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ACUTE INPATIENT CONSULTATION SERVICE
Overview:
Fellows will be expected to learn about the acute medical management of elderly patients admitted to the hospital. Fellows will have an intensive, supervised exposure to the varied clinical presentations of common diseases often found in the elderly admitted from home, assisted living, or nursing home. They will learn to recognize and manage the common geriatric syndromes as they present in the hospitalized elderly patient. Fellows will also learn the principles of consultative care as they evaluate and follow these patients as consultants.
Fellows will be assigned 2-3 new consults per session with at least 2 consults a week from the geriatric psychiatry floor. Fellows will perform the initial consultation and discuss the case with the supervising attending. Fellows will be responsible for communicating recommendations to the requesting physician. They will also be expected to take an active role in discharge planning and communicating with members of the interdisciplinary team (PT/OT/speech/case management). When appropriate, fellows will be asked to participate in and lead family meetings and end of life/ advanced care planning discussions with the supervision of the attending faculty.
Fellows will follow up on patients they have seen in consultation and present these patients to the attending for discussion and review as well. Whenever possible, fellows will follow their own outpatients who are admitted to the hospital and will perform the initial hospital consult on any patient they are following from the community.
GOALS (competencies):
By the end of this rotation, fellows will be able to:
- Recognize and manage common geriatric syndromes in the hospital in a cost efficient manner (patient care/medical knowledge/systems based practice)
- Explain the pathophysiology of aging and how it relates to disease (medical knowledge)
- Discuss the pharmacokinetics/dynamics associated with aging and its implications for drug interactions (medical knowledge)
- Recognize the role of the interdisciplinary team in this setting and its importance to the care of the elderly (interpersonal and communication skills/professionalism)
- Learn the respective roles of other healthcare professionals and how to interact with them (interpersonal and communication skills/professionalism)
- Utilize community agencies and provide effective discharge planning (patient care/systems based practice)
- Interact with attendings and housestaff of different specialties and teach them the basic principles of geriatric syndromes (patient care/medical knowledge/ interpersonal and communication skills/professionalism)
- Perform a thorough geriatric assessment encompassing cognitive, functional, and social measures (patient care/medical knowledge)
- Recognize ethical and cultural issues as they pertain to their patients (patient care/interpersonal and communication skills)
TEACHING METHODS:
Teaching occurs with direct patient care and case discussions with the attending physicians. Fellows are expected to perform independent geriatric consultations and provide follow-up visits to their panel of hospitalized patients. These cases will be precepted and reviewed by the supervising attending. The learning environment stimulates independent reading and education. Fellows will have the opportunity to interact with medical and surgical housestaff and will be asked to provide bedside teaching and discussion relevant to their patients. Formal didactic sessions will be held weekly and fellows will have the opportunity to present cases for morbidity and mortality review and case based discussion at various times throughout the year.
METHODS OF EVALUATION:
Goals of the rotation will be reviewed with each fellow and the program director at the beginning of the year and at the mid year review. On a monthly basis attendings will be asked to complete a written evaluation of the fellow’s progress. An attending will also be assigned to sit down with each fellow and review the rotation and provide formative feedback to the fellow at the end of each month. Written evaluations will be forwarded to the program director for review and will be kept in the fellow’s file. Fellows may review their evaluations at anytime, however they will be required to meet with the program director biannually to review and discuss their performance. Fellows will be asked to complete a monthly evaluation of their rotations and attending as well. This material will be forwarded to the program director to review and utilize to assess that goals of the rotations are being met and to make changes to the rotations where needed to better meet those goals. At the discretion of the program director, should he/she feel that fellows are not meeting the specific goals of the rotation, review of these goals will be scheduled with each fellow. The program director will have quarterly review with all key clinical faculty regarding their teaching performance based on feedback from the fellows. Fellows will be asked to perform a mini-CEX with a faculty member monthly. Over the course of the year, the fellow should have completed a mini CEX encompassing at least: (1) history taking (2) physical exam (3) data review and synthesis (4)patient education or counseling (5) interpersonal communication skills (6) synthesis of systems based practice into the care of the patient. Results of the mini-CEX will be reviewed at the time of mini-CEX and forwarded to the program director to file in the fellows record.
