PROGRAM Goals and Objectives Family practice residents in this PGY3 Care of the Elderly program will learn special skills, knowledge and attitudes to support their future focus practice in Care of the Elderly that may include primary care and consultative work. PROGRAMS GOALS: In this program residents will: Establish effective professional relationships with older patients, their family, caregivers and substitute decision makers within the primary care setting and specialized geriatric care systems. Learn comprehensive and clinical assessment skills of the frail elderly, including assessment of mental function. Become familiar with the atypical presentation of illness and the management of common geriatric and psychogeriatric problems. Expand their clinical and administrative skills, knowledge and leadership abilities to work effectively with inter-professional team members in acute hospitals, long-term care facilities and the community, including the older patient s home. Residents will be encouraged to set personal learning objectives that may include perceived or previously identified areas of interest. Residents must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centered care and service to an elderly population. 1
PROGRAM OBJECTIVES: Residents will acquire the following competencies through graduated responsibility: MEDICAL EXPERT Physicians are skilled clinicians who provide comprehensive, continuing care to patients and their families within a relationship of trust. Care of the Elderly physicians apply and integrate medical knowledge, clinical skills and professional attitudes in their provision of care. Their expertise includes knowledge of their patients and families in the context of their communities, and their ability to use the patient-centered clinical method effectively. As Family Medicine Experts they integrate all the CanMEDS- Family Medicine (CanMEDS-FM) roles in their daily work. ME.1. Integrate all the CanMEDS-FM roles in order to function effectively with a focused practice in Care of the Elderly ME.1.1 ME.1.2 ME.1.3 ME.1.4 Utilize relevant competencies contained within the CanMEDS-FM roles when approaching clinical situations with elderly patients Prioritize professional duties when faced with multiple competing demands when caring for an elderly patient population. Describe the role of the Care of the Elderly physician in situations beyond immediate patient care (e.g., participation in geriatric health care management, policy development and planning) Consider issues of elderly patient safety and ethical dimensions in the provision of care and other professional responsibilities ME.2. Establish and maintain clinical knowledge, skills and attitudes required to care for older adults ME.2.1 ME.2.2 ME.2.3 ME.2.4 Apply acquired knowledge, skills and attitudes to daily clinical practice of care of the elderly. Recognize personal limits in knowledge, skills and attitudes in relation to care of the elderly. Implement a personal learning program in response to the diversity of a primary care practice with a focused Care of the Elderly patient population Contribute to the enhancement of quality of care in their practice, integrating the available best evidence and best practices in geriatric medicine ME.3. Demonstrate proficient assessment and management of older adults using the patient centered clinical method ME.3.1 ME.3.2 ME.3.3 ME.3.4 ME.3.5 Describe the components of the patient centered clinical method as they apply to care of elderly patients. Demonstrate skilled interviewing and physical examination techniques in gathering clinical data about elderly patients. Explore both the disease and the elderly patient s personal experience of illness Consider the whole person when caring for elderly patients (e.g., life history, personal, and developmental issues, context Biopsychosocial) ME.3.4.a Discuss the effects of psychological aging and its implication for therapeutic choices in palliative patients Involve elderly patients in the process of defining problems and priorities, setting goals of treatment and in the re-evaluation of these goals as appropriate 2
ME.3.6 ME.3.7 ME.3.8 Incorporate disease prevention and health promotion of older adults into the clinical encounter Apply characteristics of a therapeutic and caring relationship to foster enhanced patient-physician relationships Manage time and resources effectively ME.4. Provide comprehensive and continuing care to older adults incorporating appropriate preventive, diagnostic and therapeutic interventions ME.4.1 ME.4.2 ME.4.3 ME.4.4 ME.4.5 Provide broad-based, long term, medical and psychiatric primary contact and comprehensive continuing care to a defined population of older patients through the spectrum of health promotion and disease prevention; diagnosis; acute treatment, chronic disease management; rehabilitation; long term care and end of life care. ME.1.4.a Manage acute medical conditions ME.1.4.b Assess and manage behavioural and psychological symptoms of dementia. ME.1.4.c Assess and manage mood and anxiety disorders in the elderly ME.1.4.d Describe available community resource and means for accessing them in