SWEDISH
Swedish Family Medicine
ADVANCED TRAINING
IN GERIATRICS
Leadership Development in Family
Medicine
I. LETTER OF AGREEMENT
Sign with Dr. Borman FEBRUARY
II. CREDENTIALING MARCH
Should start as soon as possible
Organized wi...
VII. CLINIC
1. Pod Nurse
2. Computers
3. Laboratory
4. Geriatric, Family Medicine Clinics
5. Consultation Clinic
6. Precep...
XIV. CERTIFICATE OF QUALIFICATIONS IN GERIATRICS
1. Request application from ABFP in May (1-888-995-5700)
2. Send our appl...
MISSION
Advanced Training in Geriatrics (ATG) prepares family medicine physicians to be leaders in the
medicine of compreh...
References: 4
II. Pharmacology
A. The GMR describes how aging effects pharmacokinetics and pharmacodynamics.
B. The GMR de...
References: 46, 1, 2, 3, 6, 8, 9, 13, 15, 17, 19, 20, 80, 83
VI. Palliative Care
A. The GMR reviews the history of palliat...
Experiential Domains: IA, C, D, E, III C
References: 1, 46, 51, 52, 53, 62, 63, 2, 3, 6, 8, 9
IX. Chronic Disease Manageme...
A. The GMR summarizes current diagnostic, preventative and treatment alternatives
for CEREBROVASCULAR DISEASE distinguishi...
1. Office Based Ambulatory Care – Individual and Group Visits, Primary
Care, Multidisciplinary Services and Specialty Care...
2. Professional or Physician-Centered
3. Institutional
4. Societal
B. The GMR identifies four principles of medical ethics...
7. Professional and Political Organizations at the local, county, state, regional and
national level
B. The GMR distinguis...
introduction of end of life planning. Through out the year, the GMR may work
with family medicine residents and medical st...
medicine. The Director of Rehabilitation Medicine Services provides Precepting
and teaching.
C. Highline Multispecialty Ce...
B. University of Washington Division of Geriatrics and Gerontology
a 1. Grand Rounds twice a month
b 2. Journal Club once ...
G. Research
The GMR can develop an independent research project or can elect to participate in
some of the projects alread...
14. Clinics in Geriatric Medicine, Death and Dyng. May 2000; 16(2).
15. Clinics in Geriatric Medicine, Alzheimers Disease....
50. www.usc.edu/isd/locations/science/gerontology/web_resources.htm.
51. Healthy People 2010, www.healthypeople.gov/docume...
HISTORY
Swedish Family Medicine initiated the Advanced Training in Geriatrics program in July of 2000. The
program include...
GRATUITIES AND FEES
Fellows may not accept gratuities or fees from patients for personal services provided as part of
resi...
involved, appropriate teaching for their benefit is indicated. When patients of the geriatric fellow are
hospitalized from...
be obtained from the family (or guardian) in such death, that fact will be documented in the medical
record.
13.3 Criteria...
If the patient has a social worker, notify the social worker to work with the clinic team in developing
interventions as w...
Physician Presence Requirement
The general rule set forth in the teaching physician policy is that the teaching physician ...
operating room nurse (there is no required information that the teaching surgeon
must enter into the medical records).
B. ...
In the case of complex or high-risk procedures for which the CPT description and/or
medical policy specify personal (in pe...
• Have no other responsibilities at the time of the service for which payment is
sought.
• Assume management responsibilit...
teaching physician presence policy would apply to any services in which residents are involved for
which the teaching phys...
reason, it might be appropriate to classify the individual as a resident not in an approved program
under Section 415.202....
sends a letter or referral form to the practitioner the patient will be seeing. Common examples of
referral are medical, l...
2. Physicians who will not be issued UPINs are as follows:
VAD000 Use for physicians employed by the Veterans Administrati...
MANAGING THE RESIDENT IN DIFFICULTY:
GUIDE TO DUE PROCESS AT SWEDISH FAMILY MEDICINE
1. THE ADVISOR PROGRAM
A. Healthy gro...
5. Probation or suspension may be immediately initiated during this stage if a
problem is identified that is deemed suffic...
The purpose of an organized procedural curriculum is to ensure that residents in training have
appropriate exposure, both ...
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  1. 1. SWEDISH Swedish Family Medicine ADVANCED TRAINING IN GERIATRICS Leadership Development in Family Medicine
  2. 2. I. LETTER OF AGREEMENT Sign with Dr. Borman FEBRUARY II. CREDENTIALING MARCH Should start as soon as possible Organized with Cami Ostrom 1. Highline 2. Swedish Medical Center 3. U of Washington Clinical Instructor Status III. SCHEDULES MARCH-MAY August 1st - July 31st Includes 1/2 day of: Family Medicine Precepting Family Medicine Clinic Geriatrics Continuity Clinic Geriatrics Consulting Clinic 2 1/2 Days of Longterm Care OFF ** See your specific schedule IV. CALL FMS Call: Each fellow takes 5 weekends per year covering FMS and OB. Schedule with Cami Ostrom and let director know the schedule you select. 1. For all non-Medicare patients the geriatric fellow will be attending physician, billing for hospital activity under their own name and supervising residents. 2. For any Medicare patients there will be a separate faculty member to precept the fellow for medical patients or that faculty member may simply handle the Medicare cases individually. This is the faculty member you are replacing by taking call. 3. The geriatric fellow cannot bill for Medicare business directly. 4. Residency Duty Hour Requirements must be followed. If the geriatric medicine resident spends a 24th shift in the hospital due to obstetric responsibilities, then the covering faculty member must relieve the resident to go home and rest. V. EMPLOYMENT New Physician Orientation AUGUST Human Resources JULY 1. Employment contract and mandatory education modules. 2. Benefits, Vacation, Insurance, Health, Disability, Life, Medical Malmedicine, Sick Leave, FMLA, Cosmic events 3. Parking 4. Other VI. HOSPITAL JUNE GME 1. Meal cards 2. Call Room Keys OB 3. Computer Systems Must register 4. Dictation: Call 386-2968 for Transcription Number and Instructions 5. Radiology ORIENTATION
  3. 3. VII. CLINIC 1. Pod Nurse 2. Computers 3. Laboratory 4. Geriatric, Family Medicine Clinics 5. Consultation Clinic 6. Precepting (Giving and Receiving) 7. Dictation/EMR VIII. ROTATIONS 1. Phone List of contact peoples 2. Locations: Rehab, Kline Galland, Bessie Burton, ElderPlace, Swedish Home Care 3. Services, Highline, Senior Care Harborview, The Summits at First Hill, Ballard, TCU 4. Systems at these places: See Training Manual 5. Develop goals and objectives: what do you want out of it 6. Reading in each topic area add in other resources you find helpful IX. ELECTIVES 1. 7 Elective Blocks (Plan to use them wisely) 2. Develop goals and objectives and follow up at completion 3. Research 4. Clinical Rotations: Swedish, Private medicine, groups, U of WA 5. Study Geriatric Review Syllabus for CAQ Examination X. PROGRAM DEVELOPMENT/TEACHING 1. Give didactics for SFM and Providence Residents 2. Teaching residents in clinic, in hospital 3. Prepare for new fellows, Geriatric Tract, Interviewing residency and fellow applicants 4. Program Development, Update Brochure, Grant Development XI. UNIVERSITY OF WASHINGTON FACULTY DEVELOPMENT FELLOWSHIP Your fellowship within a fellowship! 1. Keep director informed about your project 2. Be sure to arrange call for nursing home and hospital patients during that time. XII. CME 1. Plan to attend American Geriatrics Society Conference as part of your CME 2. Total 5 days and $1,500 for the year Budget 3. CME can be used for travel and lodging expenses, books, software, any learning related item. 4. See Cami Ostrom for details XIII. ADVISING/ EVALUATIONS 1. There are resident and attending evaluation forms for each rotation available on the web: www.new-innov.com 2. Your feedback to the program is essential. You need to write a short summary of each rotation for inclusion in the manual to assist future fellows and email it to Cami. 3. Each fellow will meet quarterly with the Director to review progress, overall goals and Exchange feedback. The last of these shall be an Exit Interview. (Quarterlies will be held in September, December, and March, and the Exit Interview will be in June). 4. New Innovations
  4. 4. XIV. CERTIFICATE OF QUALIFICATIONS IN GERIATRICS 1. Request application from ABFP in May (1-888-995-5700) 2. Send our application in June 3. To complete the application you need: Letter from Director to verify training Copy of License 2x2 photo Monday $785 if sent in before July 1st $985 if sent in after July 1st 4. Notary (Amy Bingell) 5. Due Date before August 1st 6. Letter confirming completion of program must be sent in by Director XV. ANNUAL SWEDISH GERIATRICS SYMPOSIUM 1. Each year ATG designs, organizes and supervises a day long CME conference. 2. Each fellow will present a professional presentation or an interactive workshop. 3. Symposium will be held in February, 2007. A theme will be chosen in June or July so you can plan your topic well in advance.
