Experiential Domains: I A, B, E, III B, VB

               References: 46, 1, 2, 3, 6, 8, 9, 13, 15, 17, 19, 20, 80, 83

VI.  Palliative Care

1. The GMR reviews the history of palliative care and development of hospice philosophy and services.

2. The GMR outlines the current Medicare Hospice Benefit including admission requirements, covered services, exclusions and role of the primary care physician.

3. The GMR integrates end of life counseling into ambulatory and acute care and is facile in the use of Physician Orders for Life Sustaining Therapy forms, Advance Directives, Living Wills, Uniform Organ Donation, and Health Care Durable Power of Attorneys.

4. The GMR defines and evaluates decision-making capacity for end of life planning.

5. The GMR employs patient and family centered values to deliver bad news and conduct a family conference about end of life planning and treatment goals.

6. The GMR formulates assessment and management plans for terminal pain, dyspnea, Delirium, nausea, constipation, nutrition and hydration.

7. The GMR recognizes and responds to spiritual and cultural aspects that influence end of life care.

                Experiential Domains: I D, E, II A, III B

                References: 5, 54, 14, 31, 32, 73, 2, 3, 6, 8, 9

VII.  Geropsychiatry

1. The GMR summarizes the natural history and epidemiology of psychiatric illness in the aging population

2. The GMR diagnoses and treats common psychiatric diseases in the elderly including affective disorders, anxiety and psychoses.

3. The GMR defines and differentiates cognitive disorders including minimal cognitive change, Alzheimer’s Dementia, Vascular Dementia, Lewey Body Dementia, and Frontotemporal Dementia.

4. The GMR diagnoses and manages dementia and its complications using a multidisciplinary approach including environmental, behavioral and pharmacological strategies to support the patient and their family/caregivers.

5. The GMR recognizes delirium, identifies risk factors and common causes of delirium in the elderly and establishes an algorithm for diagnosis and management of delirium using environmental, behavioral and pharmacological means.

Experiential Domains: I B, D, E, II C

References: 8, 15, 46, 68, 69, 82, 2, 3, 6, 8, 9

VIII.  Preventative Medicine in Geriatrics

1. The GMR differentiates primary, secondary and tertiary prevention activities.

2. The GMR synthesizes concepts of life expectancy, comorbitity, risk/benefit analysis and patient preferences to develop a shared decision making approach to preventative screening counseling for the elderly.

3. The GMR compares and contrasts current Unites States Preventative Services Task Force recommendations with recommendations from the American Cancer Society, the American College of Physicians and the American Geriatric Society.

4. The GMR counsels elderly patients on preventative strategies for:

1. Cancer screening including breast, colon, prostate, cervical, lung, skin and ovarian cancers

2. Cardiovascular Disease screening and prevention including coronary artery disease, stroke, hypertension, dyslipidemias

3. Endocrine disorders screening and prevention including diabetes mellitus, thyroid disorders

4. Immunizations and Chemoprophylaxis

5. Counseling for healthy lifestyle modifications including smoking cessation, physical activity, nutrition, dental health and injury prevention

Experiential Domains: IA, C, D, E, III C

References: 1, 46, 51, 52, 53, 62, 63, 2, 3, 6, 8, 9

IX.  Chronic Disease Management

1. The GMR applies current technologies in systems based practice to identify, diagnose and manage common chronic diseases in the elderly.

2. The GMR integrates patient/caregiver counseling and education, nonpharmacologic measures, nutrition and exercise prescription, pharmacologic treatments and appropriate subspecialty referral into the active management of chronic diseases.

3. The GMR anticipates associated morbidities for each chronic disease process and develops primary and secondary prevention strategies to complement treatment of complications.

4. The GMR maintains a biopsychosocial focus in chronic disease management to continually assess patient values while addressing well-being, function and quality of life.

5. The GMR utilizes prognostic indicators to identify the terminal phase of chronic illness and counsels patients and their families about intensity of treatment and end of life care issues including palliative care and hospice referral.

