Learning Portfolio:

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Learning Portfolio:

  1. 1. Learning Portfolio:<br />Definition: Learner owned, longitudinal, professional development tool<br />Competency: Practice Based Learning and Improvement<br />Goal: To assist the fellow in the development of self assessment and reflection skills and habits. This portfolio can serve as a means to track competencies as they are met, and to serve as a basis for evaluation of experience and performance by the fellow and in review, by the program director<br />Guidelines:<br />Each fellow should begin and regularly contribute to his/her individual learning portfolio. The portfolio should be reviewed regularly with the Program Director and any mentors in the division, but there may and should be parts of the portfolio that are meant only for the fellow and may be kept private.<br />Components:<br /><ul><li>Clinical Exposures/Encounters/ Case Log
  2. 2. Dementias (especially Non-Alzheimer’s)
  3. 3. Keep log of all patients/diagnoses seen in Memory Disorders clinic (goal is 20 new patient evaluations throughout year)
  4. 4. Key Geriatric Syndromes
  5. 5. “zebras”
  6. 6. Palliative care content
  7. 7. Topics of interest (cases to follow, future abstracts or case reports)
  8. 8. Required Cases to Log:
  9. 9. 20 new patient evaluations through memory disorders clinic
  10. 10. 10 Home visits
  11. 11. Inpatient service:
  12. 12. Advanced Care/Family discussions
  13. 13. Functional Assessments
  14. 14. Hospital problems:
  15. 15. Delirium
  16. 16. Skin assessment/risk for ulcers
  17. 17. Falls risk
  18. 18. Palliative care service: patient/family discussions
  19. 19. Procedures
  20. 20. Consultations (hospital, NH, ambulatory, home, other settings)
  21. 21. Home Visits
  22. 22. Traditional inpatient/outpatient procedures
  23. 23. Joint aspiration
  24. 24. Geriatric specific procedures
  25. 25. Urodynamics or PVR
  26. 26. Experiences
  27. 27. Family Discussions/advanced care planning
  28. 28. Self Assessment:
  29. 29. Preceptor Assessment/feedback
  30. 30. Full geriatric assessments and documentation
  31. 31. Self assessment
  32. 32. Preceptor assessment/feedback
  33. 33. Gait Assessment
  34. 34. Scholarship
  35. 35. Large group presentations (slides and evaluations)
  36. 36. Topic reviews
  37. 37. Assigned projects/work with research projects
  38. 38. Case reports
  39. 39. Journal club work
  40. 40. Abstracts and papers
  41. 41. Posters for conferences/meetings
  42. 42. QI projects:
  43. 43. Document QI project
  44. 44. Chart review of your patients: ACOVE indicators
  45. 45. Timeline
  46. 46. Outcomes
  47. 47. Abstract or paper?
  48. 48. Teaching talks
  49. 49. Grand rounds talks
  50. 50. Future case reports and projects that need to be written up in future
  51. 51. Knowledge
  52. 52. Topics reviewed: patient related, conference, reading, Geriatric Review syllabus or board review activities/reading. How were you exposed to information/topic?
  53. 53. Reading
  54. 54. Conference
  55. 55. Observed in patient
  56. 56. Cared for patient
  57. 57. Taught other learners
  58. 58. Professional Development:
  59. 59. Teaching Portfolio
  60. 60. CV
  61. 61. Career goals and plans
  62. 62. Personal Reflections
  63. 63. Clinical experiences
  64. 64. Significant interpersonal interactions
  65. 65. Specific Geriatric Competencies expected of geriatric Fellows (adapted from the AGS Fellowship Director’s workgroup, 2007)
  66. 66. Gerontology: The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated) must be able to:
  67. 67. Describe the major demographic trends in the US, with a particular focus on the aged, and explain the social implications of those changes.
  68. 68. Describe the primary physiologic changes of aging of each organ system and their clinical implications
  69. 69. Discuss the major psychological changes that occur with aging; be able to articulate Ericksonian approaches as they are relevant to specific patient cases in ambulatory, long term care and hospice settings.
  70. 70. List the most commonly accepted theories of biologic aging and discuss evidence that supports each theory.
  71. 71. Discuss cultural aspects of aging, including knowledge about demographics, health care status of older persons in diverse ethnicities, access to health care, cross-cultural assessment of culture specific beliefs and attitudes towards aging and healthcare, and its impact on patient and family experiences in different clinical settings.
