The Portal of Geriatrics Online Education

University of Hawaii, John A. Burns School of Medicine

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Achieving Quality Improvement and ACGME Core Competency Training Through a Nursing Home Polypharmacy Intervention

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Other Learning Resource Type: 
Quality Improvement Model
Product Information
Estimated time to complete: 
999
Abstract: 

Polypharmacy is common in elderly nursing home patients and predisposes them to risk of potentially inappropriate medication uses, potential drug-drug interactions, and increased health care costs. This innovative model of an educational quality improvement intervention project addresses polypharmacy and inappropriate medication use among nursing home residents using standardized tools and fulfills the ACGME core competencies of Practice-based Learning and Improvement and Systems-based Practice for Geriatric Medicine trainees.The intervention consists of 6 phases: pre-intervention training session, identification of target population, data collection, identification of potentially inappropriate medications, identification of potential drug-drug interactions and contraindications, and implementation. The intervention requires approximately 5 hours for 5-7 fellows and faculty geriatricians for 70-80 nursing home residents with polypharmacy. We found that the intervention worked best when incorporated into protected didactic "workgroup" sessions.This intervention increases medication safety, reduces medication costs and provides practical experience and education on polypharmacy and inappropriate medication use to Geriatric Medicine trainees and nursing home community physicians.

Educational objectives: 
  1. To fulfill ACGME core competencies of Practice-based Learning and Improvement and Systems-based Practice for Geriatric Medicine fellows.
  2. To provide practical education on polypharmacy and inappropriate medication uses among nursing home residents to Geriatric Medicine fellows and nursing home community physicians.
  3. To provide practical experience in a nursing home quality improvement project.
Additional information/Special implementation requirements or guidelines: 

The tools used in this intervention are the Beers Criteria to identify potentially inappropriate medications and the Epocrates online drug-drug interaction program to identify potential drug-drug interactions and contraindications. These tools can be replaced by more updated or relevant tools according to settings or target populations to optimize the intervention effects.

We recommend using the updated Beers Criteria: freely available on the American Geriatrics Society Website: http://www.americangeriatrics.org/health_care_prof...

We found that the implementation of this quality improvement project was most successful when there was a dedicated faculty geriatrician overseeing the project. We designated "workgroup" times on the didactic schedule for the Geriatric Medicine trainees to review the selected patients' charts to complete the data collection form. The faculty geriatrician and the trainees discussed the potential recommendations for each patient as a group, which was also very helpful and provided an additional method of teaching. We also found it very helpful to have the nursing home consultant pharmacist and nursing home director of nursing assist in identifying the nursing home patients with polypharmacy and providing input about the impact of the project on the nursing home staff. We had very positive feedback from both the consultant pharmacist and director of nursing about this project.

Publications from, presentations from, and/or citations to this product: 

Publications:

Tamura BK, Bell C, Lubimir K, Iwasaki W, Ziegler L, Masaki K. Physician Intervention for Medication Reduction in a Nursing Home: The Polypharmacy Outcomes Project. J Am Med Dir Assoc. 2011; 12(5):326-30.

Kojima G, Bell C, Tamura BK, Inaba M, Lubimir K, Blanchette PL, Iwasaki W, Masaki K. Reducing Cost by Reducing Polypharmacy: The Polypharmacy Outcomes Project. J Am Med Dir Assoc.2012 Sep 4. [Epub ahead of print]

Presentations:

Lorenzo P, Bell C, Iwasaki W, Masaki K, Blanchette P. Polypharmacy Improvement Adherence Project: Nursing Home Medication Cost Outcomes. Poster presentation at American Geriatrics Society Meeting, Chicago, May 2009, (role: Co-mentor, co-author of Fellow Pia Lorenzo). Abstract in J Am Geriatr Soc 2009; 57(1, suppl): S147-148.

Lubimir K, Ziegler L, Bell C, Masaki K, Iwasaki W, Blanchette P. "Cost-Effectiveness of Reducing Polypharmacy in a Nursing Home: The Polypharmacy Outcomes Project." Poster Presentation, American Geriatrics Society Meeting, Washington, D.C., May 2008 (role: Co-mentor, co-author of Fellow Karen Lubimir). Abstract in J Am Geriatr Soc 2008; 56(1, suppl): S50-51.