Experiential Domains: ALL

References: 1, 45, 51, 52, 53, 65, 2, 3, 6, 8, 9

 

1.  CARDIOVASCULAR DISEASE

1. The GMR reviews theories on the pathogenesis of ARTERIOSCLEROSIS and rationally applies the current National Cholesterol Education Program Adult Treatment Panel guidelines to elderly patients.

2. The GMR utilizes knowledge about the epidemiology of CORONARY HEART DISEASE to stratify patients into low, moderate and high risk categories to develop diagnostic, therapeutic and management strategies.

3. The GMR assesses the etiologies and precipitants of CONGESTIVE HEART FAILURE to direct primary and secondary prevention efforts while implementing current diagnostic, therapeutic and management strategies.

4. The GMR diagnoses significant CARDIAC ARRHYTHMIAS in the elderly and demonstrates the appropriate use of pharmacologic therapies and distinguishes the indications for pacing and implantable cardioverter defibrillator devices.

5. The GMR differentiates PERIPHERAL VASCULAR DISEASE into arterial and venous categories and articulates current diagnostic and management strategies for each.

6. The GMR recognizes the critical role of HYPERTENSION in vascular disease and integrates recommendations from the current Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC VII) into management strategies for elderly patients.

                References: 21, 22, 23, 47, 48, 49, 50, 2, 3, 6, 8, 9

2.  PULMONARY DISEASE

1. The GMR differentiates CHRONIC OBSTRUCTIVE PULMONARY DISEASES into asthma, chronic bronchitis and emphysema to guide management with medications, oxygen therapy and pulmonary rehabilitation.

2. The GMR examines current theories on the pathophysiology of DIFFUSE PARENCHYMAL LUNG DISEASE (DPLD) to develop diagnostic and treatment plans.

References: 24, 25, 26, 27, 2, 3, 6, 8, 9

3.  NEUROLOGIC DISEASE

1. The GMR summarizes current diagnostic, preventative and treatment alternatives for CEREBROVASCULAR DISEASE distinguishing four subtypes of ischemic events (large artery atherothrombotic, embolic, small vessel lacunar and other) and four subtypes of intracranial hemorrhage (deep hypertensive, lobar, aneurysm and vascular malformations).

2. The GMR differentiates PARKINSON’S DISEASE AND RELATED MOVEMENT DISORDERS and can individualize treatment with dopaminergic agents and additional pharmacologic therapies to manage movement disorders, wearing-off phenomenon, dyskinesias and nonmotor features.

                References: 68, 2, 3, 6, 8, 9

4.  ENDOCRINEOPATHIES

1. The GMR diagnoses THYROID DISEASES in the elderly including hypothyroid, hyperthyroid and sick euthyroid conditions and implements appropriate treatments for management.

2. The GMR employs current guidelines to monitor and manage DIABETES MELLITUS in the elderly with attention to glycemic control through diet, exercise and medications and the prevention and treatment of diabetic complications.

3. The GMR distinguished PRIMARY AND SECONDARY HYPERPARATHYROIDISM from PAGET’S DISEASE OF BONE and applies effective management strategies for each condition.

                References: 2, 3, 6, 8, 9

5.  DISORDERS OF MOBILITY AND MUSCULOSKELETAL DISEASES

1. The GMR diagnoses and manages degenerative conditions of the skeleton such as OSTEOARTHRITIS, SPINAL STENOSIS AND OSTEOPOROSIS evidence based medicine strategies.

2. The GMR reviews rheumatologic conditions common in the elderly including POLYMYALGIA RHEUMATIC, TEMPORAL ARTERITIS, RHEUMATOID ARTHRITIS.

3. The GMR evaluates and manages mobility and gait disturbances from medical and traumatic conditions and employs a multidisciplinary approach to enhance independence.

References: 20, 70, 71, 2, 3, 6, 8, 9

6.  GENITOURINARY CONDITIONS IN AGING

1. The GMR elucidates a relevant sexual history from older patients and monitors sexual health and function thought out the life span.

