Geriatric Fellowship Rotation Descriptions and Objectives

Faculty

• Deepak Mandi, M.D.

Description of Rotation and Educational Experience

Fellows will gain experience in patient safety, quality improvement (QI), and administrative aspects of the practice of medicine. Fellows will shadow various clinical specialists in QI and participate in QI activities. Fellows will have the opportunity to meet one-on-one with senior management and leadership to learn about the administrative aspects of medical practice.

Objectives

Faculty

• Jorge Caariego, M.D.
• Viviana Colmegna, M.D.

Description of Rotation and Educational Experience

During the Geriatric Psychiatry rotation the geriatric medicine fellow will learn about the role of mental health care professionals in providing comprehensive care for older adults, along with the diagnosis and treatment of specific geropsychiatric syndromes. The fellow will interact with other professionals (psychologists, social workers, psychiatric nurses) in the context of an interprofessional team. Patient care experiences on this rotation will include inpatient consultations on an acute care medical unit, and care and follow up of patients on an acute care psychiatry unit and mental health care in the outpatient setting.

Objectives

Note: Objectives are based on ACGME requirements and milestones recommended by the American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP). Some of these requirements and milestones overlap.

The objectives of this rotation, concordant with the ACGME requirements and the AGS/ADGAP curricular milestones for geriatrics fellowship programs, are to train fellows to:

1. Demonstrate knowledge of geriatric assessment, including medical, affective, cognitive, functional status, social support, economic, and environmental aspects related to health; activities of daily living (ADL); the instrumental activities of daily living (IADL); medication review and appropriate use of the history; physical and mental examination; and interpretation of laboratory results
2. Assess cognitive status and affective states (IV.A.2.a).(1).(c)
3. Demonstrate knowledge of behavioral sciences, including psychology and social work (IV.A.2.b).(9)
4. Demonstrate knowledge of pharmacologic problems associated with aging, including changes in pharmacokinetics and pharmacodynamics, drug interactions, over-medication, appropriate prescribing, and adherence (IV.A.2.b).(12)
5. Demonstrate knowledge of the pivotal role of the family in caring for the elderly, and the community resources (formal support systems) required to support both the patient and the family (IV.A.2.b).(6)
6. Demonstrate knowledge of the ethical and legal issues pertinent to geriatric medicine, including limitation of treatment, competency, guardianship, right to refuse treatment, advance directives, designation of a surrogate decision maker for health care, wills, and durable power of attorney for medical affairs (IV.A.2.b).(16)
7. Provide care that is based on the patient’s preferences and overall health (IV.A.2.a).(1).(e)
8. Demonstrate effective communication skills with patients, families, professional colleagues, and community groups (IV.A.2.d).(1)
9. Demonstrate knowledge of psychosocial aspects of aging, including interpersonal and family relationships, living situations, adjustment disorders, depression, bereavement, and anxiety (IV.A.2.b).(13)
10. Demonstrate high standards of ethical behavior, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interest (IV.A.2.e).(1)
11. Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care (IV.A.2.f)
12. Distinguish the clinical presentation and prognosis of changes in cognition and/or affect among people with normal aging, mild cognitive impairment, dementia, delirium, and depression. (GS 55)
13. Perform, interpret, and articulate the strengths and limitations of the commonly used cognitive and mood assessment tools. (GS 56)
14. Identify clinical situations where a psychiatric referral, psychological counseling, or neuropsychological assessment is indicated and integrate the findings into the patient's plan of care. (GS 57)
15. Diagnose and manage the potentially reversible/treatable causes of cognitive and affective changes in older adults. (GS 58)
16. Identify and manage depression. (GS 59)
17. Diagnose and manage the causes of dementia, including Alzheimer's disease, vascular dementia, Lewy body dementia, dementia of Parkinson's Disease, alcoholic dementia, frontotemporal dementia, Creutzfeldt–Jakob Disease and Normal Pressure Hydrocephalus as well as other rare causes. Recognize and appropriately refer ambiguous cases for further evaluation. (GS 60)
18. Assess and manage cognitive, functional, and disruptive behavioral manifestations of dementia, both behaviorally and pharmacologically. (GS 62)
19. Provide initial evaluation and management of insomnia and other sleep disorders and, when indicated, refer to a sleep specialist. (GS 66)
20. Recognize and document signs of elder abuse and/or neglect and refer to community resources and adult protective services when appropriate. (SBC 36)
21. Demonstrate the ability to manage the care of patients with multimorbidities by integrating the evidence, patient's goals, life expectancy and functional trajectory. Document clinical reasoning when management differs from standard treatment recommendations. (CEP 22)
22. Demonstrate expertise in medication management by justifying medication regimen and duration based on age related changes in pharmacokinetics and pharmacodynamics, maximizing medication adherence, the common lists of medications that should be avoided or used with caution in older adults, and consideration of the reported benefits and known and unknown risks when prescribing a newly-released medication, realizing that older adults with multimorbidities are often underrepresented in clinical trials. (CEP 10)
23. Demonstrate expertise in transitions of care by communicating the following to the receiving provider through discussion or timely discharge summary: medication reconciliation, an assessment of patient’s cognition and function, pending medical results and follow-up needs. (CEP 31)
24. Recognize the complexity of geriatric care and demonstrate the ability to prioritize care, in a time-efficient manner, during encounters with geriatric patients (CEP37)
25. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care. (CEP 1)
26. Uses strategies to enhance clinician-patient oral and written communication in patients with hearing, vision, or cognitive impairment. (CEP 3)
27. Provides compassionate care while establishing personal and professional boundaries with patients and families/caregivers. (CEP 6)
28. Assess and incorporate family/caregiver needs and limitations, including caregiver stress, into patients' management plans. (CEP 24)
29. Refer patients to appropriate home health and support services to maximize ability to remain in their homes. (GS 48)
30. Serve as an advocate for older adults and caregivers within various healthcare systems and settings. (SBC 38)\
31. Identifies patients who are frail or otherwise at risk for death, dependency and/or institutionalization over the next few years. (CEP 21)
32. Works effectively as a member or leader of an interprofessional health care team. (CEP 2)

