A Clinical Pharmacist-Led Transitions of Care Program for Veterans with Two Planned Care Transitions (Hospital to Skilled Care and Skilled Care to Home) amid the COVID-19 Pandemic.

Transitional care teams have been shown to improve patient safety. We describe a novel transitional care team with a clinical pharmacist as team leader initiated amid the COVID-19 pandemic. The program focused on Veterans with 2 planned transitions of care: hospital to skilled nursing facility (SNF) and from SNF to home. Ninety older Veterans were enrolled, and 79 medication errors and 80 appointment errors were identified. We conclude that a pharmacist-led program can improve safety in patients with 2 planned transitions of care.

Age-friendly care in the Veterans Health Administration: Past, present, and future.

The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.

Introducing Aquifer Geriatrics, the American Geriatrics Society National Online Curriculum.

Aquifer Geriatrics, formerly web-based Geriatrics Education Modules, was initially developed through Donald W. Reynolds Foundation funding, and is now the national curriculum of the American Geriatrics Society and the Association of Directors of Geriatric Academic Programs. Aquifer Geriatrics consists of 26 evidence-based, peer-reviewed, online case-based modules based on the Association of American Medical Colleges/John A. Hartford Foundation Minimum Geriatrics Competencies for Medical Students and is available by subscription at www.aquifer.org/courses. This curriculum aims to help address the national shortage of geriatrics educators, complement current teaching, bridge content gaps in geriatrics education, and standardize geriatrics-focused educational content. This report will describe the development of Aquifer Geriatrics, highlight best practices to incorporate cases in a variety of teaching settings, describe teaching methods that utilize the curriculum to create a robust experience for learners, and address the cost of obtaining the curriculum. J Am Geriatr Soc 67:811-817, 2019.

Pathogenesis, Diagnosis, and Treatment of Venous Thromboembolism in Older Adults.

Older adults have a significantly greater risk of venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, than younger adults. The cause of this greater risk is thought to be multifactorial, including age-related changes in hemostatic factors and greater comorbid conditions and hospitalizations, but is not completely understood. Moreover, VTE remains underrecognized in older adults and may present atypically. Thus, a low index of clinical suspicion is essential when evaluating older adults with possible VTE. Despite this underrecognition in older adults, the diagnostic approach remains similar for all age groups and includes estimation of pretest probability, measurement of the D-dimer, and imaging. Antithrombotic agents are the mainstay of VTE treatment and, when used appropriately, substantially reduce VTE recurrence and complications. The approval of novel oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, provide clinicians with new therapeutic options. In some individuals, NOACs may offer advantages over warfarin, including fewer drug interactions, more-predictable anticoagulation, and lower risk of bleeding. Nevertheless, anticoagulation of VTE in older adults should always be performed cautiously, because age is a risk factor for bleeding complications. Identifying modifiable bleeding risk factors and balancing the risks of VTE recurrence with hemorrhage are important considerations when using anticoagulants in older adults.

Geriatricians' interest to learn bedside portable ultrasound (GEBUS) for application in the clinical practice and in education.

BACKGROUND: Technological advances have allowed ultrasound machines to become portable, pocket-size aids to diagnosis and clinical examination. As technology becomes more available, physicians are challenged to educate themselves and new generations of health providers in the usage of bedside portable ultrasonography. OBJECTIVES/DESIGN: The aim of this study was to survey a representative sample of geriatricians in South Carolina to evaluate their current knowledge about the use of ultrasound machines in the primary care of the elderly, to determine their willingness to adopt the technology and willingness to educate physicians and medical students, and to identify hurdles for the implementation in the clinical and educational environment. PARTICIPANTS: Fourteen physicians and geriatricians participated in the survey. SETTING: Outpatient geriatric practice, Program of All-inclusive Care for the Elderly, inpatient geriatric practice, home-based care, Veterans Affairs hospital program. SURVEY: A 22-item survey regarding geriatric bedside ultrasound (GEBUS) in the clinical setting and in education. RESULTS: Most physicians (92.8%) had heard of GEBUS performed by primary care physicians, and 21.4% had previous formal training. That same percentage also had some training in interpreting ultrasound. Only one physician felt comfortable using the machine and none felt ready to instruct other medical staff and students. Most of the participating group of physicians (71%-85%) expressed an interest in learning this new skill to apply in clinic, research, and medical education. Challenges for wide implementation were identified. CONCLUSIONS: GEBUS is a technology that is now available to the practitioner. Participating geriatricians are ready to embrace this technology in clinical practice and in medical education. Challenges to current implementation include cost, training, liability, credentialing, and lack of reimbursement.

Non-verbal communication between primary care physicians and older patients: how does race matter?