service of community based elderly patients. ME.1.4.e Assess and manage risks of community-based patients. ME.1.4.f Develop discharge plans for elderly patients. ME.1.4.g Perform medication reconciliations for patients admitted to hospital ME.1.4.h Assess the rehabilitation potential of elderly patients ME.1.4.i Provide medical supervision of rehabilitation for elderly patients ME.1.4.j Conduct in-home assessments of outreach patients to determine individual level of care requirements that reflect knowledge of the long-term care system. ME.1.4.k Discuss psychosocial issues of palliative patients and identify strategies to manage these ME.1.4.l Assess symptoms, including pain, in geriatric patients with consideration of specific populations e.g. patients with cognitive impairment, frail elderly Apply current standards of preventive care relevant to older patients Utilize diagnostic and therapeutic interventions in accordance with available evidence, balancing risks, benefits and costs to meet the needs of elderly patients Determine the medical fitness of elderly patients to drive. Assess capacity of elderly patients to make decisions about medical treatment, financial issues, appointing a power of attorney, and making of a will. ME.4.6 Assess and manage physical, psychological and social needs of elderly palliative patients. ME.4.6.a Apply palliative medicine knowledge, skills and attitudes in the care of geriatric patients ME.5. Attend effectively to complex clinical situations in the care of older adults ME.5.1 ME.5.2 ME.5.3 ME.5.4 Apply clinical reasoning strategies to adapt the scope of clinical evaluations to the needs of individual older patients given their particular context Develop diagnostic hypotheses informed by prevalence, community incidence and consideration of urgent treatable problems relevant to an older population. Identify relevant priorities for management, based on the elderly patient s perspective, medical urgency and the context Make clinical decisions informed by best available evidence, past experience and the elderly patient s perspective ME.5.4.a Assist in the management of common symptoms of palliative patients. 3
ME.5.5 ME.5.6 ME.5.7 ME.5.4.b Assist in the management of oncological and palliative emergencies (e.g. cord compression). Recognize and respond to the ethical dimensions in clinical decision-making in relation to the care of an elderly patient population. Use time effectively in assessment and management Manage multiple clinical issues of an elderly patient simultaneously, both acute and chronic, often in a context of uncertainty. ME.6. Demonstrate proficient and evidence-based use of screening tools and performance-based measures in the care of older adults ME.6.1 ME.6.2 Employ diagnostic and therapeutic procedures in a timely manner, including obtaining informed consent. Provide documentation of procedures performed, outcomes attained and follow-up planning that supports an interprofessional approach to care of the elderly. ME.7. Coordinate patient care, including collaboration and consultation with other health professionals and caregivers ME.7.1 ME.7.2 ME.7.3 Coordinate the care of older patients with interprofessional care providers and teams of providers Apply the competencies of the Collaborator role in team-based care of the elderly, and when working with consulting health professionals Engage the family, caregivers, substitute decision makers, and other caregivers appropriately in the care of older patients, while abiding by the ethical standards of patient autonomy and consent COMMUNICATOR As Communicators, physicians facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. CM.1. Develop rapport, trust and ethical therapeutic relationships with older patients, their family, caregivers, and substitute decision-makers CM.1.1 Recognize that being a good communicator is a core clinical skill for physicians, and that physician-patient communication can foster patient satisfaction, adherence, improved clinical outcomes and physician satisfaction. CM.1.2 Establish positive therapeutic relationships with older patients, their family, caregivers and substitute decision makers that are characterized by understanding, trust, respect, honesty and empathy CM.1.2.a Manage family conferences CM.1.3 Demonstrate respect for patient confidentiality, privacy and autonomy CM.1.4 Listen effectively CM.1.5 Utilize strategies to enhance communication such as an awareness of, and responsiveness to, non-verbal cues CM.1.6 Facilitate a structured clinical encounter CM.1.7 Demonstrate effective use of communication skills in the setting of cultural diversity (e.g., Aboriginal, francophone), cognitive, visual and hearing impairments CM.1.8 Demonstrate respect for the boundaries in the doctor-patient relationship 4
