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Chronic Care Clerkship - Conjoint 690

Introduction to Geriatrics Clinical Focus

COURSE OBJECTIVES:

It is hoped that students will learn the importance of professional partnership necessary to deliver comprehensive care to elderly patients. One specific goal is that students master skills of functional assessment for frail, chronically ill, and medically complex elderly patients. Students will become skilled at identifying medical and non-medical issues impacting an individual's functional status and which affects quality of life. They will be encouraged to develop attitudes of respect, empathy and appreciation for limitations posed by physical, emotional, psychological and environmental barriers to independence. Clerks will learn that rather than seeking single answers to some of these questions, they will identify a multitude of solutions, often creative and always developed by teamwork. Students will complete Conjoint 690 Geriatrics with an understanding for the limitations of therapeutic options based on unsupported evidence, age-related adverse outcomes, competing medical co-morbidity, medical futility and patient wishes. It is intended that students appreciate the constraints of caring for individuals at the end of their lives, and the need to develop a more extensive partnership to facilitate care and address often unmet needs at this unique time.

COURSE EXPECTATIONS AND GOALS:

Educational Goals:

  • To gain knowledge of, and skills in, the care of chronically ill and functionally impaired older adults.
  • To understand the complexity of geriatric issues, including medical, psychosocial, and economic factors that impact functional status and site of care.
  • To understand the role of interdisciplinary providers in developing comprehensive patient assessments and establishing therapeutic goals in caring for older patients. Students will participate in interdisciplinary care meetings and will become familiar with the roles of each of the professional team members.
  • Students will gain knowledge and skills in the elements of Comprehensive Geriatric Assessment (CGA) and targeted strategies for patients who benefit most from such assessment. Students will become skilled in the use of the tools of CGA (ADL, IADL, GDS, MMSE, 'get up and go testing').
  • Students will gain knowledge in special topics in Geriatrics including:

    • Dementia
    • Delirium
    • Falls
    • Incontinence
    • Biology of aging
    • Economics of aging-mechanisms of financing care of older adults
    • Functional dependence and options for levels of care
    • Elder abuse
  • Students will participate in at least one home care visit of an elderly patient. Students will appreciate how the home environment impacts quality of life, medical compliance and functional status. A written and oral presentation of this experience is required for successful completion of the course. Formatted questions will be provided to all students.
  • Students will attend all formal teaching conferences and lectures offered at their assigned clinical sites.
  • Students will complete any reading assignments and examinations developed or this clerkship or assigned by the geriatric module coordinator.

Here are some of the experiences you will encounter within the month you are on Geriatrics:

You will work as a member of interdisciplinary care teams, developing care plans addressing medical and functional goals of care, and developing placement strategies based on functional needs patient wishes and available resource options.

You will observe a variety of living arrangements where individuals are provided with the levels of personal care commensurate with their specific needs.

You will participate in care delivered to those with life-limiting and terminal medical conditions. You will appreciate the important role the care team plays in managing the end-of-life medical, psychological and spiritual needs of that individual and their family.

You will make a home visit, ideally to the living situation of a patient that you have previously worked with during their in-patient stay, but if not, you will identify the elements of personal care and degree of assistance an individual requires to live within their community. For some, this environment may be a nursing home, for others it may be an adult family home, or their own dwelling where they may live alone or with a number of caregivers.

In addition to the formal didactics scheduled for the first day at UWMC, you will attend the on-going educational opportunities supported by the Division of Gerontology and Geriatric Medicine including:

•  Geriatric Grand Rounds - HMC Research (R&T) Conference Room 117, 8:00am - 9:00am, the first, third and fifth Fridays (when applicable) of the month.

•  Geriatric Journal Club - HMC R&T Conference Room, 8:00am - 9:00am, the second Friday of the month - please see Geriatrics website for journal article beforehand Geriatric Research Conference - HMC R&T Conference Room, 8:00am - 9:00am, fourth Friday of the month.

•  Geriatrics Pre-clinic Conference - Building 1/812 PSVAHCS - Seattle GRECC Conference Room, 8:00am - 9:00am, Wednesday's.

 

ASSIGNED TEXTBOOK FOR COURSE:

Essentials of Clinical Geriatrics: 5th edition, Kane, RL, Ouslander, JG, Abrass, IB 2004 McGraw-Hill, available in UW Medical Bookstore or on loan through UW and VA libraries.

