Acute Care for the Elderly Unit Interdisciplinary Experience Anna Goroncy, MD

GENERAL DESCRIPTION

The Acute Care for the Elderly Unit Interdisciplinary Experience will provide medical students and family medicine residents with an introduction to the basic principles of providing safe and effective care to frail older adults as part of an interprofessional team.

Students and residents will undergo a 2-hour orientation to the ACE unit model of care and spend time shadowing the attending geriatrician on ACE. Each day students meet briefly (about 20-30 minutes) with the attending geriatrician or geriatric fellow to discuss: medication management, falls, geriatric assessments in the hospital, delirium and taking a complete social history. They then have the opportunity to put these new skills into practice with 2-3 patients on the unit. Tools and assessments practiced include: Geriatric Depression Screen, Mini-Cog, CAM, social history, fall risk assessment and complete medication review and reconciliation. Students present their findings to the ACE team as part of Structured Interdisciplinary Bedside Rounds and then after rounds discuss their findings further with the attending geriatrician and ACE nurse practioner.

As the next level of their new learning, the roles of other interdisciplinary team members will be observed and explained. Finally, the learner will spend time with 3 members of the IDT: geriatrician, therapist and PCA.

Expectations for interdisciplinary experience on the ACE unit:

Learner will review assigned articles (attached) and be prepared to discuss these articles with Dr. Schlaudeckeror Dr. Goroncy and the rest of the ACE team prior to the interdisciplinary experience.

Learner will spend one day working alongside physical therapist and occupational therapist participating in initial evaluations and follow up visits.

Learner will spend one day working alongside a Patient Care Assistant participating in direct patient care and interdisciplinary bedside rounds.

Learner will complete a 1-2 page thoughtful, personal reflectionfor each interdisciplinary day.Learner may to reflect on what surprised her, what could be done differently and how it will impact her future care, or anything else meaningful from the experience.

DETAILED COURSE OBJECTIVES

The student should be able to:

Assess and describe baseline and current functional abilities in an older patient by collecting historical data from multiple sources, making sure to include instrumental activities of daily living, activities of daily living, and capacity/competence assessment, and performing a confirmatory hearing and vision examination.

Develop a preliminary management plan for patients presenting with functional deficits, including adaptive interventions and involvement of interdisciplinary team members from appropriate disciplines, such as social work, nursing, rehabilitation, nutrition, and pharmacy.

Identify potential hazards of hospitalization for all older adult patients (including immobility, delirium, medication side effects, malnutrition, pressure ulcers, procedures, peri and post operative periods, transient urinary incontinence, and hospital acquired infections) and identify potential prevention strategies.

Explain the risks, indications, alternatives, and contraindications for indwelling (Foley) catheter use in older adult patients.

Explain the risks, indications, alternatives, and contraindications for physical and pharmacological restraint use.

Explain the roles of each interdisciplinary team member in maintaining function and safety for hospitalized older adults.

Discuss strategies to incorporate inputs from interdisciplinary team members in future practice in caring for older adults in other settings.

Identify appropriate times to utilize various screening tools including Geriatric Depression Screen, Mini-Cog, CAM, social history, fall risk assessment and complete medication review and reconciliation.

Demonstrate use of these screening tools with patients on the ACE unit.

Assigned Resources:

1. Will My Patient Fall?JAMA. 2007;297:77-86

David A. Ganz, MD, MPH, YeranBao, MD, Paul G. Shekelle, MD, PhD Laurence Z. Rubenstein, MD, MPH

2. The Patient Who Falls “It’s Always a Trade-Off.” JAMA. 2010;303(3):258-266

Mary E. Tinetti, MD Chandrika Kumar, MD

3. Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Intern Med. Nov.2009;169(21):1952-1960.

John C. Woolcott, MA; Kathryn J. Richardson, MSc; Matthew O. Wiens, BSc, Pharm, PharmD; Bhavini Patel, MPharm; Judith Marin, BPharm, PharmD; Karim M. Khan, MD, PhD; Carlo A. Marra, BSc, Pharm, PharmD, PhD

4. Ten Ways to Improve the Care of Elderly Patients in the Hospital. Journal of Hospital Medicine. 2011;6:351–357.

Angelena Maria Labella, MD, Susan Eva Merel, MD, Elizabeth Anne Phelan, MD, MS

DOI 10.1002/jhm.900

5. Rethinking the Social History. New England Journal of Medicine. Oct. 2014; 371;14.

Heidi L. Behforouz, M.D., Paul K. Drain, M.D., M.P.H., and Joseph J. Rhatigan, M.D. DOI: 10.1056/NEJMp1404846

6. Delirium in Elderly People. Lancet. March 2014. 383: 911–22.

Sharon K. Inouye, M.D., MPH, Rudi G. J. Westendorp, M.D., PhD, and Jane S. Saczynski, Ph.D.

S0140-6736(13)60688-1