Looking back, moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0.

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.

The Interprofessional Teaching Observation Program: A Faculty Development Workshop on Peer Feedback of Interprofessional Teaching.

Introduction: Faculty development focused on interprofessional education (IPE) is essential to any IPE initiative aiming to produce a collaborative practice-ready workforce. Many faculty have not received IPE in their own training and struggle with interprofessional teaching. Methods: To train faculty to conduct a peer-teaching observation and provide feedback focused on interprofessional teaching, we created a 3-hour didactic and skills practice workshop. The didactic portion considered ways interprofessional teaching differed from uniprofessional teaching, discussed elements of effective feedback, and reviewed the critical steps of a peer-teaching observation. In the skills practice portion, participants watched videos of different teaching scenarios and role-played as a peer observer providing feedback to the instructor in the videos. Participants completed a pre/post self-assessment and workshop evaluation form. Results: Eighteen faculty from four professions (dentistry, medicine, nursing, and pharmacy) participated in the workshop from 2020 to 2021. On a 5-point scale (1 = poor, 5 = excellent), participants rated the overall workshop quality 4.9 and the likelihood of making a change in their teaching/professional practice 4.8. Workshop participants' self-reported ability to provide feedback to a peer on their interprofessional teaching improved after workshop participation (preworkshop M = 2.9, postworkshop M = 3.8, p < .01). Discussion: This IPE-focused faculty development workshop allows participants to practice skills and share their own interprofessional teaching insights and challenges. The workshop is adaptable for different professions and settings and for in-person or online implementation. It also can be integrated into an existing program or utilized as a stand-alone workshop.

Geriatrics Evaluation and Management in the Veterans Administration-An Historical Perspective.

Comprehensive geriatric assessment, defined as an interdisciplinary assessment and development of an overall plan of treatment and follow-up, has become a fundamental part of clinical geriatric care. Since the 1970s, the US Department of Veterans Affairs (VA) has encouraged the development of geriatric evaluation and management programs. Evolution of geriatric evaluation and management has occurred over time and many VA medical centers have transferred inpatient geriatric evaluation programs to long-term care Community Living Centers, home, and outpatient settings. Availability of geriatric resources and trained personnel across the continuum of care as well as administrative collaboration between care components are critical to the successful implementation of geriatric services. Facilities may need to prioritize their resources and utilize the most effective and relevant elements of geriatric evaluation and management according to patient population needs, available space, resources, and institutional priorities. New risk assessment tools derived from the VA's experience in geriatric evaluation may be useful for targeting services for other high-risk populations.

Excellence in Transitional Care of Older Adults and Pay-for-Performance: Perspectives of Health Care Professionals.

UNLABELLED: Article-at-a-Glance Background: Care transitions across health care settings are common and can result in adverse outcomes for older adults. Few studies have examined health care professionals' perspectives on important process measures or pay-for-performance (P4P) strategies related to transitional care. A study was conducted to characterize health care professionals' perspectives on (1) successful transitional care of older adults (age 65 years and older), (2) suggestions for improvement, and (3) P4P strategies related to transitional care. METHODS: In a qualitative study, one-hour semistructured in-depth interviews were conducted in an acute care hospital, a skilled nursing facility, two community-based primary care practices, and one home health care agency with 20 health care professionals (18 physicians and 2 home health care administrators) with direct experience in care transitions of older adults and who were likely to be affected by P4P strategies. RESULTS: Findings were organized into three thematic domains: (1) components and markers of effective transitional care, (2) difficulties in design and implementation of P4P strategies, and (3) health care professionals' concerns and unmet needs related to delivering optimal care during transitions. A conceptual framework was developed on the basis of the findings to guide design and implementation of P4P strategies for improving transitional care. CONCLUSION: In characterizing health care professionals' perspectives, specific care processes to target, challenges to address in the design of P4P strategies, and unmet needs to consider regarding education and feedback for health care professionals were described. Future investigations could evaluate whether performance targets, educational interventions, and implementation strategies based on this conceptual framework improve quality of transitional care.

Clinician roles and responsibilities during care transitions of older adults.