Rotation Activities

During the rotation, the fellow will care for a panel of patients over age 60 admitted to the inpatient psychiatry service, complete assigned mental health consultations in the hospital, and will attend weekly outpatient psychiatry clinics. The fellow will be responsible for:

• History and physical examinations
• Daily rounds and appropriate documentation
• Physician orders
• Discharge planning/assessment

During this rotation the fellow will have the following experiences:

• Perform a complete psychiatric evaluation including forming appropriate diagnostic conclusions and plan(s) of care.
• Identify the appropriate use of diagnostic techniques (i.e., MRI, labs, EEG, neuro-psych testing, etc.) in the context of geriatric psychiatry.
• Explain the use of appropriate psychopharmacologic agents and ECT in the management of geriatric psychiatric patients.
• Discuss the fundamentals of psychotherapy with geriatric patients.
• Identify when to utilize/refer to community agencies supportive of geriatric psychiatry patients.
• Describe medico-legal issues that are germane to geriatric psychiatry (i.e. capacity, POA, advance directives, etc.)

Faculty

• Ritu Mehrotra, M.D.
• Doron Nuchovich, M.D.

Description of Rotation and Educational Experience

The home care rotation consists of a varying schedule in the care of homebound older adult veterans along with structured scholarly activities. The fellows’ schedule will be unique in order to accommodate their continuity clinic schedule, and to accommodate the schedules of teaching faculty for home visits. This rotation will be based at the Home-Based Primary Care (HBPC) at VA Medical Center, West Palm Beach. The fellow will make home visits with the HBPC staff and participate in interdisciplinary team meetings.

Objectives

The objectives of this rotation, concordant with the ACGME requirements and the AGS/ADGAP curricular milestones for geriatrics fellowship programs, are to train fellows to:

1. Assess functional status (IV.A.2.a).(1).(a))
2. Assess cognitive status and affective states (IV.A.2.a).(1).(c))
3. Provide appropriate preventive care, and teaching patients and their caregivers regarding self-care (IV.A.2.a).(1).(d))
4. Provide care that is based on the patient’s preferences and overall health (IV.A.2.a).(1).(e))
5. Demonstrate knowledge of the pivotal role of the family in caring for the elderly, and the community resources (formal support systems) required to support both the patient and the family (IV.A.2.b).(6))
6. Demonstrate knowledge of the cultural aspects of aging (IV.A.2.b).(19))
7. Demonstrate knowledge of the behavioral aspects of illness, socioeconomic factors, and health literacy issues (IV.A.2.b).(20))
8. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care. (CEP 1)
9. Provide compassionate care while establishing personal and professional boundaries with patients and families/caregivers. (CEP 6)
10. Perform home visits, demonstrate modification of the physical exam for the home setting, and assess physical safety of the environment. (CEP 47)
11. Refer patients to appropriate home health and support services to maximize ability to remain in their homes. (CEP 48)
12. Know the different presentation, management and underlying pathophysiology of common diseases in older adults (including but not limited to: hypertension, coronary artery disease, osteoporosis, hypothyroidism, infections, and the acute abdomen; adjusting drug dosage for renal function). (CEP 18)
13. Demonstrate expertise in medication management by justifying medication regimen and duration based on age related changes in pharmacokinetics and pharmacodynamics, maximizing medication adherence, the common lists of medications that should be avoided or used with caution in older adults, and consideration of the reported benefits and known and unknown risks when prescribing a newly-released medication, realizing that older adults with multimorbidities are often underrepresented in clinical trials. (CEP 10)
14. Recognize patient risk factors for pressure ulcers, and in high risk patients work with an interprofessional team to develop a prevention plan.
15. Stage pressure ulcers and demonstrate proficiency in describing their clinical characteristics (e.g., size, color, exudate).
16. Develop a treatment plan for pressure ulcers with an interprofessional team, incorporating the indications for surgical and non-surgical treatments for ulcers (e.g., debridement, classes of wound care products and treatments, pressure relieving devices, etc.).
17. Uses strategies to enhance clinician-patient oral and written communication in patients with hearing, vision, or cognitive impairment. (CEP 3)
18. Recognize the complexity of geriatric care and demonstrate the ability to prioritize care, in a time-efficient manner, during encounters with geriatric patients (SBC 37)
19. Skillfully discuss and document goals of care and advance care planning with elderly Individuals and/or their families/caregivers in the home care setting. (CEP 4)
20. Provide compassionate care while establishing personal and professional boundaries with patients and families/caregivers. (CEP 6)
21. Serve as an advocate for older adults and caregivers within various healthcare systems and settings. (SBC 38)
22. Demonstrate the ability to teach patients, caregivers and others about aging-related healthcare issues. (SBC 40)
23. Identify patients who are frail or otherwise at risk for death, dependency and/or institutionalization over the next few years. (CEP 21)
24. Recognize the limitations of the evidence base and critically review the medical literature for studies that are valid and applicable to the care of older adults. (CEP 20)
25. Work effectively as a member or leader of an interprofessional health care team. (CEP 2)

