The Portal of Geriatrics Online Education

10 SCC: Develop management plan for patients with functional deficits

10. 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.

Palliative Care of a Patient with End-Stage Liver Disease: An Unfolding Case Study

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Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Other Learning Resource Type: 
Interactive Online Web Module
Product Information
Estimated time to complete: 
2
Abstract: 

This case study was developed for use in academic coursework and as a standalone training for health care providers (MDs, ARNP, Pharmacists, Social Workers, Nurses). This unfolding case study about the management of an adult in the midst of a health crisis. This case is a composite of many actual cases seen in clinical practice. During the course of this case study, learners are presented with information as the providers learn of the patient’s emergent and ongoing health concerns – from his Emergency Department admission through the development of his palliative care plan. Learners are asked to make decisions and use their best judgment about how to care for this patient and family.

Educational objectives: 

By the end of this case study, the learner will be better able to:

  1. Understand the natural history and disease management of end stage liver disease (ESLD).
  2. Use evidence-based practice to collaboratively develop and refine goals of care for patients with chronic, progressive conditions.
  3. Work interprofessionally to ensure the best quality of care for the patient and family.
Date posted: 
Fri, 09/14/2018
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 08/15/2018
Contact Person/Corresponding Author:



Suggested Citation:
Palliative Care of a Patient with End-Stage Liver Disease: An Unfolding Case Study. POGOe - Portal of Geriatrics Online Education; 2018 Available from: https://pogoe.org/taxonomy/term/99

ACUTE MANAGEMENT OF OLDER ADULT FOUND DOWN WITH ALTERED MENTAL STATUS

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Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Other Learning Resource Type: 
Interactive website
Product Information
Estimated time to complete: 
2
Abstract: 

This case study was developed for use in academic coursework and as a standalone training for health care providers (MDs, ARNP, Pharmacists, Social Workers, Nurses). This unfolding case study about the management of an older adult in the midst of a health crisis. This case is a composite of many actual cases seen in Emergency Departments. During the course of this case study, learners are presented with information as the providers learn of the patient’s emergent and ongoing health concerns – from her Emergency Department admission through her Intensive Care Unit stay. Learners are asked to make decisions and use their best judgment about how to care for this patient.

Educational objectives: 

 

  • Apply knowledge of evidence-based care provision to an older adult found with altered mental status after a ground level fall
  • Describe the contributions of the interprofessional team to care management
  • Demonstrate effective communication during handoffs in care
Publications from, presentations from, and/or citations to this product: 

Citations are listed at the bottom of the screen throughout the case study.

Date posted: 
Fri, 07/27/2018
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Tue, 05/22/2018
Contact Person/Corresponding Author:



Suggested Citation:
ACUTE MANAGEMENT OF OLDER ADULT FOUND DOWN WITH ALTERED MENTAL STATUS. POGOe - Portal of Geriatrics Online Education; 2018 Available from: https://pogoe.org/taxonomy/term/99

Compendium of Five Case Studies: Lessons for Interprofessional Teamwork in Education and Workplace Learning Environments

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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: 
999
Abstract: 

The VA Centers of Excellence in Primary Care Education began educational activities in Academic Year 2011-2012 to improve primary care education, particularly to harmonize the education of clinician trainees with the emerging and future practice of primary care exemplified by patient centered care such as VA’s Patient Aligned Care Team model for primary care delivery. This volume shares examples of educational strategies that have
emerged from the first four academic years of the project, with each chapter being a case study from a participating site. Each case study reports on the implementation of a curricular element within their unique Center of Excellence. These case studies are intended to be of use to those interested in introducing curricular activities in accredited programs for health profession trainees that will lead to
the advancement of interprofessional, Veteran/patient-centered primary care. These case studies also represent one component of the project’s evaluation plan, designed by Annette Gardner, Ph.D. We have attempted to inform readers about the context of the institutions and readiness for change, the steps each program completed to design and develop strategies, gain leadership commitments,
implement, and evaluate these interventions in the spirit of continuous improvement. Additional reports about the project have been published, are in press, or are in the pipeline. Further, many of the references in this document have full-text available online. We have provided live links for ease of access to these additional resources.

Educational objectives: 

Shared Decision-Making: Care is aligned with the values, preferences and cultural perspectives of the patient. Curricula focus is on communication skills necessary to promote patient’s self-efficacy.


Sustained Relationships: Care is designated to promote continuity of care; curricula focus on longitudinal learning relationships.


Interprofessional Collaboration: Care is team based, efficient and coordinated, curricula focus is on developing trustful, collaborative relationships.


Performance Improvement: Care is designed to optimize the health of populations; curricula focus on using the methodology of continuous improvement in redesigning care to achieve quality outcomes.

