- Email: [email protected]
Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Assessment and Management of Geriatric Mental Health Issues
Am J of Geriatric Psychiatry 27:7 (2019) 706−711
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.ajgponline.org
Special Issue Article
Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Assessment and Management of Geriatric Mental Health Issues LalithKumar K. Solai, M.D., Keerthana Kumar, M.D., Elizabeth Mulvaney, M.S.W., Daniel Rosen, Ph.D., M.S.W., Juleen Rodakowski, O.T.D., M.S., O.T.R./L., Tanya Fabian, Pharm.D., Ph.D., Jennifer H. Lingler, Ph.D., C.R.N.P., Charles F. Reynolds III, M.D., Daniel Sewell, M.D. ARTICLE INFO
ABSTRACT
Article history: Received November, 29 2018 Revised April, 17 2019 Accepted April, 30 2019
Introduction: The population in United States aged 65 and older has rapidly grown and is projected to grow faster than any other segment of the population. Despite this demographic shift, the nation’s geriatric workforce is shrinking. Aim: The primary goal of the fellowship was to form a learning collaborative that would help trainees in medicine, nursing, social work, pharmacy and occupational/physical therapy understand the roles of each discipline involved in the provision of geriatric mental healthcare and to enhance basic knowledge of common geriatric syndromes. Methods: Faculty from the University of Pittsburgh developed a format for the mini-fellowship. Trainees from five disciplines were recruited for participation in the mini-fellowship. This was offered annually over four-year period, hosted by the John A. Hartford Foundation Centers of Excellence in Geriatric Psychiatry at the University of Pittsburgh and University of California at San Diego. Results: Eighty-one participants across five schools of the health sciences completed the mini-fellowship. Feedback was positive: most participants appreciated learning from other team members, endorsed appreciation of the contributions of other disciplines to patient care,
Key Words: Aging mental health interprofessional training geriatric workforce
From the Department of Psychiatry (LKS, TG, CFR), University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh Medical Center (LKS, TF, CFR), Pittsburgh, PA; Institute of Medical Boards (KK), Overland Park, Kansas, KS; School of Social Work (DR), University of Pittsburgh, Pittsburgh, PA; School of Health and Rehabilitation Sciences, Department of Occupational Therapy (JR), University of Pittsburgh, Pittsburgh, PA; School of Pharmacy (TF), University of Pittsburgh, Pittsburgh, PA; School of Nursing (JHL), University of Pittsburgh, Pittsburgh, PA; and the University of California, Department of Psychiatry, San Diego (DS). Send correspondence and reprint requests to LalithKumar K. Solai, M.D., University of Pittsburgh School of Medicine, Department of Psychiatry, 3811 O’Hara St., Rm. T266, Pittsburgh, PA 15213. e-mail: [email protected] © 2019 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jagp.2019.04.018
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Solai et al. and reported improved understanding of three major geriatric syndromes. Conclusion: Conducting an interdisciplinary mini-fellowship in geriatric mental health was feasible and well received by trainees. The fellowship enabled better appreciation for the provision of geriatric mental health care within the context of an interprofessional team. However, decanal and faculty leadership across the schools needs to place greater emphasis on the importance of interprofessional team-based learning and to free up time for such activity. (Am J Geriatr Psychiatry 2019; 27:706−711)
INTRODUCTION
A
ccording to the U.S. Census Bureau, nearly 48 million Americans were aged 65 years or older in 2015, representing 14.9% of the U.S. population. This is an increase from 40 million Americans representing 13% of the U.S. population in 2010.1 By 2060, this age group is projected to increase to 98.2 million people, or 24% of U.S. population.2 The rate of growth (2010−2015) of the population aged 65 and older has been at 21% compared with 9.7% for the general population. Despite this demographic transition, the number of providers specializing in geriatrics has been declining.3 This trend is also apparent in geriatric mental health. For example, fill rates for geriatric psychiatry fellowship programs have declined from 91% in 1999 to around 41% in 2015.4 As of 2014, there were about 1,629 geriatric psychiatrists or 1 for every 11,526 older Americans.5 It is projected that by 2030, there will only be 1 geriatric psychiatrist for every 20,448 Americans.5 Similar patterns exist in other health professions, such as social work, where it is predicted that there is a need for an additional 70,000 geriatric social workers in the United States.6 The workforce gap is particularly concerning because treating older adults with mental disorders requires distinct knowledge and skills that cut across multiple disciplines. This presents both a challenge and an opportunity to devise effective interprofessional training approaches to prepare the next generation of clinicians to meet the mental healthcare needs of older adults growing both in number and in racial and ethnic diversity. Geriatric mental healthcare is complicated by the interplay of psychiatric illness, medical and neurologic illnesses, social and economic challenges, racial and ethnic diversity, and functional losses.7 Given the complexity of issues presented by older adults with mental
Am J Geriatr Psychiatry 27:7, July 2019
health disorders, an interprofessional approach to care is needed to optimize efficiency and outcomes of patients and informal caregivers.8 Unfortunately, effective team-based care often falls short in many settings due to a lack of integrated and coordinated care across various disciplines.9 In addition, opportunities for interprofessional education and training in various aspects of geriatric healthcare are limited.10 Owing to the shortage of clinicians trained in late-life mental and cognitive disorders, and practice in silos rather than in interprofessional teams, most older individuals will continue to be receive less than optimal care.11 Education and training in the essentials of geriatric mental healthcare are needed across the health sciences of medicine, nursing, social work, pharmacy, and occupational and physical therapy to instill the knowledge, skills, and perspectives required to meet both the current and future challenges in caring for older adults with mental disorders.12 Learning Objectives The primary learning objective of the mini-fellowship was to test the feasibility of developing a learning collaborative to enhance trainees’ understanding of the role and value of interdisciplinary teams in the care of geriatric patients with mental disorders. In addition, we aimed to increase trainees’ awareness of common geriatric mental health issues, particularly delirium, dementia, and depression, and the need for an interdisciplinary approach to the challenges faced by older adults living with these disorders and their caregivers.
