Qualitative Comments are evaluated on overall experience. Patient experience is assessed with after visit survey Resident interactions are evaluated by faculty (Family Medicine or Palliative Care Fellow) with New Innovations Evaluation and a Shadow Evaluation Fellow as faculty experience is debriefed by after visit discussion with Family Medicine faculty with Palliative Care CAQ Resident give feedback on faculty teaching and logistics of the clinic during yearly Curriculum Evaluations. Evaluations and Feedback

Overview of Supplementary Materials in STFM Resource Library Teaching Tools by Competencies Competencies by Profession Learner Teaching Tools by Profession Resident IPT Discussion Facilitation Guide Resident Self Evaluation in Confidence and Knowledge Scales and Qualitative Comments Other Evaluations: Patient, Faculty Shadow, and New Innovations by Milestones Overview of Supplementary Materials in STFM Resource Library Competencies by Profession addresses Competencies for fellows, Behavioral health interns, and family medicine interns however it was felt by Pharmacy faculty that each individual Pharmacy school has individual and differing teaching criteria.

Progression of Degree of Mastery PGY1’s expectation to learn tools and discuss in didactic. In clinic will demonstrate or shadow use of tools by interprofessional team PGY2’s expectation to be able to explain tools during didactic and contribute to discussion topics in geriatrics and palliative care. In clinic will be able to use assessment tools and begin to make recommendations with interprofessional team. PGY3’s expectation to demonstrate and teach tools during didactic and discuss with interprofessional learners. In clinic to use assessment tools and make recommendations. To be able to facilitate and work with other providers collaboratively on the interprofessional team Progression of Degree of Mastery

Content of didactic learning from residents are reviewed with a yearly resident curriculum evaluation. Sample feedback of learning points of didactics include “specific contraindications to tube feeds [in the elderly], following up efficacy of anticholinergics like donepezil after 12 wks- stop if no improvement”, “pain is often undermanaged”, “patients often believe that their terminal cancer can be cured” Evaluation from residents on self assessments are reviewed by faculty for confidence and knowledge use of tools as well as teaching efficacy for future post residency jobs and teams. Evaluation of resident overall experience and interprofessional learning experience are also reviewed. Feedback

Challenges Patient Scheduling Identification and review of assessment and also recommendations Facilitation of interprofessional team members logistics of visits And incorporating learners beyond residents (multiple interprofessional students and interns) 1650 Challenges