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

Centers of Excellence in Primary Care Education (2017). Compendium of Five Case Studies: Lessons for Interprofessional Teamwork in Education and Workplace Learning Environments 2011-2016 (S. Gilman & L. Traylor Eds.): United States Department of Veterans Affairs, Office of Academic Affiliations. ISBN: 978-0-16-094202-0

Date posted: 
Wed, 05/16/2018
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 05/16/2018
Product Viewing Instructions: 
Download Adobe pfd file
Contact Person/Corresponding Author:



Suggested Citation:
Compendium of Five Case Studies: Lessons for Interprofessional Teamwork in Education and Workplace Learning Environments. POGOe - Portal of Geriatrics Online Education; 2018 Available from: https://pogoe.org/taxonomy/term/99

Your Role in Dementia Detection and Treatment: An Interdisciplinary Approach

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Other Sponsors: 
MaineHealth - Maine Medical Center
Other Intended Learner Audiences: 
Any member of the patient team and patient family member
Other Learning Resource Type: 
Role Map
Product Information
Estimated time to complete: 
1
Abstract: 

This 30 minute "Concepts in Common" video synthesizes the key aspects of dementia from an interdisciplinary approach. All team members, including the patient and family, need to have a common understanding of key terms and each's role from a common framework.  Communicating using SBAR (Situation, Background, Assessment, Request/Recommendation)  is essential and clarified with a "Role Map."

Educational objectives: 

- Define and understand dementia and its significance in patient care

- Learn how to administer and interpret the Mini-Cog

- Define your role on an interdisciplinary team in caring for patients with dementia

- Learn how to communicate effectively about dementia using SBAR

 

Date posted: 
Mon, 10/17/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Mon, 10/17/2016
Contact Person/Corresponding Author:



Suggested Citation:
Your Role in Dementia Detection and Treatment: An Interdisciplinary Approach. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/99

Barney Smith - A Progressive Palliative Care Standardized Patient

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Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Other Intended Learner Audiences: 
Graduate Health Profession Students
Product Information
Abstract: 

This six part progressive standardized patent serves re train medical students to care for an older adult with a life limiting condition, including making the diagnosis of multiple myeloma, breaking bad news, transitions of care from the hospital to home and curative care to palliation, through advance directiive discussions, and eventually into hospice and his death. The six encounters occur from Year 2 through Year 4 of the medical school curriculum , with a scripted five year span of patient care. Educational modalities include standandized patients, simulation, web-based modules, and small group discussions. 

Educational objectives: 

1) Provide medical care for an older adult with a life limiting condition from their diagnosis through their death

2) Understand the roles of the medical provider and other health care disciplines, as individual providers and as a team, in caring for an older adult with a life limiting diagnosis as they transition from the hospital to home and from curative care to palliation

3) Assist family caregivers in identifying caregiver responsibilities and potential caregiver burden

Date posted: 
Mon, 10/17/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Mon, 10/17/2016
Contact Person/Corresponding Author:



Suggested Citation:
Barney Smith - A Progressive Palliative Care Standardized Patient. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/99

Barney Smith 3 - A Transitions of Care Interprofessional Education Standardized Patient

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Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
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Other Intended Learner Audiences: 
Health Professions Graduate Students
Product Information
Abstract: 

This transitions of care Interprofessional education standardized patient serves to train Year 3 medical students and graduate students from physical, occupational and speech therapy in the transition of care of a frail older adult from the hospital to home. It is the third of a six part progressive standarized patient encounter on palliative care. This clinical simulation is an encounter with Barney as a hospitalized patient with newly acquired functional decline. Learners gain experience in the interprofessional team assessment of a hopsitalized older adult's functional status and the team management of that patient's transition of care from the hospital to home. Educational modalities include web-based instruction , the simulation, and a small group discussion of the interprofessional set of learners immediately following the encounter facilitated by interprofessional faculty.  

Educational objectives: 

1) Perform an interprofessional, comprehensive team assessment of a hospitalized older adult's functional assessment and the team mangement of that patient's transition of care from the hospital to home. 

2) Understand the role that individual discpliness play in conducting  a comprehesive assessment of an older adult's functinal status 

3) Assess specific risks and barriers to older adult safety as they transition from the hospital to home 

4) Assist family caregivers in identfying caregiver responsibilities and potential caregiver burden 

Date posted: 
Mon, 10/17/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Mon, 10/17/2016
Contact Person/Corresponding Author:



Suggested Citation:
Barney Smith 3 - A Transitions of Care Interprofessional Education Standardized Patient. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/99

The Hospitalized Older Adult

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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: 
999
Abstract: 

Older adults are exposed to multiple hazards during hospitalization resulting in multiple complications that limit their return to their functional and cognitive baseline. It is critical that healthcare providers are trained on best practices in the care of hospitalized older adults. This product is a monthlong module for M4 students during their Sub I rotation, that focuses on educating them on the hazards of hospitalization, best practices in the care of hospitalized older adults, issues that occur during transitions of care and best practices to ensure optimal transitions across care settings. The module starts with an initial lecture on hazards of hospitalization and best practices in the care of older adults. This is followed by assignments in which students are assigned older aduts to care for. Using a checklist, they evaluate the care that these patients have received and also implement best practices in the care of their patient. They also participate in an interdisciplinary team meeting that focuses on these aspects of care.  This is followed by another assignment in which they are involved in deciding on the most appropriate discharge care setting their patient. They subsequently place a post discharge call to their patient to identify any issues thay may have encountered post discharge and assist them in resolving some of these issues. Through the month, students share their experiences on blackboard, outlining hazards they identified in their patients,  challenges in implementing best practices, choice of discharge care setting and reasons for their choices along with care transitions issues identified in their patients. Additionally they are required to review educational materials and published articles posted on blackboard, focused on hazards of hospitalization, best practices in care, settings of care and transitions of care.  A final class is held with the students at the end of the month discussing the rotation and their experiences, with a focus on settings of care and best practices in transitions of care.