METHODS The curriculum was created and implemented by faculty at the John A. Hartford Foundation Centers of
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Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Excellence in Geriatric Psychiatry; at the University of Pittsburgh (Pitt) and the University of California, San Diego (UCSD); and through funding and partnership with the American Association for Geriatric Psychiatry. Collaborating faculty represented social work, pharmacy, occupational therapy, nursing, family medicine, and geriatric psychiatry. The planning group met on a weekly basis for 6 months in 2013 to discuss development of the training program. Based on these discussions, we decided to conduct a 5-day “mini-fellowship” consisting of didactic lectures followed by case-based discussions conjointly led by faculty from the schools of the health sciences. Owing to time constraints, curriculum planning focused on core topics in geriatric psychiatry, such as dementia, delirium, and depression, for Year 01. Feedback from trainees in Year 01 indicated interest in also learning about palliative care, normal aging, pain management, and decision-making capacity. Thus, these topics were added in Year 02. In addition, based on availability of expertise and participant requests, in Year 02 we were able to feature a lecture given by a speech and language pathologist on swallowing difficulties. We recruited participants from all schools of the health sciences (medicine, nursing, pharmacy, social work, occupational and physical therapy [rehabilitation science], and speech and language pathology) via e-mail and word of mouth. Once fellows were identified, faculty addressed availability to attend and participate in the program. Finding common, protected time for participation was especially challenging, given the different schedules and requirements of participating schools. This was the single greatest challenge we encountered, despite reaching out to decanal leadership in each school. In addition, owing to budgetary constraints, we had to reduce the duration of the curriculum to 3 days from 5 days in Year 03 and to 2 days in Year 04 (reflecting the need of Pitt faculty for travel time to San Diego and the limited time available to UCSD trainees). Thus, based on participant availability, it became necessary to conduct the mini-fellowship in 2-, 3-, or 5-day formats, from 8:30 A.M. to 4:30 P.M. Participants received educational materials at the time of each presentation, but not before. As noted previously, the training format was a hybrid of lecture and case-based discussion led by an interprofessional panel of experts. All topics were presented in 45- to
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90-minute sessions. Core topic addressed the growing need for geriatric care; roles and contributions of each discipline in the care of older adults; informal support resources/community resources; adaptive tools for the elderly to enable aging safely in place; importance of autonomy; palliative care; pain management; pharmacy review; and the importance of accurate diagnosis, treatment, and prevention of delirium, dementia, and depression. After each day’s presentations, clinical case scenarios were presented for discussion by interprofessional teams with participants. This format provided trainees with an opportunity to learn from each other and to apply knowledge and skills in a real-world and interactive fashion. These discussions often centered on the challenges healthcare providers face in caring for older patients. The “take-home” point was the need to better open lines of communication with patients, families, and with other team members to address the complexities (medical, psychiatric, sociocultural, economic, and legal) presented by older adults with mental disorders. At the end of the mini-fellowship, we asked participants to complete a questionnaire using a 5-point Likert scale to evaluate different aspects of the program, emphasizing interprofessional learning and team-based case discussions.
RESULTS Over 4 years of the mini-fellowship, 81 trainees at Pitt and UCSD participated in the program, representing five clinical disciplines (Fig. 1). Table 1 maps the 5day mini-fellowship, modified based on participant feedback, offered in Years 01 and 02. The first day
FIGURE 1. Geriatric mental health mini-fellowship trainees by discipline (2014−2017).
8 6 4
5 444 4
6
7
5 55
5 5 5 4 4
2
Nurse 3
Pharmacy Social Work
222 0
0 3 days 2014 (PITT)
5 days 2015 (PITT)
3 days 2016 (PITT)
MD Rehab
2 days 2017 (UCSD)
Am J Geriatr Psychiatry 27:7, July 2019
Solai et al. TABLE 1. Geriatric Mental Health Mini-Fellowship: A Practical Learning Collaborative in Multidisciplinary Assessment and Management Day 1
Day 2
Day 3
Day 4
NORMAL AGING 8:30− 8:45 Registration
DEMENTIA 8:15−8:30 Registration
DELIRIUM 8:30−9:00 Registration
8:45−9:30 Welcoming Remarks; Who Is Going to Take Care of Me When I Am Older? GERIATRIC PSYCHIATRIST
8:30−9:30 Aging-Related Issues in Sleep Wake Disorders and in Grief GERIATRIC PSYCHIATRIST
9:00−10:15 Delirium: An Overview of the Current Field MEDICINE− GERIATRIC PSYCHIATRY SPECIALIST I
9:30−10:15 Caring Disciplines in Aging COMMITTEE MEMBERS
9:30−10:30 Dementia: An Overview of the current field NURSING SPECIALIST
10:15−10:30 BREAK
10:30−10:45 BREAK
10:30−12:00 Closure— Starting the Conversation GERIATRIC MEDICINE
10:45−12:00 Caregiver Issues; Community Resources SOCIAL WORK SPECIALIST
12:00−1:00 LUNCH 12:00−1:00 LUNCH 1:00−2:00 Maximizing Use of Informal Supports and Community Resources for Older Adults SOCIAL WORK SPECIALIST 2:00 - 2:45 Adaptive Tools for Independence in Aging OCCUPATIONAL THERAPIST
1:00−2:00 Dementia: Types of Dementia and Bedside Tools to Evaluate Them GERIATRIC PSYCHIATRIST 2:00−2:45 Dementia: Providing Bedside Care 2:45−3:00 BREAK
2:45−3:00 BREAK 3:00−4:30 Case Presentation and Discussion of Dementia with panel of experts (COMMITTEE MEMBERS)
3:00−4:30 Case Presentation and Discussion of Dementia with panel of experts (COMMITTEE MEMBERS)
DEPRESSION 8:30−9:00 Registration
END OF LIFE 8:30−9:00 Registration