  5. 5. MISSION Advanced Training in Geriatrics (ATG) prepares family medicine physicians to be leaders in the medicine of comprehensive, compassionate, cost-effective geriatric care. This program highlights leadership and academic skills to prepare ATG graduates to be teachers of geriatrics in academic and community settings. Geriatric medicine residents in ATG receive training in the continuum of care for elderly patients through experiences in acute, ambulatory, community and long term care settings. Graduates of ATG develop the knowledge, psychomotor skills and attitudes to excel in geriatrics as a part of successful family medicine careers. CLINICAL AND COGNITIVE DOMAINS LEADERSHIP DOMAINS I The Aging Process I Leadership Roles II Pharmacology II Consultative Medicine III Rehabilitation III Academic Expertise IV Geriatric Assessment IV Clinical Research V Geriatric Syndromes V Political Activism VI Palliative Care VII Geropsychiatry EXPERIENTIAL DOMAINS VIII Preventative Medicine IX Chronic Disease Management I Continuity X Long Term Care II Hospital XI Economics of Aging Care III Outpatient XII Ethics and Legal Aspects IV Didactic XIII Elder Abuse V Academic VI Leadership/Community GOALS AND OBJECTIVES: CLINICAL AND COGNITIVE DOMAINS I. The Aging Process A. The geriatric medicine resident (GMR) outlines four theories of aging and summarizes how each theory explains longevity, aging and death. B. The GMR identifies normal physiologic changes associated with aging in nine body systems: 1. Integument 2. Nervous System: Central and Peripheral 3. Cardiovascular System 4. Respiratory System 5. Gastrointestinal System 6. Urinary System 7. Reproductive System 8. Endocrine System 9. Immune System C. The GMR recognizes the psychosocial impact of aging including ethnogeriatric variations in interpersonal and family relationships, adjustment disorders, grief and bereavement D. The GMR uses knowledge of normal physiologic aging to extrapolate common patterns of aging pathophysiology. E. The GMR examines current theories of successful or healthy aging and proposes strategies to help the elderly progress in this area. F. The GMR defines current aging demographics and employs these data to predict biopsychosocial trends in geriatric care. Experiential Domains: I A,B,C, II B, III A CURRICULUM
  6. 6. References: 4 II. Pharmacology A. The GMR describes how aging effects pharmacokinetics and pharmacodynamics. B. The GMR defines four types of adverse drug effects in the elderly and specifies the impact of adverse drug effects on hospitalization and outpatient care. C. The GMR reviews the principals of polypharmacy and constructs a logical approach to reduce polypharmacy for elderly patients Experiential Domains: ALL References: 77, 2, 3, 6, 8, 9 III. Rehabilitation A. The GMR differentiates the goals and objectives for rehabilitation medicine for the elderly in acute care, long term care and ambulatory medicine settings. B. The GMR describes the requirements for admission and payment for rehabilitation services in acute inpatient rehabilitation units, skilled nursing facilities, outpatient rehabilitation centers and home health services. C. The GMR identifies the role of each multidisciplinary team member involved in rehabilitation services for stroke, amputation, cardiac disease, hip fracture and deconditioning. D. The GMR arranges appropriate rehabilitation services for common geriatric syndromes including incontinence, vestibular disease, gait disturbance and recurrent falls, deconditioning and pressure ulcer treatment. E. The GMR summarizes the advantages and limitations of assistive devices and environmental. F. The GMR assesses acute and chronic pain syndromes and develops appropriate pain management strategies for the elderly. Experiential Domains: I E, II B, III A, B References: 70, 71, 2, 3, 6, 8, 9 IV. Geriatric Assessment A. The GMR elucidates the principles of Geriatric Assessment and the importance of functional status in the elderly. B. The GMR performs Geriatric Assessment to define patient functional status in physical, cognitive, affective, social, spiritual, environmental and economic domains. C. The GMR develops a structured Geriatric Assessment Interview to evaluate nutrition, vision, hearing, memory, depression, incontinence, basic and instrumental activities of daily living, fall risk, polypharmacy, caregiver burden, elder abuse and end of life planning. D. The GMR integrates data from geriatric assessment screening tests to develop a patient centered, multidisciplinary approach for enhancing and preserving functional status. Experiential Domains: I A, B, E, II B, III A, B References: 46, 83, 2, 3, 6, 8, 9 V. Geriatric Syndromes A. The GMR diagnoses and manages the following geriatric syndromes: 1. Dementia 7. Undesired Weight Loss 2. Delirium 8. Osteoporosis 3. Depression 9. Falls and Gait Disturbance 4. Incontinence 10. Dizziness and Syncope 5. Sensory Impairment 11. Pressure Ulcers 6. Sleep Disturbance 12. Elder Abuse (see XII) Experiential Domains: I A, B, E, III B, VB
  7. 7. References: 46, 1, 2, 3, 6, 8, 9, 13, 15, 17, 19, 20, 80, 83 VI. Palliative Care A. The GMR reviews the history of palliative care and development of hospice philosophy and services. B. The GMR outlines the current Medicare Hospice Benefit including admission requirements, covered services, exclusions and role of the primary care physician. C. 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. D. The GMR defines and evaluates decision-making capacity for end of life planning. E. 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. F. The GMR formulates assessment and management plans for terminal pain, dyspnea, Delirium, nausea, constipation, nutrition and hydration. G. 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 A. The GMR summarizes the natural history and epidemiology of psychiatric illness in the aging population. B. The GMR diagnoses and treats common psychiatric diseases in the elderly including affective disorders, anxiety and psychoses. C. The GMR defines and differentiates cognitive disorders including minimal cognitive change, Alzheimer’s Dementia, Vascular Dementia, Lewey Body Dementia, and Frontotemporal Dementia. D. 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. E. 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 pharmacologic 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 A. The GMR differentiates primary, secondary and tertiary prevention activities. B. 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. C. 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. D. The GMR counsels elderly patients on preventative strategies for: 1. Cancer screening including breast, colon, prostate, cervical, lung, skin and ovarian 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
  8. 8. 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 A. The GMR applies current technologies in systems based medicine to identify, diagnose and manage common chronic diseases in the elderly. B. 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. C. The GMR anticipates associated morbitities for each chronic disease process and develops primary and secondary prevention strategies to complement treatment of complications. D. The GMR maintains a biopsychosocial focus in chronic disease management to continually assess patient values while addressing wellbeing, function and quality of life. E. 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 A. The GMR reviews theories on the pathogenesis of ATHEROSCLEROSIS and rationally applies the current National Cholesterol Education Program Adult Treatment Panel guidelines to elderly patients. B. 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. C. 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. D. 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 carioverter defibrillator devices. E. The GMR differentiates PERIPHERAL VASCULAR DISEASE into arterial and venous categories and articulates current diagnostic and management strategies for each. F. 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 A. The GMR differentiates CHRONIC OBSTRUCTIVE PULMONARY DISEASES into asthma, chronic bronchitis and emphysema to guide management with medications, oxygen therapy and pulmonary rehabilitation. B. 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
  9. 9. A. 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). B. 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 A. The GMR diagnoses THYROID DISEASES in the elderly including hypothyroid, hyperthyroid and sick euthyroid conditions and implements appropriate treatments for management. B. 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. C. 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 A. The GMR diagnoses and manages degenerative conditions of the skeleton such as OSTEOARTHRITIS, SPINAL STENOSIS AND OSTEOPOROSIS evidence based medicine strategies. B. The GMR reviews rheumatologic conditions common in the elderly including POLYMYALGIA RHEUMATIC, TEMPORAL ARTERITIS, and RHEUMATOID ARTHRITIS. C. 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 A. The GMR elucidates a relevant sexual history from older patients and monitors sexual health and function thought out the life span. B. The GMR is sensitive to the impact of chronic disease on sexual function in older patients. C. The GMR evaluates and manages SEXUAL DYSFUNCTION in male and female geriatric patients differentiating organic and psychologic etiologies. D. 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-pharmacologic therapies. References: 18, 2, 3, 6, 8, 9 X. Long Term Care A. The GMF compares and contrasts indications, utilization and limitations along the continuum of care for the elderly highlighting:
  10. 10. 1. Office Based Ambulatory Care – Individual and Group Visits, Primary Care, Multidisciplinary Services and Specialty Care 2. Home Based Care – Physician Home Visits, Home Health Care, Home Services, Home Hospice Services 3. Community Based Care – Senior Centers, Cultural Centers, Faith Based Services, Congregate Housing, Assisted Living, Adult Group Homes, Programs for All Inclusive Care, Custodial Care 4. Institutional Based Care – Subacute and acute levels of Hospital Care and Long Term Care B. The GMR reviews a historical perspective of long term care legislation including: 1. 1935 Social Security Act State oversight to promote quality 2. 1965 Older Americans Act Federal oversight 3. 1983 Institute of Medicine Study: Improving the quality of nursing home care 4. 1997 Omnibus Budget Reconciliation Act Nursing Home Reform Amendments, MDS Minimum Data Set, RAP Resident Assessment Protocols 5. 1999 Federal Medicare Balanced Budget Refinement Act C. 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. D. The GMR reviews medical direction and management in long term care including: 1. Federal and State Regulations 2. Residents’ rights and working with families 3. Quality and risk management 4. 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 A. The GMR appraises historical perspectives on payment for geriatric care in the United States including: 1. 1935 Social Security Act 2. 1965 Older Americans Act including Title III targeting home services, Title XVIII Medicare and Title XIX Medicaid, Title XX Social Services Block Grants 3. 1983 Medicare Hospice Benefit 4. 1991 and 1998 Social Security Act Revisions 5. 2003 Medicare Reform Act. B. 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. C. The GMR contrasts the impact of marriage, gender, longevity and frailty on utilization of health care resources. D. The GMR identifies strengths and weaknesses of current U.S. health care policy predicting challenges and trends for the future. Experiential Domains: ALL References: 45, 10, 11, 12, 32, 33, 36, 37, 81, 84, 2, 3, 6, 8, 9 XII. Ethics and Legal Aspects of Geriatrics A. The GMR distinguishes four levels of medical ethics: 1. Clinical or Patient-Centered
  11. 11. 2. Professional or Physician-Centered 3. Institutional 4. Societal B. The GMR identifies four principles of medical ethics: 1. 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 2. Beneficence: The obligation to do good 3. Non-Maleficence: The obligation to avoid harm 4. Justice: Nondiscrimination - The duty to treat individuals fairly. Distribution - The duty to distribute resources fairly, non-arbitrarily and noncapriciously C. The GMR analyzes ethically charged issues in geriatric care including: D. The GMR utilizes patient, family, institutional and community resources to help resolve medical ethical dilemmas. a. Informed Consent and Informed Refusal b. Decisional Capacity c. Surrogate Decision Making: Hierarchy of Substituted Judgement d. Benefits vs. Burden of Therapies e. Quality of Life f. Life Sustaining Therapies g. Artificial Hydration and Nutrition h. Medical Futility i. Withholding or Withdrawing Therapies j. Physician Assisted Suicide and Euthanasia Experiential Domains: ALL References: 55, 56, 57, 58, 30, 79, 2, 3, 6, 8, 9 XIII. Elder Abuse A. The GMR defines five types of elder abuse and distinguishes the subjective and objective findings to identify each type. B. The GMR integrates screening for elder abuse and caregiver strain into geriatric assessment and clinical care activities. C. The GMR recognizes risk factors for elder abuse in victims and caregivers. D. The GMR employs a multidisciplinary approach for identification, intervention and prevention of elder abuse. E. 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. F. 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 GOALS AND OBJECTIVES: LEADERSHIP DOMAINS I. Leadership Roles in Family Medicine and Geriatrics A. The GMR identifies the multiple levels of leadership opportunities available to family medicine and geriatric physicians including: 1. Direct patient care 2. Clinic and hospital management 3. Patient and professional advocacy 4. Community participation and activism 5. Public Health 6. Administrative Medicine
  12. 12. 7. Professional and Political Organizations at the local, county, state, regional and national level B. The GMR distinguishes important leadership skills in the areas of Communication, Problem Solving, Feedback and Appraisal, Planning and Organization C. 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 A. 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 A. The GMR utilizes current medical informatics to promote evidence based teaching and learning. B. The GMR incorporates theories of adult learning and knowledge of learning styles to develop clinical teaching, precepting and evaluation skills. C. The GMR synthesizes legal concepts for managing resident evaluations, non- reappointment and termination of residents, residents with disabilities and illness issues. D. The GMR incorporates principles of conflict management, negotiation and collaboration to promote an effective workplace environment. E. The GMR conducts a needs assessment to construct a curriculum with instructional objectives, educational strategies and evaluative tools. F. The GMR appreciates current pressures on graduate medical education from a financial and political perspective. Experiential Domains: ALL IV. Clinical Research A. The GMR describes the types of scholarly activities that can result in peer reviewed publication. B. The GMR reviews clinical research design methods comparing and contrasting prospective, retrospective, case studies and randomized controlled studies. C. The GMR acknowledges the role of the Institutional Review Board in reviewing, approving and monitoring research activities. V. Political Activism A. The GMR identifies leadership strategies for political expression including: 1. Public speaking and media involvement (written, aural and visual) 2. Legal advocacy 3. Participation in community and professional organizations 4. Lobbying at local, state and national levels 5. Running for political office EXPERIENTIAL DOMAINS I. CONTINUITY EXPERIENCES The GMR is involved in five longitudinal learning environments: A. Geriatric Continuity Clinic The GMR spends one half day per week providing comprehensive care for a panel of their own continuity geriatric patients. This experience highlights continuity, prevention, geriatric assessment, and management of acute and chronic diseases and
  13. 13. introduction of end of life planning. Through out the year, the GMR may work with family medicine residents and medical students in a teaching and supervisory role during this clinic. Precepting for this experience is provided the ATG Director. B. Geriatric Consulting Clinic The GMR spends one half day per week performing geriatric assessments and consultative services for ambulatory patients referred from outside providers and from other physicians within Swedish Family Medicine (SFM) community. This consultative service promotes education about current evidenced-based geriatric care for patients, their caregivers and for the community physicians requesting consultation. Precepting for the Geriatric Consultation clinic and shared by the ATG Director and two CAQ internal medicine physicians. C. Family Medicine Clinic The GMR spends one half day per week providing comprehensive care for a panel of their own continuity patients and caring for the urgent care needs of same day appointment patients in the SFM system. This experience heightens and maintains the GMR skills in family medicine required for the Certificate of Added Qualifications in Geriatrics. The SFM faculty physicians provide precepting. D. LTC at Bessie Burton Sullivan Skilled Nursing Residence and Kline Galland Home The GMR spends four to eight half days per week managing the acute and long term care of their own patient panels in two facilities. The Bessie Burton Sullivan (BBS) experience combines sub-acute, custodial and dementia care. The GMR is precepted by the Medical Director. BBS is owned and operated by a private non- profit Jesuit university. The Kline Galland (KG) experience highlights dementia and custodial care in a private non-profit organization founded within the Jewish community. Besides direct patient care the GMR provides staff in-service educational events and sits on the quarterly Medical Panel Meetings. There is also a month long rotation at KG working with the Medical Director and the Director of Nursing Services to highlight long-term care administration. The GMR is precepted by the ATG Director and the KG Medical Director. E. ElderPlace This Program for All Inclusive Care (PACE) site incorporates assisted living, adult day services, geriatric medical and multidisciplinary services and acute and long term care for a panel of 200 frail elderly patients. The GMR spend two half days per month at the center providing medical services, participating in the geriatric multidisciplinary team meetings and visiting patients off site in their assisted living and adult family group homes. Two CAQ family medicine physicians and the multidisciplinary staff share precepting. II. HOSPITAL EXPERIENCES The GMR participates in three hospital environments: A. 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. B. 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
  14. 14. medicine. The Director of Rehabilitation Medicine Services provides Precepting and teaching. C. 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. A. 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. B. 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. C. 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. D. 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: 1. The Robert Woods Johnson Palliate Care Residency Training Course 2. Virtual Clinics with Stu Farber, MD 3. Joslin Diabetes Center 4. Movement Disorders Clinic at the VA 5. Group Health Cooperative Geriatric Primary Care Services Research 6. Home Care Physicians 7. The American Medical Directors Association Certification Course 8. The ElderAbuse Council of King County 9. Neurology 10. Rheumatology 11. 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: A. 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.
