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