NURSING HOME ROTATION:
Overview:
The nursing home rotation is a longitudinal rotation designed to teach fellows how to treat and manage patients in both short term rehabilitation and long term custodial care. Various nursing homes will be used to allow fellows to have an appreciation for different models of nursing home care and practice. Fellows are expected to develop proficiency in caring for complex medical, functional, and social problems faced by residents of a nursing home. They will learn professionalism and interpersonal skills when dealing with nursing home staff.
Geriatric Fellows will be given patient assignments in Nursing Homes by the supervising attendings. Fellows will carry a panel of 10-20 patients in both short term rehabilitation and long term custodial care. They will be assigned to patients with a variety of medical issues including at least, but not limited to wounds, dementia, dementia related behavior disorders, end of life and hospice care.
Fellows will assume the role of junior attending physician for their patient panel, and shall be considered the main doctor for this patient. Fellows will write orders in the chart under the supervision of an attending.
Phone calls and messages from the various facilities and patients shall first be addressed by the fellow.
In the event a fellow does not respond in a timely fashion to his/her messages, these messages will be given to the supervising attending physician.
Fellows are expected to:
- Approve admission and discharge orders
- Conduct an H&P within 48 hours of admission/ readmission
- Review monthly medications orders
- Write monthly/bimonthly renewal notes
- Communicate with residents and families on issues pertaining to the care of their patient including advanced directives with each admission and yearly
- Manage ongoing care daily via telephone calls from nursing staff
- Answer daily telephone calls from the nursing facilities in a timely fashion.
- Triage on-call phone calls when on-call, document the calls appropriately, and discuss calls with the supervising attending the following day
- Discuss patient care and update the supervising attending within 1 week of seeing the patient for a regulatory visit or within 1 day of seeing the patient for an acute issue
- Fellows may be asked to see patients of the supervising attendings at the facilities on an urgent basis at the discretion of the supervising attending as long as it does not interfere with their ongoing responsibilities and does not create an undue service burden for the fellow
GOALS (competencies):
By the end of this rotation, fellows will be able to:
- Demonstrate proficiency in assessment and management of nursing home residents (patient care/medical knowledge)
- Show proficiency in the interdisciplinary management of acute illness, behavioral problems, and geriatric syndromes for patients in the nursing home (patient care/medical knowledge/interpersonal skills and communication/professionalism)
- Describe the reimbursement structure for short term rehabilitation, long term care, and hospice in long term care (systems based practice)
- Summarize federal regulations governing nursing home care (systems based practice)
- Explain the MDS and uses for the MDS (systems based practice)
- Recognize the responsibilities of the medical director (systems based practice/patient care/professionalism)
- Complete a quality improvement project (practice based learning)
- Recognize polypharmacy and take steps to streamline medications to improve function and reduce cost (systems based practice/patient care)
- Learn the respective roles of other healthcare professionals and how to interact with them (interpersonal and communication skills/professionalism)
- Utilize community agencies and provide effective discharge planning for patient in short term rehabilitation (patient care/systems based practice)
- Identify ethical and cultural issues as they pertain to their patients (patient care/interpersonal and communication skills)
TEACHING METHODS:
Teaching occurs with direct patient care and case discussions with the attending physicians. Fellows are expected to present findings of their patients to the attending within 1 day for acute visits, admissions, and readmissions, and within one week for monthly regulatory visits. Attending will review medical records and orders for the fellow’s patients and provide feedback based on the fellows performance. Fellows are expected to read on pertinent geriatric literature and apply evidence based strategies in the care of their patients. Articles and suggested texts will be provided by the attendings as clinical situations arise. Fellows and attendings are expected to round together at least every 2 months to review more difficult patients and have direct bedside teaching. Didactic sessions will cover federal regulations, MDS, medical director responsibilities, and nursing home reimbursement. Fellows will have the opportunity to present cases for morbidity and mortality review and case based discussion at various times throughout the year.