  15. 15. B. University of Washington Division of Geriatrics and Gerontology a 1. Grand Rounds twice a month b 2. Journal Club once a month c 3. Research Rounds once a month C. Swedish CME Grand Rounds Every Thursday morning a variety of medical topics are presented. The GMR is encouraged to present one SMC Grand Rounds D. 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: A. University of Washington Family Medicine Faculty Development Fellowship The GMR, if selected, can participate in this exceptional training opportunity. 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. B. 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. C. Faculty Attending Call Responsibilities The GMR directs all activities on the Family Medicine hospital service for six weekends during the year. 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. D. 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: 1. 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 2. Geriatric Medicine Consultations The geriatric Consultation services, both inpatient and outpatient provide an avenue for educating referring physicians and the family medicine team. 3. 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. E. 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. F. Swedish Annual Geriatric Medicine Symposium Each GMR prepares a professional presentation on a geriatric topic for this one-day continuing medical education symposium
  16. 16. G. 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. 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. A. 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, B. 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. REFERENCES: 1. Clinics in Geriatric Medicine, Successful Aging: Preventive Gerontology. Feb 2002; 18(3). 2. WR Hazzard, et al. Principles of Geriatric Medicine and Gerontology, 5th Ed. 2003, Mc-Graw- Hill, Pennsylvania. 3. Tallis RC. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology, 6th Edition, Elsemier Science Limited. 4. Physical Change and Aging: A Guide for the Helping Professions, 4th Ed. SV Saxon and MJ Etten, 2002, Tiresias Press, Inc. New York. 5. Improving End of Life Care: A Resource Guide for Physician Education, 3rd Ed. DE Weissman et al., The Medical College of Wisconsin, Inc. 6. Geriatric Review Syllabus 5th Edition, American Geriatric Society 7. www.sma.org.sg/whatsnew/ethics/Y2_S2_suresh.ppt 8. Clinics in Geriatric Medicine, Geriatric Mental Health. Nov 2003; 19(4). 9. Essentials of Clinical Geriatrics, 5th Edition. RL Kane, JG Ouslander, IB Abrass; 2004, McGraw- Hill 10. www.nber.org National Bureau of Economic Research 11. URL: http:papers.nber.org/tmp/5055-w6980.pdf D Lakdawalla and T Philipson: Aging and the Growth of Long Term Care; 1999. 12. URL: http:papers.nber.org/tmp/28068-w6547.pdf D Lakdawalla and T Philipson: The Rise in Old Age Longevity and the Market for Long Term Care 13. Clinics in Geriatric Medicine, Visual and Auditory Challenges. Feb 1999; 15(1).
  17. 17. 14. Clinics in Geriatric Medicine, Death and Dyng. May 2000; 16(2). 15. Clinics in Geriatric Medicine, Alzheimers Disease. May 2001; 17(2). 16. Clinics in Geriatric Medicine, Pain Management. Aug 2001; 17(3). 17. Clinics in Geriatric Medicine, Undernutrition. Nov 2002; 18(4). 18. Clinics in Geriatric Medicince, Sexuality. Aug 2003; 19(3). 19. Clinics in Geriatric Medicine, Osteoporosis. May 2003; 19(2). 20. Clinics in Geriatric Medicine, Falls and Syncope in Elderly Patients. May 2002; 18(2). 21. JAMA 285; 2486, 2001. National Cholesterol Education Program Adult Treatments Panel III NCEP-ATP III) 22. JAMA 2003; 289; 2560-2573. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure VII . 23. J Am Coll Cardiol 38:2101, 2001. ACC/AHA Guidelines for the evaluation and management of CHF in the adult: Executive Summary. 24. Barnes PJ: Medical progress: Chronic obstructive pulmonary disease. N Engl J Med 343(4):269, 2000. 25. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease. NHLBI/WHO workshop report. Global Initiative for Chronic Obstructive Lung Disease. NHLBI Publication No. 270. 2001. 26. Am J Respir Crit Care Med 161;646,2000. Idiopathic pulmonary fibrosis: Diagnosis and treatment. International consensus statement. American Thoracic Society (ATS) and the European Society (ERS). 27. Selman M et al: Idiopathic pulmonary fibrosis: Prevailing and evolving hypotheses about its pathogenesis and implication for therapy. Ann Intern Med 134:136, 2001. 28. Katz PR, Kane RL, Mezz MD. Advances in Long Term Care Vol. 1, 1991 29. Hawes C. Institute of Medicine: Improving the quality of Nursing Home care, 1983 30. Jecker NS. Aging and Ethics: Philosophical Problems in Gerontology, Humana Press, 1992. 31. www.ijic.org/publish/articles/000132/ Wiener JM and Tilly J. End-of-Life Care in the Unites States: Policy issues and model programs of integrated care. 32. Hogan C, Lunney J, Gabel J and Lynn J. Medicare beneficiaries’ cost of care in the last year of life. Health Affairs, 2001; 20(4): 188-195. 33. Spillman R, Lubitz J. The effect of longevity on spending for acute and long-term care. NEJM, 2000; 342(19): 1409-1415. 34. www.aoa.gov/about/legbudg/oaa/legbudg_oaa.asp 35. Bedzine RW, Rubenstein LZ, Snyder L. Medical Care of the Nursing Home Resident: What physicians need to know. American College of Physicians, 1996. 36. Ahmed A and Sims RV. Demographic characteristics of U.S. nursing homes and their residents: Highlights of the national nursing home survey, 1995. Annals of Long Term Care, 2000; 8(11). 37. Feder J, Komisar HL, Niefeld M. Long term care in the U.S.: An Overview. Health Affairs; 19(3). 38. Ettinger WH. The business of medicine: The Balanced Budget Act of 1997: Implications for the medicine of geriatric medicine. JAGS, 1998; 46(4). 39. Boult C. Long term care in its infancy. JAGS, 1999; 47(2). 40. Ouslander JG, Osterweil D, Morley J. Medical care in the nursing home, 2nd Ed; McGraw-Hill, 1997. 41. www.elderabusecenter.org 42. www.metrokc.gov/proatty/Elder/Index.htm 43. www.preventelderabuse.org 44. www.aoa.gov/prof/notes/Docs/Elder_Abuse_Neglect.pdf 45. Evashwick CJ. The Continuum of Long-Term Care 2nd Edition, Delmar Thompson Learning. 46. The Geriatric Assessment Binder, collected readings on geriatric assessment. 47. www.clinicalevidence.org, Cardiovascular websites 48. www.acc.org, American College of Cardiology 49. www.cdc.gov/health/cardiov.htm Centers for Disease Control
  18. 18. 50. www.usc.edu/isd/locations/science/gerontology/web_resources.htm. 51. Healthy People 2010, www.healthypeople.gov/document/ 52. United States Preventative Services Task Force, www.ahcpr.gov/clinic/uspstfix.htm 53. Immunizations, http://www.cdc.gov/incidod/hip/GUIDE/immune.htm. 54. End of Life/Palliative Education Resource, www.eperc.mcw.edu 55. Jonsen AR. Clinical Ethics: a practical approach to ethical decisions in clinical medicine. McGraw-Hill/Appleton & Lange; 5th Edition (May 22, 2002). 56. AMA Code of Ethics on PDA, www.ama-assn.org/go/ceja. 57. On Line Fellowship in Physician Ethics and Professionalism, www.ama-assn.org/go/ife. 58. Code of Medical Ethics On Line Courses, www.ama-assn.org/go/erc. 59. AFFP Medical Quality Clearing House, http://www.aafp.org/quality/. 60. Agency for Healthcare Research & Quality, www.ahrq.gov. 61. Clinical Medicine Guidelines, www.guidelines.gov. 62. Cochrane Library, www.update-software.com/clibng/cliblogon.htm. 63. Evidence Based Medicine Resource Center, www.ebmny.org. 64. Institute of Medicine www.iom.edu/search_results 65. Institute of Medicine Crossing the Quality Chasm, www.nap.edu/books/0309072808 66. Institute of Medicine To Err is Human, www.nap.edu/readingroom. 67. Leapfrog Group, www.leapfroggroup.org. 68. Yudofsky SC, Hales RE. Synopsis of Neuropsychiatry; American Psychiatric Publishing, Inc. 69. Wyszynski AA. A Case Approach to Medical-Psychiatric Medicine; American Psychiatric Publishing, Inc. 70. Hay RM, Kraft G, Stolov WC. Chronic Disease and Disability: A Contemporary Rehabilitation Approach to Medical Medicine; Demos, New York, 1994. 71. Kauffman TL. Geriatric Rehabilitation Manual; Churhill Livingson, May 1994. 72. Spratt JS, Hawley RL, Haye RE. Home Health Care: Principles & Medicine. 73. Means to An End: A Report on Dying in America. www.lastacts.org/files/misc/meansfull.pdf. 74. Austin BJ, Fleisher LK. Financing End of Life Care: Challenges for an aging population. www.hcfo.net/pdf/eolcare.pdf. 75. Curriculum of Primary Care Geriatrics AND Annotated Syllabus of Geriatric References, Geriatric Educational Resources for Residency Training in Family Medicine and Internal Medicine, The John A. Hartford Geriatric Consortium for Residency Training, Stanford University Geriatric Education Resource Center. 76. www.dent.ucla.edu/2001/Geriatric3.htm. 77. Journal of Applied Physiology issues October through December 2003 feature Highlighted Topics on Physiology of Aging including Theories of aging, Aging and sarcopenia, Aging and energy balance, Pathogenesis of osteoporosis, Aging and the cardiovascular system, Aging and human temperature regulation. 78. Gordis, L. Epidemiology, 2nd Edition, 2000,WB Saunders Company. 79. Hayley DC, Cassel CK, Snyder L. Ethical and legal issues in nursing home care. Arch Intern Med. 156(3):249-256. 80. Rodheaver GT. Pressure ulcer debridement and cleansing: A review of current literature. Ostomy/Wound Management, Vol. 45, No. 1A, 80S-85S; January 1997. 81. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Programof all-inclusive care for the elderly (PACE): An innovative model of integrated geriatric care and financing; JAGS 45:223-232, 1997. 82. Stahl SM. Essential Phsychpharmacology 83. Boult C, et al. Outpatient geriatric evaluation and management. JAGS; 46:296-302, 1998. 84. Abromovitz, L. Long term care insurance made simple. Health Information Press, 1999.