Ziegler L, Lubimir K, Bell C, Masaki K, Iwasaki W, Blanchette P. “Medication Reduction in a Teaching Nursing Home: The Polypharmacy Outcomes Project.” Poster Presentation, American Geriatrics Society Meeting, Washington, D.C., May 2008, (role: Co-mentor, co-author of Fellow Laura Ziegler). Abstract in J Am Geriatr Soc 2008; 56(1, suppl): S49-50.

Date posted: 
Fri, 06/07/2013
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Fri, 06/07/2013
Contact Person/Corresponding Author:



Suggested Citation:
, , , , , and . Achieving Quality Improvement and ACGME Core Competency Training Through a Nursing Home Polypharmacy Intervention. POGOe - Portal of Geriatrics Online Education; 2013 Available from: https://pogoe.org/taxonomy/term/1209

Primer of Medical Directorship in the Nursing Home for Geriatric Medicine Fellows

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Estimated time to complete: 
999
Abstract: 

We developed this curriculum for first year Geriatric Medicine Fellows to prepare them for the role of nursing home medical director. This curriculum has been integrated into the Department of Geriatric Medicine's Fellowship training program at the John A. Burns School of Medicine, University of Hawaii. The curriculum should be taught by an AMDA Certified Medical Director. Seven one-hour sessions are delivered over a 3-month period. The curriculum is based on AMDA’s description of the roles and responsibilities of the medical director as outlined in their position statement. These roles and responsibilities are divided into four categories: 1) Physician leadership, 2) Patient Care-Clinical Leadership, 3) Quality of Care, and 4) Education, Information and Communication. Fellows should be guided through this framework in developing strategies to address issues specific to each topic. Throughout these sessions, we ask the fellows to describe examples of cases they have seen during their clinical rotations in the LTC facilities. This leads to richer learning and application during the didactic sessions.

Educational objectives: 

The primary goal of the curriculum is to equip fellows with skills and knowledge that are uniquely applied to the role of medical direction in nursing homes. Specific learning objectives include:

  1. The fellow will be able to describe the roles of the medical director in a LTC facility according to American Medical Directors Association (AMDA)'s position statement
  2. The fellow should be able to apply what they have learned in order to fulfill the responsibilities of the medical director role
  3. The fellow will recognize the value of teamwork as a critical aspect in effective medical direction
Additional information/Special implementation requirements or guidelines: 

The seminar series should be scheduled in the middle of the first year of the fellowship. Scheduling this curriculum in the middle of the academic year ensures that fellows have sufficient clinical experience, a strong foundation in nursing home care, and an appreciation of the role of LTC facilities within the complex medical care system.

The integration of medical directorship training into a geriatric medicine fellowship program proved to be synergistic. Core concepts were able to be covered efficiently over seven one-hour seminars. The focus on case discussions provided the opportunity to practice application. The seminars complemented and supplemented the clinical aspects of their geriatric medicine fellowship training very well.

Date posted: 
Thu, 06/27/2013
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Thu, 06/27/2013
Contact Person/Corresponding Author:



Suggested Citation:
and . Primer of Medical Directorship in the Nursing Home for Geriatric Medicine Fellows. POGOe - Portal of Geriatrics Online Education; 2013 Available from: https://pogoe.org/taxonomy/term/1209

Standardized Patient: Ted Lee

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Estimated time to complete: 
1
Abstract: 

Ted Lee was developed as part of a multi-station, standardized patient assessment. The student’s performance is measured by checklists filled out by the standardized patient and by the evaluation of responses to written questions on the interstation exercise. This Standardized Interdisciplinary Team Meeting scenario was developed as part of a multi-station, standardized patient assessment. The student’s performance is measured by checklists filled out by the standardized team members and by the evaluation of responses to written questions on the interstation exercise.   It is designed to be the first of two consecutive stations used to assess interdisciplinary team skills.  This patient is a 75 year old retired male who has been hospitalized for the last 3 days after a fall at home which resulted in a fracture of the right humeral shaft. Work up since admission was unremarkable.  An orthopedic consult was obtained and recommended conservative management and physical therapy. Mr. Lee knows he will have trouble caring for himself at home, but refuses to go to a Rehabilitation Unit even for a short period of time.  The student’s task is to interview and examine Mr. Lee in preparation for an interdisciplinary team meeting to discuss discharge plans.

