Introduction to the Integrated Geriatrics and Palliative Medicine Fellowship Helen Fernandez, M.D., MPH Professor Fellowship Director, Geriatrics and Co-Director, Integrated Geriatrics and Palliative Care Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai
Acknowledgements Original concept and proposal to ABIM Incredible work from Dr. Nathan Goldstein, Dr. Robert Arnold and Christine Ritchie They identified overlaps and opportunities to seek about dual training
Disclosures None I am a Mets Fan
Objectives Review clinical importance for collaboration of geriatrics and palliative care Discuss educational imperative for integrated geriatrics and palliative care trainees Explain the ABIM/AAFP Pilot Integrated Geriatrics and Palliative Medicine Fellowship
Geriatrics and Palliative Care Needs 80% of Medicare beneficiaries have more than one chronic progressive medical condition These patients are the most likely to see their doctor, to be hospitalized and to die Most physicians now care for older individuals with multiple chronic progressive illnesses Fields are already working together to create shared agendas for areas of overlap (e.g. AGS-AAHPM collaboration)
Care For the Seriously Ill at the Turn of the Century (2000) Unprecedented gains in life expectancy: exponential rise in number and needs of Americans living with serious illness Cause of death shifted from acute sudden illness to chronic disease Untreated physical symptoms Unmet patient/family needs An unresponsive health care system facing enormous and increasing expenditures
GERIATRICS AND PALLIATIVE CARE WHAT IS THE RELATIONSHIP?
Specialty Based Care GERIATRICS PALLIATIVE CARE Morrison, S.
Morrison, Sean Patient Centered Care Well Older Adults Cancer Gait Disorders Stroke Preventive care Advanced Organ Failure Stable chronic dx Chronic Critical Illness Geriatric syndromes Frailty Peri-operative care Dementia Osteoporosis AIDS TBI Cancer (<65) Genetic/ Developmental Disorders Pediatric Oncology Cystic Fibrosis
Similarities Structure Emphasis on the interdisciplinary team Workforce issues Education Some shared competency domains Some overlap in the population served Courtesy of Dr. Christine Ritchie
Similarities Clinical Clinical care of older adults with serious illness and complex care needs Comprehensive and holistic care across continuum Attention to psychosocial needs Addresses the patient, family and loved ones as one unit requiring care Emphasis on the provision of care by an interdisciplinary team Courtesy of Dr. Christine Ritchie
Geriatrics and Palliative Care So, not only do professionals caring for older adults need to know about palliative care, palliative care specialists also need to know about issues that are specific to this aging population such as pharmacokinetic of medications, geriatrics syndromes as well as administrative and clinical issues associated with long term care facilities.
Current State of Training Geriatrics and palliative medicine fellowships are both clinically-focused one-year programs They do not allow enough time to provide trainees with educational or research skills By not adequately preparing young physicians to enter academic medicine, we limit their ability to improve the health care system for older adults with serious and chronic illness
Educational Need To meet the needs of this growing population more educators and researchers in geriatric palliative care are needed to build models of care, train the clinicians of the future, and be institutional change agents 1 palliative medicine MD for every 1,700 people with serious illness Only 7029 certified geriatricians
Clinical Requirements Trainees will demonstrate clinical competency in both geriatrics and palliative medicine over 16 months To do this we will take advantage of overlapping requirements Ambulatory care experiences will focus on older patients with chronic progressive illness
ABIM/AAFP Competency Based Integrated Geriatrics and Palliative Care Fellowship In 2011, ABIM approved an exception to the traditional individual geriatrics and palliative care In 2012, ABIM/AAFP approved Competency Based Integrated Fellowships In 2014, University of Texas at San Antonio was approved as a second pilot site
Examples of Overlapping Rotations Rotation Core Geriatrics Skills and Knowledge Core Palliative Care Skills and Knowledge Comment Inpatient Geriatrics Management of geriatric syndromes; complex medical management of older adults Communication about goals of care Medical care focused on decreasing the burden of illness Core requirement for geriatrics certification and emphasizes how the two fields are integrated at the patient s bedside. Home Care Management of frail older adults with complex medical problems and functional disability Continuing conversations about goals of care; knowledge of systems to assure symptom control and safety while patient at home Home care patients are older individuals with chronic complex disease. Balances keeping patients at home while maintaining the highest quality of life. Sub-Acute Rehab Management of complex, older, medically ill patients in the immediate postacute-hospitalization phase Management of pain and other symptoms, conversations about transition management and goals of care Patients need continued post-hospital management. Uncontrolled symptoms lead to decreased ability to participate in rehab. Transition discussions for patients that don t meet rehab goals.
Rotation Core Geriatrics Skills and Knowledge Core Palliative Care Skills and Knowledge Comment Geriatric Psychiatry Management of psychiatric symptoms in older adults Management of psychiatric symptoms in older adults Managing psychiatric symptoms in older adults is a core element of both geriatrics and palliative care. There is significant overlap between the two fields in terms of treating depression and delirium. Long-Term Care Management of chronic medical conditions in older patients with decreased functional ability Assuring benefits of treatment outweigh burdens; management of pain and other symptoms in the longterm care setting. Management of chronic medical conditions while assuring that the benefits of treatments outweigh burdens. Demonstration of how the two fields are integrated in the longterm care setting.