CM.2. Elicit and synthesize accurate information from, and perspectives of, older patients, their family, caregivers, substitute decision makers, colleagues and other professionals CM.2.1 Gather information about the older patient s beliefs, concerns and expectations about the presenting illness. CM.2.2 Explore the elderly patient s psychosocial context CM.2.3 Conduct an interview with multiple participants such as the patient s family, caregivers and other professionals to gather information about factors affecting the patient. CM.2.4 Synthesize information from other sources, such as the elderly patient s family, caregivers and other professionals CM.3. Convey needed information and explanations accurately to older patients, their family, caregivers, substitute decision makers, colleagues and other professionals CM.3.1 Provide information to older patients, their family, colleagues and other professionals in a humane and understandable manner that encourages discussion and participation in decision-making CM.3.2 Disclose error / adverse events in an effective manner CM.4. Develop a common understanding on issues, problems and plans with older patients, their family, caregivers, substitute decision makers, colleagues and other professionals to develop, provide and follow-up on a shared plan of care CM.4.1 Identify and explore problems to be addressed from an encounter with an elderly patient, including the patient s context, responses, concerns, and preferences CM.4.2 Respect diversity and difference, including but not limited to the impact of gender, religion and cultural beliefs on decision-making CM.4.3 Encourage discussion, questions, and interaction in clinical encounters with elderly patients. CM.4.4 Engage older patients, their family, caregivers, substitute decision makers and relevant health professionals in shared decision-making CM.4.5 Communicate effectively as a member or leader of a health care team or other professional group CM.4.6 Provide follow-up contact with patient and family using a form of communication that will achieve the best outcome for the elderly patient and family CM.4.7 Address challenging communication issues such as motivating behavioural change, delivering bad news, and addressing anger or dependency CM.4.8 Provide therapeutic interventions through supportive and other counseling techniques used in primary care of the elderly CM.4.9 Utilize an interpreter to facilitate communication when appropriate. CM.5. Convey oral and written information effectively CM.5.1 Maintain clear, accurate, and appropriate records (e.g., written, electronic) to enhance communication about clinical encounters with and plans for elderly patient. CM.5.2 Use written and oral communication effectively for referral and collaborative care of an elderly patient population CM.5.3 Present verbal reports of clinical encounters with and plans for elderly patients in an effective manner CM.5.4 Communicate appropriately using electronic mail and other electronic means, while maintaining patient confidentiality 5
CM.5.5 Present medical information to the public or media about a medical issue relevant to the Care of the Elderly when requested or needed by a community COLLABORATOR As Collaborators, physicians work with patients, families, healthcare teams, other health professionals, and communities to achieve optimal patient care. CL.1. Participate in a collaborative interprofessional model in the care of older adults CL.1.1 Describe the physician s roles and responsibilities to other professionals. CL.1.1.a Describe the consultative role of a focused Care of the Elderly physician CL.1.2 Describe the roles and responsibilities of other professionals within a health care team serving an elderly patient population CL.1.3 Recognize and respect the diversity of roles, responsibilities and competencies of other professionals in relation to one s own when caring for an elderly population. CL.1.4 Collaborate with others to assess, plan, provide, and integrate care for individual elderly patients or groups of elderly patients. CL.1.4.a Function effectively in a shared care model of practice. CL.1.4.b Participate in interprofessional assessment and management of palliative patients in various settings of care (in-patient, out-patient, community). CL.1.5 Work with others to assess, plan, provide and review non-clinical tasks, such as research problems, educational work, program review or administrative responsibilities. CL.1.6 Participate effectively in interprofessional team meetings CL.1.7 Enter into interdependent relationships with other professions for the provision of quality care for the elderly CL.1.8 Utilize the principles team dynamics to enhance team performance. CL.1.9 Contribute to working relationships on teams and participate in a collegial process to designate appropriate team leadership roles. CL.1.10 Respect team ethics, including confidentiality, resource allocation and professionalism CL.1.11 Demonstrate leadership in a healthcare team CL.1.11.a Supervise junior housestaff CL.2. Maintain a positive working environment with consulting health professionals, health care team members, and community agencies involved in the care of an elderly patient population CL.2.1 Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team CL.2.2 Work with other professionals to prevent conflicts CL.2.3 Employ collaborative negotiation to resolve conflicts CL.2.4 Respect differences, misunderstandings and limitations in other professionals CL.2.5 Recognize one s own differences, misunderstandings and limitations that may contribute to interprofessional tension CL.2.6 Reflect on interprofessional team function CL.3. Engage and facilitate elderly patients, their families, caregivers and substitute decision makers as active participants in the care of elderly patients CL.3.1 Negotiate the identification of problems and priorities of interventions with elderly patients, their family, caregivers and substitute decision makers while maintaining primary responsibility to the elderly patient. 6