2. The GMR is sensitive to the impact of chronic disease on sexual function in older patients.

3. The GMR evaluates and manages SEXUAL DYSFUNCTION in male and female geriatric patients differentiating organic and psychologic etiologies.

4. The GMR recognizes and manages common complications or menopause and prostatic hypertrophy and implements evidenced based data to prescribe estrogens, testosterone and other pharmacologic and non-pharmcologic therapies.

X.  Long Term Care

1. The GMF compares and contrasts indications, utilization and limitations along the continuum of care for the elderly highlighting:

   Office Based Ambulatory Care – Individual and Group Visits, Primary Care, Multidisciplinary Services and Specialty Care Home Based Care – Physician Home Visits, Home Health Care, Home Services, Home Hospice Services Community Based Care – Senior Centers, Cultural Centers, Faith Based Services, Congregate Housing, Assisted Living, Adult Group Homes, Programs for All Inclusive Care, Custodial Care Institutional Based Care – Subacute and acute levels of Hospital Care and Long Term Care

2. The GMR reviews a historical perspective of long term care legislation including:

   1935 Social Security Act State oversite to promote quality 1965 Older Americans Act Federal oversite 1983 Institute of Medicine Study: Improving the quality of nursing home care 1997 Omnibus Budget Reconciliation Act Nursing Home Reform Amendments, MDS Minimum Data Set, RAP Resident Assessment Protocols 1999 Federal Medicare Balanced Budget Refinement Act

3. The GMR summarizes fiscal considerations in long term care: The scope, costs and division of payments between the private and public sectors, and the utilization of long term care insurance.

4. The GMR reviews medical direction and management in long term care including:

   Federal and State Regulations Residents’ rights and working with families Quality and risk management Medical Director Role and Responsibility

                Experiential Domains: I D, E, II A, B, C, III B

                References: 45, 12, 28, 29, 33, 34, 35, 36, 37, 38, 39, 40, 79, 81, 84, 2, 3, 6, 8, 9 

XI.  Economics of Aging Care

1. The GMR appraises historical perspectives on payment for geriatric care in the United States including:

   1935 Social Security Act 1965 Older Americans Act including Title III targeting home services, Title XVIII Medicare and Title XIX Medicaid, Title XX Social Services Block Grants 1983 Medicare Hospice Benefit 1991 and 1998 Social Security Act Revisions 2003 Medicare Reform Act.

2. The GMR reviews current trends in health care financing highlighting the proportion of private payment, insurance, Medicare, Medicaid and other government financing utilized to pay for physicians, hospital care, nursing homes and other care.

3. The GMR contrasts the impact of marriage, gender, longevity and frailty on utilization of health care resources.

4. The GMR identifies strengths and weaknesses of current U.S. health care policy predicting challenges and trends for the future.

                Experiential Domains: ALL

XII.  Ethics and Legal Aspects of Geriatrics

1. The GMR distinguishes four levels of medical ethics:

   Clinical or Patient-Centered Professional or Physician-Centered Institutional Societal

2. The GMR identifies four principles of medical ethics:

   Autonomy: The duty to respect a persons right to independent. self-determination regarding the course of their lives and issues concerning the integrity of their bodies and minds. Beneficence: The obligation to do good. Non-Maleficence: The obligation to avoid harm. Justice: Nondiscrimination - The duty to treat individuals fairly.      Distribution - The duty to distribute resources fairly, non-arbitrarily and noncapriciously.

3. The GMR analyzes ethically charged issues in geriatric care including:

   Informed Consent and Informed Refusal Decisional Capacity Surrogate Decision Making: Hierarchy of Substituted Judgement Benefits vs. Burden of Therapies Quality of Life Life Sustaining Therapies Artificial Hydration and Nutrition Medical Futility Withholding or Withdrawing Therapies Physician Assisted Suicide and Euthanasia

4. The GMR utilizes patient, family, institutional and community resources to help resolve medical ethical dilemmas.

                Experiential Domains: ALL

XIII.  Elder Abuse

1. The GMR defines five types of elder abuse and distinguishes the subjective and objective findings to identify each type.