  19. 19. HISTORY 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 2005 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 medicine teachers.  To prepare family medicine geriatric specialists for a life long career of learning and critical analysis. PROCEDURES AND POLICIES 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. VACATION Fellows are eligible for 15 working days of paid vacation. Vacation scheduling should be cleared with the AFG director to ensure adequate patient coverage. CONTINUING MEDICAL EDUCATION 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 (ILLNESS, INJURY, AND COMPLICATIONS OF PREGNANCY) 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. MEDICAL CARE OF FELLOWS AND THEIR FAMILIES Fellows may not select a Swedish family medicine resident or faculty member for their own or their family's medical care. PROCEDURES AND POLICY
  20. 20. GRATUITIES AND FEES 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. MOONLIGHTING Geriatric Fellows are independent licensed physicians and may medicine outside of the fellowship. They must demonstrate adequate medical malmedicine 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. ACGME Duty Hours Rule: "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." SWEDISH FAMILY MEDICINE CLINIC 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 medicine that 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 CONTINUITY AND CONSULTING CLINIC PRECEPTING 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 CONSULTATIONS AND HOSPITAL ADMISSION 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 Medicine Service residents are
  21. 21. 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 medicine team and the geriatric preceptor should be done before their 9:30am work rounds. COVERAGE FOR GERIATRIC FELLOW PATIENTS 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 Medicine 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. BACKUP ARRANGEMENTS IN CARE OF ILLNESS OR EMERGENCIES 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. Restraint Policy Swedish Medical Center is committed to providing a safe environment for all patients. Swedish seeks to provide that environment by first ensuring that care has been given to resolve physiologic, psychosocial and environmental factors that might place patients at risk for harm to themselves or others. If the patient remains at risk after these interventions have been put into place, restraints used are the least restrictive as possible for as short a time as possible and at all times are used with respect to the patient's rights and dignity. A Registered Nurse will initiate the patient safety protocol in the plan of care for the following reasons: 1. The patient is at risk of harm to self or others. Risk is identified during the patient assessment process when the patient exhibits problems or significant findings. 2. The patient is at risk to disrupt necessary treatment, such as the patient pulling out a urinary catheter, IV, nasogastric tube or endotracheal tube. A physical order is not required to initiate this protocol; however, a physician must personally assess the patient at least every 24 hours. Verbal Orders If a Clinician orders restraints, a time limited verbal or written order is required. Verbal orders must be signed within 24 hours. The order will include the reason for the restraint, type of restraint, duration of order including a start time and end time (not to exceed 24 hours) and will indicate if the order is an initial restraint order or a reorder. A new ordered is required if a physician orders re- application of a restraint when the patient has been restraint free greater than 60 minutes and/or behavior is not related to the original episode. 13.1 Postmortem Policy. It shall be the policy of the Hospital and Medical Staff that a postmortem examination will be actively utilized as a quality management mechanism. 13.2 Permission. The Attending Practitioner or his/her designee is expected to request permission for an autopsy in the event of a death which meets the criteria specified herein. If permission cannot
  22. 22. be obtained from the family (or guardian) in such death, that fact will be documented in the medical record. 13.3 Criteria for Autopsies. 13.3.1 General Criteria. An autopsy shall be requested: a. When the attending Practitioner desires to have one conducted for clinical reasons. b. When a death is unexplained or unexpected. 13.4.1 Autopsy Performance. a. The Pathology Department shall perform all autopsies that meet the specified criteria for which valid permission has been obtained. b. The pathologists, in conjunction with the attending Practitioner, shall have the authority to perform limited autopsies, depending upon the circumstances of the individual cases. c. A postmortem examination will be performed within 48 hours of the time that the Pathology Department receives a legal and valid permit. 13.4.2 Autopsy Reporting. a. Preliminary or provisional reports of every autopsy will be provided within two (2) days of the time the gross examination is performed. b. Final autopsy reports shall be completed and forwarded within 60 days of the gross examination. c. The autopsy report will be sent to the Attending Practitioner, the health information services department and any other treating Practitioner who requests a report. d. The Pathology Department will report annually to the Medial Staff's Quality Management Committee regarding Postmortem Examination activities. Patient Record System According to the RRC: The FPC patients' records must be maintained in the FPC for easy and prompt accessibility at all times. The record system should be designed to provide information on patient care ad the Fellows' experience. These records must be well maintained, legible and up-to-date, ad should document the patient's primary physician. The record system must provide the data for patient care audit and chart review of all facets of family care, including care rendered in the FPC, in the hospital, at home, by telephone, through consultations, and by other institutions. Protocol for Caring for Agitated/Disruptive Patients If the patient/family is verbally and/or physically disruptive, the staff providing care should notify their administrative supervisor, the clinic manager. The role of the administrative supervisor is to coordinate resource needs and administrative communication. The supervisor may wish to call Security for help and ongoing security support by dialing 3000. Security can be asked to come to the clinic or stand by on alert.
  23. 23. If the patient has a social worker, notify the social worker to work with the clinic team in developing interventions as well as to help assess patient-family situation. In an acute emergency, 911 should be called. Medicare Patients CLINIC 1. Fellows cannot bill as primary physician for Medicare. The hospital receives Graduate Medical Education passthrough funds from Medicare for each Fellow. 2. All NEW Medicare patients billed at CPT level 99203 or less, the preceptor does not have to physically see the patient, the orange form must be completed and preceptor name dictated into the medical record. Fellow bills under appropriate preceptor. 3. All NEW Medicare patients, billed at CPT level 99204 or more, must be seen by the attending preceptor, an orange billing slip is prepared and preceptor's name dictated into medical record. Fellow bills under appropriate preceptor. 4. For established Medicare patients billed at CPT level 99213 or less, the preceptor does not have to physically see the patient, the orange form must be completed and preceptor name dictated into the medical record. Fellow bills under appropriate preceptor. 5. For established Medicare patients billed at CPT level 99214 or more, the preceptor must physically see the patient, prepare the orange form and the preceptor name is dictated into the medical record. Fellow bills under appropriate preceptor. 6. All consultations must be seen by preceptor billed as #3,5 HOSPITAL 1. Fellows cannot bill as primary physician for Medicare patients. 2. For all hospital admissions, consults, subsequent care an attending preceptor must see the patient with in 24 hours, review the fellows care plan and bill appropriately for services rendered. Attending physician preceptor bills for all hospital care. NURSING HOME 1. Fellows cannot bill as primary physician for Medicare patients. 2. Attending preceptor must be available at the time of visit to render charges. 3. Fellow sees the patient, reviews care plan, preceptor reviews and sees patient as indicated, documents visit in the chart along with the fellows note. Fellows bill under appropriate preceptor. Non-Medicare Patients When the Fellow is precepting or seeing patients that are not part of the geriatric fellowship the clinic can bill for his services under that Fellow's physician billing code. TEACHING PHYSICIAN SERVICES MEDICARE BILLING
  24. 24. Physician Presence Requirement The general rule set forth in the teaching physician policy is that the teaching physician should be present during any services in which he or she involves a resident for which carrier payment will be sought. The instructions that follow address situations in which the teaching physician may bill for services or procedures in which he or she is not present for the duration of the service for procedure. Evaluation and Management (E/M) Services: The teaching physician must be physically present during the portion of the service that determines the level of E/M service billed. The teaching physician must personally document his/her presence and participation in the services in the medical records, either in writing or via a dictated note. Documentation should be expressed in the following manner for these major categories of E/M service: 1. Initial Hospital Care, Emergency Department Visits, Office Visits-New Patients, Office Consultations or Hospital Consultations A personal notation must be entered by the teaching physician documenting his or her participation in the three key components of these services (e.g., history, examination and medical decision making). If the teaching physician is repeating key elements of the service components obtained previously and documented by the resident (e.g., the patient's complete history and physical examination), the teaching physician need not repeat the documentation of these components in detail. Rather, the documentation of the teaching physician may be brief, summary comments that tie into the resident's entry and which confirm or revise the key elements. Therefore, the documentation of the key elements may be satisfied by the combination of entries into the medical records made by the resident and the teaching physician. The key elements include: • Relevant history of present illness and prior diagnostic tests, • Major finding(s) of the physical examination, • Assessment, clinical impression or diagnosis, and • Plan of care. 2. Subsequent Hospital Care, Office Visits-Established Patient A personal notation by the teaching physician must be entered highlighting two of the three key components of these services (e.g., history, physical examination and medical decision- making). Again, if key elements are repeated by the teaching physician, documentation may be handled as outlined in the preceding instructions (see 1 above). Procedures In order to bill for surgical, high-risk or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure. 1. Surgery (Including Endoscopic Operations) The teaching surgeon is responsible for the pre-operative, operative and post-operative care of the beneficiary. The teaching surgeon may determine which post-operative visits are to be considered "key" and require his or her presence. During the period in which the teaching surgeon does not have to be physically present, he or she should remain immediately available to return to the procedure. If the teaching physician leaves the operating room after the key portion(s) of the surgical procedure or during the closing of the surgical field to become involved in another surgical procedure, he or she must arrange for another physician to be immediately available to intervene in the original case should the need arise, in order to bill for the original procedure. A. Single surgery: When the teaching surgeon is present for the entire period between the opening and closing of the surgical field, his or her presence may be demonstrated by notes in the medical records made by the physician, resident, or