9:00−10:15 Late-Life Depression: An Overview of the Current Field MEDICINE−GERIATRIC PSYCHIATRY SPECIALIST
9:00−10:15 End of Life Care in Dementia Patients- Challenges and Opportunities SPEECH LANGUAGE PATHOLOGIST
10:15−10:30 BREAK
10:15−10:30 BREAK
10:30−12:00 Late Life Depression: Treatment Options MEDICINE− GERIATRIC PSYCHIATRY SPECIALIST
10:30−12:00 Pain Management in Palliative Care PHARMACY SPECIALIST
12:00−1:00 LUNCH
1:00- 2:00 Capacity and Decision-Making in End-ofLife Care MEDICINE− GERIATRIC PSYCHIATRY SPECIALIST
10:15−10:30 BREAK 10:30−12:00 Delirium: Impact of Delirium on Patients NURSE SPECIALIST 12:00−1:00 LUNCH 1:00−2:00 Strategies for Early Detection/Treatment and/or Prevention of Delirium MEDICINE SPECIALIST
1:00 - 2:00 Depression: Impact of Depression on Patients OCCUPATIONAL THERAPIST
2:00−2:45 Pharmacy Review of Delirium PHARMACY SPECIALIST
2:00−2:45 Late-Life Suicide: CRISIS EXPERT
2:45−3:00 BREAK
2:45−3:00 BREAK
3:00−4:30 Case Presentation and Discussion of Delirium with Panel of Experts (COMMITTEE MEMBERS)
3:00−4:30 Case Presentation and Discussion of Depression with Panel of Experts (COMMITTEE MEMBERS)
12:00−1:00 LUNCH
2:00−2:45 SUMMARY: Bringing it all together MEDICINE−GERIATRIC PSYCHIATRY SPECIALIST I 2:45−3:00 BREAK
included an introduction to the various healthcare disciplines as well as a discussion of normal healthy aging. Each of the successive days centered on mental disorders prevalent in older adults but often poorly understood, misdiagnosed, or inadequately treated in older adults: dementia, delirium, and depression. The last day of the fellowship was devoted to palliative care, pain management, decision-making capacity, and topics related to mortality (including suicide) in older patients. Quantitative feedback from a participant survey conducted after the first year of the fellowship (Table 2) indicated that most participants either “agreed” or “strongly agreed” that the training was effective and had a positive impact on their learning
Am J Geriatr Psychiatry 27:7, July 2019
Day 5
3:00−4:30 Case Presentation and Discussion of Depression with Panel of Experts (COMMITTEE MEMBERS)
and appreciation for the distinctive contributions of each discipline, which, when combined, yielded a whole greater than the sum of its parts. Quantitative data in Years 02 and 03 (not presented) yielded similar post-test evaluation results. Finally, qualitative feedback from participants (Table 3) conveyed the trainees’ enjoyment at learning new information in an interprofessional setting taught by faculty experts from five schools of the health sciences. Participants reported increased knowledge about geriatric mental disorders and a greater appreciation for the contributions made by other members of the care team. Some frustration was also expressed, however, that the important contributions of nursing were still not fully appreciated.
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Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional TABLE 2. Geriatric Mental Health Mini-Fellowship Quantitative Feedback (N = 70) Strongly Disagree 1
Disagree 2
Neutral 3
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0
I am satisfied with the overall program There was an appropriate mix of lecture/panel discussion/class discussion There was an appropriate use of videos and other media There was an appropriate amount of hands-on/interactive class activities The reading materials were useful There were enough breaks throughout the day I am satisfied with the overall objective of bringing multidisciplinary trainees together Trainees will be able to identify strengths of each disciplinary in training Trainees will be able to better identify ways to improve team work Trainees will have a better understanding of the three common syndromes in geriatric mental health from a multidisciplinary perspective Learning from faculty from other disciplines was useful The content was relevant to my practice
Agree 4
Strongly Agree 5
0 3 (4.3%) 4 (5.7%) 3 (4.3%) 4 (5.7%) 0 0
20 (28.6%) 18 (25.7%) 41 (58.6%) 18 (25.7%) 21 (30%) 22 (31.4%) 16 (22.9%)
50 (71.4%) 49 (70%) 25 (35.7%) 49 (70%) 45 (64.3%) 48 (68.6%) 54 (77.1%)
2 (2.8%) 0 0
0 4 (5.7%) 0
24 (34.3%) 19 (27.1%) 22 (31.4%)
44 (62.9%) 47 (67.2%) 48 (68.6%)
0 0
5 (7.2%) 3 (4.3%)
15 (21.4%) 18 (25.7%)
50 (71.4%) 49 (70%)
TABLE 3. Geriatric Mental Health Mini-Fellowship Qualitative Feedback “I will definitely look to other disciplines to share the expertise I am now more familiar with. I also now feel more confident when speaking in a multi-disciplinary group.” (2014) “This fellowship has definitely increased my understanding of other professions and improved my ability to care for geriatric patients.” (2014) “The interaction with teams was key, was stimulating and engaging; the time spent with my own specialty was less stimulating and less engaging.” (2014) “Focus on the disciplines and what they actually do, the first activity on the first day should have been about this, I feel other disciplines still do not have and understanding of what advanced nurse/practitioner does, do a survey to see what each discipline thinks of others and then have a discussion.” (2014) “It would be very helpful and informative if, at the beginning of the series, there was a brief overview of all roles, and healthcare disciplines represented. Although during the lunch activities everyone was able to interact and was able to ask questions, it was difficult to get a clear picture of the different disciplines.” (2014) “I think others would agree with this, but the sessions focused on my own discipline were the least helpful to the expansion of my knowledge, but necessary to the program, even the sessions with which I was already familiar were still very interesting.” (2014) “I enjoyed working and talking with other medical professionals as it gave me a different perspective on patient care. I also greatly appreciated the flash drive of the presentations.” (2014) “Small groups with other health professionals, learning about their discipline and their perspective; interactive cases, lectures from interdisciplinary team as well. Also having