CL.3.2 CL.3.3 CL.3.4 Negotiate the methods and goals of treatment with elderly patients, their family, caregivers and substitute decision makers while maintaining primary responsibility to the elderly patient. Establish the respective roles of the focused practice care of the elderly physician and elderly patient Collaborate with elderly patients, their family, caregivers, substitute decision makers and health care team to optimize health MANAGER As Managers, physicians are central to the primary health care team and integral participants in Health care organizations. They use resources wisely and organize practices that are a resource to their patient population to sustain and improve health, coordinating care within the other members of the health care system. MG.1. Participate in activities that contribute to the effectiveness of their own practice, healthcare organizations and systems MG.1.1 Describe the role of the focused practice Care of the Elderly physician in the health care system and their relationships with other health care professionals, and community organizations MG.1.2 Collaborate with other health care professionals and community organizations to provide coordinated care for elderly patients. MG.1.3 Participate in systemic quality process evaluation and improvement (e.g., patient safety initiatives) MG.1.4 Participate in continuous quality improvement activities within their own practice environment (e.g., practice audits) MG.1.5 Describe the structure and function of the current health care system as it pertains to elderly patients (e.g., hospital based, community based, specialized geriatric systems) MG.1.5.a Discuss challenges commonly encountered by elderly living in the community. MG.2. Manage their practice and career effectively MG.2.1 Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life. MG.2.2 Manage a practice including financial and human resources aspects, collaboratively when indicated. MG.2.3 Implement processes to ensure continuous quality improvement within a practice MG.2.3 Utilize information technology, including electronic medical records to plan appropriately for elderly patient care MG.3. Allocate finite healthcare resources appropriately MG.3.1 Allocate healthcare resources to older adults appropriately, balancing effectiveness, efficiency and access with optimal elderly patient care. MG.3.1.a Describe the challenges of managing finite resources when caring for longterm care residents. MG.3.2 Apply evidence and management processes for cost-appropriate care MG.3.3 Manage access to scarce community resources and referral sources judiciously 7
MG.3.4 Integrate knowledge of the structure of the healthcare system and its components in the provisions of care to an elderly patient population. MG.3.4.a Discuss the availability of resources to long-term care residents. MG.3.4.b Describe the administrative structure of long-term care facilities including the role of attending physicians and medical directors. MG.4. Serve in administration and leadership roles, as appropriate MG.4.1 Chair or participate effectively in committees and meetings MG.4.2 Discuss the principles that can guide change in health care practice that relates to care of an elderly patient population MG.4.3 Contribute to policy development related to systems of health care related to the care of the elderly MG.4.4 Participate in relevant administrative roles related to clinical care of an elderly patient population HEALTH ADVOCATE As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations. HA.1. Respond to individual patient health needs and issues as part of elderly patient care HA.1.1 HA.1.2 HA.1.3 Identify the health needs of an individual elderly patient Advocate for individual older patients around health matters Implement health promotion and disease prevention policies and interventions for individual elderly patients and for the elderly patient population served HA.2. Respond to the health needs of the communities they serve HA.2.1 HA.2.2 HA.2.3 Describe the practice community they serve, in particular the elderly community. Identify opportunities for advocacy, health promotion and disease prevention for seniors care and respond appropriately Appreciate the possibility of competing interests between the elderly population they serve and the wider community HA.3. Identify the determinants of health for the elderly population they serve HA.3.1 HA.3.4 Identify the determinants of health for seniors including barriers to accessing care and resources. Identify vulnerable, marginalized, and current at risk groups (e.g., frail seniors, older patients with disability or the cognitively impaired) and respond as needed HA.4. Promote the health of individual older patients, communities and populations HA.4.1 HA.4.2 HA.4.3 Describe approaches to implementing changes in determinants of health of the older patient population Describe how public policy, healthcare delivery and healthcare financing impact access to care and the health of the older population Identify points of influence in the healthcare system and its structure that relate to the care of an elderly patient population 8