Educational objectives: 

On completion, the instructor will be able to:

  • Evaluate a student’s ability to take a focused history and perform a focused physical exam related to a patient who is disabled after a fall in preparation for an interdisciplinary team meeting.
Additional information/Special implementation requirements or guidelines: 

See the second of two consecutive stations used to assess interdisciplinary team skills at Standardized Interdisciplinary Team Meeting Case.

Date posted: 
Fri, 07/12/2013
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Tue, 07/16/2013
Contact Person/Corresponding Author:



Suggested Citation:
, , , , and . Standardized Patient: Ted Lee. POGOe - Portal of Geriatrics Online Education; 2013 Available from: https://pogoe.org/taxonomy/term/1209

Standardized Interdisciplinary Team Meeting Case

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Estimated time to complete: 
1
Abstract: 

This Standardized Interdisciplinary Team Meeting scenario was developed as part of a multi-station, standardized patient assessment. The student’s performance is measured by checklists filled out by the standardized team members and by the evaluation of responses to written questions on the interstation exercise. It is designed to be the second of two consecutive stations used to assess interdisciplinary team skills. The case materials for the first station (Ted Lee) are described separately. In this station the student must meet with Leslie Mitchell, Medical Social Worker and Jamie Jones, RN for an interdisciplinary team meeting. The social worker believes that the best disposition is for the patient to be sent to an SNF Rehabilitation Unit for further physical and occupational therapy. The nurse believes that Mr. Lee will refuse to go to an SNF facility because he perceives it to be a nursing home and recommends that the patient be kept in the hospital until he is strong enough to go home with home care physical therapy. The student’s task is to help the team create a discharge plan for Mr. Lee.

Educational objectives: 

On completion, the learner will be able to:

  1. Actively participate in an interdisciplinary team meeting.
Additional information/Special implementation requirements or guidelines: 

See the first of two consecutive stations used to assess interdisciplinary team skills at Standardized Patient: Ted Lee.

Date posted: 
Fri, 07/12/2013
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Fri, 07/12/2013
Contact Person/Corresponding Author:



Suggested Citation:
, , , , and . Standardized Interdisciplinary Team Meeting Case. POGOe - Portal of Geriatrics Online Education; 2013 Available from: https://pogoe.org/taxonomy/term/1209

You're Being Paged! A Nursing Home On-Call Role-Playing Exercise

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Estimated time to complete: 
2
Abstract: 

Learning how to effectively cover phone calls from nursing home staff about nursing home patients is an important skill for Geriatric Medicine Fellows to master. Gaining competence in nursing home phone medicine addresses the ACGME competencies of patient care, medical knowledge, interpersonal and communication skills, professionalism and system-based learning.

This is an orientation for Geriatric Medicine Fellows to taking phone calls from nursing homes as part of a teaching nursing home service of a Geriatric Medicine Fellowship Program. The session is held early in the first year of a clinical geriatric medicine fellowship during a didactic session. Generally, one to two hours are set aside for this session with 6-10 fellows attending. Not all of the “cases” are used for the orientation. The faculty member facilitating the session chooses the cases to include depending on the time allotted, the number of fellows, and other factors, such as fellows’ willingness to “act out” scenarios. This orientation lays the groundwork for expectations of the fellows while on call.

To follow up this orientation, the faculty member meets with the fellows several times during the rest of the year (quarterly) to review the on-call experience of the fellows and identify any system-based problems (difficulties with transitions of care, paperwork, communication, staff interactions, etc) that affect the on-call experience. These concerns are summarized by the faculty member, who then relays the system issues to appropriate persons (i.e. nursing home facility director of nursing, medical director, emergency room physicians’ group, etc.)

Educational objectives: 

1. To enhance geriatric medicine fellows' comfort, patient care and medical knowledge competence in phone medicine for nursing home patients.

2. To improve fellows' interpersonal and communication skills necessary for covering nursing home patient phone calls while on call.