lunch with different people daily.” (2015) “Keep having the fellowship. An integrated approach is so needed.” (2015) “I would highly recommend this program to both hospital and community residents.” (2015) “I think it would be helpful to have more cases or discussion throughout the day rather than at the end of the day.” (2015) “Most trainees were unfamiliar with the specific function of other disciplines, so it was useful.” (2016) “More interaction during some of the lectures would be helpful.” (2016) “Participation is this mini-fellowship has given me a broader understanding of the multiple aspects of geriatric care and I have no doubt that I will be a better physician because of it. I anticipate utilizing other members of the healthcare team more frequently and earlier than I had in the past.” (2016) “Perhaps a session on what makes Interprofessional practice uncomfortable: e.g., boundaries, egos, lack of knowledge, etc.” (2016) “I know nothing about OT, so information/presentation on this topic was phenomenal and highly useful.” (2016)
DISCUSSION Based on our literature review and knowledge of current available training programs, this Hartford Foundation−sponsored geriatric mental health minifellowship is the first of its kind to bring together trainees from across the health sciences. Although several other geriatric interprofessional trainings are offered, none are specific to mental health issues in later life.
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Solberg and her team13 conducted a half-day, interprofessional “boot camp” training in geriatrics. This program was well received, and based on post-test data, participants reported having gained knowledge in geriatric issues. The secondary goal of the Solberg program addressed interprofessional learning, which was reported to be beneficial.13 Similarly, the Geriatric Outreach and Training with Care (GOT Care!) initiative at the University of Connecticut trained 177 students in
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Solai et al. interprofessional geriatric care with a statistically significant improvement in students’ levels of collaborative practice skills in seven of eight subscales of the Collaborative Practice Assessment Tool.14 In addition, Geriatric Interdisciplinary Team Training programs funded by the John A. Hartford Foundation have benefitted more than 1,300 trainees in healthcare professions at eight different centers. Based on postcourse data, the faculty saw the most improvement in attitudinal measures with the self-reported Team Skills Scale.10 Finally, the Interprofessional Geriatric Training Institute at the Geriatric Education Center of Nova Southeastern University in Fort Lauderdale, Florida, has conducted annual trainings on various geriatric topics for the last 10 years; however, we were unable to locate published reports on the outcomes of their training. Developing and implementing innovative interprofessional training opportunities in geriatric mental health could lead to better health outcomes, higher quality of care, and lower costs.10 Providing education and training in geriatric mental health issues across disciplines appears to be a feasible way to prepare for the impending geriatric mental healthcare needs that the current workforce is ill equipped to manage.11 Our data indicated that the training was well received by participants and that it served to break down barriers between the different disciplines,
based on better understandings of others’ specific expertise, roles, and contributions. Although a limitation of the present study was the absence of performance data from pre- to postfellowship, it would not be realistic to expect to see such change after very brief exposure. Rather, our intention was to explore the feasibility and acceptability of interprofessional training in geriatric mental health. The single greatest challenge encountered was the need to find available time and to coordinate across the schools of the health sciences. Although we spoke with all of the deans of the participating schools and were generally well received, carving out time for cross-disciplinary training remains a formidable challenge. This situation is unlikely to change until incentives to change are in place, possibly as a result of health system and payor demands attendant to the shift from volume- to value-based care. Further assessment of patient- and carer-centered outcomes is also needed, together with implementation and dissemination research to foster uptake by health systems. Presented at the American Association of Geriatric Psychiatry, 2017 Annual Meeting, in Dallas, Texas, on March 26, 2017. Funding support from John A. Hartford Foundation grant and NIA P50 P50AG005133 (Jennifer H. Lingler).
References 1. U.S. Census Bureau: 2015 U.S. Census Report. (online). Available at: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. Accessed November 27, 2016 2. Ortman JM, Velkoff VA, Hogan H: An Aging Nation: The Older Population in the United States, Current Population Reports Washington, DC, U.S. Census Bureau, 2014. P25–1140 3. Warshaw GA, Bragg EJ, Shaull RW, et al: Academic geriatric programs in US allopathic and osteopathic medical schools. JAMA 2002; 288:2313–2319 4. Brotherton SE, Etzel SI: Graduate medical education, 2014-2015. JAMA 2015; 314:2436–2454 5. American Geriatrics Society. The Geriatric Workforce Policy Studies Center 2016: what are the current and projected future doctor to patient ratios in geriatrics? (online). Available at: http://www.americangeriatrics.org/advocacy_public_policy/ gwps/gwps_faqs/id:3188. Accessed November 28, 2016 6. Pace PR: The need for geriatric social workers. NASW News 2014, February. Available at: http://www.socialworkblog.org/ nasw-news-article/2014/02/need-for-geriatric-social-workgrows/. Accessed November 29, 2018 7. Institute of Medicine: Retooling for an Aging America. Washington, DC, National Academies Press, 2008 8. Partnership for Health in Aging Workgroup on Interdisciplinary Team Training in Geriatrics: Position statement on interdisciplinary
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9.
