The Teaching Nursing Home (?) PAUL R. KATZ, MD, CMD PROFESSOR OF MEDICINE UNIVERSITY OF TORONTO BAYCREST GERIATRIC HEALTH CARE SYSTEM

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1 The Teaching Nursing Home (?) PAUL R. KATZ, MD, CMD PROFESSOR OF MEDICINE UNIVERSITY OF TORONTO BAYCREST GERIATRIC HEALTH CARE SYSTEM

2 Consequences of the Geriatric Tsunami Number of older adults with two limitations in ADLs will grow by 1/3 over the next 25 years 40% chance of NH admission after age 65 16% of persons 85 yrs and over reside in NHs in US; 32% in Canada reside in institutions

3 Residential Care Facilities 2007/2008 Statistics Canada Catalogue no X Homes for the Aged (not including Facilities for Mental Disorders) Total number = 2182 Total number residents = 230,397 Total number residents 85 and over = 81,335 (35%) The number of LTC beds in Canada is projected to increase from 280,000 (2008) to 690,000 by 2038 (Rising Tide: The Impact of Dementia on Canadian Society. Alzheimer Society of Canada, 2010)

4 Academics and the Nursing Home HISTORY AND RATIONALE

5 Historical Perspective RWJ Teaching Nursing Home Program ( ) Affiliations established between 11 university schools of nursing and NHs in order to influence RN and APN student competence, faculty research and resident health outcomes Results included improved attitudes regarding aging, enhanced clinical experiences, increased research and improvement of some clinical measures such as ADLs Alternative models have focused on local vs regional educational needs, forged close linkages with medical schools and/or incorporated geriatric centers encompassing the full continuum of care

6 Goals of a Teaching Nursing Home The Gerontologist 48: 8-15, 2008 Promote culture change and person-directed care Create a culture of learning and promote interdisciplinary education and practice Seek to transform negative images in academia of the nursing home Educate tomorrow s leaders and workforce in institutional long term care Test and disseminate evidence-based practice Leverage existing resources to improve competencies at all levels (direct care staff, NH leadership and faculty) Equitable NH/Academic partnership

7 What is a Teaching Nursing Home? Any nursing home that devotes resources and energies into education and research programs, however modest, independent of the existence of formal university affiliations.

8 Academics and the Nursing Home Clinics in Geriatric Medicine 1995: Despite increasing importance in the health care delivery system: NHs remain relatively isolated from the rest of the health care system There is a lack of understanding of the complexity of care that takes place in the NH Credibility of health care professionals working in the NH is often lacking

9 Academics and the Nursing Home Clinics in Geriatric Medicine 11: , 1995 Wide spectrum of care needs, reflective of the heterogeneity of the NH population, offers the substrate upon which basic principles of geriatric care can be demonstrated Despite significant frailty and prevalence of chronic illness, there remains great potential to enhance physical and psychological function and to impact on quality of life

10 Academics and the Nursing Home Clinics in Geriatric Medicine 11: , 1995 With many NH residents lacking adequate social and economic supports, and in the terminal stages of illnesses and/or in need of extensive chronic care services A variety of medical, legal, ethical, and administrative issues constantly challenge the resourcefulness of the primary care provider. Care is less technologically dependent and more person centered

11 Academics and the Nursing Home Clinics in Geriatric Medicine 11: , 1995 Care is predicated on an interdisciplinary approach with a focus on functional independence rather than disease per se or diagnostic modalities The NH is an ideal place to better understand the linkages between acute and long term care systems and to highlight inadequate or inappropriate care practices

12 Academics and the Nursing Home Clinics in Geriatric Medicine 11: , % of medical schools in the U.S. use nursing homes as training sites (J Am Geriatr Soc 53:136, 2005) Nursing homes offer advantages as teaching sites: Time and space Less frenetic pace allows for both thoroughness and reflection Less competition at the bedside for patient access and faculty attention

13 Reflections of Medical Students Regarding the Care of Geriatric Patients in the Continuing Care Retirement Community (JAMDA 11:506, 2010) Medical students assigned to write open ended reflection paper regarding experience in CCRC Six themes emerged Initial exposure to dementia Confronting death and dying Diversity of care and services for the elderly Cost of care Seniors can lead active lives Rewards of the team-patient relationship

14 Reflections (cont) I am extremely uncomfortable with death and dying. I want to learn to understand the process and how to become comfortable with passing on. My interactions made me think about the fact that I will someday be dependent upon someone else we will all be dependent if we live long enough. The complex housed such a diverse spectrum of health and fitness, I realized my attending could care for a whole community in many different ways within a single day.