2. The GMR integrates screening for elder abuse and caregiver strain into geriatric assessment and clinical care activities.

3. The GMR recognizes risk factors for elder abuse in victims and caregivers.

4. The GMR employs a multidisciplinary approach for identification, intervention and prevention of elder abuse.

5. The GMR summarizes Washington state law relating to mandatory reporting of suspected elder abuse cases, demonstrating appropriate notification of Adult Protective Services and local law enforcement personnel.

6. The GMR documents the integration of subjective and objective data about suspected elder cases to support legal investigation by the proper authorities.

Experiential Domains: ALL

References: 41, 42, 43, 44, 2, 3, 6, 8, 9

 

I.  Leadership Roles in Family Medicine and Geriatrics

1. The GMR identifies the multiple levels of leadership opportunities available to family medicine and geriatric physicians including:

   Direct patient care Clinic and hospital management Patient and professional advocacy Community participation and activism Public Health Administrative Medicine Professional and Political Organizations at the local, county, state, regional and national level

2. The GMR distinguishes important leadership skills in the areas of Communication, Problem Solving, Feedback and Appraisal, Planning and Organization.

3. The GMR conducts a personal leadership style and skills assessment focusing on strengths, weaknesses, opportunities and threats.

Experiential Domains: V A, B, C, D, E, F

II.  Consultative Medicine

1. The GMR demonstrates skill as a geriatric specialist by providing consultative services in the hospital, long term care and ambulatory clinic settings.

                Experiential Domains: I B, II A, B

III.  Academic Expertise

1. The GMR utilizes current medical informatics to promote evidence based teaching and learning.

2. The GMR incorporates theories of adult learning and knowledge of learning styles to develop clinical teaching, precepting and evaluation skills.

3. The GMR synthesizes legal concepts for managing resident evaluations, non-reappointment and termination of residents, residents with disabilities and illness issues.

4. The GMR incorporates principles of conflict management, negotiation and collaboration to promote an effective workplace environment.

5. The GMR conducts a needs assessment to construct a curriculum with instructional objectives, educational strategies and evaluative tools.

6. The GMR appreciates current pressures on graduate medical education from a financial and political perspective.

Experiential Domains: ALL

IV.  Clinical Research

1. The GMR describes the types of scholarly activities that can result in peer reviewed publication.

2. The GMR reviews clinical research design methods comparing and contrasting prospective, retrospective, case studies and randomized controlled studies.

3. The GMR acknowledges the role of the Institutional Review Board in reviewing, approving and monitoring research activities.

V.  Political Activism

1. The GMR identifies leadership strategies for political expression including:

   Public speaking and media involvement (written, aural and visual) Legal advocacy Participation in community and professional organizations Lobbying at local, state and national levels Running for political office

I.  CONTINUITY EXPERIENCES

The GMR is involved in five longitudinal learning environments:

II.  HOSPITAL EXPERIENCES

The GMR participates in three hospital environments:

1. Swedish Medical Center First Hill

The GMR’s primary acute care experience is at the largest tertiary care hospital of the Swedish Medical Center system. The GMR is the attending physician (with supervisory precepting by the ATG director and SFM faculty to meet Medicare guidelines) for patients admitted from their outpatient clinics, the long term care centers and ElderPlace. As attending physicians, the GMR works in the intensive care units, the coronary care step down units and all general medical units. The GMR interacts with the family medicine resident hospital team in a supervisory and educational role. Geriatric Consultation Services are also provided in this acute care setting.

2. Swedish Medical Center Providence

The GMR participates in a one month rotation with the Providence Rehabilitation Medicine Team to provide inpatient care and consultation services in rehabilitation medicine. The Director of Rehabilitation Medicine Services provides Precepting and teaching.

