Utilizing Community Resources for Medical Education

1. Utilizing Community Resources for Medical Education Jamehl L. Demons, MD Aging Conference February 9, 2011

2. Persons Over 50 Population Growth From 2000 to 2012 – Forsyth County Data Source: 2000 (US Census) 2001 -2009 (Population Estimates) 2010 -2013 (Population Projections)

3. Percent of Population Over 50 with a Disability in Forsyth County

4. Community Resources • Senior Services • Tab Williams Adult Day Center • Living-at-Home • Meals on Wheels • Area Agency on Aging • Family Caregiver Support Group • Ombudsman Program for nursing homes • Shepherd’s Center • Senior Financial Care • Seniors’ Health Insurance Info Program

5. Older Adults as Volunteers Source: Independent Sector, America’s Senior Volunteers, June 2000

6. SMILE Senior Mentor Independent Living Education Jamehl L. Demons, MD

7. Community Partnership • Senior Services, Inc of Forsyth County • Nonprofit organization • Meals on Wheels (MOW) • Nearly 1000 seniors receive hot meals every weekday. • Delivered by close to 1400 volunteers • Many volunteers over age 65

8. SMILE (Senior Mentor Independent Living Experience) • Unique opportunity for medical student education outside the usual confines of hospital and clinic • 2nd year medical students make a single ride (approx 1.5-2hours) on a MOW route and interview the driver/volunteer • Introduces the concept of successful aging

9. Interview Skills Students collect more than a medical history • Life history • Work history • How successfully aged – deliverer & not recipient • Currently do to remain active • Interface w/ medical profession • How things have changed in the last 50 years (home births, Dr. housecalls, technology) • Mentor’s experience with healthcare system • Accept instruction • Mentor’s recommendations for new doctors.

10. Counseling Important part of being physician • AGE Page • Developed by the National Institute on Aging • Rotate topics: Falls, immunizations, depression, etc. • Effective communication • Make it understandable to non medical persons

12. Mentor Recruitment & Training Utilize partnership talents • MOW volunteer coordinator selected names • Letter of invitation from coordinator and WFUSM • Orientation luncheon • Description of program • Skit demonstrating good and bad performance • Review of Evaluation form

14. Evaluation • Parts • Mentor feedback • Reflection Paper • thoughtful analysis beyond facts • Reviewed by a Geriatrician • Completion is required • Affects professionalism grade of geriatrics rotation

15. Reflection Paper • Describe the essential elements of your SMILE experience that are likely to influence the way you practice medicine with your older patients. • (Minimum 1/2 page; Maximum 2 pages)

16. Student Reflections • “The only advice he could provide for young doctors is continue to care.” • “It was interesting to hear him speak how healthcare had changed.” • “He thinks that gaining your patients’ trust is the most important thing a doctor can do.” • “He shared… the most important thing I can do as a doctor is listen.”

17. Student Reflections • “I also observed that chronological age has little predictive value when it comes to health and vitality in the elderly.” • “I was truly humbled by the reality that older adults cannot be stereotyped; they are diverse.” • “She looked somewhat frail so I was surprised when she swiftly grabbed the cooler…” • “An eye opening experience that reminded me of the importance of caring for people, not simply treating patients.”

18. Student FeedbackIs one session sufficient? • Perhaps a few more days in the schedule (such as afternoons) with planned rides • This may need to be required more than once in a year. I’m not completely sold on a single 3 hour experience being particularly revolutionary. It is a valuable experience but would gain even more power through reinforcement of the principles one is exposed to on the route. • I didn’t really have strong feelings about older adults to begin with and the 2 hour ride-along didn’t do much to affect my opinion one way or the other. I do have a better opinion of volunteers and the Meals on Wheels program though.

19. Student FeedbackUnderstanding the Purpose? • I felt like my driver was not really an elderly person. … same age as my parents, and maintains about the same functionality. … more useful to observe elderly patients utilize the healthcare system, as we would see them in our future. • I feel like I had very limited interactions with the MOW recipients, and therefore did not have a significant amount of time to change my attitudes. • I think the mentor having to evaluate us made the meeting less relaxed. I would understand if we were on the wards and we were having to treat a patient, but a spending a day talking with someone should not.

20. Impact of SMILE • Introduces 2nd year medical students to the concept of successful aging • Novel means to provide health prevention education to high functioning seniors • Provides greater assessment of student in addition to faculty

21. Medical Student Competencies • Demonstrate effective physician-patient interaction skills • Effectively interact with patients from diverse cultural backgrounds (seniors have a different “culture” than 20somethings) • Knowledge of healthcare delivery systems

22. What We’ve Learned • SMILE definitely innovative program. • Bronze medal winning product in 2010 Reynolds Grantees Annual meeting • www.pogoe.org

23. Falls Prevention of Homebound Elders

24. Morbidity • 30% of all community-dwelling persons over 65yo fall per year • 50% of all community-dwelling persons over 80yo fall per year • 1600 falls per 1000 nursing home patients per year • 40% of nursing home admissions are in part because of falls

25. Injury • Fifth most common cause of death in the elderly • Falls cause 80% of all injuries of elderly • 15% require medical attention • 40% of these require hospitalization • average stay 8-15 days

26. Injury • 1% incidence of hip fracture from falls= 250,000 per year • 25% of persons >80yo with hip fracture will die in the next year compared to 15% in the general population over 80 • An objective of the US Public Health Service is to reduce hip fractures in the over 65 population from 714/100K to <600/100K by the year 2000

27. Financial Cost • Individual hospitalization for fall-related injury ~$6500 • Annual cost $12,600,000,000 • ?Subsequent long term costs • nursing care • nursing home admission • physical therapy

28. Psychological Costs • 50% develop fear of falling • 25% restrict activity to avoid further falls • Decreased independence • Fear of falling develops in 20-45% of nonfallers

29. Senior Services of Forsyth County • Nonprofit organization with many sections to help aging population • Meals on Wheels • Paid staff assesses appropriateness for program semi-annually

30. Utilizing Existing Programs • Meals on Wheels Assessment • Falls related questions added • Have you fallen in the last 6months • Are you afraid of falling • Anyone answers yes offered falls program

31. Falls Assessment Clinic • Free • One-time, in-home, comprehensive falls risk assessment • Includes • Medical History and physical exam • Tinetti Performance Oriented Mobility Assessment (POMA) • Home environment assessment

32. Education Component • Internal medicine and Family medicine residents • Read the assessment • Read AGS White paper on Falls Prevention • Perform the assessment • Review recommendations supervised by Brooke Davis

33. Falls assessments 3rd year medical students during Geriatrics • Single visit with the MOW assessor • Ask the falls-related questions • Mediation review • Get up and Go • Mini-cog • Brief home assessment • Findings reviewed with faculty at the end of the rotation

34. What We’ve Learned • Close collaboration with community partner • Assist recruiting drivers/volunteers • Match students with drivers • Assessor interaction with students • Know your student • SMILE Better in 2nd year curriculum than 3rd • Focus on interviewing skills • 3rd year want to focus on more clinical activities

35. What We Don’t Know… yet • Does early interaction with healthy, active seniors increase interest in Geriatrics as a career? • Is one visit enough to make a difference in history of ageism at the time of patient interactions?

36. Supported by funding from the Donald W. Reynolds foundation Jeff Williamson, MD, MHS PI Hal H. Atkinson, MD, MS Co-PI Jan Lawlor, Project coordinator SMILE Brooke Davis, Project coordinator Falls Clinic