Required Reading Assignments: */**

Week 1: Chapters 1-2
The Aging Patient and Geriatric Assessment
pps 1-70

Week 2: Chapters 5-7
Differential Diagnosis and Management
pps 93-275

Week 3: Chapters 11-14
General Management Strategies
pps 281-356

Week 4: Chapters 15-17
Health Services, Nursing Home Care, Ethical Issues
pps 389-474

The Geriatrician in the Nursing Home
pps 113-119

* Additional resources are posted on Conjoint 690 website.

** This order is suggested, however students are encouraged to read text consistent with the topics most relevant to their experience.

 

CLINICAL ROTATIONS:

Students will be provided in-depth exposure to principles of geriatric medicine as practiced in hospitals, long term care settings, and home care at two academic sites of geriatric care: the Veteran's Affairs Medical Center-Transitional Care Unit (VAMC-TCU) and Harborview Medical Center-Long Term Care Service (HMC-LTC).
These institutions have well-developed clinical programs delivering high quality of geriatric care to older adults in our community, and participate in the training of medical professionals within the University of Washington School of Medicine. Each site offers a different perspective of care and at each site the structure of the rotation is unique, with many common denominators.

Students assigned to HMC-LTC will rotate between sites of care and will have preceptors at each site.

Students assigned to VAMC-TCU will have a single preceptor, the attending physician for Transitional Care Unit (TCU).

 

CLINICAL ROTATION SITES AND SERVICES OFFERINGS
at HMC-LTC:

The Geriatric Inpatient Service is imbedded in the general medical service and is located on the 4E hospital unit. The geriatric medicine service is identified as Med-G, and serves patients who have needs of care requiring a limited extended hospital stay in recovery from acute medical illness, trauma or surgery and who would benefit from rehabilitative efforts in order to maximize their function. The Med G team also provides comprehensive inpatient consultation to patients over age 65 with rehabilitative or palliative/end-of-life care needs throughout HMC, including the surgical units and ICUs. Students on HMC-LTC will be as integrated into the Med G and LTC teams: the HMC team is comprised of the following:

  • Medicine MD component:
    Medicine Attending
    Geriatric Fellow
    Medicine R-2 or R-3
    Medicine R-1
  • Rehabilitation component:
    Occupational Therapist
    Physical Therapist
    Speech Therapist
  • Social Work:
    Medical Social Worker
  • Nursing Svc:
    RN 4E Nurse Manager
    RN Patient Care Coordinator

Rotation Assignment Service Offerings at HMC-LTC:
Outpatient Clinic at HMC (Senior Care Clinic - 4W)
Acute Hospital Care (Medicine G team - 4E)
Hospital-based Consultation (Medicine G team - HMC)
Long-Term Care (LTC sites)
Geriatric Rehabilitative Care (LTC sites)
Hospice Care (LTC sites)

Harborview Long-term Care (HMC-LTC)

Bessie Burton Sullivan Nursing Home
Wayne C McCormick, MD
1020 E. Jefferson (3 blks E of HMC)
Caroline Coleman, ARNP

Bailey Boushay House
Wayne C. McCormick, MD
2720 E. Madison
Caroline Coleman, ARNP

First Hill Care Center
Mariluz Villa, MD
1334 Terry (7 blks N of HMC)
Nicole Pashek ARNP

Schedule for HMC-LTC

The weekly schedule for students will be as follows - students will split into 2 groups depending on total number on rotation. Both groups will have the same experience.

  • Monday Morning:
    • Contact Med G Attending for patient assignment
      (both groups)
    • Morning Report 10:00am - 11:00am
    • Attending Rounds: Med G 4E 11:00am - 12:30pm
  • Monday Afternoon:
    • Work with Med G patients:
      chart review, patient contact, and rehab

  • Tuesday Morning 8:30am - 12:00pm
    • Group 1 - SeniorCare Clinic 4W
    • Group 2 - Bailey Boushay/Bessie Burton (meet at Bailey)
  • Tuesday Afternoon 1:30pm - 3:00pm
    • Interdisciplinary Rounds 4E Conference Room

  • Wednesday Morning:
    • Contact Med G Attending for patient assignment
      (both groups)
    • Morning Report 10:00am - 11:00am
    • Attending Rounds Med G 4E 11:00am - 12:30pm
      (both groups)
  • Wednesday Afternoon:
    • Work with Med G patients:
      chart review, patient contact, and rehab