BACKGROUND: Non-verbal communication is an important aspect of the diagnostic and therapeutic process, especially with older patients. It is unknown how non-verbal communication varies with physician and patient race. OBJECTIVE: To examine the joint influence of physician race and patient race on non-verbal communication displayed by primary care physicians during medical interviews with patients 65 years or older. DESIGN, SETTING, AND PARTICIPANTS: Video-recordings of visits of 209 patients 65 years old or older to 30 primary care physicians at three clinics located in the Midwest and Southwest. MAIN MEASURES: Duration of physicians' open body position, eye contact, smile, and non-task touch, coded using an adaption of the Nonverbal Communication in Doctor-Elderly Patient Transactions form. KEY RESULTS: African American physicians with African American patients used more open body position, smile, and touch, compared to the average across other dyads (adjusted mean difference for open body position = 16.55, p < 0.001; smile = 2.35, p = 0.048; touch = 1.33, p < 0.001). African American physicians with white patients spent less time in open body position compared to the average across other dyads, but they also used more smile and eye gaze (adjusted mean difference for open body position = 27.25, p < 0.001; smile = 3.16, p = 0.005; eye gaze = 17.05, p < 0.001). There were no differences between white physicians' behavior toward African American vs. white patients. CONCLUSION: Race plays a role in physicians' non-verbal communication with older patients. Its influence is best understood when physician race and patient race are considered jointly.

Commentary: Aging America: meeting the needs of older Americans and the crisis in geriatrics.

The aging of the United States population will offer unprecedented challenges and opportunities for the health care system at large, and particularly medical education. In this issue of Academic Medicine, three articles provide opportunities for medical educators and others to ponder anew how we can address this so-called "age wave" as the baby boomers become senior boomers. Leipzig and colleagues describe their process for identifying 26 recommended geriatrics competencies for medical students, Reuben and colleagues examine the results of the first cohort of Reynolds Foundation geriatrics education grants, and Bernard and colleagues discuss the benefits of committing to developing departments of geriatrics at academic health centers. In addition, the recent Institute of Medicine (IOM) report, Retooling for an Aging America: Building the Health Care Workforce, highlights many of these issues. In this commentary, the authors discuss implications of selected articles from this issue and the IOM report, in hopes of provoking discussion and consideration of solutions to address the challenges faced by medical educators and by those who make public policy.

The national evaluation of senior mentor programs: older adults in medical education.

OBJECTIVES: To identify models for senior mentor programs (SMPs), critical factors in program development, achievement of goals and objectives, effect on medical school environment, and future of programs. DESIGN: Ten SMPs were systematically selected to represent a variety of medical schools, geographic regions, and program types. The National Senior Mentor Program Evaluation relied upon archived data within the programs and new data collected during site visits. Archived data included internally conducted program evaluations, student course evaluations, and survey and focus group results. Site visit data were collected from key informant interviews with program staff and faculty, medical school leadership and students, and older adults serving as mentors. SETTING: Ten U.S. medical schools with SMPs. PARTICIPANTS: Evaluation participants at each site included program faculty, key medical school administrators, participating students, and mentors. MEASUREMENTS: Program evaluation. RESULTS: All 10 programs demonstrated a positive effect on student attitudes toward older adults. Student acceptance of the programs was strong, and mentor acceptance and support were extraordinary. Eight of the 10 programs were operating in 2008 and having considerable effect on medical school environments. Most of the operating programs expect to be continuing for 5 or more years into the future. CONCLUSIONS: The findings of the national evaluation point toward continuation and likely growth of the senior mentor phenomenon in U.S. medical education.

Does it stick? Effects of an integrated vertical undergraduate aging curriculum on medical and surgical residents.

Experts acknowledge the unmet need for all physicians to have basic knowledge of aging and competency in geriatric care given the context of population aging. The University of South Carolina (USC) School of Medicine implemented a highly successful program of aging-oriented undergraduate medical training, including a geriatrics vertical curriculum and its senior mentor program-a required, 4-year experience matching students with older community volunteers, referred to herein as the integrated vertical curriculum in geriatrics (IVC). In earlier work, it was established that IVC graduating classes were significantly more likely to report exposure to and coverage of various geriatrics topics than prior USC classes or other U.S. medical graduates. Here the results of a follow-up survey of USC graduating classes before and after exposure to the IVC and contemporaneous Medical University of South Carolina (MUSC) graduates after two to three years of residency (before the initiation of a senior mentor program at MUSC) is reported. Of 403 graduates, 227 returned questionnaires (response rate 56%). Significantly more IVC (2004) than pre-IVC (2003) and 2003 and 2004 MUSC graduates rated themselves fairly or very well prepared by their undergraduate education to treat older adults seen in residency (95% vs 77% and 52%; P<.001). Implications of this and other findings are discussed.

The middle of the road: results from the aging semantic differential with four cohorts of medical students.