Rotation Activities

During the rotation, the geriatric medicine fellow will perform the following activities:

• Patient Care: The fellow will work with attendings conducting home care visits to deliver primary care to home bound veterans. The fellow will go on home visits with individual interdisciplinary staff that may include: PT, Nursing, Dietetics, and Social Work.
• The fellow will continue with their continuity clinic at VA outpatient clinic on their assigned ½ day per week.
• Administrative: As part of inter-professional practice, it is important to understand the role of the healthcare team. You will have a 1-hour session with the Medical Director of HBPC, HBPC PharmD and HBPC Psychologist to understand their roles. You will also attend Interdisciplinary Team (IDT) meetings as assigned during the rotation.

Faculty

• Michael Silverman, M.D.
• Deepak Mandi, M.D.

Description of Rotation and Educational Experience

During the Hospice and Palliative Care rotation, the geriatric medicine fellow will learn about comprehensive care for older adults with serious illness and limited life expectancy. The fellow will interact with other professionals (psychologists, social workers, nurses and chaplains) in the context of an interprofessional team. Patient care experiences on this rotation will include inpatient consultations on an acute care medical unit, outpatient consults and care of patients admitted to an inpatient Hospice unit.

Objectives

The objectives of this rotation, concordant with the ACGME requirements and the AGS/ADGAP curricular milestones for geriatrics fellowship programs, are to train fellows to:

1. Demonstrate knowledge of hospice care, including pain management, symptom relief, comfort care, and end-of-life issues (IV.A.2.b).(8))
2. Demonstrate knowledge of the management of patients in long-term care settings, including palliative care, administration, regulation, and financing of long-term institutions, and the continuum from short- to long-term care (IV.A.2.b).(5))
3. Demonstrate knowledge of the ethical and legal issues pertinent to geriatric medicine, including limitation of treatment, competency, guardianship, right to refuse treatment, advance directives, designation of a surrogate decision maker for health care, wills, and durable power of attorney for medical affairs (IV.A.2.b).(16))
4. Demonstrate knowledge of the pivotal role of the family in caring for the elderly, and the community resources (formal support systems) required to support both the patient and the family (IV.A.2.b).(6))
5. Provide care that is based on the patient’s preferences and overall health (IV.A.2.a).(1).(e))
6. Demonstrate effective communication skills with patients, families, professional colleagues, and community groups (IV.A.2.d).(1) )
7. Demonstrate knowledge of psychosocial aspects of aging, including interpersonal and family relationships, living situations, adjustment disorders, depression, bereavement, and anxiety (IV.A.2.b).(13))
8. Demonstrate high standards of ethical behavior, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interest (IV.A.2.e).(1))
9. Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care (IV.A.2.f))
10. Counsel patients and families/caregivers about the range of options for palliative and end of life care. (CEP27)
11. Assess, manage, and provide anticipatory guidance for patients and families/caregivers for common non pain symptoms during severe chronic illness or at the end of life. (CEP 28)
12. Individualize pain control utilizing the most effective pharmacologic and non-pharmacologic strategies based on the etiology and chronicity of the patient's pain.
13. Prescribe pain medications with instructions and methods to prevent common. (CEP 12) complications including constipation, nausea, fatigue and opioid toxicity (myoclonus and hyperalgesia), using equianalgesic dosing conversion and opioid rotation when needed. (CEP 13)
14. Identify and manage depression. (GS 59)
15. Discuss with patients and families/caregivers the risks and benefits of appetite stimulants, nutritional supplementation, enteral tube feeding, and parenteral nutrition, particularly in patients with advanced dementia or near end-of-life. (GS 73)
16. Identify swallowing disorders in patients with involuntary weight loss or recurrent pneumonias, and work with an interprofessional team to evaluate, manage, and educate patient and caregiver(s) based on goals of care. (GS 74)
17. Demonstrate the ability to manage the care of patients with multimorbidities by integrating the evidence, patient's goals, life expectancy and functional trajectory. Document clinical reasoning when management differs from standard treatment recommendations. (CEP 22)
18. Demonstrate the ability to manage psychosocial aspects of the care of older adults including interpersonal and family relationships, living situations, adjustment disorders, bereavement, and anxiety. (CEP 23)
19. Assess and incorporate family/caregiver needs and limitations, including caregiver stress, into patients' management plans. (CEP24)
20. Demonstrates expertise in medication management by justifying medication regimen and duration based on age related changes in pharmacokinetics and pharmacodynamics, maximizing medication adherence, the common lists of medications that should be avoided or used with caution in older adults, and consideration of the reported benefits and known and unknown risks when prescribing a newly-released medication, realizing that older adults with multimorbidities are often underrepresented in clinical trials. (CEP 10)
21. Recognize the complexity of geriatric care and demonstrate the ability to prioritize care, in a time-efficient manner, during encounters with geriatric patients (CEP37)
22. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care. (CEP 1)
23. Uses strategies to enhance clinician-patient oral and written communication in patients with hearing, vision, or cognitive impairment. (CEP 3)
24. Provides compassionate care while establishing personal and professional boundaries with patients and families/caregivers. (CEP 6)
25. Serve as an advocate for older adults and caregivers within various healthcare systems and settings. (SBC 38)
26. Identifies patients who are frail or otherwise at risk for death, dependency and/or institutionalization over the next few years. (CEP 21)
27. Works effectively as a member or leader of an interprofessional health care team. (CEP 2)
28. Effectively lead a family/caregiver meeting. (CEP 7)

