Additional Block Rotations
Home Care Block Rotation
At least half of the homebound people in the United States are over the age of 65 years. Clearly, there is a great need for systems to address the needs of homebound persons. Geriatricians will be called on to participate in these systems and indeed, will likely be expected to make house calls a routine part of their practices. Fortunately, most practitioners who participate in house calls consider these visits to be among the most enjoyable and rewarding aspects of their work.
Goals of the Home Visit Block Rotation:
- To become proficient in the art and science of house calls
- To understand the financial, legal, and safety issues with regards to house calls
- To be able to identify patients for whom house calls are appropriate
- To become more confident providing palliative care in the home
- To become comfortable and skilled at interacting with Home Care Agencies and their representatives
In order to meet these goals, the majority of the home visit rotation will be spent with the Mount Sinai Visiting Doctors Program. This program is a collaboration of the Division of General Internal Medicine and the Brookdale Department of Geriatrics and Palliative Medicine. It provides comprehensive care to 1000 homebound persons throughout Manhattan each year and serves as an outreach program for patients who are unable to participate in traditional outpatient care and who are at high risk of being lost to follow-up. These patients generally fall into one of four categories:
- Frail elderly persons
- Patients with psychiatric illnesses
- Patients with debilitating neuromuscular diseases
- Terminally ill patients
The Visiting Doctors program has a patient census of 850, making it the largest academic home visit programs in the country. The program now consists of fifteen attending physicians, two nurse practitioners, two nurse coordinators, four social workers, five medical office assistants, and a research assistant. Linda DeCherrie, MD, Joanna Sheinfeld, MD, and Cameron Hernandez, MD, are Board Certified in Geriatrics. Amy Frieman, MD, Arik Olson, MD, Joanna Sheinfeld, MD, Yasmin Meah, MD, Peter Gliatto, MD, and Theresa Soriano, MD, are Board Certified in Palliative Medicine.
During this rotation, fellows will make home visits four (4) days per week (not Coffey Practice day). Visits will be made with the geriatrics and medicine faculty. Fellows will participate in once weekly interdisciplinary meetings (Wednesday afternoons at 3pm) and have some formal didactic sessions to learn the practical aspects of home care.
In addition to regularly scheduled visits, there will be opportunities to do urgent visits for patients with acute problems needing evaluation. Fellows will be encouraged to identify and visit patients that they follow in the Coffey Geriatric Practice who might benefit from a one-time home visit.
Fellows also play a role in educating medical students and will be asked to lecture on geriatric topics that relate to home care.
Fellows will be asked to look up a topic of interest related to home care and present briefly at one of the interdisciplinary meetings
Jewish Home Lifecare Long-Term Care Rotation
During the JHL rotation, fellow responsibilities include resident care primarily on Friedman 7. Fellows work under the primary supervision of Dr. Rebecca Chatterjee and at times with Dr. Kenneth Boockvar, who cares for the majority of residents on Sutro 4.
Resident care is to encompass more than rounds and attendance to daily medical needs. Most residents have multiple organ system involvement and their care requires follow-up inquiry, repeated exams, and the thought and interest and time that will provide the best care for them, and also the best learning experience for you. Fellows attend team sessions with other caregivers, often also with resident or family, involving each resident's needs and personal choices. They are also be assigned to observe specialists conducting Jewish Home clinics in orthopedics, ophthalmology and dermatology, to benefit from their experience with geriatric problems in these fields. Fellows also attend palliative care rounds with Dr. Simon Kassabian or Dr. Betty Lim. It is anticipated that at their advanced level of training, the fellow is self-motivated to glean the maximum possible information pertaining to care of these oldest and frailest people.
Other than Coffey clinic day and Thursday academic afternoons, fellows are at Jewish Home Lifecare daily from 9AM to 5 PM and do not have other MSSM Geriatrics duties during the rotation period. Fellows are given a schedule indicating times of regular conferences, seminars and clinics they are expected to attend (and at some to present). When there are no meetings and routine clinical duties are completed, fellows have time to do follow-ups for other residents and explore relevant topics in more detail.
Jewish Home Lifecare Sub-Acute Rehabilitation Medicine Rotation
The JHH Rehabilitation rotation involves the medical care and rehabilitation of patients admitted to a thirty-eight bed Sub-Acute Care Unit (Friedman 3) at Jewish Home Lifecare devoted mainly to geriatric rehabilitation.
Mount Sinai Geriatric Psychiatry Rotation
The fellow will spend a month on the Consultation Liaison Psychiatry Service at The Mount Sinai Hospital. During this rotation, the fellow will focus specifically on the psychiatric issues of geriatric inpatients. The fellow will act in the capacity of a consulting psychiatrist under the supervision of an Attending Psychiatrist, boarded in the subspecialty of Psychosomatic Medicine.
The fellow will perform psychiatric evaluations, diagnostic assessments and formulate both medication and behavioral treatment plans for geriatric inpatients. The population served will include patients on the general medical and surgical wards of the hospital for whom psychiatric consultation by the primary team is requested. The fellow will be exposed to the mental health issues that present in late life, and gain insight into the unique aspects and advantages of psychiatric treatment in the medically ill.
