1 st month MON TUES WED THURS FRI 8-9AM

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1 MODELS OF CARE ROTATION Rotation Coordinator: Cathleen Colón-Emeric, MD Office: x 6777 Pager: Overview: This rotation provides practice experience with several models of care for frail or cognitively impaired older adults including homecare, Video-Telehealth Geriatric Consultations, Dementia Support Services (outpatient and homebased), Transitional Care Programs, Continuing Care Retirement Communities, PACE, community programs, Accountable Care Organizations, and Exercise and Mobility Programs for older adults. General Learning Goals: 1) Collaborating with and leading multi-disciplinary teams engaged in providing care to frail older adults in a variety of settings and care models 2) Understanding the role of home care in frail & cognitively impaired older adults 3) Performing comprehensive evaluation and management of cognitive impairment, including diagnosis, pharmacologic treatment, behavioral management, caregiver training, and home safety assessments 4) Managing transitions of care in at risk older adults to reduce adverse events and unnecessary health care use 5) Understanding the role of physical activity in the maintenance of function in older adults, and providing an exercise prescription Schedule: COACH home visits (2-3 weeks) Telehealth Consults (1-2 weeks) 1 st month MON TUES WED THURS FRI 8-9AM 8-9AM Geriatrics Tuesday AM Grand Rounds Duke Didactics North Room :30AM COACH team meeting (2-3 weeks Nasher Museum Reflections Tour Observation (1 week) STRIDE (1-2 weeks) (or CV clinic) Long Term Care Rounds at TFAD or CV Medicine Grand Rounds Duke North Room 2002 Geriatrics Fellows Conf. GRECC conf room VA (3012) Musculoskeletal Clinic (2 weeks) TLC Partners Home visits (2 weeks) 1-3 PM Clinic 1:30 Duke Connected Care Geriatric Rounds Telehealth Consults Geriatrics PT/OT CLC gym (2-3 weeks) Long Term Care Senior PharmAssist (2 weeks, see prearranged dates in table) Bone Health Consults (1-2 weeks) Clinic COACH home visit contacts: Judith Davagnino, Madeline Weiner, Simone Robinson STRIDE contact: John Bartle Telehealth Consults: Christy Knight 2 nd month MON TUES WED THURS FRI 8-9AM Tuesday AM Didactics CBOC PACT Geriatrics (2 weeks) HBPC home visits (2 weeks) 9AM Gerofit Rounds (1 week, 9:30 am) Contact Gerofit staff in advance Renal Silver (2 weeks) 8-9AM Geriatrics Grand Rounds Duke North Room 2001 PACE (4 weeks)* Long Term Care Rounds at TFAD or CV Medicine Grand Rounds Duke North Room 2002 Geriatrics Fellows Conf. GRECC conf room VA (3012)

2 CBOC PACT Geriatrics (3 weeks) HBPC home visits (3 weeks) 1-3 PM Bone Health Consults (1-2 weeks) Clinic PACE (4 weeks) Long Term Care Senior PharmAssist (2 weeks, pre-arranged dates in table) Geriatrics Clinic 8B *CV clinic fellows will go to PACE instead during this rotation. MSK clinic: Kim Huffman MD TLC Partners Home Visits: Collen Wojciechowski Geriatrics PT/OT: Tasala Rufai Fellow Responsibilities: 1. Meet with rotation director week 1, final week of rotation, and as needed to set goals, review progress, and give/receive feedback. 2. Arrange clinical experiences with the contact provider. Arrive at clinical experiences on time. 3. Participate in/lead team meetings with the interdisciplinary team. 4. Document all clinical encounters as guided by faculty. 5. Seek feedback from colleagues regularly during the rotation. Goals, objectives and logistics by experience: see table at: Evaluation Formative: - Fellow will seek feedback from faculty and non-md providers. - Fellow will meet with Rotation Director at mid-point of the rotation to review objectives and progress toward achieving them. Summative: - Global evaluations collected from members of the interdisciplinary team and a composite evaluation is written by the Rotation Director. - Fellow meets with Rotation Director to review performance and achievement of learning objectives. - Fellow meets with Program Director to review evaluation. Required Readings:

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4 Models of Care Rotation Goals, Logistics, and Readings June 21, 2017 Experience Goals and Objectives Logistics Readings Bone Health Service Understand the role of Fracture Liaison services in reducing secondary fractures, mortality, and cost in older adults Complete osteoporosis e-consults for high risk patients COACH Complete home assessments in the management of patients with cognitive impairment Duke Connected Care Geriatrics PACT Geriatrics PT/OT Practice caregiver education and support Understand the risks and benefits of pharmacologic and behavioral interventions for dementia with behavioral disturbance Describe how accountable care organizations are funded, and how services provided differ from fee-forservice Medicare Participate in a population management program for high risk older adults Appreciate how geriatrics primary care differs from standard primary care practices including staff:patient ratios and coordination with care managers and IDT Describe the roles of Physical, Occupational, and Speech Therapy in the care of post-acute and long-term care patients. Determine the appropriateness of assistive devices for older adults with mobility impairments Describe commonly used adaptive equipment for older adults with functional impairments Contact Dr. Colón-Emeric to set up a date Cathleen.colonemeric@duke.edu VA x 6777 Judith Davagnino, SW, Judith.Davagnino@va.gov VA x Review CPRS for patient information before home visit Contact Dr. White Heidi.white@duke.edu Duke Connected Care office, 718 Rutherford Street, Durham. Review cases ahead of time in EPIC; list will be sent out to you via the previous week Contact Dr. Soheili Kambiz.Soheili@va.gov or pager (919) Directions to the Raleigh CBOC, Contact Tasala Rufai ahead of time to arrange dates tasala.rufai@va.gov abs/ /ep ra? code=aace-site 8.short /article.aspx?articleid= &linkId= pmc/articles/pmc /

