Kiawah Island Golf Resort Charleston, SC Aging Q3 2011 Fall Faculty Retreat.
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Transcript of Kiawah Island Golf Resort Charleston, SC Aging Q3 2011 Fall Faculty Retreat.
Kiawah Island Golf ResortCharleston, SC
Aging Q3
2011 Fall Faculty Retreat
Welcome to Kiawah Island!
Aging Q3 Update
• Completed 9 ACOVEs to date
• In the middle of Pain Management (ends Jan 20)
• 5 remain– (Pressure Ulcers and Malnutrition are combined in
1 ACOVE)
Year 1:2009-2010
1. Vision Loss (May (June 2) – Sept 4)
Chair: Bill Moran, MD
2. Falls and Mobility (Sept 8 – Dec 14)
Chair: Kathy Wiley, MD
3. Dementia (Dec 15 – Mar 22 2010)
Chair: Pam Pride, MD
Year 2: 2010-2011
4. Continuity of Care (Mar 23-June 21)
Chair: Kim Davis, MD
5. Med Use & Safety (Jun 22-Sep 21)
Chair: Amy Thompson, PharmD
6. Screening/ Prev Sep 28-Dec13
Chair: Elisha Brownfield, MD
7. Hospital Care/Transitions (Dec 14- Mar 15, 2011)
Chair: Neal Axon, MD
Year 3: 2011-2012
8. End of Life Care (Mar 17- Jul 5)
Chair: Paul Rousseau, MD
9. Osteoporosis (July 21 – Oct 21)
Chair: Jay Brzezinski, MD
10. Pain Management (Oct 24-Jan 20, 2012)
Chair: Roger Kyle, MD
11. Osteoarthritis (Jan 23 – Apr 11, 2012)
Chair: Cathryn Caton, MD
Year 4: 2012-2013
12. Depression (Apr 12-July 19)
Chair: Bill Moran, MD
13. Urinary Incontinence (July 20 – Oct 17) Chair: Fletcher Penney, MD
14/15. Pressure Ulcers/Malnutrition
(Oct 18 – Jan, 16 2013) Chair: Keri Holmes
Maybank, MD
16. Hearing Loss (Jan 17 – Apr17, 2013)
Chair: Brad Keith, MD
Vision Falls Dementia Continuity of Care
Med Use & Safety
Screening &
Prevention
Hospital Care/ &
Transitions
End of Life Care
Osteoporosis
ACOVE Skill
Fundu- scopic Exam72/99 (73%)
Timed Up & Go
64/100 (64%)
Mini-Cog68/96
(70.8%)
Primary Care Med
Rec80/97 (83%)
Med Rec82/134 (61%)
Health Mainten-
ance37/96 (39%)
Discharge Summaries
70/96 (73%)
Commun. and Adv. Directives Role Play
60/96 (62.5%)
FRAX75/95 (79%)
≥75% correct answers on Pre-test
44/70 (63%)
11/67 (16.4%)
28/69 (40.6%)
35/76# (46%)
20/72## (27.8%)
12/76# (15.8%)
27/72#(37.5%)
37/67 ##(55.2%)
27/92## (29.3%)
≥75% correct answers on Post-Test
57/80 (71.2%)
34/69 (49.3%)
24/76 (31.6%)
22/72# (30.6%)
24/76## (35.5%)
29/72# (40.3%)
38/67#(56.7%)
37/72 ##(51.4%)
48/77## (62.3%)
p-value p=0.2489 p<0.0001 p = 0.2558 p=0.0419 p=0.5174 p<0.0001 p=0.0163 p=0.6907 p<0.0001
Resident’s Detailed
83/99 (83.8%)
86/100 (86%)
79/96 (82.3%)
85/97 (87.6%)
82/134 (61.2%)
75/96 (78%)
80/96 (83%)
75/96 (78%)
80/95 (84.2%)
# = ≥67% correct answer; # # = ≥80% correct answers
Manuscripts and Publishing
• Patrick
Aging Q3 Manuscript Progress Table (11-30-11)Lead Team Title Target Journals NotesCaton, Wiley, Moran ,Zapka Teaching Falls Screening Evaluation
and Management in an IM Residency Program
JAGS - Submitted J Am Geriatr Soc. 2011 Aug 24. doi: 10.1111/j.1532-5415.2011.03555.x. [Epub ahead of print] PMID: 21883104 [PubMed - as supplied by publisher]
Moran, Davis, Mauldin, et al Where Are My Patients? Southern Medical Journal - Submitted
Accepted
Brownfield, Mauldin,Marsden, Iverson, Thompson
Immunizations Screening AJIC - Submitted Revisions
Moran ,Zapka, Iverson, Davis, Wiley, Pride, Zhao
Innovation in Design and Evaluation in Geriatric Education - Aging Q3
Academic Medicine - Submitted Accepted - Revisions
Thompson, Freeland, Zhao, Mauldin, Dizzy Making Drugs Pharmacotherapy - Submitted Revisions
Black, Mauldin, Moran, Caton Estimated Cost Effectiveness of a Resident Physician: Training Program to Reduce Falls in Elderly
JGIM - Submitted In Review