10.
11.
12.
13.
14.
team training in geriatrics: An essential component of quality healthcare for older adults. J Am Geriatr Soc 2014; 62:961–965 Institute of Medicine: Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academies Press, 2001 Fulmer T, Hyer K, Flaherty E, et al: Geriatric interdisciplinary team training program evaluation results. J Aging Health 2005; 17:443–470 Institute of Medicine: The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC, National Academic Press, 2012 American Geriatrics Society: Existing Formal Geriatrics Competencies and Milestones. Available at: http://www.americangeriatrics. org/health_care_professionals/education/curriculum_guidelines_competencies/existing_formal_geriatrics_competencies. Accessed November 29, 2016 Solberg LB, Solberg LM, Carter CS: Geriatric care boot camp: an interprofessional education program for health care professionals. J Am Geriatr Soc 2015; 63: 997−100 Shellman JM, Malcolm M, LeClaire A, Cave A, Rees C: An interprofessional geriatric training and outreach program: student, patient and provider outcomes. Innov Aging 2017; 1:825–826
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.ajgponline.org
Special Issue Article
Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Assessment and Management of Geriatric Mental Health Issues LalithKumar K. Solai, M.D., Keerthana Kumar, M.D., Elizabeth Mulvaney, M.S.W., Daniel Rosen, Ph.D., M.S.W., Juleen Rodakowski, O.T.D., M.S., O.T.R./L., Tanya Fabian, Pharm.D., Ph.D., Jennifer H. Lingler, Ph.D., C.R.N.P., Charles F. Reynolds III, M.D., Daniel Sewell, M.D. ARTICLE INFO
ABSTRACT
Article history: Received November, 29 2018 Revised April, 17 2019 Accepted April, 30 2019
Introduction: The population in United States aged 65 and older has rapidly grown and is projected to grow faster than any other segment of the population. Despite this demographic shift, the nation’s geriatric workforce is shrinking. Aim: The primary goal of the fellowship was to form a learning collaborative that would help trainees in medicine, nursing, social work, pharmacy and occupational/physical therapy understand the roles of each discipline involved in the provision of geriatric mental healthcare and to enhance basic knowledge of common geriatric syndromes. Methods: Faculty from the University of Pittsburgh developed a format for the mini-fellowship. Trainees from five disciplines were recruited for participation in the mini-fellowship. This was offered annually over four-year period, hosted by the John A. Hartford Foundation Centers of Excellence in Geriatric Psychiatry at the University of Pittsburgh and University of California at San Diego. Results: Eighty-one participants across five schools of the health sciences completed the mini-fellowship. Feedback was positive: most participants appreciated learning from other team members, endorsed appreciation of the contributions of other disciplines to patient care,
Key Words: Aging mental health interprofessional training geriatric workforce
From the Department of Psychiatry (LKS, TG, CFR), University of Pittsburgh School of Medicine, Pittsburgh, PA; University of Pittsburgh Medical Center (LKS, TF, CFR), Pittsburgh, PA; Institute of Medical Boards (KK), Overland Park, Kansas, KS; School of Social Work (DR), University of Pittsburgh, Pittsburgh, PA; School of Health and Rehabilitation Sciences, Department of Occupational Therapy (JR), University of Pittsburgh, Pittsburgh, PA; School of Pharmacy (TF), University of Pittsburgh, Pittsburgh, PA; School of Nursing (JHL), University of Pittsburgh, Pittsburgh, PA; and the University of California, Department of Psychiatry, San Diego (DS). Send correspondence and reprint requests to LalithKumar K. Solai, M.D., University of Pittsburgh School of Medicine, Department of Psychiatry, 3811 O’Hara St., Rm. T266, Pittsburgh, PA 15213. e-mail: [email protected] © 2019 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jagp.2019.04.018
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Am J Geriatr Psychiatry 27:7, July 2019
Solai et al. and reported improved understanding of three major geriatric syndromes. Conclusion: Conducting an interdisciplinary mini-fellowship in geriatric mental health was feasible and well received by trainees. The fellowship enabled better appreciation for the provision of geriatric mental health care within the context of an interprofessional team. However, decanal and faculty leadership across the schools needs to place greater emphasis on the importance of interprofessional team-based learning and to free up time for such activity. (Am J Geriatr Psychiatry 2019; 27:706−711)
INTRODUCTION
A
ccording to the U.S. Census Bureau, nearly 48 million Americans were aged 65 years or older in 2015, representing 14.9% of the U.S. population. This is an increase from 40 million Americans representing 13% of the U.S. population in 2010.1 By 2060, this age group is projected to increase to 98.2 million people, or 24% of U.S. population.2 The rate of growth (2010−2015) of the population aged 65 and older has been at 21% compared with 9.7% for the general population. Despite this demographic transition, the number of providers specializing in geriatrics has been declining.3 This trend is also apparent in geriatric mental health. For example, fill rates for geriatric psychiatry fellowship programs have declined from 91% in 1999 to around 41% in 2015.4 As of 2014, there were about 1,629 geriatric psychiatrists or 1 for every 11,526 older Americans.5 It is projected that by 2030, there will only be 1 geriatric psychiatrist for every 20,448 Americans.5 Similar patterns exist in other health professions, such as social work, where it is predicted that there is a need for an additional 70,000 geriatric social workers in the United States.6 The workforce gap is particularly concerning because treating older adults with mental disorders requires distinct knowledge and skills that cut across multiple disciplines. This presents both a challenge and an opportunity to devise effective interprofessional training approaches to prepare the next generation of clinicians to meet the mental healthcare needs of older adults growing both in number and in racial and ethnic diversity. Geriatric mental healthcare is complicated by the interplay of psychiatric illness, medical and neurologic illnesses, social and economic challenges, racial and ethnic diversity, and functional losses.7 Given the complexity of issues presented by older adults with mental
Am J Geriatr Psychiatry 27:7, July 2019
health disorders, an interprofessional approach to care is needed to optimize efficiency and outcomes of patients and informal caregivers.8 Unfortunately, effective team-based care often falls short in many settings due to a lack of integrated and coordinated care across various disciplines.9 In addition, opportunities for interprofessional education and training in various aspects of geriatric healthcare are limited.10 Owing to the shortage of clinicians trained in late-life mental and cognitive disorders, and practice in silos rather than in interprofessional teams, most older individuals will continue to be receive less than optimal care.11 Education and training in the essentials of geriatric mental healthcare are needed across the health sciences of medicine, nursing, social work, pharmacy, and occupational and physical therapy to instill the knowledge, skills, and perspectives required to meet both the current and future challenges in caring for older adults with mental disorders.12 Learning Objectives The primary learning objective of the mini-fellowship was to test the feasibility of developing a learning collaborative to enhance trainees’ understanding of the role and value of interdisciplinary teams in the care of geriatric patients with mental disorders. In addition, we aimed to increase trainees’ awareness of common geriatric mental health issues, particularly delirium, dementia, and depression, and the need for an interdisciplinary approach to the challenges faced by older adults living with these disorders and their caregivers.