5 Geriatric Video Telehealth Participate in evaluation and management of older patients with geriatric syndromes using telehealth Describe how non-face to face models of care are implemented and evaluated within health systems. Look in VA Shared Folder S://GRECC/Vitel Gem/0 Scheduled Patients for schedule of consults. Let the provider (Colón-Emeric, Yanamadala, Hall) know if you are planning to attend the session oi/abs/ / #.V17ObnLmrcs Gerofit Understand the relationship between physical activity and the development of functional impairment in older adults Provide exercise prescriptions for older adults Understand the role of the exercise physiologist in geriatrics research, education and patient care or call Adrienne Wagenblast to arrange an experience based on their schedule for new intakes/programs for the week m/science/article/pii/s /article.aspx?articleid= Home Based Primary Care Musculoskeletal clinic Nasher Museum Reflections Tour Observation Collect functional and psychosocial information during home visits Describe patient selection, team roles, and expected outcomes for a home based primary care program Diagnose and treat common musculoskeletal problems including rotator cuff disorders, back pain, knee pain, and hip pain. Develop proficiency in common joint and bursal aspirations/injections Use rehabilitation as a treatment modality for musculoskeletal disorders Describe components of dementiafriendly communities Participate in a community program designed to engage people with dementia and their caregivers Contact for availability: Becky Betts PA Rebecca.Betts2@va.gov Carol McMorrow, PA Carol.McMorrow@va.gov Mon Thurs 7:30 to 4: Riitta Malkki, HBPC/TLC PA, rita.malkki@va.gov or page Dr. Kim Huffman (kim.huffman@duke.edu) to introduce yourself and let her know what weeks you will be coming Only offered on the 4 th Tuesday of every month. Contact Brittany Halberstadt at reflections@duke.edu or call to schedule your observation. 7.full.pdf+html /article.aspx?articleid= munity/#reflections

6 PACE List the enrollment criteria, funding, and appropriate patient selection for PACE Identify how acute, post-acute, and chronic care are handled in the PACE model Renal Silver Understand the role of geriatric assessment in serious chronic disease management and advanced care planning Senior PharmASSIST List principles of appropriate prescribing in older adults List factors that influence medication access and adherence in older adults Gain an appreciation for motivational interviewing and addressing social determinants of health Understand the basics of Medicare A, B, C and D Pre-set Dates: Schlientz 8/9 and 8/30 Ramlal 9/13 and 9/27 Stout 10/4 and 10/18 Clark 12/13 and 12/27 Ogunwale 1/10 and 1/24 Tun 5/9 and 5/23 STRIDE Appreciate the risk of functional decline and other hazards of hospitalization associated with immobility. Understand the impact of an early hospital mobilization program and posthospital discharge exercise counseling. 650 Alexander Avenue, Durham, NC Karen Oldham koldham@voa.org Directions: E+north+carolina/@ , ,11z/data=!4m5!4m4!1m0!1m2!1m1! 1s0x89ace555fb35e77b:0xdf5cf82d9e768d1b Contact Rasheeda Hall Rasheeda.stephens@duke.edu Specific dates have been pre-arranged: Contact Marilyn Disco if you cannot go to the dates in your block month Marilyn@seniorpharmassist.org Directions: rmassist,+406+rigsbee+ave+%23+201,+durha m,+nc+27701/@ , ,15z/data=!4m2!3m1!1s0x89ace :0x6662bbe60a04f883 Contact John Bartle (john.bartle@va.gov) VA x /default/files/documents/dem entia_friendly_communities_ full_report.pdf m/science/article/pii/s X oi/ /jgs.14262/abstract pmc/articles/pmc / ent/17/1/6.short doi/ /j x/pdf

7 TLC Partners Recognize the potential problems arising during transitions of care, and to experience a model shown to reduce recurrent hospitalizations Evaluate an older adult in their home environment Contact Colleen Wojciechowski, NP by colleen.wojciechowski@va.gov. Please travel with the Nurse Practitioner. Review CPRS information ahead of time and be prepared to discuss the patient s condition and potential problems in transitions with the NP. ngmaterials/transitionalcare ofolderadultshospitalizedwit hheartfailure-1262.pdf