1. Primary Care Program Office, PCS May 2011

2. Purpose: To provide virtual education support primarily to rural primary care providers (PCP) to help ensure all Veterans receive uniform, competent, expert care by VHA physicians regardless of geographic setting. Geriatrics - Dementia -Frailty -Sex & Driving - Advanced Care Planning -Screening Mental Health -Evaluation & Treatment of Anxiety, Depression, & Suicidality -Alcohol Misuse -PTSD Pain Management -Complex Chronic Pain -Stepped Integrated Pain Care Post Combat Care -Post Deployment for Frontline Providers -C&P Process -Environmental Agent Exposure -Military Culture

3. Each course is prepared by a nationally recognized subject matter experts who are also expert clinicians and excellent teachers Each module is comprised of four to five courses Within LMS, there are multiple means of learning including watching the courses and reviewing of the slides. Each course has an exam as a means of verifying learning. Once the learner passes the exam, they will receive a certificate of completion. The course is also ACCME accredited and learners will receive 1 hour of Continuing Medical Education (CME) credits per course

4. ModuleLMS ID No. Title and Direct Link GeriatricsVA 8896 Advance Care Planning: A Collaborative Interdisciplinary Process GeriatricsVA 8897 Co morbidity and Frailty: Two Important Concepts in Geriatric Care GeriatricsVA 8900 Evaluation and Management of Dementia: Key Concepts for Primary Care GeriatricsVA 8910 Screening for Common Geriatric Conditions among Older Adults in Primary Care GeriatricsVA 8911 Sex and Driving: Two Tough Conversations We Need to Have with our Older Patients Mental HealthVA 8899 Evaluation and Management of Alcohol Misuse in Primary Care Mental HealthVA 8901 Evaluation of Anxiety, Depression, and Suicidality in Primary Care Mental HealthVA 8909 Screening and Evaluation of PTSD in Primary Care Mental HealthVA 8914 Treatment of Anxiety and Depression in Primary Care Pain ManagementVA 8898 Collaborative Care Model of Complex Chronic Pain Pain ManagementVA 8905 Practical Suggestions for Helping Veterans with Complex Chronic Pain Pain ManagementVA 8913 Stepped Integrated Pain Care in the VHA, Part 1 Pain ManagementVA 8912 Stepped Integrated Pain Care in the VHA, Part 2 Post Combat CareVA 8886 Environmental Agent Exposures in Veterans and Risk Communication for Frontline Providers Post Combat CareVA 8888 Post Deployment Care for Frontline Providers Post Combat CareVA 8890 The Compensation and Pension Exam Process and VA Benefits Post Combat CareVA 8891 Why Military Culture Matters: The Military Member's Experience Tip: LMS Search

5. May Geriatrics: May 18, 2011 @ 1PM EST June Pain Management: June 15, 2011 @ 1PM EST Jully Post Combat Care: July 20, 2011 @ 1PM EST August Mental Health: Aug 17,2011 @ 1PM EST Questions regarding the Primary Care Rural Health Education Initiative may be directed to Miyako Wilson at 202-461-7180 or Gordon Schectman at 414-384-2000 ext.42684.

6. Heather Whitson, MD Durham Geriatric Research, Education, and Clinical Center (GRECC) Duke University School of Medicine B. Josea Kramer, PhD Greater Los Angeles GRECC UCLA David M. Geffen School of Medicine

7.  >50% of Veterans seen in VHA Primary Care are age 65 and above  >30% are age 75 and above  Rural counties have higher proportions of elderly residents than urban and suburban ones; trend is even greater for Veterans  Elderly rural Veterans are challenged by travel, communications, non-institutional resources, community support systems …the resources described in this hour are offered to help support and enhance your Primary Care PACT’s abilities and confidence to do as much as you can for the older Veterans in your panels!

8.  New non-institutional programs supported by the Office of Rural Health (ORH) ◦ New and modified Home-Based Primary Care programs ◦ VHA/Indian Health Service collaborations  Non-institutional extended care pilots ◦ Dementia care “circuit riders” ◦ Mobile vans  A variety of GRECC* educational materials and opportunities ◦ Pocket cards of GEC services; Differential Diagnoses; Geriatric Assessment; Falls assessment ◦ CBOC educational outreach/QI training (VISNs 11, 19) ◦ Monthly Geriatrics Audioconferences (national)  4 th Thursday, 3 pm eastern, 1-800-767-1750; x89095#  Audio and visual content archived at http://www.greccaudio.geriu.org/ http://www.greccaudio.geriu.org/ ◦ “Geri-Scholars”--an intensive specifically for rural primary care clinicians  Primary Care Rural Health Education Series *http://www.va.gov/GRECC/GRECC_Demographics_and_Profiles.asphttp://www.va.gov/GRECC/GRECC_Demographics_and_Profiles.asp

9. A collaboration of VA Office of Geriatrics and Extended Care and Geriatric Research Education & Clinical Centers (GRECC) B. Josea Kramer, PhD Director, VA Geriatric Scholars Program Associate Director for Ed/Eval, GRECC VA Greater Los Angeles Healthcare System GRECC A program made possible by funding from the VA Office of Rural Health

10. VISN# CBOC # Scholars VISN# CBOC # Scholars 1 912 23 2 56 1567 3331688 4331735 5241889 6361946 7452034 8782110 97 2200 1081123812 1158 Geriatric Scholars Program: 2008-2010 140 VA Scholars 40 States, 2 US Territories 110 # Rural Clinic