METHODS The curriculum was created and implemented by faculty at the John A. Hartford Foundation Centers of
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Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Excellence in Geriatric Psychiatry; at the University of Pittsburgh (Pitt) and the University of California, San Diego (UCSD); and through funding and partnership with the American Association for Geriatric Psychiatry. Collaborating faculty represented social work, pharmacy, occupational therapy, nursing, family medicine, and geriatric psychiatry. The planning group met on a weekly basis for 6 months in 2013 to discuss development of the training program. Based on these discussions, we decided to conduct a 5-day “mini-fellowship” consisting of didactic lectures followed by case-based discussions conjointly led by faculty from the schools of the health sciences. Owing to time constraints, curriculum planning focused on core topics in geriatric psychiatry, such as dementia, delirium, and depression, for Year 01. Feedback from trainees in Year 01 indicated interest in also learning about palliative care, normal aging, pain management, and decision-making capacity. Thus, these topics were added in Year 02. In addition, based on availability of expertise and participant requests, in Year 02 we were able to feature a lecture given by a speech and language pathologist on swallowing difficulties. We recruited participants from all schools of the health sciences (medicine, nursing, pharmacy, social work, occupational and physical therapy [rehabilitation science], and speech and language pathology) via e-mail and word of mouth. Once fellows were identified, faculty addressed availability to attend and participate in the program. Finding common, protected time for participation was especially challenging, given the different schedules and requirements of participating schools. This was the single greatest challenge we encountered, despite reaching out to decanal leadership in each school. In addition, owing to budgetary constraints, we had to reduce the duration of the curriculum to 3 days from 5 days in Year 03 and to 2 days in Year 04 (reflecting the need of Pitt faculty for travel time to San Diego and the limited time available to UCSD trainees). Thus, based on participant availability, it became necessary to conduct the mini-fellowship in 2-, 3-, or 5-day formats, from 8:30 A.M. to 4:30 P.M. Participants received educational materials at the time of each presentation, but not before. As noted previously, the training format was a hybrid of lecture and case-based discussion led by an interprofessional panel of experts. All topics were presented in 45- to
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90-minute sessions. Core topic addressed the growing need for geriatric care; roles and contributions of each discipline in the care of older adults; informal support resources/community resources; adaptive tools for the elderly to enable aging safely in place; importance of autonomy; palliative care; pain management; pharmacy review; and the importance of accurate diagnosis, treatment, and prevention of delirium, dementia, and depression. After each day’s presentations, clinical case scenarios were presented for discussion by interprofessional teams with participants. This format provided trainees with an opportunity to learn from each other and to apply knowledge and skills in a real-world and interactive fashion. These discussions often centered on the challenges healthcare providers face in caring for older patients. The “take-home” point was the need to better open lines of communication with patients, families, and with other team members to address the complexities (medical, psychiatric, sociocultural, economic, and legal) presented by older adults with mental disorders. At the end of the mini-fellowship, we asked participants to complete a questionnaire using a 5-point Likert scale to evaluate different aspects of the program, emphasizing interprofessional learning and team-based case discussions.
RESULTS Over 4 years of the mini-fellowship, 81 trainees at Pitt and UCSD participated in the program, representing five clinical disciplines (Fig. 1). Table 1 maps the 5day mini-fellowship, modified based on participant feedback, offered in Years 01 and 02. The first day
FIGURE 1. Geriatric mental health mini-fellowship trainees by discipline (2014−2017).