  25. 25. operating room nurse (there is no required information that the teaching surgeon must enter into the medical records). B. Two overlapping surgeries: In order to bill for two overlapping surgeries, the teaching surgeon must be present during the key portions of both operations. Therefore, the key portions may not take place at the same time. When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure. The teaching surgeon must personally document the key portion of both procedures in his or her notes to demonstrate that he or she was immediately available to return to either procedure in the event of complications. Note: In the case of three concurrent surgical procedures, the role of the teaching surgeon is classified as a supervisory service to the hospital and may not be billed as a physician service. 2. Anesthesia The teaching physician must be present during induction, emergence and any other portion of the procedure payable on a time basis. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a non-physician anesthetist, the anesthesiologist should bill his/her services as medical direction (modifier QK). The medical records must document the teaching anesthesiologist's presence or participation in the administration of the anesthesia. The teaching physician's presence is not required during the pre- or post-operative visits with the beneficiary. 3. Endoscopic Procedures In order to bill for procedures performed through an endoscope, the teaching physician must be present during the entire viewing (which includes insertion and removal of the device). Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement. 4. Interpretation of Diagnostic Radiology and Other Diagnostic Tests If a resident prepares and signs the interpretation of diagnostic radiology and/or other diagnostic tests, the teaching physician must indicate that he or she has personally reviewed the image and the resident's interpretation and either agrees with it or edits the findings. A countersignature alone on the interpretation is not sufficient documentation for payment. 5. Psychiatry The teaching physician supervising the resident must be a physician. The teaching physician presence requirement may be met by concurrent observation of the service by use of a one- way mirror or video equipment. Audio-only equipment does not meet this exception to the physical presence requirement. 6. Time -Based Codes For procedure codes specifying time, the teaching physician must be present for the period of time for which the claim is made. For example, a code that specifically describes a service of from 20 to 30 minutes is payable only if the teaching physician is present for 20 to 30 minutes. Time spent by the resident in the absence of the teaching physician or time spent by the teaching physician alone with the beneficiary cannot be added to meet the amount of time specified by the code. Examples of codes that fall into this category include: • Individual medical psychotherapy (CPT 90804-90829), • Critical care services (CPT 99291-99292), • E/M codes in which counseling and/or coordination of care dominates (more than 50%) of the encounter and time is considered the key or controlling factor to qualify for a particular level of E/M service, • Prolonged services (CPT 99354-99359), • Care plan oversight (CPT 99375), or • Anesthesia. 7. Other Complex or High-Risk Procedures
  26. 26. In the case of complex or high-risk procedures for which the CPT description and/or medical policy specify personal (in person) supervision of the procedure's performance, the teaching physician must be present with the resident for the service to be payable under Medicare. These procedures include: • Interventional radiologic and cardiologic supervision and interpretation codes, • Cardiac catheterization, • Cardiovascular stress tests, or • Transesophageal echocardiography. 8. Maternity Services The physician presence requirement for both vaginal and Cesarean delivery applies like any other surgery. If the teaching physician's only involvement was at the time of delivery, the teaching physician should bill the delivery-only code. He/she must be present for the delivery. In order to bill for the global procedures, the teaching physician must be present for the minimum indicated number of visits when such a number is specified in the description of the code. 9. Election of Costs for the Services of Physicians in a Teaching Hospital A teaching hospital may elect to receive payment on a reasonable cost basis for the direct medical and surgical services of its physicians in lieu of fee schedule payments for such services. All physicians who render covered Medicare services in the hospital must agree in writing not to bill charges for such services, or if the physicians are employees of the hospital, they must, as a condition of employment, be precluded from billing such services. When the hospital elects payment on a reasonable cost basis, Medicare payments are made exclusively by the hospital's intermediary and fee schedule payment is precluded. 10. Assistant at Surgery Services Furnished in Teaching Hospitals When a teaching hospital has a training program related to the medical specialty required for a surgical procedure, no payment can be made for the services of assistants at surgery if a qualified resident was available to perform the services. However, under certain exceptional circumstances (e.g., emergency, life-threatening situations which require immediate treatment), payment may be made for the services of a physician assistant at surgery even though a qualified resident is available. 11. Multiple Physician Specialties Involved in Surgery In situations requiring team surgery, payment is made in the form of a single team fee, on a "by report" basis. When the services of physicians of different specialties are necessary during surgery and each specialist is required to play an active role in the patient's treatment because of the existence of more than one medical condition requiring diverse, specialized medical services, the physician furnishing the concurrent care is functioning at a different level than that of an assistant at surgery. Payment is made in such cases on a regular fee schedule basis. Exception to Physician Presence Requirement Teaching physician claims for services furnished by residents without the presence of a teaching physician are payable for certain low and mid-level E/M services (CPT codes 99201-99203 and 99211-99213) when all of the following conditions are met: 1. The services must be furnished in a center located in the outpatient department of a hospital or another ambulatory care entity in which the time spent by residents in patient care activities is included in determining intermediary payments to a hospital. This requirement is not met when the resident is assigned to a physician's office away from the center or makes home visits. 2. Any resident furnishing the service without the presence of a teaching physician must have completed more than six months of an approved residency program. 3. The teaching physician in whose name the payment is sought must not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability. The teaching physician must:
  27. 27. • Have no other responsibilities at the time of the service for which payment is sought. • Assume management responsibility for those beneficiaries seen by the residents. • Ensure that the services furnished are appropriate. • Review with each resident during or immediately after each visit, the beneficiary's medical history, physical examination, diagnosis and record of tests and therapies. • Document the extent of his or her own participation in the review and direction of the services furnished to each beneficiary. 4. The patients seen must be an identifiable group of individuals who consider the center to be the continuing source of their health care and in which services are furnished by residents under the medical direction of teaching physicians. The residents must generally follow the same group of patients throughout the course of their residency program, but there is no requirement that the teaching physicians remain the same over any period of time. 5. The range of services furnished by residents includes all of the following: • Acute care for undifferentiated problems or chronic care for ongoing conditions including chronic mental illness. • Coordination of care furnished by other physicians and providers. • Comprehensive care not limited by organ system or diagnosis. The types of residency programs most likely to qualify for the primary care exception include: Family Medicine, General Internal Medicine, Geriatric Medicine, Pediatrics, TEACHING PHYSICIAN SERVICES CLARIFICATION – ‘FELLOWS’ Background Many questions have been raised concerning Medicare's payment policy for the services of 'fellows.' Because the term 'fellows' can be assigned to different individuals for different reasons, the relationship between the teaching physician policy and the service of 'fellows' is unclear. CMS has provided the following clarification regarding the payment policy for individuals designated as 'fellows' under various conditions. 'Fellows' in an Approved Program As defined in 42 CFR 413.86(b), a resident means an intern, resident, or fellow who participates in an approved medical residency program including programs in osteopathy, dentistry and podiatry. That section defines an "approved medical residency program" as including: • A program approved by 1 of 4 national organizations cited in 42 CFR 415.152, • A program that counts toward certification in a specialty or subspecialty listed in either the Directory of Graduate Medical Education Programs published by the American Medical Association (AMA) or the Annual Report and Reference Handbook published by the American Board of Medical Specialties (ABMS), or • A fellowship program in geriatric medicine approved by the Accreditation Council for Graduate Medical Education (GME). Thus, a 'fellow' who is in a program meeting any of the preceding criteria is considered a resident in an approved program. Under the law, the costs associated with the services of the resident in an approved program in a hospital are payable as hospital services. It does not make any difference whether or not the hospital incurs compensation costs for the services of the resident. The hospital is entitled to receive direct GME payments for the time the resident or fellow spends working in the hospital (including all inpatient and outpatient settings that are a part of the hospital). For example, if the services are furnished in a clinic that is a part of the hospital, such as a component of the hospital outpatient department, the services are payable through the direct GME payment mechanism. The