METHODS OF EVALUATION:
Goals of the rotation will be reviewed with each fellow by the program director at the beginning of the year and at the mid year review. The supervising attending is expected to provide feedback during or at the end of each interaction. Additionally, the attendings will be asked to submit a formal written evaluation of the fellow’s progress quarterly. Written evaluations will be forwarded to the program director for review and will be kept in the fellow’s file. Fellows may review their evaluations at anytime, however they will be required to meet with the program director biannually to review and discuss their performance. Fellows will be asked to complete a quarterly evaluation of their rotations and attendings as well. This material will be forwarded to the program director to review and utilize to assess that goals of the rotations are being met and to make changes to the rotations where needed to better meet those goals. At the discretion of the program director, should he/she feel that fellows are not meeting the specific goals of the rotation, review of these goals will be scheduled with each fellow. Attendings will be asked to perform spot record review of nursing home charts and give the fellow feedback on their practice of care. Fellows must identify a quality improvement project by the 3 rd month of the fellowship. They are expected to prepare a written quality improvement project plan and timeline for their portfolios. Fellows will meet with the program director or associate program quarterly to review progress of their project. They will be given formative feedback at the time of these sessions and a written evaluation quarterly as to the progress of their assignment.
HOME CARE
OVERVIEW:
The Bridgeport Hospital Center for Geriatric Medicine’s home visit program consists of 140-200 patients divided into 3 teams. Teams consist of a nurse case manager, nurse practitioner, and attending physician. The attending physician performs all initial visits. Follow up care is provided primarily by the nurse practitioner under the supervision of the physician with the physicians making follow up visits in a 1:3 or 1:4 ratio with the nurse practitioner. These teams meet monthly to discuss patients and review care. Fellows will be assigned to one of the three teams and be given a panel of 10 patients. Fellows will be expected to perform the initial assessment with the attending physician. For the first 3 months the fellow will perform supervised home care follow up visits with the nurse practitioner until they have shown proficiency in the care of homebound elderly. As the year progresses, fellows will be allowed to perform independent follow up visits with the back up of an attending.
GOALS (competency):
By the end of this rotation, fellows will be able to:
- Recognize and treat common geriatric syndromes including dementia, memory impairment, delirium, depression, anxiety, falls, incontinence, weight loss and malnutrition, arthritis, chronic pain, dementia related behaviors, osteoporosis, polypharmacy, (medical knowledge/patient care)
- Effectively interact with an interdisciplinary team (interpersonal skills and communication/professionalism)
- Develop sensitivity to spirituality, cultural competency, and cultural disparities (professionalism/patient care)
- Discuss advanced care planning (advanced directives, POAs, conservatorships) (interpersonal and communication skills/patient care)
- Treat patients with a goal of improving function and quality of life (patient care/professionalism)
- Understand the complexities of treating frail homebound elders (systems based practice/patient care/medical knowledge)
- Make appropriate referrals for community resources (systems based practice/patient care)
- Work effectively with professional staff from home care agencies (interpersonal and communication skills/patient care)
- Make appropriate referrals for ancillary tests and other physician services (systems based practice/patient care/medical knowledge)
- Deliver appropriate and compassionate end of life care (interpersonal and communication skills/patient care/professionalism)
TEACHING METHODS:
Teaching occurs via direct observation of initial home visit assessment and case based discussion of follow up visits. Attendings will review documentation and notes from any visits not directly supervised and provide teaching based on these notes and discussion of cases. Fellows will participate in monthly team meetings which will include review of patients and their care and a brief formal didactic session relevant to home care medicine by a member of the home care team. Fellows will be asked to read independently. Articles and suggested texts will be provided by the attending as clinical situations arise.