8 6 4
5 444 4
6
7
5 55
5 5 5 4 4
2
Nurse 3
Pharmacy Social Work
222 0
0 3 days 2014 (PITT)
5 days 2015 (PITT)
3 days 2016 (PITT)
MD Rehab
2 days 2017 (UCSD)
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Solai et al. TABLE 1. Geriatric Mental Health Mini-Fellowship: A Practical Learning Collaborative in Multidisciplinary Assessment and Management Day 1
Day 2
Day 3
Day 4
NORMAL AGING 8:30− 8:45 Registration
DEMENTIA 8:15−8:30 Registration
DELIRIUM 8:30−9:00 Registration
8:45−9:30 Welcoming Remarks; Who Is Going to Take Care of Me When I Am Older? GERIATRIC PSYCHIATRIST
8:30−9:30 Aging-Related Issues in Sleep Wake Disorders and in Grief GERIATRIC PSYCHIATRIST
9:00−10:15 Delirium: An Overview of the Current Field MEDICINE− GERIATRIC PSYCHIATRY SPECIALIST I
9:30−10:15 Caring Disciplines in Aging COMMITTEE MEMBERS
9:30−10:30 Dementia: An Overview of the current field NURSING SPECIALIST
10:15−10:30 BREAK
10:30−10:45 BREAK
10:30−12:00 Closure— Starting the Conversation GERIATRIC MEDICINE
10:45−12:00 Caregiver Issues; Community Resources SOCIAL WORK SPECIALIST
12:00−1:00 LUNCH 12:00−1:00 LUNCH 1:00−2:00 Maximizing Use of Informal Supports and Community Resources for Older Adults SOCIAL WORK SPECIALIST 2:00 - 2:45 Adaptive Tools for Independence in Aging OCCUPATIONAL THERAPIST
1:00−2:00 Dementia: Types of Dementia and Bedside Tools to Evaluate Them GERIATRIC PSYCHIATRIST 2:00−2:45 Dementia: Providing Bedside Care 2:45−3:00 BREAK
2:45−3:00 BREAK 3:00−4:30 Case Presentation and Discussion of Dementia with panel of experts (COMMITTEE MEMBERS)
3:00−4:30 Case Presentation and Discussion of Dementia with panel of experts (COMMITTEE MEMBERS)
DEPRESSION 8:30−9:00 Registration
END OF LIFE 8:30−9:00 Registration
9:00−10:15 Late-Life Depression: An Overview of the Current Field MEDICINE−GERIATRIC PSYCHIATRY SPECIALIST
9:00−10:15 End of Life Care in Dementia Patients- Challenges and Opportunities SPEECH LANGUAGE PATHOLOGIST
10:15−10:30 BREAK
10:15−10:30 BREAK
10:30−12:00 Late Life Depression: Treatment Options MEDICINE− GERIATRIC PSYCHIATRY SPECIALIST
10:30−12:00 Pain Management in Palliative Care PHARMACY SPECIALIST
12:00−1:00 LUNCH
1:00- 2:00 Capacity and Decision-Making in End-ofLife Care MEDICINE− GERIATRIC PSYCHIATRY SPECIALIST
10:15−10:30 BREAK 10:30−12:00 Delirium: Impact of Delirium on Patients NURSE SPECIALIST 12:00−1:00 LUNCH 1:00−2:00 Strategies for Early Detection/Treatment and/or Prevention of Delirium MEDICINE SPECIALIST
1:00 - 2:00 Depression: Impact of Depression on Patients OCCUPATIONAL THERAPIST
2:00−2:45 Pharmacy Review of Delirium PHARMACY SPECIALIST
2:00−2:45 Late-Life Suicide: CRISIS EXPERT
2:45−3:00 BREAK
2:45−3:00 BREAK
3:00−4:30 Case Presentation and Discussion of Delirium with Panel of Experts (COMMITTEE MEMBERS)
3:00−4:30 Case Presentation and Discussion of Depression with Panel of Experts (COMMITTEE MEMBERS)
12:00−1:00 LUNCH
2:00−2:45 SUMMARY: Bringing it all together MEDICINE−GERIATRIC PSYCHIATRY SPECIALIST I 2:45−3:00 BREAK
included an introduction to the various healthcare disciplines as well as a discussion of normal healthy aging. Each of the successive days centered on mental disorders prevalent in older adults but often poorly understood, misdiagnosed, or inadequately treated in older adults: dementia, delirium, and depression. The last day of the fellowship was devoted to palliative care, pain management, decision-making capacity, and topics related to mortality (including suicide) in older patients. Quantitative feedback from a participant survey conducted after the first year of the fellowship (Table 2) indicated that most participants either “agreed” or “strongly agreed” that the training was effective and had a positive impact on their learning
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Day 5
3:00−4:30 Case Presentation and Discussion of Depression with Panel of Experts (COMMITTEE MEMBERS)
and appreciation for the distinctive contributions of each discipline, which, when combined, yielded a whole greater than the sum of its parts. Quantitative data in Years 02 and 03 (not presented) yielded similar post-test evaluation results. Finally, qualitative feedback from participants (Table 3) conveyed the trainees’ enjoyment at learning new information in an interprofessional setting taught by faculty experts from five schools of the health sciences. Participants reported increased knowledge about geriatric mental disorders and a greater appreciation for the contributions made by other members of the care team. Some frustration was also expressed, however, that the important contributions of nursing were still not fully appreciated.