HA.4.4 HA.4.5 HA.4.6 Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism Appreciate the possibility of conflict inherent in the role of health advocate for an elderly patient or population with that of manager or gatekeeper Describe the role of the medical profession in advocating collectively for health and patient safety SCHOLAR As Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of knowledge. SC.1. Maintain and enhance professional activities through ongoing self-directed learning based on reflective practice SC.1.1 SC.1.2 SC.1.3 SC.1.4 Describe the principles of maintaining professional competence, implementing a personal knowledge management system Recognize and reflect on learning issues in practice Conduct a personal practice audit Formulate and monitor a personal learning plan related to Care of the Elderly. SC.2. Critically evaluate medical information, its sources, and its relevance to one s own practice, and apply this information to practice decisions about care of an elderly patient population SC.2.1 SC.2.2 SC.2.3 Describe the principles of critical appraisal Critically appraise retrieved geriatric evidence to address a clinical question Integrate critical appraisal conclusions into the clinical care of the elderly SC.3. Facilitate the education of older patients, their family, caregivers, substitute decision makers, trainees, other health professional colleagues, and the public, as appropriate SC.3.1 SC.3.2 SC.3.3 SC.3.4 SC.3.5 SC.3.6 SC.3.7 Describe principles of learning relevant to medical education and the benefits of collaborative learning Collaboratively identify learning needs and desired learning outcomes of others in relation to the care of an elderly patient population Deliver a learner-centered presentation about the Care of the Elderly to a general health care provider audience Facilitate the learning of others through the appropriate selection of content and the implementation of effective teaching strategies Self-assess and reflect on a teaching encounter Provide timely, informative feedback Describe the principles of ethics as these apply to teaching SC.4. Contribute to the creation, dissemination, application, and translation of new knowledge and practices SC.4.1 SC.4.2 SC.4.3 SC.4.4 Describe the principles of research and scholarly inquiry Evaluate the relevance, validity, and applicability of geriatric research findings to one s practice and individual patients Describe the principles of research ethics Complete a scholarly project on a topic related to Care of the Elderly 9
SC.4.5 Disseminate the findings of a study PROFESSIONAL As Professionals, physicians are committed to the health and wellbeing of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour. PR.1. Demonstrate a commitment to their older patients, profession, and society through ethical practice PR.1.1 PR.1.2 PR.1.3 PR.1.4 PR.1.5 PR.1.6 PR.1.7 Exhibit professional behaviors in practice, including honesty, integrity, reliability, compassion, respect, altruism, and commitment to older patients well-being Demonstrate a commitment to delivering the highest quality care of older patients and the maintenance of competence Respond to ethical issues encountered in practice Demonstrate respect for colleagues and team members Manage conflicts of interest Abide by the principles and limits of patient confidentiality as defined by professional practice standards and the law Maintain appropriate professional boundaries PR.2. Demonstrate a commitment to their older patients, profession, and society through participation in profession-led regulation PR.2.1 PR.2.2 PR.2.3 PR.2.4 PR.2.5 Apply the professional, legal and ethical codes of practice, including knowledge of the CMA Code of Ethics, and the roles of the CMPA, CPSO, CCFP and OMA Fulfill the regulatory and legal obligations required of current practice Demonstrate accountability to professional regulatory bodies Respond to others unprofessional behaviours in practice Participate in peer review PR.3. Demonstrate a commitment to physician health and sustainable practice PR.3.1 PR.3.2 PR.3.3 Balance personal and professional priorities to ensure personal health and a sustainable practice Strive to heighten personal and professional awareness and insight Respond to other professionals in need PR.4. Demonstrate a commitment to reflective practice PR.4.1 PR.4.2 PR.4.3 Gather information about personal performance, know one s own limits, and seek help appropriately Demonstrate an awareness of self, and an understanding about how one s attitudes and feelings impact their practice Reflect on practice events, especially critical incidents, to enhance self-knowledge 10