  • Thursday Morning:
    • Medical Grand Rounds 8:00am - 9:00am UWMC or HMC R&T
      (both groups)
    • LTCS Conference 10:00am - 12:00pm; PS 5130
  • Thursday Afternoon:
    • Group 1 - First Hill Nursing Home
    • Group 2 - SeniorCare Clinic 4W

  • Friday Morning:
    • Geriatrics Grand Rounds 8:00am - 9:00am HMC
      (both groups)
    • Morning Report 10:00am - 11:00am 2W ICU Conference Room
    • Attending Rounds Med G 4E 11:00am - 12:30pm
  • Friday Afternoon:
    • Work with patient of choice to prepare case presentation Reading and study

MEDICAL STUDENT ROLES AND RESPONSIBILITIES at HMC-LTC

  • The student will work with the Med G Team and will participate as a member of the interdisciplinary care team. Students will be exposed to several patients in multiple venues during the week.
  • Students will work with at least one patient weekly; they should work with one patient from each of the following categories during the 4 week rotation:
    • Geriatric patient with rehabilitation needs
    • Long-term care patient
    • Palliative care patient
    • Hospice care patient
  • Students will perform the ADL and IADL assessment, and MMSE examination on all patients followed, and any other assessments that are indicated.
  • Under attending and nurse practitioner supervision, students will see their patients, review progress notes and chart orders, participate in all conferences and meetings pertaining to their patient, attend and present their patient during Interdisciplinary Care Rounds and during attending rounds, and assume communication with family and other primary caregivers regarding the patient's progress, as appropriate.

 

CLINICAL ROTATION SITES AND SERVICES OFFERINGS
at VAMC-TCU:

The TCU is a 38-bed in patient unit serving an intermediate care stage in the continuum between acute and long-term care. Patients on the TCU need extended hospital care in recovery from acute medical illness, trauma or surgery and benefit from interdisciplinary rehabilitative care in order to maximize their function. The TCU also offers inpatient palliative/end-of-life care. Students will be as integrated into the TCU's housestaff team. The team is comprised of the following:

  • Medicine/MD component:
    Medicine Attending
    Geriatric Medicine Fellow
    Medicine R-1
    Family Practice R-3
  • Rehabilitation therapy component:
    Occupational Therapist
    Physical Therapist
  • Social Work:
    Medicine Social Worker
  • Nursing Services:
    TCU Nurse Manager
    Clinical Specialist
    Two Nurse Practitioners (ARNP)

Rotation Assignment Service Offerings at VAMC-TCU:
Geriatric rehabilitative care
Sub-acute medical care
Chronic long-term care
Palliative Care
Hospice care

MEDICAL STUDENT ROLES AND RESPONSIBILITIES at VAMC-TLC

  • The student will work with the Medicine Team and will participate as a member of the TCU interdisciplinary care team.
  • Students will work up at least one patient weekly; they should work with one patient from each of the following categories of care during the 4 week rotation:
    • Geriatric patient with identified rehabilitation needs
    • Long-term care patient
    • Palliative care patient
    • Hospice care patient
  • Students will perform the following screening evaluations on all their patients: ADL and IADL assessment, MMSE examination, and any other evaluations that are indicated.
  • Under supervision, students assume clinical responsibility for the patients assigned to them. Students will perform the clinical responsibilities and duties attendant to in-patient care on the TCU, including rounding on their patient Tues-Fri.'s complete progress notes and chart orders, participate in all conferences and meetings pertaining to their patients, attending and presenting their patients at the Multidisciplinary Rounds and during attending rounds, and communicate with family and other primary caregivers regarding the patient's progress.

 

RESOURCE CONTACTS

Geriatric Course Director:
Kayla Brodkin, MD
Office phone/voice mail 206-277-1881
Pager: 206-570-0843
Email: Kayla.brodkin@med.va.gov

HMC-LTC Site Coordinator:
Itamar B. Abrass, MD
Office phone/voice mail 206-744-9100
Email: itamar@u.washington.edu

Wayne C. McCormick, MD
Office phone/voice mail 206-744-9113
Email: mccorm@u.washington.edu

VAMC-TCU Site Coordinator:
M. Scott Cohen (Michael.Cohen3@va.gov)
Office phone 206-264-2864

 

 

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