3. Highline Multispecialty Center Geropsychiatry Unit

   The GMR spends one month at the inpatient geropsychiatry unit admitting and managing patients with a variety of primary and dementia related psychiatric conditions. Precepting and teaching is provided the Director of Psychiatric Services and other staff psychiatrists.

                               

III.  OUTPATIENT EXPERIENCES

The GMR completes three defined outpatient rotations and has 6 blocks of elective time throughout the year to customize outpatient training experiences in geriatric sub-specialty medicine.

1. Swedish Rehabilitation Medicine Rotation

The GMR observes outpatient geriatric rehabilitation activities at the Providence and First Hill sites including the incontinence clinic with pelvic floor physical therapy, the wound care center, vestibular clinics, gait and balance therapies, fitting and training with assistive devices.

2. Swedish Home Care Services

The GMR has opportunities to observe and participate in home health care and hospice care provided by this non-profit organization. There is time to participate in the executive management meetings to learn about the organizational structure, operations, strategic planning and marketing.

3. SeniorCare Clinic

The GMR provides care in an internal medicine geriatric clinic designed for multidisciplinary care including on-site pharmacy, mental health services, social workers, nutritionists, physicians and geriatric nurse services. University of Washington Division of Geriatric and Gerontology faculty provides precepting.

4. Elective Opportunities

   The greater Seattle region hosts a wealth of opportunities for individualized learning in the field of geriatrics. The GMR is free to design and develop electives that support individual areas of interest and inquiry. Some of the electives developed to date include: The Robert Woods Johnson Palliate Care Residency Training Course Virtual Clinics with Stu Farber, MD Joslin Diabetes Center Movement Disorders Clinic at the VA Group Health Cooperative Geriatric Primary Care Services Research Home Care Physicians The American Medical Directors Association Certification Course The ElderAbuse Council of King County Neurology Rheumatology Ethnogeriatrics

IV.  DIDACTIC EXPERIENCES

The program features a commitment to provide each GMR with 5 days and a $1,500 budget for continuing medical education to support attendance at the Annual Scientific Assembly of the American Geriatrics Society. A one-year subscription to the American Geriatrics Society is provided. Additional time off for valuable didactic experiences can be approved through the ATG director. The GMR is encouraged to attend a regular selection of free didactic experiences to enrich learning including:

1. Geriatric Noon Series

   A weekly seminar featuring guest presenters on a variety of geriatric issues. The GMR will present at least one Geriatric Noon Seminar during the year.

2. University of Washington Division of Geriatrics and Gerontology

   Grand Rounds twice a month Journal Club once a month Research Rounds once a month

3. Swedish CME Grand Rounds

   Every Thursday morning a variety of medical topics are presented. The GMR is encouraged to present one SMC Grand Rounds

4. Swedish Ethics Conference

   Once a month an interactive case based discussion on medical ethics

V.  ACADEMIC EXPERIENCES

The GMR participates as a junior faculty member at SFM with a multitude of academic opportunities:

1. University of Washington Family Medicine Faculty Development Fellowship

The GMR, if selected, can participate in this exceptional training opportunity.  This is not a given experience, but a possibility.  Five weeks throughout the year the GMR meets with other junior faculty in the Family Medicine Residency Network for a concentrated program of professional and personal development.

2. Geriatric Didactics

The GMR presents didactic lectures on geriatric syndromes and other areas of interest in geriatrics for the family medicine residents from the Providence and First Hill. These presentations are case centered and evidence based.

3. Faculty Attending Call Responsibilities

The GMR directs all activities on the Family Medicine hospital service for four weekends, per fellow, during the year. An extra call weekend is optional for each fellow.  Adequate supervision for Medicare billing and maintaining resident duty hours is required. The GMR supervised the family medicine residents for all clinical activities including hospital rounds, telephone triage, obstetric triage and labor and delivery. 