Litvin, Davis, Moran, Zapka, Iverson, Zhao
Innovations in Medical Education JAGS – Submitted In Review
Axon, Marsden, Mauldin, Iverson, Thompson
A Curriculum with Individualized and Team-based Feedback to Improve Discharge Summary Quality
JAGS In Progress
Thompson, Mauldin, Moran, Iverson Medication Safety and the Elderly - Aging Q3
Pharmacotherapy In Progress
Iverson, Moran, Mauldin Dementia In Progress
Moran, Rousseau, Adler, Iverson, Mauldin
End of Life – Advanced Directives In Progress
End of Life Care ACOVE # 8
End of Life Care Working Group
Chair:Paul Rousseau, MD
Working Group Members: Leigh Vaughan MD
Rog Kyle MD Elisha Brownfield MD William P. Moran MD
Cara Litvin MD Mary Adler RN
Lisa Roberge PA-CLeah Clanton MD (Resident)
Amanada Overstreet MD (Resident)
Objectives
• How to estimate life expectancy
• How to communicate about Advanced Care Directives
• How to lead a family meeting to discuss EOL issues and/or deliver bad news
Interesting Results• 57% (568/998) of patients seen were asked if they have an
ACD • 23% of patients asked (131/568), DO have an ACD
– 51% (67/131) Resident knows their wishes– 20% (26/131) Copy in the chart
• 77 % (437/568)of patients asked, don’t have ACD– 49% (214/437) want to discuss ACD today– 25% (111/437) want to discuss ACD at a follow up visit
More!
• In 18% (99/537) of those patients for whom the resident estimated life expectancy using the Covinsky scale, the resident documented the results did have an influence on the clinical decision making.
Role Plays60/96 (62.5%) of Residents participated in
at least 1 Role Play
Resident Reported Confident or Very Confident
Pre Test Post Test
Discussing ACDs 58/96 (60%) 66/96 (69%)
Leading a Family Meeting
44/96 (46%) 53/96 (55%)
OsteoporosisACOVE #9
Osteoporosis ACOVE Working Group
Working Group Chair:Jay Brzezinski, MD
Working Group Members: Pamela Pride MD
Leonard Lichtenstein MDAmy Thompson PharmD
Brad Keith MDLara Hourani (Resident)
Tamela Sill, RN
Learning Objectives
• Who to refer for a DXA scan
• How/when to use a FRAX
• Treatment options for Osteoporosis
Have you ever calculated a FRAX score?
A FRAX score is useful when:
A 70 year old female patient has a symptomatic compression fracture of her thoracic spine.
Which of the following is true?
The # of treated patients that are needed to cause osteonecrosis of the jaw (NNH) is rouhgly:
The # of treated osteoporosis patients that are needed to prevent any fracture (NNT) is roughly:
Which of the following is not a risk factor for osteoporosis?
On a scale of 1-5 with 1 being no confidence and 5 being very confident, rate your confidence in your ability to decide ho to treat Osteoporosis in elderly
females:
220/613=35.9% of patients seen (females 65+) had a DEXA scan documented it was done or
referred
N=116 (done ‘yes’) + 104 (order ‘yes’)=220D=613
81/95 = 85.3% of residents demonstrated use of FRAX
158/170=92.9% of those patients who had a frax calculated and documented, the resident reported the results had influence on clinical decision
Pain ManagementACOVE #10
Pain Management ACOVE Working GroupChair:
Rogers Kyle, MD
Working Group Members:Deborah Dewaay MD
Amy Thompson PharmDJayne Quinn, RN
Objectives• All patients 65+ presenting in the clinic will be
assessed for chronic and persistent pain.
• All hospitalized adult patients on Gen Med will be assessed for uncontrolled pain, including the use of PCA management for pain.
• All hospitalized adult patients on Gen Med on opioid therapy for pain will be assessed for efficacy and side effects.