Didactic sessions will focus on the psychiatric interview and performance of a mental status evaluation, prescription of each of the major classes of psychotropic medication and the management of the behavioral disturbances of dementia. Medico-legal issues, such as the assessment of decision making capacity and the need for guardianship will be assessed, and the fellow will have the opportunity to attend court hearings involving these aforementioned issues.
By the conclusion of the rotation, the fellow will have a deeper appreciation for the role of the psychiatric consultant and for the integration of psychiatric consultation within the geriatric inpatient population.
Bronx VA Rotation B - Geriatrics Research Education and Clinic Center (GRECC); JJ Peters (Bronx) VAMC
The Bronx VA Rotation presents outstanding clinical, educational and research opportunities for geriatrics fellows. These opportunities include:
- Working with unique patient populations
- Gaining expertise and facility in all aspects of Comprehensive Geriatric Assessment
- Addressing geriatrics and palliative care issues concurrently in an interdisciplinary setting
- Teaching internal medicine house staff and other trainees at the bedside and through formal didactics
- Developing and to participating in clinical research projects that utilize the richness of the VA's EMR and the investigational resources of the GRECC
Unique Patient Populations
In contrast to many community-based geriatric populations, which are overwhelmingly female, the VA's 65+ population, in both the inpatient and outpatient settings, is almost entirely male. A key feature of the VA program is the "embedded" geriatric consultation clinic in which the geriatrics team performs CGAs within older veterans' home primary care clinics where the vast majority of the VA's geriatrics patients receive their care. During the second quarter of FY 2009, an "embedded" geriatrics/palliative care clinic opened in the dialysis unit. A new interdisciplinary ALS clinic directed by Dr. Elizabeth Lindenberger, MD, opened in FY 2010 to address functional and palliative care issues in this special population. If this model of providing geriatric assessment in patients' home clinics proves successful, it will be extended to additional diagnosis based clinics.
On the inpatient side, fellows have the opportunity to improve the care of older veterans as they face the various "hazards of hospitalization" in a setting where many staff members are not familiar with the principles of geriatrics.
Integration of Palliative Care and Geriatrics
The VA has a very active Palliative Care Program that includes an Inpatient Consultation Service, an Inpatient Hospice Unit and an Interdisciplinary Palliative Care Fellowship Program. Fellows who are at the VA on Mondays attend Palliative Care Interdisciplinary Rounds at 10:30 AM. Fellows have the opportunity to work with the palliative care team while they are here at the VA, and, indeed, there is significant overlap between patients requiring geriatrics and palliative care consultations. Additionally, the new "embedded" clinic in dialysis and the planned interdisciplinary ALS clinic provide not only comprehensive geriatric assessment for patients faced with the life limiting diagnoses of ESRD and ALS, but also full palliative care assessment. Fellows will have the opportunity to perform these complete assessments in the setting of a full interdisciplinary team that includes nurses, social workers, psychologists and chaplains in addition to the geriatrics and palliative care physicians.
Beginning in July 2008, the GRECC has been sponsoring a monthly noon conference series for internal medicine housestaff on a variety of geriatrics and palliative care topics. All members of the geriatrics and palliative care teams have participated in these presentations. Fellows have the opportunity to prepare and present formal lectures in this series while they are at the VA. There are additional formal teaching opportunities to participate in a variety of geriatrics, palliative care and ethics in-services for the VA's professional staff in across the continuum of the VA's clinical settings, as well as opportunities to speak at other institutions. Clinical teaching is another key component of the fellows' experience here at the VA. Fellows generally attend intake rounds on each of the two medical wards weekly to help teams identify patients with unmet geriatrics needs. Fellows are responsible for communicating consultation findings and recommendations to housestaff, teaching at the bedside, running family meetings, and modeling expert geriatric care. Fellows also teach and supervise geriatric nurse practitioner students and other trainees when they rotate on the geriatrics service.
Research opportunities abound at the VA whether fellows are interested in clinical research, educational research or health systems research. The VA's nation-wide EMR is a tremendous resource, as are the research support staff and faculty at the GRECC. As noted above, one of the 2009 second-year fellows completed data collection for two different research projects. He presented a poster on one of them at the 2009 AGS meeting. Several of the current second year fellows are already working on research projects at the VA. Fellows are encouraged to participate in existing projects or to develop their own. Two of our 2010 second-year fellows completed research projects at the VA: one performed a quality improvement project around advance care planning, the other an educational intervention on geriatrics competencies for internal medicine house staff. Both were accepted for poster presentations, the former at the 2010 AGS meeting, the latter at Mount Sinai's Research Day.
Other Clinical Opportunities
The VA's clinical staff represents the full spectrum of disciplines that can be called on to care for older veterans. Fellows have opportunities to work with and learn from other health care professionals as part of ad hoc interdisciplinary teams formed around particular patients. These include, but are not limited to, nurses, social workers, speech pathologists, chaplains, nutritionists, physical therapists, occupational therapists, substance abuse counselors, psychiatrists, geriatric psychiatrists, physiatrists, ethics specialists, wound care specialists, geriatricians, palliative care specialists, pain specialists, urologists, audiologists and ophthalmologists. The GRECC faculty can also direct and assist fellows in setting up more formal experiences in any of these or other areas of special interest.
Fellowship Academic Coordinator
Brookdale Department of Geriatrics and Palliative Medicine
One Gustave L. Levy Place
New York, NY 10029-6574