4. Family Medicine Teaching Requirements

   The GMR has many opportunities to teach geriatric care and principles to physicians in our community, the family medicine residents and visiting medical students:

   Family Medicine Hospital Team Rounds The GMR is present at the family medicine hospital team rounds each Tuesday to review geriatric topics pertinent to the patient load. Communication with the family medicine team is an important teaching function for the GMR as attending physician for admitted geriatric patients. Geriatric Medicine Consultations The geriatric Consultation services, both inpatient and outpatient provide an avenue for educating referring physicians and the family medicine team. Precepting The GMR has one half day per week precepting family medicine residents in their continuity clinics. This experience strengthens both family medicine and geriatric teaching skills on a one-to-one level.

5. Swedish Family Medicine Faculty Meeting

   The GMR is an active participant in the weekly faculty meetings with exposure to administrative issues, problem identification and solution strategies for quality improvement, resident concerns, residents in trouble and faculty growth and development.

6. Swedish Annual Geriatric Medicine Symposium

   Each GMR prepares a professional presentation on a geriatric topic for this one-day continuing medical education symposium

7. Research

   The GMR can develop an independent research project or can elect to participate in some of the projects already underway at ATG. In addition to formal research, the ATG implements quality improvement projects using the Swedish Medicine Center Plan/Do/Study/Act system. As more GMRs enter ATG from the four year Geriatric Track the plan is to design a research project during the second year of the track, to initiate the project in the third year and to complete and hopefully publish the research project during the final year of the program.

VI.  Leadership/Community

As a very visible ambassador for the new and growing ATG program, each GMR can excel in a multitude of leadership roles in every experiential setting. In addition to the experiences already outlined above, the GMR can focus on activities within the broader community.

1. The Summit at First Hill Lecture Circuit

The GMR provides six presentations on Wellness Topics to an audience of senior citizens who reside at local senior housing development that includes independent and assisted living units. The one-hour presentations include medical and health information targeted to the lay audience and a lively question and answer session.

2. Community Health Presentations

In addition to presenting at Swedish Grand Rounds for the physician community, the GMR has opportunity to present geriatric topics to seniors in the community through the auspices of the Swedish Community Health Program, and to other civic and philanthropic organizations. To date presentations on dementia, depression, osteoarthritis,

3. Medical Grand Rounds

   The GMR is encouraged to educate the physician community to enhance geriatric knowledge and skills for all providers. Over the year, the GMR can seek out opportunities to provide Grand Round presentations at Swedish Medical Center, at the University of Washington Geriatric and Gerontology Grand Rounds and at other medical organizations throughout the Seattle greater community.

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CURRICULUM MANUAL

Swedish Family Medicine initiated the Advanced Training in Geriatrics program in July of 2000. The program includes a four year geriatric track that combines three years of family medicine training culminating in a 12 month geriatric fellowship focusing on faculty and leadership development. While residents are progressing through the longitudinal program, Advanced Training in Geriatrics (ATG) is selecting qualified individuals for the fellowship year. We expect by 2008 all the R4 positions will be filled by individuals in the Geriatric track.

The goals and objectives of ATG include:

• To develop well trained family physicians with a broad range of skills including excellent population based geriatric knowledge and skills

• To foster longitudinal development in leadership, faculty development, and community involvement that will generate a new generation of geriatric family practice teachers.

• To prepare family practice geriatric specialists for a life long career of learning and critical analysis.

The Advanced Training in Geriatrics program is under the direction of Swedish Family Medicine Residency Program, therefore many of the same policies and procedures contained in the Swedish Curriculum manual pertain tot he geriatric medicine residents.

Fellows are eligible for 15 working days of paid vacation. Vacation scheduling should be cleared with the AFG director to ensure adequate patient coverage.

Fellows have 5 days and $1,500 budget for CME provided by the program. These funds cover the required American Geriatrics Annual Conference for the fellowship. Any remaining funds can be spent on lodging or travel to CME activities, books, software, equipment or other educational materials. See Amy Bingell for CME information and forms.