OBJECTIVES: To identify the perceived roles and responsibilities of clinicians during care transitions of older adults. DESIGN: Qualitative study involving 1-hour in-depth semistructured interviews. Audiotapes of interviews were transcribed, coded, and analyzed, and themes and subthemes were generated. SETTING: An acute care hospital, a skilled nursing facility, two community-based outpatient practices, and one home healthcare agency. PARTICIPANTS: Forty healthcare professionals directly involved in care transitions of older adults (18 physicians, 11 home healthcare administrative and field staff, four social workers, three nurse practitioners, three physician assistants, and one hospital case manager). MEASUREMENTS: Perspectives of healthcare professionals regarding clinicians' roles and responsibilities during care transitions were examined and described. RESULTS: Content analysis revealed several themes: components of clinicians' roles during care transitions; congruence between self- and others' perceived ideal roles but incongruence between ideal and routine roles; ambiguity in accountability in the postdischarge period; factors prompting clinicians to act closer to ideal roles; and barriers to performing ideal roles. A conceptual framework was created to summarize clinicians' roles during care transitions. CONCLUSION: This study reports differences between what healthcare professionals perceive as ideal roles of clinicians during care transitions and what clinicians actually do routinely. Certain patient and clinician factors prompt clinicians to act closer to the ideal roles. Multiple barriers interfere with consistent practice of ideal roles. Future investigations could evaluate interventions targeting various components of the conceptual framework and relevant outcomes.

Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review.

BACKGROUND: Readmission and mortality after hospitalization for community-acquired pneumonia (CAP) and heart failure (HF) are publically reported. This systematic review assessed the impact of social factors on risk of readmission or mortality after hospitalization for CAP and HF-variables outside a hospital's control. METHODS: We searched OVID, PubMed and PSYCHINFO for studies from 1980 to 2012. Eligible articles examined the association between social factors and readmission or mortality in patients hospitalized with CAP or HF. We abstracted data on study characteristics, domains of social factors examined, and presence and magnitude of associations. RESULTS: Seventy-two articles met inclusion criteria (20 CAP, 52 HF). Most CAP studies evaluated age, gender, and race and found older age and non-White race were associated with worse outcomes. The results for gender were mixed. Few studies assessed higher level social factors, but those examined were often, but inconsistently, significantly associated with readmissions after CAP, including lower education, low income, and unemployment, and with mortality after CAP, including low income. For HF, older age was associated with worse outcomes and results for gender were mixed. Non-Whites had more readmissions after HF but decreased mortality. Again, higher level social factors were less frequently studied, but those examined were often, but inconsistently, significantly associated with readmissions, including low socioeconomic status (Medicaid insurance, low income), living situation (home stability rural address), lack of social support, being unmarried and risk behaviors (smoking, cocaine use and medical/visit non-adherence). Similar findings were observed for factors associated with mortality after HF, along with psychiatric comorbidities, lack of home resources and greater distance to hospital. CONCLUSIONS: A broad range of social factors affect the risk of post-discharge readmission and mortality in CAP and HF. Future research on adverse events after discharge should study social determinants of health.

The geriatric floating interdisciplinary transition team.

Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.

Conference attendance and performance on the in-training examination in internal medicine.

The objective of this study was to describe the relationship between attendance at conferences during residency training and residents' performance on the In-Training Examination (ITE) in Internal Medicine. Nineteen house officers participated in the study. Conference attendance records were retrospectively reviewed for the one-year period preceding the ITE (pre-ITE), and in the three-month period after house officers received their ITE scores (post-ITE). After receiving their scores, participants completed a questionnaire asking about study habits and opinions about conferences. Attendance was taken at 126/165 (76.4%) conferences pre-ITE and 32/42 (76.2%) conferences post-ITE. House officers attended a mean of 35% (range, 10-59) of the conferences pre-ITE and 32% (range, 9-75) post-ITE (p = 0.365). There was no correlation between prior conference attendance and ITE scores (Spearman correlation coefficient -0.230, p = 0.34), and no correlation between score and conference attendance post-ITE (Spearman correlation coefficient 0.174, p = 0.48). Participation in clinical rotations also failed to influence ITE scores in that content area (all p > 0.05). The findings of this study suggest conference attendance does not influence ITE scores. Medical educators may need to rethink and study how best to impart medical knowledge.