11. Primary Care Providers Support Team Members

12. Mandatory Components Intensive Didactic Geriatric Medicine, ≥30 hours CME/CEU Intensive Didactic Quality Improvement, ≥8 hours CME/CEU Initiate local QI Project to improve care for older Veterans

13. Optional Components Distance Education - QI LiveMeeting & Telephone Conference - Aging Successfully Newsletter -Webinar Series at request of Geriatric Scholars -Web-based education: “Challenges to Delivering Geriatric Care for Veterans in Rural Settings -Monthly GRECC Audio Conferences Clinical Practicum, various foci Mentoring for Clinical Coaching for Quality Improvement Learning Community Interdisciplinary Team Training On-Site & Virtual (Pilot FY11) On-Going Support: Enduring Educational Materials Alumni Geriatric Course intensives & Practica

15. Goals: To provide professional development to the health provider participating in the Geriatric Scholars program Objectives: Webinar Part 1 – To improve their communication skills in knowledge transfer with their peers who work in Community Based Outpatient Clinics (CBOCS) Webinar Part 2 – To define the basic theories of adult learning to better understand what motivates and engages adults to incorporate new information into their health behaviors Webinar Part 3 – To identify literacy barriers that affect learning in older patients. “SLIDES WILL BE ARCHIVED” For Further Assistance Contact: Lauren Ila Jones, Ph.D. Program Manager, Geriatric Scholars Program GRECC/VA GLAHS-Sepulveda Campus 16111 Plummer St. (11E) Ph (818) 891-7711 x9156; lauren.jones@va.gov

16.  Geriatric Scholars Program information  State-of-the-Art Geriatrics ◦ Toolkits, Clinical Guidelines, Resources  CPRS Templates  Education calendar  Discussion Boards http://vaww.portal.gla.med.va.gov/sites/GRECCNew/scholars/default.aspx

17.  Evaluation: Application of knowledge  Participation in annual Geriatrics & Extended Care Leads conference  Projects on display in facilities and VISN offices Other benefits: Meets recertification requirement: Self evaluation of practice performance Project approval through Quality Management

20. “This program has helped me with my day to day practices. I feel more comfortable in my role. I can communicate better with my team and patients...” “Please send my thanks to the people in charge--you really motivated me to decide to go back and do my doctorate.” “Very fortunate to have the opportunity to be a part of the program.” “It's been great - great to learn something new on a regular basis.”

21.  New class enrollment will be announced by DUSHOM to the Networks  VISNs nominate Scholars to attend  Eligibility: ◦ Rural VA CBOCs, VA employee ◦ Discipline ◦ Commitment to complete course New Class Enrollment Starting Soon!

22.  Josea Kramer, PhD  Kenneth Shay, DDS  Judy Howe, PhD  Ronni Chernoff, PhD  Steven Barczi, MD  Kathy Horvath, PhD  Terri Huh, PhD  Nina Tumosa, PhD  Michele Saunders, DMD  Robert Dittus, MD & Jacob Hathaway, MD Greater Los Angeles GRECC VA Office of GEC Bronx GRECC Little Rock GRECC Madison GRECC New England GRECC Palo Alto GRECC Saint Louis GRECC San Antonio GRECC Tennessee Valley GRECC & Nat’l VA Quality Scholars

23. Main goal: To increase providers’ comfort and knowledge about important and common geriatric conditions and issues

24. Almost all providers in the VA have experience and skill in caring for older adults We all have a lot to learn

25. Assessment and referral of geriatric conditions Frailty Dementia and other cognitive changes Palliative care Falls and locomotor problems Pharmacology in older adults Genitourinary issues in older adults Long-term care Caregiver and home assessment Musculoskeletal diseases in older adults Infections in older adults Circulatory diseases in older adults Endocrinopathies in older adults

26.  Advance Care Planning: A Collaborative Interdisciplinary Process  Comorbidity and Frailty: Two Important Concepts in Geriatric Care  Evaluation and Management of Dementia: Key Concepts for Primary Care  Screening for Common Geriatric Conditions among Older Adults in Primary Care  Sex and Driving: Two Tough Conversations We Need to Have with our Older Patients

27. Next of Kin Hierarchy in VA A relative 18 years of age or older, in the following order of priority: – Spouse – Child – Parent – Sibling – Grandparent – Grandchild – Close friend

28. Pearls for Management  Less May Be More ◦ Avoid polypharmacy.  Can the problem be addressed without a prescription pad? ◦ More permissive approach chronic disease management ◦ Cease preventive screening if life expectancy is < 5 years U.S. Air Force Photo by Airman 1 st Class Adam Grant/Released

29. Current Year Peak Year After Peak Veterans563,758 2012 571,614 Decline Thru 2022 Enrollees317,943 2015 339,248 Slight Decline Thru 2022 Patients192,724 2017 218,017 Very Slight Decline Thru 2022 Dementia in the VA Urban rural split: 38% of Veterans live in rural areas and 75% of rural Veterans are over the age of 65.

30. Screening for Urinary Incontinence Single item screener (with follow-up items for positive response) “During the past 3 months, have you leaked urine (even a small amount)?” If yes, then ask: “During the past 3 months, did you leak urine most often”: “When you were coughing, laughing, sneezing, lifting or exercise?” (suggests stress incontinence) “When you had the urge to urinate, but you couldn’t get to the toilet fast enough?” (suggests urge incontinence) Neither or both

31. Older adults are sexually active  Population survey (n=3005, age range 57 – 85)  Sexual activity is associated with quality of life  Predictors of reduced sexual activity: – Advanced age, lack of partner, female sex, poor health of person or partner Lindau ST, et al. NEJM, 2007 Age% sexually active 57 – 6473 65 – 7453 75 – 8526