Sick leave may accumulate at the rate of one day per month of full employment. In the case of sickness (as enumerated above), you are to be seen by your personal physician and notify the program director of your absence. If the physician so recommends that you be excused from duty, you should present this recommendation to the director who will work out the details of this excuse and be responsible for documenting time off. Your physician is also responsible for recommending when you may return to duty. If the duration of your of your excused illness exceeds your accumulated paid sick leave, you will not be paid for days missed unless these days are taken as vacation. If you do not have vacation time, the director may request you to extend your residency by the amount of time lost due to illness.

Fellows may not select a Swedish family practice resident or faculty member for their own or their family's medical care.

Fellows may not accept gratuities or fees from patients for personal services provided as part of residency training. Funds from fees generated in the Family Medicine Clinic will be collected as part of operating revenues for the Clinic and training program.

Geriatric Fellows are independent licensed physicians and may practice outside of the fellowship. They must demonstrate adequate medical malpractice insurance to cover moonlighting activities as the fellowship policy will not extend to any moonlighting activities. ATG expects that moonlight activities will not detract from a full educational experience for the fellows.

"Duty hours are defined as all clinical and academic activities related to the residency program, including patient care, administrative duties related to patient care, the provision for transfer of patient care, time spent in house during call activities, and scheduled academic activities like conferences. It does not include reading and preparation time spent away from the duty site.

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of in-house call. Home call does not count, except for the hours spent in hospital after you are called in. However, home call cannot be so frequent as to preclude rest and reasonable personal time for the resident.

Moonlighting must not interfere with the educational program. The program director must comply with all the program sponsors policies on moonlighting. Moonlighting that occurs within the residency or within the sponsoring institution or at the non-hospital sponsor's primary clinical site must be counted in the 80 hour limit."

The attending staff, residents and nurses are divided into teams so that the patients assigned to members of a team may be seen by other team members when the patient's primary doctor is not in clinic. The goal is to create a smaller group practice which will enable patients to identify their physicians and their partners and to look to them for back-up care in the absence of their personal physician. This will also afford the team members a better opportunity for continuity of care by restricting the total size of the patient population that they are expected to know.

Geriatric Preceptors are available for the fellows for the geriatric continuity and consulting clinics.

• Use of the preceptors is mandatory to meet Medicare billing requirements. (See Medicare Billing Letter)

• Geriatric preceptors are available:

• To answer specific questions, as an information resource

• To work through complex problem solving

• For general or specific care discussion

• To confirm physical findings or assist with procedures

• To observe fellow interpersonal exchange and give feedback

• To confirm proposed management plan

• To review practice management

When the geriatric fellow is asked to consult on a clinic patient or hospital patient the geriatric preceptor should be notified. The fellow will evaluate the patient and develop a set of recommendations to answer the consultative question. The recommendations will be reviewed by the preceptor and then the dictation can be completed. The fellow must communicate with the requesting physician by phone and written format. If the Family Practice Service residents are involved, appropriate teaching for their benefit is indicated.

When patients of the geriatric fellow are hospitalized from clinic, the ER or nursing homes, the fellow will act as the attending physician with supervision from the geriatric preceptor to meet Medicare guidelines. An attending admission note will be written and dictated within 24 hours of admission, daily communication with the family practice team and the geriatric preceptor should be done before their 9:30am work rounds.

Fellows are expected to cover their own patients during clinic hours 9:00-5:30. You must notify your team nurse, telecommunications at the hospital and a geriatric fellow, the director or other responsible resident to provide continuous coverage during absences, vacations or CME time. This includes patients in the hospital, from clinic and the nursing homes. After clinic hours patient responsibilities may be signed out to the Family Practice Service resident on call. It is suggested that fellows retain phone contact with the nursing homes during after-hours during the week to better understand this population of patients and how their care needs differ from other populations.

Please notify the director, the clinic scheduler, and the chief resident promptly if you have to be absent so alternate arrangements can be made to accommodate your patient's needs.

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