Educational objectives: 

At the end of this course, each participant will be able to:

1. Describe the hazards of hospitalization of older adults.

2. Evaluate the care and implement best practices in the management of a hospitalized older adult.

3. Enumerate the discharge options available in a particular case scenario.

4. Compare and contrast the problematic elements of care transition with those of an ideal care transition.

Date posted: 
Tue, 10/25/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Tue, 10/25/2016
Contact Person/Corresponding Author:



Suggested Citation:
The Hospitalized Older Adult. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/99

Family Medicine Resident and Geriatric Fellow Longitudinal Home Visit Curriculum

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

With an aging population, the need to train primary care residents and geriatric fellows in home-based care continues to grow. A needs assessment of family medicine residents and geriatric fellows' attitudes and knowledge was performed to guide a novel, longitudinal home care curriculum based out of a Home-Based Primary Care practice within the Family Medicine Center.

Fellows are assigned a panel of two home visit patients from the Family Medicine Center's Home-Based Primary Care practice. Fellows follow these patients monthly and manage their care between visits.  In today’s rapidly changing clinical environment, primary care physicains and geriatricians must be adapt at analyzing systems and processes they work under and making changes to improve patient care. A new home visit program is a natural venue for a specific, achievable quality improvement intervention with support from faculty, the Home Based Primary Care practice team and the Family Medicine Center Patient and Family Advisory Council. 

The longitudinal family medicine resident curriculum is based on graded autonomy and focused objectives for each level with the ultimate goal of residents feeling empowered to include home visits in their future practice. After home visit sessions, residents complete personal, written reflections after each visit to optimize learning and retention, as well as for giving a venue for processing potentially challenging situations. Sample reflections are included. Third-year residents facilitate an interdisciplinary case conference to address various social determinants of health, home safety issues and medication concerns. By residency graduation, residents will complete 10-14 home visits. 

 
Educational objectives: 
  1. Describe challenges and opportunities unique to patient care in the home environment.  
  2. Review medication use and adherence while identifying medications that are no longer effective, are duplicative or carry greater burden than benefit.  Identify medications that you would recommend stopping and create a schedule for stopping these medications.
  3. Develop and implement a safety plan to make the patient’s home environment safer.
  4. Develop a personal plan to integrate home visits into your future practice.

Fellow-specific objectives:

  1. Develop, document and manage patient- and family-centered care plans related to patient’s health conditions and expected trajectory with emphasis on personal goals of care in collaboration with an interprofessional health care team and community service providers.
  2. Implement a process improvement as part of the Home Based Primary Care team.  

 

Date posted: 
Wed, 10/19/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 10/19/2016
Contact Person/Corresponding Author:



Suggested Citation:
Family Medicine Resident and Geriatric Fellow Longitudinal Home Visit Curriculum. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/99

Interdisciplinary Health Profession Module Videos

:  
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: 

Care teams often don't know how to effectively and efficiently collaborate when addressing a patient’s health. Depending on a patient’s needs, team leadership can shift at any given moment from one person to another. Because of this constant jockeying and adaptation, educating learners about their own interprofessional relationships is becoming incredibly important. These videos and the corresponding text supplements provide a context for interprofessional team members to discover more about what it takes to become a member of another profession. This knowledge, combined with their own experiences and clinical practice, will assist in preparing learners for the next-generation of team-based healthcare.

Educational objectives: 

After watching these short 2-3 minute videos, interprofessional teams will be able to contextualize their own relationship within the group dynamic, understand the educational requirements that go into other disciplines, and formulate an effective team-based learning approach for future activities.

Date posted: 
Tue, 09/27/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Tue, 09/27/2016
Contact Person/Corresponding Author:



Suggested Citation:
Interdisciplinary Health Profession Module Videos. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/99

VirginiaGeriatrics.Org

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

The VirginiaGeriatrics.Org website consists of 6 primary resources and a secondary list of resources for further research. These primary resources include a video archive of the geriatric grand round lecture series, interactive pre-clinical basic science geriatric case studies for medical students, more advanced geriatric case studies for clinical residents, a quick consult guide for geriatric consults, an "ask the expert" discussion resource, and various educational materials related to the Virginia Geriatrics Society Conference. Additionally, spread through the website are external educational resources to complement the core material. Finally, there are some resources for patients and families that may be interested in contacting clinics and/or geriatricians.

Educational objectives: 

Listed through 6 primary education sections (Grand Rounds, Med Student Materials, Resident Materials, Quick Consults, Ask the Expert, etc)

Date posted: 
Thu, 09/22/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Thu, 09/22/2016
Contact Person/Corresponding Author:



Suggested Citation:
VirginiaGeriatrics.Org. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/99

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