Rotation Activities

During the rotation, the fellow, as assigned by attending, will care for a panel of patients who are admitted to the VAMC WPB Valor Way hospice unit including:

• History and physical examinations
• Daily rounds and appropriate documentation
• Physician orders
• Discharge planning/assessment

The fellow, as assigned by and in consultation with attending, will complete palliative care consults in the hospital and will attend weekly palliative care clinics. During this rotation the fellow will:

• Perform a complete palliative care evaluation with appropriate diagnostic conclusions and plan of care.
• Describe the use of appropriate psychopharmacologic agents in the management of End of Life Care.
• Discuss the fundamentals of hospice care.
• Identify when to utilize/refer to community hospice agencies supportive of comfort care in the home setting.
• Describe medico-legal issues that are germane to end of life care (i.e. capacity, health care surrogacy, advance directives, etc.)

Faculty

• Michael Silverman, M.D.
• Deepak Mandi, M.D.
• Ricardo Blondet, M.D.

Description of Rotation and Educational Experience

The Geriatric Medicine Fellow will gain experience and knowledge in all aspects of geriatrics in acute hospital settings including:

• Rounding/embedded with the general medical or hospitalist service and providing extra attention and teaching related to the geriatric patients on the service;
• Following geriatric clinic/fellows’ own patients when in hospital, and;
• Providing geriatric consults on request to general medicine and other services (e.g. surgery, ortho, psych and rehab)

Objectives

The objectives of this rotation, concordant with the ACGME requirements and the AGS/ADGAP curricular milestones for geriatrics fellowship programs, are to train fellows to:

1. Assess functional status (IV.A.2.a).(1).(a))
2. Assess cognitive status and affective states (IV.A.2.a).(1).(c))
3. Provide care that is based on the patient’s preferences and overall health (IV.A.2.a).(1).(e))
4. Demonstrate knowledge of iatrogenic disorders and their prevention ( IV.A.2.b).(18))
5. Demonstrate knowledge of pharmacologic problems associated with aging, including changes in pharmacokinetics and pharmacodynamics, drug interactions, over-medication, appropriate prescribing, and adherence (IV.A.2.b).(12))
6. Demonstrate knowledge of management of patients in long-term care settings, including palliative care, administration, regulation, and financing of long-term institutions, and the continuum from short- to long-term care ( IV.A.2.b).(5))
7. Demonstrate knowledge of topics of special interest to geriatric medicine, including cognitive impairment, depression and related disorders, falls, incontinence, osteoporosis, fractures, sensory impairment, pressure ulcers, sleep disorders, pain, senior (elder) abuse, malnutrition, and functional impairment (IV.A.2.b).(10))
8. Demonstrate knowledge of diseases that are especially prominent in the elderly or that may have atypical characteristics in the elderly, including neoplastic, cardiovascular, neurologic, musculoskeletal, metabolic, and infectious disorders (IV.A.2.b).(11))
9. Demonstrate effective communication skills with patients, families, professional colleagues, and community groups (IV.A.2.d).(1) )
10. Demonstrate high standards of ethical behavior, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interest (IV.A.2.e).(1))
11. Provide geriatric consultation in all settings with attention to multimorbidity, age-related changes in physiology, function, treatment efficacy and response, medication management and psychosocial issues. (CEP 25)
12. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care. (CEP 1)
13. Uses strategies to enhance clinician-patient oral and written communication in patients with hearing, vision, or cognitive impairment. (CEP 3)
14. Provides compassionate care while establishing personal and professional boundaries with patients and families/caregivers. (CEP 6)
15. Serves as an advocate for older adults and caregivers within various healthcare systems and settings. (SBC 38)
16. Skillfully discusses and document goals of care and advance care planning with elderly individuals and/or their families/caregivers across the spectrum of health and illness. (CEP 4)
17. Know the different presentation, management and underlying pathophysiology of common diseases in older adults (including but not limited to: hypertension, coronary artery disease, osteoporosis, hypothyroidism, infections, and the acute abdomen; adjusting drug dosage for renal function). (CEP 18)
18. Demonstrate the ability to manage the care of patients with multimorbidities by integrating the evidence, patient's goals, life expectancy and functional trajectory. Document clinical reasoning when management differs from standard treatment recommendations. (CEP 22)
19. Recognizes the limitations of the evidence base and critically review the medical literature for studies that are valid and applicable to the care of older adults. (CEP 20)
20. Regularly re-assess goals of care to recognize patients likely to benefit from palliative and/or hospice care, including those with non-cancer diagnoses (e.g., Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Dementia). (CEP 26)
21. Assess and incorporate family/caregiver needs and limitations, including caregiver stress, into patients' management plans. (CEP 24)
22. Refer patients to appropriate home health and support services to maximize ability to remain in their homes. (SBC 48)
23. Demonstrate expertise in medication management by justifying medication regimen and duration based on age related changes in pharmacokinetics and pharmacodynamics, maximizing medication adherence, the common lists of medications that should be avoided or used with caution in older adults, and consideration of the reported benefits and known and unknown risks when prescribing a newly-released medication, realizing that older adults with multimorbidities are often underrepresented in clinical trials.(CEP10)
24. Individualize pain control utilizing the most effective pharmacologic and non-pharmacologic strategies based on the etiology and chronicity of the patient's pain. (CEP 12)
25. Prescribe pain medications with instructions and methods to prevent common complications including constipation, nausea, fatigue and opioid toxicity (myoclonus and hyperalgesia), using equianalgesic dosing conversion and opioid rotation when needed. (CEP 13)
26. Demonstrate expertise in transitions of care by identifying, with the inter-professional team, the most appropriate care setting(s) for a patient, including independent living, assisted living, long-term care, acute rehabilitation, subacute rehabilitation, home care, primary care at home, adult day care, Program of All-Inclusive Care for the Elderly (PACE)-like program, and hospice based on the needs and preferences of the patient and families/caregivers, and the admission and payment requirements for each setting. (CEP 30)
27. Demonstrate expertise in transitions of care by communicating the following to the receiving provider through discussion or timely discharge summary: medication reconciliation, an assessment of patient’s cognition and function, pending medical results and follow-up needs. (CEP 31)
28. Recognize the complexity of geriatric care and demonstrate the ability to prioritize care, in a time-efficient manner, during encounters with geriatric patients (CEP37)
29. Demonstrate the ability to teach patients, caregivers and others about aging-related healthcare issues. (CEP 40)
30. Reduce iatrogenic events (CEP 29, 42)
31. Recognize common and subtle presentations of delirium and manage appropriately. (CEP 43)
32. Perform pre-operative assessments for older patients and document specific peri-operative management recommendations to improve patient care and safety based on type of surgery and patient characteristics. (CEP44)
33. Works effectively as a member or leader of an interprofessional health care team.
34. Identifies patients who are frail or otherwise at risk for death, dependency and/or institutionalization over the next few years. (CEP 21)