  72. 72. Demonstrate the ability to critically analyze the medical literature and apply it appropriately to clinical practicie.
  73. 73. Diseases in the elderly:
  74. 74. General:
  75. 75. Describe and interpret the most common atypical presentations of disease among elders
  76. 76. Compare and contrast the pathophysiology, presentation, and management of the most common diseases between elders and younger adults (HTN, CAD, hypothyroidism, infections, acute abdomen)
  77. 77. Identify clinical situations where life expectancy, functional status, and patient preferences should override standard treatment recommendations, and implement appropriate management strategies in those cases.
  78. 78. Cardiovascular:
  79. 79. Diagnose and manage the most common CV diseases of elders and identify instances in which those diseases might present or be managed differently than younger individuals.
  80. 80. Discuss the pathophysiology, diagnosis, sequelae, and management of systolic hypertension in elders.
  81. 81. Discuss diagnosis and management of atrial fibrillation in elders, including strategies for determining risks and benefits of warfarin use in individual cases.
  82. 82. Identify elders for whom hypertension should be managed more or less aggressively based on age, functional status, and comorbidities.</li></ul>Diagnose and manage the most common disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals for the following systems:<br /><ul><li>Dermatologic
  83. 83. Endocrinologic:
  84. 84. Gastrointestinal:
  85. 85. Geniturinary:
  86. 86. Hematologic and Oncologic:
  87. 87. Infectious Diseases:
  88. 88. Kidney disease and electrolyte disorders:
  89. 89. Neurologic diseases:
  90. 90. Ophthalmologic:
  91. 91. Oral/dental:
  92. 92. Otologic:
  93. 93. Podiatric:
  94. 94. Pulmonary
  95. 95. Rheumatologic/ Musculoskeletal:
  96. 96. Gynecologic:
  97. 97. Geriatric Psychiatry:
  98. 98. Appropriately identify clinical situations where a neuropsychological assessment is indicated and integrate the findings into the patient’s plan of care
  99. 99. Determine whether the patient has capacity to make a specific medical decision and identify strategies for dealing with patients who lack decision making capacity
  100. 100. Define competence, describe the methods for determining legal competence, and identify resources for assisting patients who lack legal competence.
  101. 101. Distinguish among the clinical presentations of normal aging, mild cognitive impairment, delirium and dementia
  102. 102. Perform, interpret, and articulate limitations of common cognitive screens, including the mini-cog and the MMSE< based on patter, age norms, and educational norms
  103. 103. Diagnose and manage the major causes of dementia, including Alzheimer’s disease, vascular dementia, Lewy Body dementia, dementia of Parkinson’s disease and frontotemporal dementia. Recognize and appropriately refer ambiguous cases for further evaluation.
  104. 104. Formulate a differential diagnosis and implement an evaluation and management plan for patients with mild, moderate and severe dementia
  105. 105. Assess and manage cognitive and behavioral manifestations of dementia, both behaviorally and pharmacologically, based on current best evidence.
  106. 106. Identify dementia patients who might be appropriate for hospice care, and initiate discussions with caregivers.
  107. 107. Formulate a differential diagnosis and implement an evaluation and management plan for depressive symptoms and major depression.
  108. 108. Diagnose anxiety and anxiety related disorders and implement a management plan.
  109. 109. Formulate a differential diagnosis for causes of mood disorders and personality changes in older adults.
  110. 110. Formulate a differential diagnosis and implement an evaluation and management plan for psychotic symptoms and hallucinations.
  111. 111. Diagnose and manage substance abuse in older adults.
  112. 112. Formulate mental health care plans that include cultural aspects of mental health among differing ethnicities, culture specific beliefs and attitudes towards mental health care.
  113. 113. Formulate, evaluate, and manage medical causes of cognitive changes in older adults.
  114. 114. Demonstrate effective communication and care planning with inter-professional team members in the care of older adults with mental health disorders.
  115. 115. Demonstrate proper documentation in mental health care plans.