METHODS OF EVALUATION:
Goals of the rotation will be reviewed with each fellow and the program director at the beginning of the year and at the mid year review. The supervising attending or nurse practitioner is expected to provide feedback during or at the end of each session. Additionally, the attending and nurse practitioners will be asked to submit a formal written evaluation of the fellow’s progress quarterly. Written evaluations will be forwarded to the program director for review and will be kept in the fellow’s file. Fellows may review their evaluations at anytime, however they will be required to meet with the program director biannually to review and discuss their performance. Fellows will be asked to complete a quarterly evaluation of their rotations and attendings as well. This material will be forwarded to the program director to review and utilize to assess that goals of the rotations are being met and to make changes to the rotations where needed to better meet those goals. At the discretion of the program director, should he/she feel that fellows are not meeting the specific goals of the rotation, review of these goals will be scheduled with each fellow. Written evaluations of the fellow will also be obtained from patients, patient’s family, and nurse case managers to complete a 360 degree evaluation to assess skills in interpersonal relationships and communication and professionalism.
OUTPATIENT GERIATRIC CONSULTATION (GERIATRIC ASSESSMENT CENTER)
OVERVIEW:
The Bridgeport Hospital Center for Geriatric Medicine’s Geriatric Assessment Center is an interdisciplinary assessment center for frail elderly patients. Patients present to the center for a comprehensive assessment, consultation, and follow up for common geriatric syndromes. Each 1.5-2 hour long appointment involves cognitive and neuropsychiatric evaluation by nurses trained in these evaluations. Nurse case managers also meet with families, take history from the families, and make referrals to community resources. The physicians evaluate the patient, meet with the nurse and nurse case manager, and formulate a plan that is discussed with the patient and family, and communicated to the patient’s primary care physician via letter.
GOALS (competencies):
By the end of this rotation, fellows will be able to:
- Perform a comprehensive outpatient geriatric assessment (patient care/medical knowledge)
- Recognize and treat common geriatric syndromes including dementia, memory impairment, delirium, depression, anxiety, falls, incontinence, weight loss and malnutrition, arthritis, chronic pain, dementia related behaviors, osteoporosis, polypharmacy (medical knowledge)
- Recommend appropriate screening and disease prevention strategies to patients and referring doctors (patient care/medical knowledge)
- Effectively interact with an interdisciplinary assessment team (interpersonal and communication skills/professionalism)
- Develop sensitivity to spirituality, cultural competency, and cultural disparities (interpersonal and communication skills/professionalism)
- Discuss advanced care planning (advanced directives, POAs, conservatorships) (interpersonal and communication skills/patient care)
- Treat patients with a goal of improving function and quality of life (patient care/professionalism)
- Understand the limitations and barriers to providing these types of assessments in the community (systems based practice)
TEACHING METHODS:
Fellows will be asked to evaluate one new patient and perform one follow up per session. They will be responsible for the evaluation of the patient, coordination of information from the nurse and nurse case manager, formulation of the plan of care, and communication of the assessment via dictated letter to the referring doctor. The attending physician will oversee these responsibilities. The cases will be discussed by the fellow and the attending and teaching will occur based on this direct patient care. A brief session of formal didactics will be held either before the session begins or at the conclusion of the day. Fellows will be expected to read independently. Fellows may be asked to review topics related to the care of their patient and present their findings the following week during the didactic session. Articles and suggested texts will be provided by the attending as clinical situations arise.
METHODS OF EVALUATION:
Goals of the rotation will be reviewed with each fellow and the program director at the beginning of the year and at the mid year review. The supervising attending is expected to provide feedback during or at the end of each session. Additionally, the attendings will be asked to submit a formal written evaluation of the fellow’s progress quarterly. Written evaluations will be forwarded to the program director for review and will be kept in the fellow’s file. Fellows may review their evaluations at anytime, however they will be required to meet with the program director biannually to review and discuss their performance. Fellows will be asked to complete a quarterly evaluation of their rotations and attendings as well. This material will be forwarded to the program director to review and utilize to assess that goals of the rotations are being met and to make changes to the rotations where needed to better meet those goals. At the discretion of the program director, should he/she feel that fellows are not meeting the specific goals of the rotation, review of these goals will be scheduled with each fellow. Once a month the clinic didactic session will consist of a brief Chart Stimulated Recall exercise. For the patients evaluated at that visit, the attending and fellow will discuss the reasons behind the proposed work-up, the interpretation of the findings, the diagnoses and how they were arrived at, and the proposed treatment plan. Fellows will be evaluated in writing and receive oral feedback based on their medical knowledge, understanding of systems based practice, use of scientific evidence to support decision making (practice-based learning) and patient care skills. Written evaluations will be forwarded to the program director for review.