Rotation Activities

The fellow will be part of the Geriatrics inpatient consultation team. Under the direction of geriatrics faculty they will complete inpatient consult on acute care medical and surgical units. The fellow will also be part of the inpatient internal medicine teaching rounds 3 days a week and provide input to the teaching team in the management of Geriatric Syndromes and other illness seen typically in the hospitalized older adult. The fellow will attend the utilization management rounds and will facilitate appropriate placement or discharge of hospitalized patients.

Faculty

• Michael Silverman, M.D.
• Elizabeth Harrison, M.D.
• Olga Shteiman, M.D.

Description of Rotation and Educational Experience

This rotation will take place in the West Palm VA Medical Center Military Manor Community Living Center (CLC), which cares for both long-term care (LTC) and post-acute care (PAC) patients. These two components of the curriculum are therefore integrated in two 4-week blocks.

The LTC component of the rotation will introduce the fellow to the care of patients in the nursing home setting. The fellow will have a panel of LTC patients assigned for their longitudinal care experience and will serve as the primary physician and manage the care for their panel of patients for the duration of their fellowship.

The PAC component of the rotation will introduce the fellow to the care of patients in the skilled nursing facility (SNF) setting. This rotation will take place in the Liberty South unit of the CLC, which specializes in the care of complex patients who have recently been discharged from the hospital.

The fellow will admit and follow both PAC and LTC patients during the rotation and participate in morning report, interdisciplinary team meetings (IDT) and bedside rounds.

Objectives

The objectives of this rotation, concordant with the ACGME requirements and the AGS/ADGAP curricular milestones for geriatrics fellowship programs, are to train fellows to:

1. Assess functional status (IV.A.2.a).(1).(a))
2. Assess cognitive status and affective states (IV.A.2.a).(1).(c))
3. Provide care that is based on the patient’s preferences and overall health (IV.A.2.a).(1).(e))
4. Demonstrate knowledge of iatrogenic disorders and their prevention ( IV.A.2.b).(18))
5. Demonstrate knowledge of pharmacologic problems associated with aging, including changes in pharmacokinetics and pharmacodynamics, drug interactions, over-medication, appropriate prescribing, and adherence (IV.A.2.b).(12))
6. Demonstrate knowledge of management of patients in long-term care settings, including palliative care, administration, regulation, and financing of long-term institutions, and the continuum from short- to long-term care ( IV.A.2.b).(5))
7. Demonstrate knowledge of topics of special interest to geriatric medicine, including cognitive impairment, depression and related disorders, falls, incontinence, osteoporosis, fractures, sensory impairment, pressure ulcers, sleep disorders, pain, senior (elder) abuse, malnutrition, and functional impairment (IV.A.2.b).(10))
8. Demonstrate knowledge of diseases that are especially prominent in the elderly or that may have atypical characteristics in the elderly, including neoplastic, cardiovascular, neurologic, musculoskeletal, metabolic, and infectious disorders (IV.A.2.b).(11))
9. Demonstrate effective communication skills with patients, families, professional colleagues, and community groups (IV.A.2.d).(1) )
10. Demonstrate high standards of ethical behavior, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interest (IV.A.2.e).(1))
11. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care. (CEP1)
12. Work effectively as a member or leader of an inter-professional health care team. (CEP2)
13. Uses strategies to enhance clinician-patient oral and written communication in patients with hearing, vision, or cognitive impairment. (CEP 3)
14. Skillfully discuss and document goals of care and advance care planning with elderly individuals and/or their families/caregivers across the spectrum of health and illness. (CEP4)
15. Assess patients for capacity to make a specific medical decision and, if lack of capacity is determined, identify strategies and resources for decision-making, including guardianship. (CEP5)
16. Demonstrate expertise in transitions of care by communicating the following to the receiving provider through discussion or timely discharge summary: medication reconciliation, an assessment of patient’s cognition and function, pending medical results and follow-up needs. (CEP 31)
17. Recognize the complexity of geriatric care and demonstrate the ability to prioritize care, in a time-efficient manner, during encounters with geriatric patients. (CEP37)
18. Reduce iatrogenic events (CEP 42)
19. Provide compassionate care while establishing personal and professional boundaries with patients and families/caregivers.( CEP 6)
20. Individualize pain control utilizing the most effective pharmacologic and non-pharmacologic strategies based on the etiology and chronicity of the patient's pain. (CEP 12)
21. Recognize and manage the care of patients at high risk for poor outcomes from common conditions such as deconditioning, stroke, hip fracture, and dysphagia (CEP 16)
22. Demonstrate the ability to manage the care of patients with multimorbidities by integrating the evidence, patient's goals, life expectancy and functional trajectory. Document clinical reasoning when management differs from standard treatment recommendations. (CEP 22)
23. Demonstrate the ability to manage psychosocial aspects of the care of older adults including interpersonal and family relationships, living situations, adjustment disorders, bereavement, and anxiety. (CEP 23)
24. Demonstrate expertise in medication management by justifying medication regimen and duration based on age related changes in pharmacokinetics and pharmacodynamics, maximizing medication adherence, the common lists of medications that should be avoided or used with caution in older adults, and consideration of the reported benefits and known and unknown risks when prescribing a newly-released medication, realizing that older adults with multimorbidities are often underrepresented in clinical trials. (CEP 10)
25. Demonstrate expertise in transitions of care by identifying, with the interprofessional team, the most appropriate care setting(s) for a patient, including independent living, assisted living, long-term care, acute rehabilitation , subacute rehabilitation, home care, primary care at home, adult day care, Program of All-Inclusive Care for the Elderly (PACE)-like program, and hospice based on the needs and preferences of the patient and families/caregivers, and the admission and payment requirements for each setting. (SBC 30)
26. Individualize LTC patient management considering prognosis, comorbidity, patient and caregiver goals, and available resources especially in the following situations: (a) consideration for transfer to the acute care hospital; (b) weight loss, dehydration, swallowing disorders; (c) agitation and problem behaviors. (SBC 49)
27. Regularly re-assess goals of care to recognize patients likely to benefit from palliative and/or hospice care, including those with non-cancer diagnoses (e.g., Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Dementia). (CEP 26)
28. Recognize the limitations of the evidence base and critically review the medical literature for studies that are valid and applicable to the care of older adults. (CEP 20)
29. Serve as an advocate for older adults and caregivers within various healthcare systems and settings. (SBC 38)
30. Describe the role of a long-term care medical director and demonstrate an understanding of nursing home and long-term care regulations and requirements, including the minimum data set. (SBC 50)
31. Manage acute problems in long-term care via telephone call. (SBC 51)
32. Recognize the complexity of geriatric care and demonstrate the ability to prioritize care, in a time-efficient manner, during encounters with geriatric patients (SBC 37)
33. Participate in quality improvement efforts to enhance the quality of care of older adults. (SBC 33)
34. Conduct an appropriate evaluation of patients who fall or are at risk for falling, implement strategies to reduce future falls, fear of falling, injuries, and fractures, and follow-up on referrals. (GS 53)
35. Assess and manage cognitive, functional, and disruptive behavioral manifestations of dementia, both behaviorally and pharmacologically (GS 62)
36. Recognize patient risk factors for pressure ulcers, and in high risk patients work with an interprofessional team to develop a prevention plan. (GS 63)
37. Provide initial evaluation and management of insomnia and other sleep disorders and, when indicated, refer to a sleep specialist. (GS 66)
38. Identify, evaluate and treat the most common forms of both reversible and chronic urinary incontinence using non-pharmacological interventions where possible. (GS 69)
39. Refer when appropriate for urologic or gynecologic evaluation including urodynamic testing, pessary evaluations, pelvic floor muscle training. (GS 70)
40. Identify, evaluate and manage urinary retention and incomplete bladder emptying including the appropriate use of intermittent catheterization or indwelling bladder catheters. (GS 71)
41. Identify and appropriately evaluate and manage involuntary weight loss. (GS 72)
42. Discuss with patients and families/caregivers the risks and benefits of appetite stimulants, nutritional supplementation, enteral tube feeding, and parenteral nutrition, particularly in patients with advanced dementia or near end-of-life. (GS 73)
43. Identify swallowing disorders in patients with involuntary weight loss or recurrent pneumonias, and work with an interprofessional team to evaluate, manage, and educate patient and caregiver(s) based on goals of care. (GS 74)
44. Identify, evaluate and manage constipation and fecal impaction using non-pharmacological and pharmacological modalities. (GS 75)
45. Identify and provide initial evaluation and management of fecal incontinence. (GS 76)

Rotation Activities

During the rotation the fellow will be involved in the following activities:

• Patient Care: The fellow will work with attendings on seeing new admissions and caring for a panel of existing PAC and LTC patients. The fellow’s panel will consist of about 10-15 PAC patients and see them approximately every 7-10 days or more frequently as indicated clinically. The fellow will also be responsible for 10-15 LTC patients who will be seen at least monthly and as needed based on their clinical condition. Additionally, the fellow will be responsible for managing your patient’s acute concerns, labs, diagnostic tests, and progress towards their established goals of care.
  
