There is a dearth of existing available educational resources that pictorially contrast normal age-related anatomic and histological organ system changes. (Most of the available resources demonstrate normal versus pathologic.)

Pivotal to Image Atlas completion was developing partnerships with the UMMS pathology department and anatomy and cell biology division. UMMS' Advancing Geriatrics Education (AGE)/Reynolds summer student, UMMS MS2 Patrick Bonavitacola, forged new working relationships with the director of surgical pathology and renal pathology, the current chief resident, and the co-director of the MS1 DSF course. Existing images were culled from: 1) the former chief of pathology's legacy slide collection within the UMMS pathology department, 2) dissections in the anatomy lab; and 3) recent autopsies in the pathology lab. Images were also incorporated from local textbooks and an image database taken with permission from the University of Connecticut.

Formal discussions have been held with the DSF course directors, who are currently reviewing the PowerPoint module and strategizing  how to best integrate this model and original content into the DSF curriulum. UMMS geriatricians will teach from this curriculum in the anatomy lab this fall.

The pilot Navigator Program was instituted during the 2009-2010 academic year through which 11 medical students were trained as Student Navigators (SNs), serving a total of 22 patients in an outpatient cardiology clinic (http://www.pogoe.org/node/2458). Based on pilot program evaluation data and a student focus group discussion facilitated by geriatrician faculty advisors, the intention of the program has been changed such that each student is now paired with one older patient whom they navigate throughout an academic year in order to provide a more longitudinal patient-centered experience. Geriatrician faculty advisors and preceptors in the UMMS Longitudinal Preceptor Program now allow SNs to see patients in their respective practices while longitudinally following those patients to sub-specialist appointments.

One of the keys in piloting the Navigator Program at UMMS was the involvement of a Student Navigator Leader, one of the leaders of the medical school’s student-run Geriatrics Interest Group (GIG).  The Student Navigator Leader is a second year medical student who is responsible for the day-to-day management of the program, including the oversight of Student Navigator orientation and the collection of all Navigator program evaluation data.  (To encourage and support these student leaders, the co-leaders of the GIG receive a modest stipend through our Reynolds grant, in part, for Navigator Program leadership.)  Prospective Navigators are recruited through GIG-sponsored luncheons and student group meeting presentations, as well as through direct classmate recruitment by the GIG leaders and members.

Two geriatrician faculty in the Division of Geriatric Medicine, appointed as faculty advisors to the Navigator Program, are responsible for weekly meetings with the Student Navigator Leaders, mentoring student leadership development, and oversight of data collection and analysis.

New SNs are trained jointly by geriatrician faculty advisors and experienced SNs using a “Train-the-Trainers” model.  Current Navigators train new Navigators, who are given a newly developed Student Navigator Resource Handbook upon enrollment, which includes professional literature specific to geriatric prescribing, medication reconciliation, effective communication with older persons, and geriatric specialty-specific considerations.  The Student Navigator leaders oversee new SN training and meet weekly with the geriatricians for mentoring.  The geriatrician faculty advisors facilitate small groups with participating SNs three times during the academic year to teach the modules presented in the Handbook.

Once trained, the SN accompanies their assigned older patient into the examination room, taking notes on a standardized template to document vital signs, test results, assessments, instructions, and medication changes.  Immediately following the visit, the SN summarizes the information with the patient (and caregiver) and provides a copy of the standardized encounter form which includes a reconciled medication list that has been signed by the participating physician.

Additional features built into Navigator 2.0 include an exit interview with the patient (and family) to discuss their respective experiences with the program, as well as how the Navigator Program influenced the SN's own communication style and outlook before entering residency. Additionally, the SN is required to navigate their patient a minimum of three times during the academic year to receive credit for participation. It is also expected that the Navigator Program will become an officially sanctioned Optional Enrichment Elective through the UMMS Office of Medical Education.

Four Program Evaluation forms are used in the Navigator Program, and have been revamped for Navigator 2.0 to represent the updated goals and geriatric competencies of the new curricula (three modules in the newly developed Handbook).

1. Student Survey
2. Patient Survey
3. Provider Survey
4. Overall Student Survey

Patients are asked to complete an evaluation form, which may either be completed and returned to the SN at the end of the session or later mailed to the Student Navigator Leader in a self-addressed stamped envelope provided to the patient. The Student Navigators are responsible for returning completed evaluation forms to the Student Navigator Leader, who oversees the collection of all evaluation data. The Student Navigator Leader also collects monthly evaluations from participating physicians. After collecting all these various forms, the Student Navigator Leader forwards all evaluation data to the UMMS Division of Research and Evaluation.

For more information on this program at UMMS, go to http://umassmed.edu/AGE/Navigator.aspx.

Getting Started – Recruitment:

a) Faculty Advisors – Faculty Advisors work closely with medical students involved in the Medical School’s Geriatrics Interest Group (GIG). One GIG student is appointed the Student Navigator Leader and Faculty Advisors meet bi-monthly with the Student Navigator Leader to offer counsel, review the past month’s Navigator data, and discuss recent evaluation data from students, patients, and faculty. A Student Navigator Resource Handbook is developed by the Faculty Advisors and distributed to new Student Navigators with relevant articles in the areas of effective older patient-physician communication, polypharmacy in the elderly, and the burden of multiple co-morbidities on older patients.

b) Medical student champions – One of the keys to success in piloting the Navigator Program at our Medical School was the early involvement of a student champion, a GIG co-leader who initially conceived of the project. GIG leaders have continued as the Student Navigator Leader, the student in charge of the day-to-day management of the program, orientation of Prospective Navigators, and collecting and collating evaluation data. To encourage and support these student champions, the co-leaders of the GIG receive a modest stipend through our Reynolds grant, partly for their efforts in leading the Navigator Program. Medical student leadership is central to the program, which is designed to promote student leadership development through the mentorship of the Faculty Advisors. To ensure the ongoing training of new Student Navigators, a “train-the-trainer” model is used, with second-year Student Navigators responsible for training entering first year Student Navigators. Students are recruited through GIG-sponsored lunches and presentations at student group meetings, and by direct recruitment of classmates by the GIG leaders and members.

c) Outpatient clinic sites: Initially, we recommend piloting the Navigator Program at a single outpatient clinic site especially receptive to the goals of the program. We identified the physician director of a specialty clinic who has been supportive of geriatrics education. The clinic director recruited other clinic physicians to participate in the program. Faculty Advisors and Student Navigator Leaders meet with all clinic staff, including the nurse manager, nurses, medical assistants, and the desk staff. Space is also an important consideration in clinic choice to guarantee privacy for the student and patient to meet after the doctor’s visit and should be actively sought.

d) Recruiting older patients: Patients are recruited through diverse outreach efforts, including GIG leader presentations at local senior centers, and the distribution of English-Spanish bilingual brochures both as part of these presentations as well as in the participating clinics. An email account and a telephone number with voice mail have been set up for patients to conveniently request a Student Navigator. The Student Navigator Leader is responsible for monitoring both the email and voicemail accounts as well as the follow-up phone calls to patients confirming arrangements for an assigned Student Navigator to be present at an upcoming appointment. Participating physicians can also identify patients in their practice they believe would benefit from the Navigator Program and notify the Student Navigator Leader. Such patients are contacted by Student Navigators several days prior to their scheduled appointment to determine if they would like to participate in the program.