  116. 116. Geropharmacology
  117. 117. Describe age related changes in pharmacokinetics (renal, hepatic, body composition) and pharmacodynamics in older adults, and justify drug selection and dosing regimens based on these changes
  118. 118. Identify medications that should be avoided or used with caution in older adults, and discuss the principles behind those recommendations
  119. 119. Apply best practices of medication management in older adults when prescribing (including starting low, going slow, but giving adequate therapeutic trial, decreasing polypharmacy when possible)
  120. 120. Identify possible reasons for nonadherence and institute strategies to maximize medication adherence.
  121. 121. Conduct a medication reconciliation whenever transferring a patient to a different care system.
  122. 122. Regularly review all medications, including OTC and CAM, for drug-drug, drug-disease, and drug-food interactions.
  123. 123. Recommend appropriate vs inappropriate use of vitamin and mineral supplements based upon available evidence.
  124. 124. Geriatric Syndromes:
  125. 125. Frailty:
  126. 126. Identify the elements that characterize the frailty syndrome and describe the consequences of frailty
  127. 127. Implement strategies to manage patients who are frail or at risk of becoming frail
  128. 128. Estimate a patient’s life expectancy and whether s/he is vulnerable for developing functional decline in the next few years
  129. 129. Sensory loss:
  130. 130. Perform and interpret brief screens for sensory loss and make appropriate recommendations based on results
  131. 131. Describe and implement strategies to enhance communication with patients with sensory impairments
  132. 132. List indications for referral to ENT, audiology, neurology, ophthalmology/optometry or low vision services for patients with vision and/or hearing loss
  133. 133. Discuss the magnitude and impact of sensory loss on function and quality of life in older adults.
  134. 134. Interpret results of an audiology evaluation
  135. 135. Pain:
  136. 136. Manage pain effectively, including differentiating between acute/chronic pain, different types of pain, choose appropriate medications, change medications as required using dosing equivalence, and indications/contraindications for different analgesics
  137. 137. Utilize nonpharmacologic strategies for managing pain, working with other team members when appropriate
  138. 138. Manage common complications of pain medications, including constipation, nausea, fatigue, and myoclonus
  139. 139. Delirium:
  140. 140. Perform and interpret common delirium screening tools, including the CAM (confusion assessment method) and act on its results
  141. 141. Execute an urgent diagnostic workup for delirium and implement a management plan
  142. 142. Implement strategies to prevent and reduce delirium in older paitents
  143. 143. Sleep disorders:
  144. 144. Describe sleep changes with aging
  145. 145. Diagnose and manage common sleep disorders associated with aging, using nonpharmacologic methods, and when indicated, pharmacologic methods
  146. 146. Pressure ulcers:
  147. 147. Describe the complications of (medical and economic) of skin ulcers
  148. 148. Describe the risk factors (intrinsic and extrinsic) and perform/interpret a risk assessment tool (ex., Braden scale)
  149. 149. Work with medical teams to implement strategies to prevent and reduce pressure ulcers in older patients.
  150. 150. Demonstrate proficiency in the indications for and applications of non-surgical and surgical treatments for ulcers.
  151. 151. Geriatric Syndromes II
  152. 152. Incontinence:
  153. 153. Identify and treat potentially reversible causes of incontinence
  154. 154. Diagnose and treat urge incontinence and mixed incontinence with nonpharmacological and pharmacological techniques
  155. 155. Diagnose and treat stress incontinence, including nonpharmacological and pharmacologic techniques
  156. 156. Identify indications for a specialty/surgical referral
  157. 157. Manage incontinence nonpharmacologically in patients with cognitive and/or functional impairment
  158. 158. Identify when longterm indwelling bladder catheters are necessary and manage them appropriately
  159. 159. Malnutrition:
  160. 160. Evaluate for nutritional disorders using BMI, weight loss criteria, and standard tools
  161. 161. Describe appropriate indications for nutritional supplementation, enteral tube feeding, and parenteral nutrition
  162. 162. Fall and Gait Disorders:
  163. 163. Perform and interpret common gait assessments, including the “get up and go” and “timed up and go”, “Tinetti”, and iPOMA
  164. 164. Implement evidence based strategies to reduce falls and fractures in patients in all health care settings
  165. 165. Design an appropriate workup for patients who fall and implement strategies to reduce future falls, injuries, and fractures
  166. 166. Describe the magnitude and consequences of falls, including fear of falling, hip and other fragility fractures, and nursing home placement
  167. 167. Consequences of immobility
