University of Pennsylvania Interdisciplinary Geriatric Fellowship Program Division of Geriatric Medicine Section on Geriatric Psychiatry Department of Oral Medicine HRSA-sponsored

Departments, Principal Faculty Division of Geriatric Medicine Dr. Jerry Johnson, PI Section of Geriatric Psychiatry: Dr. Joel Streim, Co-PI Department of Oral Medicine: Dr. Martin Greenberg, Co-PI

Administration Natasha Charles MSEd

What does Title VII Geriatrics Health Professions Funding Support? The geriatric health professions program is financed under the interdisciplinary, community-based linkages section of the Health Resources and Services Administration (HRSA) and currently supports three initiatives. The Geriatric Academic Career Award (GACA) supports the development of newly trained geriatric physicians into academic medicine The geriatric faculty fellowships are designed to train physicians, dentists, and behavioral and mental health professionals who decide to teach geriatric medicine dentistry and psychiatry. The Geriatric Education Center (GEC) program provides grants to support collaborative arrangements involving several health professions schools and health care facilities to provide multidisciplinary training in geriatrics.

Overall Goal and Objectives  Overall Goal: Prepare fellows for roles as clinician educator faculty and for certification in geriatric medicine or psychiatry.  Aims  Exhibit the clinical, teaching, administrative and research knowledge and skills needed to function in the academic medical center setting.  Exhibit the ability to care for ethnically and socio- economically diverse patient populations  Exhibit the ability to educate trainees from diverse backgrounds to practice culturally appropriate geriatric care

What is it? Two year fellowship training program for prospective clinical educator faculty Integrated program with core, shared curriculum as well as discipline-specific curriculum Interdisciplinary including medicine, psychiatry, dentistry

Who? The Trainees Geriatric Internal Medicine or Family Medicine Physicians Geriatric Dentists Geriatric Psychiatrists Those planning academic careers as educators

Why This Program? Acute faculty shortages in all 3 Disciplines Demographic Imperative Substantial patient need at the intersection of these disciplines

Medicine, Psychiatry, Dentistry: Odd Partners? How does a dentist learn to care for a patient with AD? Many psychotropic medications cause dry mouth that then leads to dental problems A person unable to chew is at risk of malnourishment or tube feeding and associated problems Is weight loss due to disease process, mood, or problems in eating?

UPenn GIF Program 126 conference hours in a year spread across the themes of the curriculum. Weekly conferences covered 7 curriculum themes and one sub-theme. Faculty recruited from the Division of Geriatric Medicine, across the University and from collaborating institutions and agencies.

GIF Conferences 3 hour conference on Friday afternoons. –Friday 1:00-4:00 PM Cases Board Review Fellow Presentation Faculty/Outside Speaker Presentation

Major Themes and Skills Health Equity and Literacy Interdisciplinary Care and Teaching Clinical competency, core and discipline specific Palliative Care Educational Expertise Administrative skill Research Skills Communication (crosses all themes) Skills

Health Equity Introductory seminar on culture and its relevance Health education in the community seminar Visit to West Philadelphia communities U Penn Geriatric Education Center sponsored annual conference (2008 and 2009) - Health Equity and Literacy Complementary/alternative medicine and belief systems Cultural differences in preferences for advance planning directives, and palliative care Spirituality

Collaboration with Geriatric Education Center Course The course focused on: Available methods for the assessment of health literacy skills Culturally based misunderstandings that complicate care Teaching strategies for effective communication with older patients and families that lead to improved health outcomes Selection and assessment competencies for health professionals in responding to patients with limited health literacy in clinical practice

Interdisciplinary Care and Teaching Five seminars on methods issues: –Teams and teamwork –Team member roles and responsibilities –Team communication and conflict resolution –Care-planning in team practice –Multiculturalism Five seminars on the site-specific aspects of team practice in: the acute care hospital, the outpatient practice, home care practices, day care, and the nursing facility. An eleventh seminar will focus on teaching skills required to present team materials in presentations to residents and students. Once a month clinical presentations by a fellow

Theme: Education Adult Education/Models and Framework Models of Medical Education Evaluation Teaching in Clinical Settings –Small Group Learning bedside or walking rounds how to identify “teachable moments”, reinforce and correct trainees’ concepts and information Stanford Clinical Teaching Curriculum

Theme: Administration This portion of the curriculum will use bi-monthly seminars and precepted experiences. Topics covered are:  Administration of long-term care: medical directorships, Reporting (MDS), and external monitoring (eg JCAHO)  Quality improvement approaches – inpatient, outpatient, nursing homes  Evidence from health services and epidemiologic research  QI project

Theme: Collaborator Rounds Purpose: To gain an understanding of the assessment approaches and interventions used by collaborating professionals. The professionals would include: social worker, physical therapist, audiologist, speech therapist, low vision specialist, neuropsychologist, pharmacist, occupational therapist, nurse, dietician, and others as identified. In each case, the rounds would include: –Introduction to the training and functions of the discipline –Overview of patient assessment –Observation/shadowing in clinic –Exposure to basic treatment modalities –Case presentation and discussion

Theme: Research Bi-monthly seminars and precepted experiences together with conduct of a research project. Topics include:  Introduction to research methods: clinical, quantitative, qualitative study design  Issues re research on aging; generalizing from studies on younger population  Principles of community participatory research

Communications Skills (across all themes) Tailoring communication for older adults Delivering bad news by telephone Communicating with older adults with sensory loss communicating with cognitively impaired elders Conflict resolution modes with elders and their families Cultural competence in discussing advanced directives Death and Dying Family discussion of futile treatment in patients with advanced dementia Sexuality Health Equity and Literacy

Other Clinical –Core clinical competency topics: 6 topics –Palliative care 6 seminars –Liaison Rounds with collaborating professionals

Fellow Evaluations of Educational Session Evaluation:  Topic and faculty  Achievement of objectives for the theme  Timing of topic within curriculum  Faculty – teaching across sessions and in clinical rotations  Additions/changes to curriculum

Fellow Focus Group (mid year and at end of Fellowship) Sample comments:  ”[t]his experience has broadened our thinking, made it more likely that we will think of other contributors to [solving] patient problems, made the learning more interesting.”  “[my] history taking is more inclusive”  Fellows report they consult each other more often and more readily than they would have without the shared time and learning.

Conclusions  Interdisciplinary fellowship expands scope of clinical thinking and improves facility with referral and consultation  Fellows discover previously neglected opportunities for improved diagnosis and management, especially with collaborating professionals  Exposure of non-funded fellows to the curriculum increases interest in teaching and academic careers