3. To highlight expectations for professional behavior when taking calls from teaching nursing home services.

4. To promote understanding of the medical systems involved in caring for nursing home patients.

Additional information/Special implementation requirements or guidelines: 

Instructions: The attending faculty for this session needs to have the power point slides ready and distributes the nurse's notes as roles are assigned. Generally, the orientation works best if you assign a case, then distribute the nurse notes for that case, show the power point slide telling the nurse’s first words to the doctor, and then have the fellows act out the rest.

The attending faculty asks for two fellows to volunteer for each scenario:

• One fellow acts as the “fellow” answering the phone at night while on call for the teaching nursing home service of a Geriatric Medicine Fellowship program. This fellow does not have a “script” but must rely on their clinical judgment to determine what questions to ask the “nurse”. If the “fellow” is stumped, he or she must ask his or her colleagues (the other fellows at the orientation) to help with the case or management.

• The other fellow acts as the “nurse” at the teaching nursing home who is calling the “fellow” about a patient. The “nurse” must try not to volunteer information, but instead offer information that is asked. If the “fellow” is stumped and the colleagues are not able to help, the “nurse” can offer the rest of the information on the “nurse’s notes”.

• The attending faculty acts as a facilitator during this orientation, generally not jumping into the question/ answer period until the fellows feel the phone call has been resolved. At the end of the case, the faculty highlights key teaching points noted at the bottom of the case’s nurse’s notes and offers gentle, constructive feedback on the interpersonal communication skills of the fellows. Continue the cases until all fellows have had an opportunity to act as both “fellow” and “nurse”. At the end of the session, the faculty debriefs the fellows to ensure that everyone is comfortable with the learning session and the process of covering nursing home phone calls.

Date posted: 
Thu, 02/25/2010
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Tue, 01/01/2013
Contact Person/Corresponding Author:



Suggested Citation:
and . You're Being Paged! A Nursing Home On-Call Role-Playing Exercise. POGOe - Portal of Geriatrics Online Education; 2010 Available from: https://pogoe.org/taxonomy/term/1209

The Three D's Worksheet

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Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Estimated time to complete: 
1
Abstract: 

This is an interactive workshop style session. Based on a case discussion, students conceptualize the common clinical presentations onto a Venn diagram. The facilitator will take on the role of a family member and nurse, and students have the opportunity to practice obtaining a history that elicits distinguishing features, associated symptoms and time course for each of these cognitive disorders. Emphasizes the importance of getting the history from the family and interdisciplinary team. A Table of Distinguishing Features is completed by the end of the session. An assessment and plan that includes non-pharmacologic and pharmacologic interventions is elicited from the students. The session ends by asking students how they will communicate the plan of care to the family, thus emphasizing the importance of clear communication as a part of the intervention.

Educational objectives: 

1. To review the definitions of Dementia, Depression, and Delerium

2. To identify in what ways these cognitive disorders are similar (common clinical presentations)

3. To list which features help define or distinguish Dementia, Depression, or Delerium

4. To practice the approach to history taking that elicits these distinguishing features

5. To understand that communication with families is an important part of the intervention

Additional information/Special implementation requirements or guidelines: 

A blackboard/ flipchart will be required. Each student should also have a copy of the "Distinguishing Features" table, and a pen.

Date posted: 
Thu, 02/25/2010
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Thu, 10/11/2012
Contact Person/Corresponding Author:



Suggested Citation:
The Three D's Worksheet. POGOe - Portal of Geriatrics Online Education; 2010 Available from: https://pogoe.org/taxonomy/term/1209

Experience In Implementing New Expanded Curriculum In Geriatrics For A Family Medicine Residency Program

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Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Abstract: 
Developing efficient viable geriatric curriculum model for Family Medicine programs is a very hot nationwide topic nowadays, and our work effectively addresses it. For the last 3.5 years, we have successfully conducted new curriculum, increasing teaching time by 25% in the one-month 3rd year block rotation. Residents strongly agreed on relevance and importance of learning quality geriatric care for their future practices and their improved confidence and skills, and unanimously supported idea to increase the curriculum time. Our other goal is to expand a cross-cultural geriatrics component, as our residents care for a significant number of Pacific minorities population.
Educational objectives: 
Learners should be able to identify the most efficient ways of conducting geriatric medicine rotations for family medicine residency programs.
Additional information/Special implementation requirements or guidelines: 
19 third-year family medicine residents in in-/outpatient, SNF/Rehab Center, and home visits settings; didactics seminars; interdisciplinary team meetings; home visits; elements of in-patient geriatric consult services and out-patient geriatric family counseling. The strongest points were considered: one-on-one tutoring/rotation learning-to-service ratio; detailed discussions of patients seen; topics (geriatric assessment, dementia, MMSE, polypharmacy; delirium, home care). The most frequent suggestions for improvement were: more home visits; increased number of complex patients; increased topics in behavioral health, end-of-life and ethics. Absence of yet fully functional geriatric clinic was perceived as the weakest point of the program.
Date posted: 
Mon, 11/06/2006
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Sat, 05/08/2010
Contact Person/Corresponding Author:



Suggested Citation:
, and . Experience In Implementing New Expanded Curriculum In Geriatrics For A Family Medicine Residency Program. POGOe - Portal of Geriatrics Online Education; 2006 Available from: https://pogoe.org/taxonomy/term/1209

Standardized Patient: William Harris

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Abstract: 

William Harris was developed as part of a multi-station, standardized patient assessment. The students' performance is measured by checklists filled out by the standardized patient and by the evaluation of responses to written questions on the interstation exercise. This patient is a 72 year old male who comes to the outpatient clinic with a one month history of fatigue, decreased appetite, and insomnia, complaining that he can't seem to remember anything. On mental status testing, he has slight impairment of attention. The student's task is to take a pertinent history and examine the patient's mental status. A complete set of student instructions, checklists, standardized patient training materials, written exercises and a grading key are included. The associated documents are available to faculty members only. 

Educational objectives: 

Evaluation of geriatrics clinical skills for a patient presenting with symptoms of depression.

Additional information/Special implementation requirements or guidelines: 

This standardized patient has been used as part of a clinical skills assessment for medical students, internal medicine residents and geriatric medicine fellows.

Date posted: 
Wed, 09/09/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Fri, 07/27/2012
Contact Person/Corresponding Author:



Suggested Citation:
and . Standardized Patient: William Harris. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/1209

Standardized Patient: Wallace Young

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Abstract: 

Wallace Young was developed as part of a multi-station, standardized patient assessment. The student's performance is measured by checklists filled out by the standardized patient. Feedback is provided through a self-evaluation checklist that the examinee fills out immediately after the SP encounter. This patient is a 65 year old retired real estate agent presented to the outpatient clinic with a 3 month history of persistent cough, and weight loss and is found to have a large right upper lobe lung mass on chest X-ray. Trans-bronchial biopsy revealed undifferentiated large cell carcinoma. The student must counsel the patient regarding these findings. A complete set of student instructions, checklists, standardized patient training materials, and self evaluation forms are included. The associated documents are available to faculty members only. 

Educational objectives: 

Evaluation of geriatrics clinical skills related to breaking bad news to a patient with newly diagnosed cancer.

Additional information/Special implementation requirements or guidelines: 

This standardized patient has been used as part of a clinical skills assessment for medical students, internal medicine residents and geriatric medicine fellows.

Date posted: 
Thu, 01/01/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Fri, 07/27/2012
Contact Person/Corresponding Author:



Suggested Citation:
, and . Standardized Patient: Wallace Young. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/1209

Standardized Patient: Rachel Regan

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Product Information
Abstract: 

Rachel Regan was developed as part of a multi-station, standardized patient assessment. The student's performance is measured by checklists filled out by the standardized patient and by the evaluation of responses to written questions on the interstation exercise. This patient is a 50-year old female who presents to the outpatient clinic with concerns that she is experiencing menopause. The student's task is to take a pertinent history and counsel the patient. A complete set of student instructions, checklists, standardized patient training materials, written exercises and a grading key are included. The associated documents are available to faculty members only. To request materials, contact the POGOe Managing Editor at editor@pogoe.org.

Educational objectives: 


    Evaluation of geriatrics clinical skills for a patient presenting with menopausal symptoms.

Additional information/Special implementation requirements or guidelines: 

This standardized patient has been used as part of a clinical skills assessment for medical students, internal medicine residents and geriatric medicine fellows.

Date posted: 
Wed, 09/09/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Fri, 07/27/2012
Contact Person/Corresponding Author:



Suggested Citation:
and . Standardized Patient: Rachel Regan. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/1209

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