  168. 168. Describe the consequences of immobility, and implement strategies for reducing and preventing immobility
  169. 169. Dizziness/lightheadedness
  170. 170. Recognize that the most common causes of dizziness in elders is multifactorial, and implement management strategies for dealing with multifactorial dizziness
  171. 171. Recognize the symptoms of dizziness that may point to a single or serious disorder, including vertigo and near syncope, and institute an appropriate workup, referral, and management plan
  172. 172. Functional assessment and rehabilitation
  173. 173. Demonstrate the ability to perform a functional assessment that is appropriate to the health care setting
  174. 174. Recognize when a referral to PT, OT, or speech therapy is appropriate
  175. 175. Recognize indications for specific assistive devices, and be proficient in educating patients in the appropriate use of canes and walkers
  176. 176. Identify patients who are appropriate for inpatient rehabilitation units, home rehab, outpatient rehab, and nursing home rehab
  177. 177. Demonstrate the ability to assess for functional impairment (including ADLs and IADLs) and changes in functional status, using both historical and physical examination data, make appropriate recommendations based on abnormal results, and monitor changes
  178. 178. Describe the rehabilitation program and prognosis for older adults with common conditions such as stroke, hip fracture, deconditioning from illness, rotator cuff injury
  179. 179. Caring for the Elderly Patient
  180. 180. Demonstrate the ability to respectfully, effectively and consistently communicate with all members of inter and multidisciplinary teams, reflecting knowledge of other disciplines’ scope of care and commitment to shared problem solving
  181. 181. Explain the role of geriatrics in the overall health care system
  182. 182. Demonstrate sensitivity and expertise in communicating with patients and families of different cultural backgrounds, social status and literacy levels, as well as with individuals affected by sensory and /or cognitive impairments
  183. 183. Demonstrate the ability to sensitively deliver bad news to patients/families, being aware of culture, social status, literacy, personality traits, and coping styles
  184. 184. Exhibit respectful behaviors toward older adults
  185. 185. Dispel stereotypes related to older people during clinical encounters and structured teachings
  186. 186. Educate learners, patients and families, while maintaining sensitive to cultural background, social status and literacy
  187. 187. Demonstrate skills to explore and discuss advance care planning with elderly individuals who are healthy or suffer from chronic, progressive illness and those in long term care or their caregivers
  188. 188. Hospital Care
  189. 189. Implement strategies for preventing the most common potential hazards of hospitalization among elders (immobility, falls, delirium, pressure ulcers, malnutrition, procedures, indwelling catheters, nosocomial infections)
  190. 190. Implement strategies to minimize indwelling urinary catheter use, and identify the indications for indwelling catheter use
  191. 191. Formulate safe discharge plans, including working with other team members to choose the most appropriate discharge setting and services for the patient
  192. 192. Perform pre-operative assessments for older patients and make specific recommendations based on type of surgery and patient characteristics
  193. 193. Recognize the risks of, and indications for, restraint use, and implement strategies to minimize restraint use
  194. 194. Implement strategies to reduce the most common post operative complications in older adults (delirium, pain, deconditioning, urinary tract infection)
  195. 195. Ambulatory Geriatrics:
  196. 196. Perform an efficient outpatient geriatric assessment, and implement a management plan based on the findings, working with other team members as appropriate and available
  197. 197. Demonstrate the ability to manage multiple comorbidities, utilizing evidence, patient’s goals, and estimated life expectancy
  198. 198. Choose appropriate billing codes for outpatient visits
  199. 199. Demonstrate the ability to manage time efficiently in the outpatient setting
  200. 200. Utilize consultants and other team members appropriately
  201. 201. Home Care
  202. 202. Describe indications and potential benefits of a physician home care visit
  203. 203. Execute a home care visit, including modifying the physical exam for the home care setting, and performing a home safety assessment
  204. 204. Explain home care regulations and reimbursement guidelines under Medicare and Medicaid
  205. 205. Utilize the home health and support services available to help frail elders maintain independence
  206. 206. Long Term Care and Nursing Home Care
  207. 207. Modify management of common medical problems in the nursing home setting based on prognosis, comorbidity, patient goals, and resource limitations
  208. 208. Prioritize appropriate long term care settings for the patient, including independent living, assisted living, nursing home, skilled nursing home care, subacute care, adult day care, and rehabilitation unit