15 Workforce Issues

16 Workforce Reality In the U.S. only one in five primary care physicians engages in the care of nursing home residents (JAGS 45: 911, 1997) The majority spend 2 hours or less per week in NH care In Ontario 2500 physicians engage in NH care out of 23,000 (if 50% are primary care = 22 %) Between 1990 and 2000 there was a 5% decline in proportion of general practitioners providing services to LTC homes (CMAJ 19:429, 2002)

17 Benefits of Exposing Residents to NH Practice Improved attitudes, knowledge and skills Encouragement of NH practice after graduation Improved outcomes for NH residents (JAMA 255:2622, 1986)

18 Training Requirements College of Family Physicians of Canada and the American Academy of Family Physicians in the US emphasize longitudinal long term care experience but exposure is modest The Royal College of Physicians and Surgeons of Canada suggests geriatric experience while the American Board of Internal Medicine in the US requires such. Neither mandates long term care exposure

19 Adequacy of Training In a survey of graduating residents, fewer than 15% felt very prepared to provide nursing home care (Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA. 2001;286: )

20 Survey of the Geriatric Content of Canadian Undergraduate and Postgraduate Medical Curricula Can J Geriatr 2006;9(suppl 1): S Canadian medical schools surveyed as regards curricular content developed by geriatricians, geriatric psychiatrists or family physicians with care-of-the elderly training All schools reported mandatory geriatric content in the preclinical curricula (range of 4-36 hrs) Half of schools had a mandatory clerkship of at least 1 weeks duration Mandatory hours of geriatric training ranged between 7 and 196 hours Minority of students participated in geriatric electives

21 Survey of the Geriatric Content of Canadian Undergraduate and Postgraduate Medical Curricula Can J Geriatr 2006;9(suppl 1): S6-11 For postgraduate internal medicine, 6 of 16 programs had a mandatory rotation in geriatrics All programs offered geriatrics as an elective but it was selected by less than half the residents in all but 2 programs 15 of 16 Family Medicine programs required geriatrics (40% of residents completed an elective in the sixteenth school

22 Survey of the Geriatric Content of Canadian Undergraduate and Postgraduate Medical Curricula Can J Geriatr 2006;9(suppl 1): S6-11 Conclusions: The goals of geriatric teaching are not only to increase skills but to foster interest in the field The three schools with the highest geriatric content in the undergraduate curricula are in Quebec and all Quebec core IM programs have a mandatory geriatric rotation Quebec has recruited more residents into geriatric medicine training programs than other regions in Canada!!

23 Prerequisites for Optimal Training Leadership (deans/chairs/program heads) must accept the importance of LTC within the continuum The facts only go so far Need to advocate for quality metrics that recognize the linkage between acute/ltc (i.e. P4P) Incentives must be aligned (i.e. hospitals held accountable for the adequacy of care transitions)

24 Prerequisites for Optimal Training Nursing home culture that embraces teaching Buy in from the NH leadership (administrator;don) is critical Association with University may enhance public relations (39% of AMDA members self identify as faculty ) Systems must be in place to accommodate varying schedules of trainees (providers available to cover calls)

25 Prerequisites for Optimal Training Longitudinal experience with adequate patient volume At least one year to appreciate the natural course of illness Assures diversity Exposure to myriad acute and chronic problems

26 Prerequisites for Optimal Training Mandated nursing home primer Uniform knowledge base that assures consistent levels of competency Focus on systems of care; regulatory environment; acute/ltc interface; principles of rehabilitation; quality measurement; capacity assessment; care planning

27 Prerequisites for Optimal Training Engaged and knowledgeable role models Demonstrate the diversity and challenge of NH care Demonstrate the skill necessary to practice effectively Counter negative stereotypes Establish credibility Highlight career opportunities

28 Future Directions Establish a Nursing Home Specialty The Netherlands paradigm Enhanced credibility; reinforces NH practice as a legitimate practice

29 The Future of NH Medicine Organized medicine must address at least 4 major issues: Mainstream medicine must reinforce NH practice as a legitimate medical practice site thus preventing further marginalization of LTC Broad based organizations (i.e.cgs;cma;rcp) must join AMDA, CGS, LTCMDAC, OLTCA etc. in defining the role of the NH physician

30 The Future of NH Medicine Attracting and retaining a competent/trained workforce Funding Training Liability reform

31 The Future of NH Medicine Adequate financial support for care of the elderly/geriatrics Dividing the same pie may not be enough Existing and proposed funding levels maybe chasing physicians out of NHs NH administrators must weigh the cost effectiveness of different organizational models and not continue to operate under the pretext of old and untested paradigms

32 The Future of NH Medicine Research to test new models of care that will guide future policy Define the optimum organizational framework Define new quality metrics Relationship between MDs and NPs/PAs New quality incentives (P4P)

33 Questions?