  28. 28. teaching physician presence policy would apply to any services in which residents are involved for which the teaching physician seeks carrier payments. If there is no such agreement under which the time in the nonprovider setting is included in the direct GME count and the resident or fellow is fully licensed, the resident or fellow's services in the nonprovider setting may be covered and billable as physician services. The claims may be billed by the fellow or reassigned to the fellow's employer. Thus, there is more flexibility regarding the way the services of a fellow are paid outside the hospital setting. 'Fellows' Not in Any Formally Organized Program The services of individuals designated as 'fellows' who are not in any formally organized training program and who are fully licensed to medicine are payable as physician services. This category includes those who have completed all residency programs but who are staying at the teaching hospital/medical school complex for a variety of reasons such as faculty appointment or to develop/refine their skills outside the context of a residency program. The teaching physician presence policy does not apply to their services because these individuals are furnishing services in the capacity of physicians. The policy was adopted in the preamble to the direct GME payment regulation, published on September 29, 1989 (54 FR 40295). 'Fellows' in an Unlisted Program Many questions pertain to the status of 'fellows' who have completed a general residency program and who are in subspecialty programs not listed in either the AMA or the ABMS publications. The questions generally address the following issues: • Whether the teaching physician presence policy applies to services furnished by these individuals, • Whether services furnished by licensed 'fellows' in these programs are payable as physician services, • Whether the policy in 42 CFR 415.202, "Services of residents not in approved GME program," or applies to their services. Payment for 'fellows' in these unlisted programs cannot be made under the direct GME payment mechanism because the programs do not meet the definition of an approved program in Section 413.86(b). However, CMS has determined that the policy in Section 415.202 is also inappropriate to apply to these situations. Section 415.202 (formerly 405.523) was established in the early days of Medicare to reimburse hospitals for the costs they incur in connection with services furnished by medical school graduates who had not yet been accepted into an approved residency program and who, in many cases, had a limited license. Under that policy, the intermediary pays 80 % of the costs incurred by hospitals for the services of these physicians under Part B. This provision was not established for the purpose of reimbursing hospitals for the costs associated with individuals who have successfully completed their approved residency programs and who have gone on to additional, more specialized training in their fields. In fact, many of the 'fellows' who fall in this unlisted program category may receive their compensation from a faculty medicine plan or some other entity other than a hospital so there would be no reimbursable payments to the hospital. CMS is in no position to make judgments about the status and quality of such programs vis-à-vis approved fellowship programs, which would inevitably be the case if they determined that, after successful completion of an approved program, an individual is reclassified from a resident in an approved program to a resident not in an approved program. CMS has determined that such reclassification would be inappropriate and not in keeping with that individual's status as a highly trained physician. Therefore, the policy on individuals who have successfully completed one or more residency programs and who are in another subspecialty program which does not meet the definition of an approved medical residency program in section 413.86(b) is that their services are covered as physician services payable under the physician fee schedule. It is believed that virtually all physicians who fall into this category would be fully licensed, however, if this were not the case, for whatever
  29. 29. reason, it might be appropriate to classify the individual as a resident not in an approved program under Section 415.202. Moonlighting 'Fellows' Services of moonlighting residents (which would include 'fellows' in an approved program) are defined in 42 CFR 415.208 as services that licensed residents perform outside the scope of an approved GME program. Services are often performed in settings away from the site of the resident or fellow's training activities and may be payable as physician services under the physician fee schedule. In addition, moonlighting by a resident or fellow in the outpatient or emergency department of his or her program hospital may be payable under the physician fee schedule if certain conditions are met. This policy has been in the MCM Section 2020.8 for many years, and it had been many years since a question had been received on the policy until it was codified in the regulations (415.208(b)(2)) in connection with the final rule addressing teaching physician policy. However, the nature of the questions being asked seems to indicate that this provision is being explored by hospitals and faculty medicine plans as a potential means of averting the physician presence policy of the teaching physician rules. While it is possible to moonlight in one's program hospital, the following considerations should be taken into account in these situations. CMS feels that a residency program (including approved fellowship programs) in a hospital is generally a full-time activity that would include such elements as "on-call" time and the training of junior residents and others as well as the learning activities of an individual resident or fellow. In developing the direct GME payment policy, Medicare did not establish a standard number of hours that constitutes a full time employee (FTE) in an approved resident program. It was recognized that programs would vary from specialty to specialty and hospital to hospital in this regard. There was a presumption that everything a resident did in the hospital was related to the residency program and no resident's activities could exceed 1.0 FTE. Therefore, moonlighting services furnished by a resident in the same hospital that includes him or her in its FTE count must be based on evidence that the services are furnished during off-hours and that rebuts the presumption that the services are being furnished as a part of the requirements of a residency or fellowship program (Refer to 42 CFR 415.208(b)(2)). The following moonlighting situations may be appropriate for billing outside the scope of one's training program: PROVIDER ENROLLMENT PROCESS Unique Provider Identification Number (UPIN) Section 9202 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA 85) requires the CMS to establish an UPIN for each practitioner who provides services for which payment is made under Medicare. When our office receives a completed PIN application for a new practitioner, the practitioner information is automatically transferred to National Heritage Insurance Company (NHIC) who then issues a UPIN for that practitioner. The UPIN enables CMS to collect and combine payment and utilization information for an individual practitioner even when they have multiple medicine settings or are members of a group medicine. The primary use of this information is to performstatistical analysis and research studies of practitioner payments and utilization. One six-digit, alpha-numeric UPIN is assigned to each practitioner regardless of the number of medicine settings he is involved in and whether in solo or group medicine. The UPIN remains the same throughout the practitioner's Medicare affiliation regardless of medicine location. The UPIN differs from the carrier assigned PIN and is reported on claims for referred or ordered services and/or diagnostic tests. The full name and UPIN of the referring or ordering practitioner must be furnished in Items 17 and 17a on the CMS-1500 claim form (or appropriate electronic claim fields). For independently practicing physical therapist (PT) and occupational therapist (OT) services, the UPIN of the attending physician and the date last seen should be reported in Item 19 on the CMS-1500 claim form or appropriate electronic equivalent. A referring physician is one who wants the specialized advice or treatment from one of his colleagues. The physician doing the referring usually
  30. 30. sends a letter or referral form to the practitioner the patient will be seeing. Common examples of referral are medical, laboratory, pathological or radiological tests and psychological consultations. An ordering/prescribing physician is one who requests that another provider perform a service (usually highly specialized). The ordering physician completes a prescription form or writes a letter to the specialized provider to inform him of the specific service to be rendered. Common examples of services that are ordered are radiology, pathology, audiology, physical therapy, orthotic and prosthetic devices and durable medical equipment. When ordering or referring services, providers should provide ICD-9-CM diagnosis codes to the performing entity. In addition, if it is believed that the service might be denied because it does not meet the medical necessity criteria outlined in Medicare's medical policies, a signed Advanced Beneficiary Notice (ABN) should be obtained and forwarded to the performing entity. Examples of services that require completion of the referring or ordering physician's full last name and first name (all that will fit in Item 17 on the CMS-1500 claim form) and UPIN (Item 17a on the CMS-1500 claim form) include: • Consultative services, (Refer to the Claim Reimbursement Overview for information regarding billing for consultations.) • Radiological services, • Radiation therapy services, • Nuclear medicine services, • Pathological services, or • Other services and diagnostic procedures performed on the basis of a physician's order (e.g., audiometric testing or psychological testing). In addition, the following suppliers must provide ordering physician data (full name and UPIN) for ordered services which they render and bill to Medicare: • Durable Medical Equipment Companies. • Orthotics/Prosthetics Suppliers. • Independent Laboratories. • Portable X-ray Suppliers. or • Independent Diagnostic Testing Facilities (IDTFs) Note: A physician providing diagnostic services to his own patient must report himself as the referring/ordering physician. For example, during the course of an office visit, Dr. Jones takes a chest X-ray and performs a complete blood count (CBC) for an established patient. Doctor Jones reports his name and UPIN in Items 17 and 17a on the CMS-1500 claim form as the ordering physician. The rest of the claim would be completed as usual, with Dr. Jones also being identified as the performing physician. CMS has provided CD-ROM UPIN directories to all Medicare carriers. Refer to the 'Contact Us' section of this CD ROM for information on ordering the UPIN Directory. If you do not have a directory, the next best source for obtaining a UPIN is from the referring/ordering physician or the Enrollment section of the NAS Website, www.noridianmedicare.com. As a courtesy to those accepting orders/referrals, physicians may wish to provide their UPINs on any written requests for services/supplies. If you are unable to obtain a UPIN from the directory, Website, or the referring/ordering physician, you may contact Medicare Part B for this information. Please have the referring/ordering physician's full name and address ready when you call. Some situations exist in which a physician has not yet been, or may never be, issued a UPIN. For these situations, CMS has developed surrogate UPINs to be used on claims for which a referring physician is needed. All surrogate UPINs consist of three letters followed by three zeros. A surrogate UPIN should be used only if the physician is one of the types in the following list and only if the physician has not been issued a UPIN as a result of his affiliation with another medicine (such as a private or clinic medicine): 1. Residents, interns and 'fellows' will be issued UPINs sometime in the future. Until then use RES000.