PRIMARY CARE EXPERIENCE
OVERVIEW:
The Bridgeport Hospital Geriatric Clinic is held every Wednesday morning. It serves a primarily urban elderly population. This is the longitudinal setting where fellows will see well elderly. The fellow’s role is to serve as the primary care physician for a panel of patients over the age of 55. They are expected to provide primary medical care, engage in screening and preventive services as appropriate, and co-ordinate care for their panel of patients. These patients demonstrate a wide spectrum of illnesses, geriatric syndromes, and preventive health challenges. They fellows are expected to see 4-8 patients per session. For clinic patients without insurance or without transportation to the outpatient Geriatric Assessment Center who would benefit from a geriatric consultation, consultations may also occasionally be seen in this setting.
GOALS (competencies):
By the end of this rotation, fellows will be able to:
- Recognize and treat common geriatric syndromes in a primary care setting including dementia, memory impairment, delirium, depression, anxiety, falls, incontinence, weight loss and malnutrition, arthritis, chronic pain, dementia related behaviors, osteoporosis, polypharmacy, (medical knowledge/patient care)
- Develop sensitivity to spirituality, cultural competency, and cultural disparities (professionalism/patient care)
- Discuss advanced care planning (advanced directives, POAs, conservatorships) (interpersonal and communication skills/patient care)
- Treat patients with a goal of improving function and quality of life (patient care/professionalism)
- Demonstrate an ability to make appropriate referrals for community resources (systems based practice/patient care)
- Demonstrate an ability to make appropriate cost effective referrals for ancillary tests and other physician services (systems based practice/patient care/medical knowledge)
- Demonstrate an understanding of the screening and preventive services for a wide variety of elderly patients based on appropriate recommendations and evidence (medical knowledge/patient care/systems based practice/ practice based learning)
TEACHING METHODS:
Teaching occurs via direct patient care and case based discussion of visits. Attendings will also review documentation and notes and provide teaching based on these notes and discussion of cases. Fellows will be asked to read independently. Articles and suggested texts will be provided by the attending as clinical situations arise.
METHODS OF EVALUATION:
Goals of the rotation will be reviewed with each fellow and the program director at the beginning of the year and at the mid year review. The supervising attending is expected to provide feedback during or at the end of each session. Additionally, the attending will be asked to submit a formal written evaluation of the fellow’s progress quarterly. Written evaluations will be forwarded to the program director for review and will be kept in the fellow’s file. Fellows may review their evaluations at anytime, however they will be required to meet with the program director biannually to review and discuss their performance. Fellows will be asked to complete a quarterly evaluation of their rotations and attendings as well. This material will be forwarded to the program director to review and utilize to assess that goals of the rotations are being met and to make changes to the rotations where needed to better meet those goals. At the discretion of the program director, should he/she feel that fellows are not meeting the specific goals of the rotation, review of these goals will be scheduled with each fellow.
CONFERENCES:Required conferences include:
- Weekly didactic conference on a variety of topics including those listed in the program overview
Fellows are required to prepare and present 2 sessions a year
- Weekly case based discussion or morbidity and mortality report
Fellows are expected to bring a case for discussion weekly
- Monthly research meeting with review of all ongoing research within the section
Monthly journal club
- Fellows are expected to present 3-4 sessions a year
Monthly Geriatric Grand Rounds at Yale School of Medicine
Quarterly faculty development workshops
Fellows also have the option to attend:
- Weekly Medical Grand Rounds at Bridgeport Hospital
- Weekly didactic sessions for residents and other fellowship programs
- Daily Internal Medicine resident morning report
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