Traditional Fellowship Program Requirements Geriatric Program Requirements Geriatric Medicine Consultation Program Inpt Pall Care Combined Demonstration Program Rotations Inpt Geri x Home care Subacute Rehab Elect Geri Psyc Hospice LTC Out pt Ambulatory Care x x Sub-Acute Care Long-Term Care Experience Geriatric Psychiatry Elective Palliative Medicine Program Requirements Inpatient Acute Care x x Home Hospice Care x x Long Term Care x x Ambulatory Care Elective x x x x x x
Rotations Rotations Each block is 4 weeks (13 blocks per year) Home Care 1 Inpt PC consults (all) 3.5 Inpt Geri consult 2 MACE (inpatient geriatrics) 2 Sub-Acute Rehabilitation 1 Geriatric Psychiatry 1 Residential Hospice 0.5 Dedicated Palliative Care/Hospice Unit 2 Long Term Care 1 Ambulatory Care 1 day/week Hospice home care (VNS) 1 Other (Specify):Teaching/urgents care 1.5 Total Clinical Blocks 16 Vacation 2 Research/scholarly activity 8 Elective 0.5 Total Block Numbers 26 blocks
Expanded Clinical Rotations New combined geriatrics and palliative care outpatient clinic New referrals for older adults with serious chronic illness Consultative practice: pain, goals of care and nonpain symptoms Home Care Program Expand primary care patients to include hospice patients Expand our primary care and geriatrics consult service to address pain, goals of care and non-pain symptoms
Expanded Curriculum Combined Geriatrics and Palliative Care Journal Club Expanded Case Conference (include geriatrics and palliative care patients) Geriatrics and Palliative Care Core Topics Research curriculum Intensive Communication Skill Training Curriculum development and effective teaching curriculum Professional development (leadership, mentorship, administration, negotiation skills)
Evaluative Mechanisms Will combine mechanisms currently in use (e.g. written evaluations, checklists of observed behaviors, OSCEs) that will simultaneously evaluate competencies for both specialties All evaluations will be competency based Fellows must demonstrate clinical competency in all ACGME domains in both fields by the end of the 16 month clinical period before they move to the 8 months of professional development Similar evaluation materials will be used across all sites
Faculty Development Two faculty members work with the ABIM assessment and evaluation team to assure that evaluation mechanisms are thorough and adequately attend to each competency Faculty development assures that the local faculty are appropriately trained in the assessment of the core competencies within the fellowship program to assure reliability between evaluators
Advisory Panel To assure oversight and that fellows meet required competencies, we have a 6 person advisory board: Prominent clinician educator from geriatrics from outside of these institution Prominent clinician educator from palliative medicine outside these institution Representative of the American Board of Internal Medicine Meet yearly to discuss the progress of each program and review curriculum Assures cross-site standardization of curriculum and evaluative mechanisms
National Initiatives UT San Antonio started integrated fellowship in 2014 Yale will start integrated fellowship in 2016 UPMC approved to start in 2017 Curricular milestones in geriatrics published in 2012 EPAs in geriatrics published in 2014 EPAs in palliative medicine published in 2015 Working group aligned curriculum milestones with reporting milestones Working group collecting and developing assessment tools and convert to toolbox
UT San Antonio Two pre-existing fellowships Multicultural environment Ethics Curriculum Allows fellows to devote more time to QI/Research/Curricular projects
YNHHS Geriatrics-Palliative Care 2 Fellows Fellowship Rotate in New Haven and Bridgeport Geriatrics and Palliative Care at both sites Professional development (8 months) will focus on Health System issue
Benefits of Health System fellowship Fellows Complementary Hospitals: Tertiary Care & Community Hospital Multiple potential sites for rotations Collaborate with Geriatrics & Palliative Care fellows Bridgeport Hospital Fellows for slots Yale-New Haven Hospital Senior leadership very supportive of Health System fellowship Yale New Haven Health System Professional Development project
Leadership Curriculum Quality Improvement and patient safety training Healthcare administration Rural training Advocacy/policy training Team training Understanding and leading change
Acknowledgements Elizabeth Lindenberger (co-director) Advisory Committee: Robert Arnold, Christie Richie Rosanne Leipzig Sean Morrison Sandra Sanchez-Reilly Lisa Walke Laura Morrison
Thank you. Questions?
History of Geriatrics and Palliative Care Training at Mount Sinai In 2003, NCI grant supported our first geriatrics-palliative care fellow By 2011, six geriatrics-palliative care fellows trained in both a traditional geriatrics and a traditional palliative care program
Other Evaluation Methods Patient and Family Care (Palliative Care) Multi-source feedback Clinical competency meetings Patient Care (Geriatric Medicine) Mini-Cexs ABIM Performance Improvement Module --- (ACOVE) Multisource feedback Medical Knowledge (Both) Board Certification Examinations* OSCE of geriatric syndromes and EBM ( beginning of first and second year)*
Other Evaluation Methods Practice-Based Learning and Improvement (Both) Clinical questions Evaluation as teachers Fellow as teachers by peers and students* In PC, AAHPM Small Group Teaching Checklist Evidence-based Journal Club; Review of Critically Appraisal Papers* (see www.pogoe.org/recap) Self evaluation Quality improvement evaluation tool Interpersonal and Communication Skills (Both) Family meeting evaluation* EPEC and Geri-talk (small group activity with trigger cases and SPs)
Other Evaluation Methods Professionalism (Both) Multisource feedback Monthly evaluation Clinical competency meetings AAHPM Reflective journaling self care exercise System-Based Practice (Both) Multisource feedback ACO QI measures Quality improvement evaluation tool
Results from Two Pilot Sites As of July 1, 2015, both sites (UTHSCSA and ISMMS) graduated 6 integrated fellows and 13 newly enrolled integrated fellows 19 abstracts and poster presentations at national meetings Completed 15 professional training programs in communication skills, curriculum development and teaching curriculum 100% of graduates have pursued academic careers