  31. 31. 2. Physicians who will not be issued UPINs are as follows: VAD000 Use for physicians employed by the Veterans Administration, who have not been issued a UPIN. PHS000 Use for physicians employed by the Public Health Service, who have not been issued a UPIN. NPP000 Effective January 1, 1999 use of this surrogate UPIN has been discontinued NPs, CNSs and PAs. These practitioners have been issued UPINs to use when they order medical services or refer patients to Medicare providers without the approval or collaboration of a supervising physician may still be used for other practitioners, e.g., CNM, clinical psychologists, as appropriate. RET000 Use for physicians who retired prior to being issued a UPIN. OTH000 Use for nonphysician practitioners or for providers who have not yet been issued a UPIN. Note: Claims received with surrogate numbers will be tracked and are potentially subject to audits. Reporting Changes to Provider Enrollment Effective November 1, 2001, the Centers for Medicare & Medicaid Services (CMS) issued new enrollment applications for Medicare Part B providers/suppliers (hereafter known as “providers”). There are now three different application forms used by Medicare Part B: • CMS 855B: Application for Health Care Suppliers that will Bill Medicare Carriers • CMS 855I: Application for Individual Health Care Practitioners • CMS 855R: Application for Individual Health Care Practitioners to Reassign Medicare Benefits These forms may be obtained from NAS’ website, www.noridianmedicare.com/provider/enrollment, or by contacting Provider Enrollment at (888) 608-8816. The following is a basic guide designed to help providers identify which form(s) apply to their office. Provider Enrollment can assist with questions on which forms are required for your particular circumstance or with questions on how to complete a specific section of the application. CMS now requires that any individual, group or organization making a change to their pay-to address without an initial enrollment application (CMS 855) on file must complete one in its entirety before a change is made to the pay-to address. In general, if you or your organization enrolled prior to 1998, this may affect you. CMS requires you to notify Medicare within 90 days of any changes regarding your provider enrollment information. To update your file, submit the appropriate form to NAS. To make changes, use the application used when you initially enrolled. Some changes require issuance of new Provider Identification Numbers (PINs). These include: • In the states of AZ, NV, OR and WA, some address changes could result in the issuance of a new PIN. Therefore, if your medicine location results in a move to a different county, please contact our office prior to submitting the 855I to find out if this might apply to you. • For the states of AZ, AK, NV, HI , IA, ND, NV, OR, SD, WA and WY, when changing Tax IDs, all providers are required to re-enroll for a new Provider identification Number (PIN). For more information, visit the Noridian Medicare website at: http://www.noridianmedicare.com
  32. 32. MANAGING THE RESIDENT IN DIFFICULTY: GUIDE TO DUE PROCESS AT SWEDISH FAMILY MEDICINE 1. THE ADVISOR PROGRAM A. Healthy growth of the resident is the primary goal of our training program. We are committed to facilitating the development of a family physician who is competent, committed, and compassionate. B. Regular feedback on performance is essential in order to provide realistic assessment and assistance should difficulties arise. The role of the advisor is to act as a spokesperson for the faculty and to provide assistance and support to the resident throughout the program. Advisors should attempt to provide feedback as soon as possible when a problem is identified. C. The advisor’s principle role is supportive rather than disciplinary. 2. THE EVALUATION PROCESS A. Initial Problem Identified 1. All residency personnel are encouraged to provide direct feedback to residents on a daily basis regarding routine concerns. 2. When problems are more serious, or of a repetitive nature, the resident’s advisor should be notified without delay. This will initiate the first step of the evaluation process, involving information gathering. The resident will be informed that this process has been initiated. 3. As soon as possible, the advisor will inform the faculty and chief resident that this process has been initiated. 4. Step B is initiated if the problem is not resolved within 30 days. 5. Observation, probation, or suspension may be immediately initiated during this stage if a problem is identified that is deemed sufficiently serious. B. Observation Cycle 1. Specific assignments or guidelines will be prescribed by the advisor with faculty input. The chief resident will be part of these discussions in order to provide input and information that my have bearing on the resident’s case. 2. The period of this observation should be from 1-3 months, preferably 1 month. 3. Feedback will be provided monthly. 4. If the problem is not resolved, the issue becomes probationary. APPENDIX
  33. 33. 5. Probation or suspension may be immediately initiated during this stage if a problem is identified that is deemed sufficiently serious. 6. Successful completion of observation requirements will result in reinstatement of the resident in good standing. If the problem recurs following completion of the observation period, the faculty will determine an appropriate level of intervention. 7. Any problem which reoccurs after two observation cycles automatically becomes probationary. 8. If certain of the observation requirements have been satisfied, but others remain problematic, the faculty has the option of extending the observation period to allow for completion of the remaining requirements. 3. THE PROBATION PROCESS A. Probation Cycle 1. Resident issues that lead to probation are by definition those that have failed observation or infractions deemed serious enough to warrant probation. Failure of a rotation, unprofessional behavior, or significant breach of standard of care are examples of events that alone could cause probation to begin immediately. 2. The resident will be notified as soon as possible of probationary status, even if formal documentation of the problem is pending. If the latter is true, he/she will be informed of pending probation by the advisor and the program director. 3. The chief resident will be included in subsequent discussion about the case. 4. An ad hoc committee of three faculty members, including the advisor, will formulate a probationary letter. The faculty will review the probationary plan generated by the ad hoc committee. 5. The probationary letter will contain the following: (1) Reason for probation (deficiencies) (2) Statement clarifying probationary status (3) Length of probation (not to exceed 90 days) (4) Specific expectations necessary to meet probation requirements (5) Assistance that will be available to meet those requirements (6) The mechanism for measuring improvement (clearly defined standards) Consequences of failure to meet probationary requirements 6. The resident will receive monthly feedback on his/her performance and additional corrective steps may be instituted to help the resident successfully complete the probation. a) The ad hoc committee will assess the results of the resident’s performance during the probationary period and inform the faculty of its findings. b) Successful completion of probationary requirements will result in reinstatement of the resident in good standing. B. Recurrence of behaviors or medicine errors that initiated probation will result in immediate resumption of probation or non-renewal of the resident’s contract. C. Residents on probation can not seek or hold residency office and may be relieved of other ancillary duties such as applicant interviews or curricular chairmanship. D. Records of probation actions are kept in the resident’s file in the residency office and may be released to future employers if requested. PROCEDURAL CURRICULUM Michael Tuggy, M.D.
  34. 34. The purpose of an organized procedural curriculum is to ensure that residents in training have appropriate exposure, both cognitively and experientially, to procedures in Family Medicine. The goal of the curriculum is to adequately train and certify each resident in the core procedures of our specialty in a coherent manner. Factors that effect a resident’s ability to competently perform a procedure include preparation in the form of reading, practicing on appropriate models, repeated exposure to the procedure even if not completing it entirely themselves, and actual performance in a supervised setting. As faculty, we should be actively scrutinizing the resident’s technique and provide detailed feedback after each procedure. If the resident demonstrates clear ability to perform the procedure, then credentialing for that procedure can be accomplished without reservation. The process of learning a procedure that is highly variable between individuals so any system should take that into account. In setting a standard of competent performance and minimum exposure, we are stating that we feel we can adequately assess technique and monitor responses to complications during the procedure. This varies by the complexity and the risk of the procedure. To actually certify a trainee, we must document enough procedures done solely by the provider to be certain of their independence in performing the procedure. Procedures will be documented with online procedure reports on MEDNAV and will state the level of competency the resident has achieved. RULES AND REGULATIONS OF THE MEDICAL STAFF OF SWEDISH MEDICAL CENTER Restraint Policy Swedish Medical Center is committed to providing a safe environment for all patients. Swedish seeks to provide that environment by first ensuring that care has been given to resolve physiologic, psychosocial and environmental factors that might place patients at risk for harm to themselves or others. If the patient remains at risk after these interventions have been put into place, restraints used are the least restrictive as possible for as short a time as possible and at all times are used with respect to the patient's rights and dignity. A Registered Nurse will initiate the patient safety protocol in the plan of care for the following reasons: 1. The patient is at risk of harm to self or others. Risk is identified during the patient assessment process when the patient exhibits problems or significant findings 2. The patient is at risk to disrupt necessary treatment, such as the patient pulling out a urinary catheter, IV, nasogastric tube or endotracheal tube A physician order is not required to initiate this protocol; however, a physician must personally assess the patient at least every 24 hours. Verbal Orders If a Clinician orders restraints, a time limited verbal or written order is required. Verbal orders must be signed within 24 hours. The order will include the reason for the restraint, type of restraint, duration of order including a start time and end time (not to exceed 24 hours) and will indicate if the order is an initial restraint order or a reorder. A new order is required if a physician orders re- application of a restraint when the patient has been restraint free greater than 60 minutes and/or behavior is not related to the original episode. PATIENT RECORD SYSTEM According to the RRC: The FPC patients’ records must be maintained in the FPC for easy and prompt accessibility at all times. The record system should be designed to provide information on patient care and the

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