  
• Rehabilitation: The fellow will work collaboratively with Physical Medicine and Rehabilitation physicians seeing patients in the post- acute unit and addressing their rehab, pain and other musculoskeletal issues.
  
  
• Staff, Patient and Family Education: The fellow will be responsible for developing and delivering a presentation to educate nursing staff in the facility and a presentation to patients and their families. The presentations should address topics of clinical importance to nurses, such as pain, diabetes, or congestive heart failure, and should last about 30 minutes. Dr. Sehgal will serve as a mentor during the development of this presentation.
  
  
• Quality Improvement Activities: The fellow will work with Dr. Mandi and Dr. Silverman to perform a simple quality improvement (QI) project. Examples of possible QI projects may include: falls, congestive heart failure, or care transitions. The fellow will present the data from their intervention during at the end of the rotation at the CLC Quality Council meeting.
  
  
• Administrative Activities: The fellow will have a 1-2-hour session with the Director of Nursing, Admission’s Director, MDS coordinator, Clinical Dietician, and Social Worker to understand their roles as well as their expectations of an attending physician and medical director. The fellow will also attend Interdisciplinary Team (IDT) meetings as assigned.

Faculty

• Monina Lim- Mabuti, M.D.
• Collen Snead, M.S.
• Loreen Blumenthal, MSPA, CC-SLP, BCS-S

Description of Rotation and Educational Experience

The Geriatric Medicine Fellow will participate in longitudinal and outpatient geriatric care at the VA West Palm Beach Medical Centers Primary Care clinics. This rotation will be both block (4 weeks) and longitudinal (1/2 day per week throughout the year) with an assigned panel of patients. The block rotation will consist of primary care experiences with scheduled and walk-in patients. The longitudinal portion will consist of experiences with a cohort of primary care patients where the fellow will assume the role of primary care physician. The clinic attending or Chief of Geriatrics will supervise the fellow’s care of the assigned cohort of patients for longitudinal primary care.

The fellow will also see older patients in the VA Outpatient Women’s Clinic to ensure adequate diversity in sexual issues among their patients, and participate in the outpatient evaluation of older adult patients in the Audiology clinic and with faculty/staff in Speech-Language Pathology.

Objectives

Outpatient Care - General

The objectives of this rotation, concordant with the ACGME requirements and the AGS/ADGAP curricular milestones for geriatrics fellowship programs, are to train fellows to:

1. 1. Assess functional status (IV.A.2.a).(1).(a))
   2. Assess cognitive status and affective states (IV.A.2.a).(1).(c))
   3. Provide appropriate preventive care, and teaching patients and their caregivers regarding self-care (IV.A.2.a).(1).(d))
   4. Provide care that is based on the patient’s preferences and overall health (IV.A.2.a).(1).(e))
   5. Demonstrate knowledge of the pivotal role of the family in caring for the elderly, and the community resources (formal support systems) required to support both the patient and the family (IV.A.2.b).(6))
   6. Demonstrate knowledge of the cultural aspects of aging (IV.A.2.b).(19))
   7. Demonstrate knowledge of the behavioral aspects of illness, socioeconomic factors, and health literacy issues (IV.A.2.b).(20))
   8. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care. (CEP 1)
   9. Provide compassionate care while establishing personal and professional boundaries with patients and families/caregivers. (CEP 6)
   10. Demonstrate current scientific knowledge of aging and the epidemiology of aging populations. (CEP 8)
   11. Demonstrate expertise in medication management by justifying medication regimens based on age related changes in pharmacokinetics and pharmacodynamics, maximizing medication adherence, the common lists of medications that should be avoided or used with caution in older adults, and consideration of the reported benefits and known and unknown risks when prescribing a newly-released medication, realizing that older adults with multimorbidities are often underrepresented in clinical trials. (CEP 10)
   12. Identify and manage medical disorders that occur in older adults. (CEP17)
   13. Know the different presentation, management and underlying pathophysiology of common diseases in older adults (including but not limited to: hypertension, coronary artery disease, osteoporosis, hypothyroidism, infections, and the acute abdomen; adjusting drug dosage for renal function). (CEP 18)
   14. Know the national guidelines for preventive care, adjust as appropriate for clinical circumstances or patient preferences, and document reasons if these guidelines are not followed. (CEP 19)
   15. Recognize the limitations of the evidence base and critically review the medical literature for studies that are valid and applicable to the care of older adults. (CEP 20)

Audiology/Speech and Language Pathology

1. 1. List the indications and contraindications for referral to Audiology for sudden hearing loss, vestibular evaluation, ototoxic monitoring, as well as routine hearing and tinnitus evaluations and rehabilitation.
   2. Identify when a speech-language and/or swallowing consultation would be appropriate.
   3. Recognize the indications and contraindications for and observe Clinical Dysphagia Evaluation as well as Video-fluoroscopic and Flexible Endoscopic evaluations of swallowing in addition to rehabilitation sessions.
   4. Identify anatomy and physiology relating to communication and swallowing in the geriatric population.
   5. Observe endoscopic and functional voice evaluations and treatment sessions.
   6. Learn the signs and symptoms of language and motor speech disorders and observe speech-language pathology assessment and treatment.