OBJECTIVES: To explore the presence of negative stereotypical attitudes among medical students and the extent to which attitudes changed over time. DESIGN: Analysis of pre- and postexperience administration of attitude measures to four cohorts of medical students (two cohorts as quasi-controls and two cohorts as curriculum "treatment" groups). SETTING: The curriculum of a community-based medical school in the United States. PARTICIPANTS: Four sequential cohorts of medical students. INTERVENTION: Experience in a required comprehensive vertically integrated curriculum. MEASUREMENTS: The Aging Semantic Differential (ASD), using an 85-year-old woman as the cue image. RESULTS: The reliability scores for all administrations were acceptable. The two control cohorts demonstrated no change in attitude scores, whereas the treatment cohorts reflected a slight shift toward more-positive scores. However, all cohorts had scores for all sittings that were in the neutral range; on average students routinely scored 70% of the 32 items neither positively nor negatively. CONCLUSION: These students seemed not to hold negative stereotypes as measured using the ASD. Although two of the 32 items prompted negative stereotyping, and six items elicited positive stereotyping, attitudes were neutral about older adults. Characteristics of the ASD itself or of the response set used in this study may have affected the results.

The Senior Mentor Program at the University of South Carolina School of Medicine: an innovative geriatric longitudinal curriculum.

This paper describes development, implementation, and evaluation strategies of a longitudinal geriatric curriculum, the Senior Mentor Program (SMP). The rationale for exposing undergraduate medical students to healthy, community-dwelling older adults is to use the relationship and activities as vehicles for improving knowledge of aging and providing students experience with aging as a stage and process. The University of South Carolina School of Medicine's major aim in geriatrics is to prepare students to become skilled physicians in care of older adults. The SMP is embedded into the curriculum. The program introduced medical students to healthy older adults, presented selected health care issues in this population, integrated material early in the curriculum, acquainted students with longitudinal patient care, and introduced students to older adults' living arrangements. The SMP is an effective means of infusing geriatric content into the medical school curriculum and positively affects mentors' and students' attitudes toward each other. This has implications for medical and professional schools, such as nursing, social work, and physical therapy.

Preparing medical students to care for older adults: the impact of a Senior Mentor Program.

PURPOSE: To provide alternative training experiences for medical students to improve the competencies needed to provide care for older adults. METHOD: Part of a comprehensive approach to integrating geriatric content at the University of South Carolina (USC) School of Medicine, the Senior Mentor Program (SMP) was launched in 2000. The SMP links pairs of students with older community volunteers in the spring of the first year. Students visit their mentors throughout medical school, and execute assignments that complement materials covered in the traditional curriculum. To evaluate the feasibility and efficacy of the SMP, the authors describe the program's operation and outputs, the extent to which undergraduate medical education at USC and the SMP meet the core competencies for care of older adults promulgated by the American Geriatrics Society (AGS), and analyze the coverage of geriatrics content from 2000 to 2005 at USC, as indicated by responses to the Medical School Graduation Questionnaire. RESULTS: From 2000 to 2005, 379 students enrolled in the SMP; 133 graduates of the classes of 2004 and 2005 have completed the SMP. Students and mentors indicated high acceptance and enthusiasm. The program has been maintained with minimal administrative burden. USC covered only half of AGS competencies before the SMP, but now covers 100%, with nearly a third met specifically through the SMP. USC graduates reporting inclusion of geriatrics throughout their four years of training rose from 66% in 2002 to 96% in 2004-05. CONCLUSIONS: The SMP has had a substantial impact on students' preparation for dealing with an aging patient population.

Medical student and senior participants' perceptions of a mentoring program designed to enhance geriatric medical education.

In 2000, the Senior Mentor Program was implemented as an innovative, instructional method in the University of South Carolina's medical school curriculum designed to enhance and strengthen student training in geriatrics. This study qualitatively analyzed second- year medical students' and senior participants' perceptions of and attitudes towards the Senior Mentor Program as an effective learning modality. A total of 36 second-year students from two consecutive classes (2002-2003) and 42 senior mentors at USC's School of Medicine participated in five and seven separate focus group interviews, respectively. The group discussions were transcribed and a content analysis performed using NVivo. The coding scheme and analyses were driven by the data collected and recurrent themes were examined across all focus groups. Overall, student and senior mentor participants viewed the program positively. Thematic comparisons by participant type indicate a shared view that the mentoring relationship has a far-reaching, educational, professional, and personal impact. Both students and seniors agreed that myths and stereotypes about aging were dispelled and students indicated that a close, caring relationship with an older person will change they way they practice. A longitudinal mentoring program that pairs students with community-dwelling seniors can be a valuable addition to traditional geriatric curricular activities designed to increase students' skills and compassion for caring for older adults.