Skills
• Manage PCA’s
• Conversion
• Pain assessment
Key Detailing Messages
• Opioid Use for Control of Pain
• Opioid Side Effects
• Non-Opioid Treatment Options
• Conversion
Pain ACOVE Participation Progress
• 6/24 = 25% of residents on IP rotation have demonstrated how to properly read a PCA
• 27/94 = 29% of residents in OP have been detailed
• 20/94 = 21.3% of residents in OP have demonstrated pain assessment
NSAIDS are useful in the treatment of moderate to severe pain.
A. B.
0%
100%A. TrueB. False
A 70 year old woman has been taking 20 mgs of oxycodone every 6 hours for two weeks for pain related to a pelvic
fracture. A reasonable next step in her pain management would be to initiate a long acting opioid such as:
A. B. C. D.
100%
0%0%0%
A. MSContin 60 mg BIDB. Fentanyl transdermal 75 mcgC. Oxycontin 20 mg BIDD. Methadone 20 mg BID
Which of the following medications might be useful in the management of neuropathic pain in the elderly?
A. B. C. D. E. F.
100%
0% 0%0%0%0%
A. NSAIDSB. AnticonvulsantsC. Topical anestheticsD. AntidepressantsE. B,C, and DF. All of the above
When prescribing pain medications, it is often useful to combine an opioid with either acetaminophen or an NSAID.
A. B.
0%
100%
A. TrueB. False
A “Word” from our Residents!
Why “Assess Geriatric Competencies?
• Drs. Clyburn and Keith
IM-FM ResidentsMinimum Geriatric Competencies
• Medication Management• Cognitive, Affective, and Behavioral Health• Complex or Chronic Illness(es) in Older Adults• Palliative and End of Life Care• Hospital Patient Safety• Transitions of Care• Ambulatory Care
Competencies and Curriculum Development
Dr. Wong
ACGME Competencies
• Patient Care• Medical Knowledge• Interpersonal and Communication Skills• Professionalism• Practice Based Learning• Systems Based Practice
Let’s Play a Game!
Drs. Caton and Thompson
M2M“Madness to Methods”Amy ThompsonCathryn Caton
• Medical College of Wisconsin• Can be adapted to any learning task• Engages the learner and their “competitive”
spirit• Encourages Creativity• Promotes transfer of behavior to real task
Upcoming ACOVEs
• Osteoarthritis – Cathryn Caton, MD• Depression – Bill Moran, MD• Urinary Incontinence – Fletcher Penney, MD• Pressure Ulcers/Malnutrition – Keri Holmes-
Maybank, MD• Hearing Loss – Brad Keith, MD
OsteoarthritisACOVE # 11
Chair: Cathryn Caton, MD
Working Group Members:Theresa Cuoco, MD
Pam Charity, MDKeri Holmes-Maybank, MD
Don Fox, MDCara Litvin, MD
Amy Thompson, PharmDKathy Wiley, MD
Lynn Manfred, MDCheryl Lynch, MD
Ashley Morris (Med Student)
Objectives
• Perform & Document functional assessment at the time of admission (H&P)– Found under ROS section of the H&P
• Improve knowledge of treatment options– Medications– Physical Therapy– Joint Replacement
Osteoarthritis
• Skill for outpatient?– Joint injection labs– Joint exams – knees, hips– Tools for evaluating patients with osteoarthritis
DepressionACOVE # 12
Chair: Bill Moran, MD
Working Group Members:Cara Litvin, MD
Delores Tetrault, MDCathryn Caton, MD
AmyThompson, PharmDBrad Keith, MD
Temeia Martin, MD (Resident)QI Residents
PHQ-2 Screen for DepressionOver the past two weeks, how often have you
been bothered by any of the following problems?
Little interest or pleasure in doing things.0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day
Feeling down, depressed, or hopeless.0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day
PHQ-2 Score Probability of major
depressive disorder (%)
Probability of any depressive
disorder (%)
1 15.4 36.9
2 21.1 48.3
3 38.4 75.0
4 45.5 81.2
5 56.4 84.6
6 78.6 92.9
Thibault, JM, Prasaad Steiner, RW. (2004) “Efficient Identification of Adults with Depression and Dementia.” American Family Physician (70):6.
The Next Steps Grant
• Training of hospitalists and surgical and medical specialists.
• Training physicians to learn to work optimally with other disciplines.
Important Areas of Consideration
• Faculty recruitment and development
• Development of new educational techniques and methodologies– Methods to assess learners’ competencies in these
areas
• Existence or creation of infrastructure to support proposed programs
Evaluations
• Survey in the envelope
• Green card in the box