  209. 209. Describe responsibilities of a nursing home medical director
  210. 210. Prevent and manage common problems in the nursing home, including functional decline, falls, incontinence, pressure ulcers, and malnutrition
  211. 211. Manage common acute problems in nursing homes via phone call, incorporating patient preferences and staffing/technological limitations into the management plan
  212. 212. Describe the most common payment sources for different long term care venues
  213. 213. Summarize important nursing home regulations, the minimum data set, the physician’s role in nursing homes, and requirements under OBRA
  214. 214. Palliative care
  215. 215. Discuss the patient’s values, including cultural values and spiritual needs and goals of care
  216. 216. Discuss advanced directives with the patients and/or surrogates, using existing tools as appropriate
  217. 217. Manage pain
  218. 218. Assess and manage common non pain symptoms at the end of life care, including nausea, constipation, dyspnea, partial/complete bowel obstruction, delirium, depression, fatigue, anxiety, and sleeplessness
  219. 219. Recognize and manage common side effects of opioids, including constipation, nausea, sedation, fatigue, and myoclonus
  220. 220. Recognize and manage the imminently dying patient; support caregivers
  221. 221. Distinguish and explain the concepts of palliative care, hospice care, Medicare hospice benefit to all stakeholders; select different sites for end of life care according to patients’/caregivers’ values and wishes; discuss the financial implications of each
  222. 222. Demonstrate sensitivity to the impact that death has on family and team members
  223. 223. Utilize the interdisciplinary team according to their expertise and patient needs
  224. 224. Manage terminal malnutrition and dehydration
  225. 225. Recognize patients likely to benefit from hospice care, including those with non-cancer diagnoses (end stage dementia, COPD, CHF, etc)
  226. 226. Economic Aspects of Care
  227. 227. Demonstrate the ability to bill Medicare appropriately for outpatient, home, inpatient, and nursing home care
  228. 228. Summarize the basic structure of Medicare, including Medicare A, B, D, Medicare Advantage, PACE, hospice, and Medigap policies
  229. 229. Describe the basic structure of Medicaid for older adults, Medi-Medi coverage, and long term care benefits
  230. 230. Outline the components of a quality improvement program to address a specific issue in geriatric care
  231. 231. Demonstrate understanding of the systems approach to medical errors, and participate in (real or simulated) case that explores the underlying system and context surrounding the occurrence of suboptimal care
  232. 232. Preventive Medicine
  233. 233. Demonstrate appropriate utilization of health promotion and screening interventions for older adults, taking into account comorbidities, life expectancy, patient preferences, and site of care
  234. 234. Choose appropriate exercise therapies based upon the patient’s comorbidities and level of function
  235. 235. Write an appropriate exercise prescription based on patient’s ability, including precautions
  236. 236. Provide counseling and education regarding the risks of overuse/misuse of substances such as alcohol, cigarettes, over the counter and prescription medicines, especially with respect to the unique features of their metabolism and risks in elder patients
  237. 237. Discuss goals of care, patient preferences, and values with patients in the context of discussing screening tests (such as colonoscopy, mammogram, PSA)
  238. 238. Caregiver, Family, Community Concerns
  239. 239. Assess for caregiver stress, and utilize team and community resources to reduce caregiver stress when it is identified
  240. 240. Incorporate caregiver needs and limitations into the management plan for homebound patients, utilizing team and community resources when appropriate.
  241. 241. Identify patients who are potentially hazardous drivers, institute management strategies to reduce risk, and comply with state and local laws surrounding at-risk drivers
  242. 242. List indications for referral to Adult Protective Services for suspected elder abuse and neglect
  243. 243. Participate in activities in which a geriatrician acts as a leader or advocate for the elders in their community/region; for example, as a community leader in activities at local hospital or senior center, county council on Aging, Alzheimer, and other associations, as well as through collegial interaction with local primary care physicians
  244. 244. Prepare and present lay education talk(s) regarding wellness and preventive medicine topics in geriatrics
  245. 245. Recognize and describe age-ism and its impact on patients, their families, physicians and the health care system</li></ul>Recognize, and adjust accordingly to, cultural differences in the meaning and experiencing of aging, illness, and death, as well as the cultural differences in the role (s) of elders in diverse communities<br />

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