Teaching Methods

The principal approach is direct care involvement. The fellow will provide and coordinate care for assigned patients assuming the role of the primary physician and coordinator of care of the patient. The fellow will be expected to review pertinent texts and journals and retrieve evidence-based literature for specific patient issues. Clinical teaching will occur during outpatient visits with the teaching attending. In addition to review of assessments and plans for each patient, selected patients may be the focus of more formal presentations and discussion by the fellow during educational conferences.

Faculty

• Ramon Cuevas-Trisan, M.D.
• Jorge García-Negron, M.D.
• Francisco Garcia, M.D.
• Jyothi Sharma, MD

Description of Rotation and Educational Experience

The geriatric medicine fellow will learn to apply the principles of PM&R to the special functional needs of the geriatric population. The fellow will participate in PM&R outpatient services at VAMC at West Palm Beach and will learn about the role of the physiatrist, what services are provided by the Medical Rehab team, when to refer, how to prescribe various therapies and assistive devices, and inpatient vs outpatient/subacute rehabilitation settings.

Fellows will also participate in the outpatient pain clinic at the VAMC medical center as part of the inter-disciplinary team (Physician, PharmD, Psychologist, Nurse). They will also learn about non- pharmacological methods of pain control.

Objectives

The objectives of this rotation, concordant with the ACGME requirements and the AGS/ADGAP curricular milestones for geriatrics fellowship programs, are to train fellows to:

PM&R

1. 1. Assess functional status (IV.A.2.a).(1).(a))
   2. Assess cognitive status and affective states (IV.A.2.a).(1).(c))
   3. Demonstrate knowledge of the general principles of geriatric rehabilitation, including those applicable to patients with orthopaedic, rheumatologic, cardiac, pulmonary, and neurologic impairments; these principles should include those related to the use of physical medicine modalities, exercise, functional activities, assistive devices, and, environmental modification, patient and family education, and psychosocial and recreational counseling. ( IV.A.2.b).(4); IV.A.2.b).(4).(a))
   4. Demonstrate knowledge of patient and family education, and psychosocial and recreational counseling for patients requiring rehabilitation care (IV.A.2.b).(14))
   5. Demonstrate knowledge of the pivotal role of the family in caring for the elderly, and the community resources (formal support systems) required to support both the patient and the family (IV.A.2.b).(6))
   6. Assess older persons for safety risk, and providing appropriate recommendations, and when appropriate, referral (V.A.2.a).(1).(f))
   7. Provide care that is based on the patient’s preferences and overall health (IV.A.2.a).(1).(e))
   8. Demonstrate effective communication skills with patients, families, professional colleagues, and community groups (IV.A.2.d).(1) )
   9. Demonstrate high standards of ethical behavior, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interest (IV.A.2.e).(1))
   10. Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care (IV.A.2.f))
   11. Know the indications and contraindications for referring patients to physical, occupational, speech or other rehabilitative therapies, and refer if appropriate. (CEP 14)
   12. Know indications for durable medical equipment, prescribe and evaluate for appropriate use. (CEP 15)
   13. Recognize and manage the care of patients at high risk for poor outcomes from common conditions such as deconditioning, stroke, progressive neurologic disorder, sarcopenia and imbalance. (CEP 16)
   14. Perform and interpret common gait and balance assessments, recognizing abnormal gaits associated with specific conditions (GS 52)
   15. Demonstrate the ability to manage the care of patients with multimorbidities by integrating the evidence, patient's goals, life expectancy and functional trajectory. Document clinical reasoning when management differs from standard treatment recommendations. (CEP 22)
   16. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care. (CEP 1)
   17. Uses strategies to enhance clinician-patient oral and written communication in patients with hearing, vision, or cognitive impairment. (CEP 3)
   18. Provides compassionate care while establishing personal and professional boundaries with patients and families/caregivers. (CEP 6)
   19. Assess and incorporate family/caregiver needs and limitations, including caregiver stress, into patients' management plans. (CEP 24)
   20. Serve as an advocate for older adults and caregivers within various healthcare systems and settings. (SBC 38)
   21. Identifies patients who are frail or otherwise at risk for death, dependency and/or institutionalization over the next few years. (CEP 21)
   22. Works effectively as a member or leader of an interprofessional health care team. (CEP 2)

Pain Management

1. 1. Individualize pain control utilizing the most effective pharmacologic and nonpharmacologic strategies based on the etiology and chronicity of the patient's pain. (CEP12)
   2. Prescribe pain medications with instructions and methods to prevent common complications including constipation, nausea, fatigue and opioid toxicity (myoclonus and hyperalgesia), using equianalgesic dosing conversion and opioid rotation when needed. (CEP13)

Rotation Activities

The geriatric medicine fellow will learn about the principles of PM&R in the outpatient setting. The fellow will participate in the evaluation of older adults with conditions such as arthritis, Parkinson’s, amputation, and deconditioning working alongside attendings, physical therapists and occupational therapists. The fellow will spend one half day in the prosthetics clinic.