Rachel K. Miller

SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients’ Healthcare from Skilled Nursing Facilities to the Community

We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.

What students experienced: a narrative analysis of essays written by first-year medical students participating in a geriatrics home visit.

To develop a house call experience for first‐year medical students introducing them to challenges that homebound, chronically ill elderly adults face.

Resident Shift Handoff Strategies in US Internal Medicine Residency Programs.

Resident Shift Handoff Strategies in US Internal Medicine Residency Programs National organizations such as the Accreditation Council for Graduate Medical Education, Agency for Healthcare Research and Quality, and Joint Commission have recommended specific strategies to improve resident handoffs, such as dedicated time and space to perform handoffs, standardized templates, and supervision by senior physicians.1,2 How these best-practice recommendations are implemented across programs is unknown. Program directors are expected to standardize and improve handoffs within their institutions’ residency programs. Their perspective on strategies and satisfaction with this process can provide insight into improving handoffs. We describe implementation of recommended handoff strategies in a US cohort of internal medicine residency programs and association with program director satisfaction.

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs

BackgroundWhile there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern.ObjectivesThe 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country.DesignNationwide survey.ParticipantsAll internal medicine program directors registered with APDIM.Main MeasuresDescriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs.Key ResultsOf the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year–End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff.ConclusionsMost internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.

An Interactive Ambulatory Nephrology Curriculum for Internal Medicine Interns: Design, Implementation, and Participant Feedback

While diminishing nephrology fellow recruitment is a known issue, more work is needed to evaluate possible interventions to reverse this trend. We designed and implemented a curriculum to increase exposure to ambulatory nephrology among internal medicine interns. The curriculum focused on key aspects of outpatient nephrology practice, including supervised clinic visits, formal themed didactic content, and an online interactive forum with assigned evidence-based readings and small-group responses to relevant cases. We obtained postcourse surveys from all participating interns. Of the 43 interns who took part in the first year of the ambulatory nephrology curriculum, 100% reported a positive didactic experience and 91% reported a positive interactive online experience. 77% reported an improvement in their familiarity with clinical nephrology practice (median 2-point increase in familiarity score on a 7-point scale, P<0.001 by signed rank testing). Qualitative feedback included praise for the high-yield topics covered by the lectures and energizing teachers. In conclusion, we successfully implemented an ambulatory nephrology curriculum using a framework that integrated formal didactics, interactive online learning, and key clinical components of outpatient nephrology care. Future investigation will evaluate whether early implementation of this curriculum is associated with increased pursuit of nephrology as a career.

Utilizing Geriatric Assessments to Fulfill the Medicare Annual Wellness Visits

Considering that most older adult patients are medically complex with multiple chronic medical issues, an astute clinician needs to understand that there are key geriatric issues that are important. Identifying hearing loss can be life changing if identified and treated. Screening a patient’s balance and recommending physical therapy can potentially avoid a devastating fall with hip fracture and hospitalization. This chapter reviews the components of the comprehensive geriatric assessment, a mainstay of geriatrics, and also explores what aspects fit into the Medicare Annual Wellness Visit.

Effect of a Community-Based Service Learning Experience in Geriatrics on Internal Medicine Residents and Community Participants

Community‐based service learning (CBSL) provides an opportunity to teach internal medicine residents the social context of aging and clinical concepts. The objectives of the current study were to demonstrate the feasibility of a CBSL program targeting internal medicine residents and to assess its effect on medical residents and community participants. internal medicine residents participated in a CBSL experience for half a day during ambulatory blocks from 2011 to 2014. Residents attended a senior housing unit or center, delivered a presentation about a geriatric health topic, toured the facility, and received information about local older adult resources. Residents evaluated the experience. Postgraduate Year 3 internal medicine residents (n = 71) delivered 64 sessions. Residents felt that the experience increased their ability to communicate effectively with older adults (mean 3.91 ± 0.73 on a Likert scale with 5 = strongly agree), increased their knowledge of resources (4.09 ± 1.01), expanded their knowledge of a health topic pertinent to aging (3.48 ± 1.09), and contributed to their capacity to evaluate and care for older adults (3.84 ± 0.67). Free‐text responses demonstrated that residents thought that this program would change their practice. Of 815 older adults surveyed from 36 discrete teaching sessions, 461 (56%) thought that the medical residents delivered health information clearly (4.55 ± 0.88) and that the health topics were relevant (4.26 ± 0.92). Free‐text responses showed that the program helped them understand their health concerns. This CBSL program is a feasible and effective tool for teaching internal medicine residents and older adults.

Making House Calls: Treating Older Adults at Home

Home care is an exceedingly valuable opportunity to serve the needs of patients who find it difficult to leave their homes. Clinicians can remain on the cutting edge of serving their patients’ needs through exploration and expansion into home care medicine. This chapter provides information on patient eligibility, preparing for and conducting a house call, basic procedures which can be done in the home, and engaging support systems in becoming active in the homebound patient’s care management. The future of home care medicine will continue to expand as more patients wish to remain in their home and age in place.