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Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional TABLE 2. Geriatric Mental Health Mini-Fellowship Quantitative Feedback (N = 70) Strongly Disagree 1
Disagree 2
Neutral 3
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0
I am satisfied with the overall program There was an appropriate mix of lecture/panel discussion/class discussion There was an appropriate use of videos and other media There was an appropriate amount of hands-on/interactive class activities The reading materials were useful There were enough breaks throughout the day I am satisfied with the overall objective of bringing multidisciplinary trainees together Trainees will be able to identify strengths of each disciplinary in training Trainees will be able to better identify ways to improve team work Trainees will have a better understanding of the three common syndromes in geriatric mental health from a multidisciplinary perspective Learning from faculty from other disciplines was useful The content was relevant to my practice
Agree 4
Strongly Agree 5
0 3 (4.3%) 4 (5.7%) 3 (4.3%) 4 (5.7%) 0 0
20 (28.6%) 18 (25.7%) 41 (58.6%) 18 (25.7%) 21 (30%) 22 (31.4%) 16 (22.9%)
50 (71.4%) 49 (70%) 25 (35.7%) 49 (70%) 45 (64.3%) 48 (68.6%) 54 (77.1%)
2 (2.8%) 0 0
0 4 (5.7%) 0
24 (34.3%) 19 (27.1%) 22 (31.4%)
44 (62.9%) 47 (67.2%) 48 (68.6%)
0 0
5 (7.2%) 3 (4.3%)
15 (21.4%) 18 (25.7%)
50 (71.4%) 49 (70%)
TABLE 3. Geriatric Mental Health Mini-Fellowship Qualitative Feedback “I will definitely look to other disciplines to share the expertise I am now more familiar with. I also now feel more confident when speaking in a multi-disciplinary group.” (2014) “This fellowship has definitely increased my understanding of other professions and improved my ability to care for geriatric patients.” (2014) “The interaction with teams was key, was stimulating and engaging; the time spent with my own specialty was less stimulating and less engaging.” (2014) “Focus on the disciplines and what they actually do, the first activity on the first day should have been about this, I feel other disciplines still do not have and understanding of what advanced nurse/practitioner does, do a survey to see what each discipline thinks of others and then have a discussion.” (2014) “It would be very helpful and informative if, at the beginning of the series, there was a brief overview of all roles, and healthcare disciplines represented. Although during the lunch activities everyone was able to interact and was able to ask questions, it was difficult to get a clear picture of the different disciplines.” (2014) “I think others would agree with this, but the sessions focused on my own discipline were the least helpful to the expansion of my knowledge, but necessary to the program, even the sessions with which I was already familiar were still very interesting.” (2014) “I enjoyed working and talking with other medical professionals as it gave me a different perspective on patient care. I also greatly appreciated the flash drive of the presentations.” (2014) “Small groups with other health professionals, learning about their discipline and their perspective; interactive cases, lectures from interdisciplinary team as well. Also having lunch with different people daily.” (2015) “Keep having the fellowship. An integrated approach is so needed.” (2015) “I would highly recommend this program to both hospital and community residents.” (2015) “I think it would be helpful to have more cases or discussion throughout the day rather than at the end of the day.” (2015) “Most trainees were unfamiliar with the specific function of other disciplines, so it was useful.” (2016) “More interaction during some of the lectures would be helpful.” (2016) “Participation is this mini-fellowship has given me a broader understanding of the multiple aspects of geriatric care and I have no doubt that I will be a better physician because of it. I anticipate utilizing other members of the healthcare team more frequently and earlier than I had in the past.” (2016) “Perhaps a session on what makes Interprofessional practice uncomfortable: e.g., boundaries, egos, lack of knowledge, etc.” (2016) “I know nothing about OT, so information/presentation on this topic was phenomenal and highly useful.” (2016)
DISCUSSION Based on our literature review and knowledge of current available training programs, this Hartford Foundation−sponsored geriatric mental health minifellowship is the first of its kind to bring together trainees from across the health sciences. Although several other geriatric interprofessional trainings are offered, none are specific to mental health issues in later life.
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Solberg and her team13 conducted a half-day, interprofessional “boot camp” training in geriatrics. This program was well received, and based on post-test data, participants reported having gained knowledge in geriatric issues. The secondary goal of the Solberg program addressed interprofessional learning, which was reported to be beneficial.13 Similarly, the Geriatric Outreach and Training with Care (GOT Care!) initiative at the University of Connecticut trained 177 students in
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Solai et al. interprofessional geriatric care with a statistically significant improvement in students’ levels of collaborative practice skills in seven of eight subscales of the Collaborative Practice Assessment Tool.14 In addition, Geriatric Interdisciplinary Team Training programs funded by the John A. Hartford Foundation have benefitted more than 1,300 trainees in healthcare professions at eight different centers. Based on postcourse data, the faculty saw the most improvement in attitudinal measures with the self-reported Team Skills Scale.10 Finally, the Interprofessional Geriatric Training Institute at the Geriatric Education Center of Nova Southeastern University in Fort Lauderdale, Florida, has conducted annual trainings on various geriatric topics for the last 10 years; however, we were unable to locate published reports on the outcomes of their training. Developing and implementing innovative interprofessional training opportunities in geriatric mental health could lead to better health outcomes, higher quality of care, and lower costs.10 Providing education and training in geriatric mental health issues across disciplines appears to be a feasible way to prepare for the impending geriatric mental healthcare needs that the current workforce is ill equipped to manage.11 Our data indicated that the training was well received by participants and that it served to break down barriers between the different disciplines,
based on better understandings of others’ specific expertise, roles, and contributions. Although a limitation of the present study was the absence of performance data from pre- to postfellowship, it would not be realistic to expect to see such change after very brief exposure. Rather, our intention was to explore the feasibility and acceptability of interprofessional training in geriatric mental health. The single greatest challenge encountered was the need to find available time and to coordinate across the schools of the health sciences. Although we spoke with all of the deans of the participating schools and were generally well received, carving out time for cross-disciplinary training remains a formidable challenge. This situation is unlikely to change until incentives to change are in place, possibly as a result of health system and payor demands attendant to the shift from volume- to value-based care. Further assessment of patient- and carer-centered outcomes is also needed, together with implementation and dissemination research to foster uptake by health systems. Presented at the American Association of Geriatric Psychiatry, 2017 Annual Meeting, in Dallas, Texas, on March 26, 2017. Funding support from John A. Hartford Foundation grant and NIA P50 P50AG005133 (Jennifer H. Lingler).
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team training in geriatrics: An essential component of quality healthcare for older adults. J Am Geriatr Soc 2014; 62:961–965 Institute of Medicine: Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academies Press, 2001 Fulmer T, Hyer K, Flaherty E, et al: Geriatric interdisciplinary team training program evaluation results. J Aging Health 2005; 17:443–470 Institute of Medicine: The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC, National Academic Press, 2012 American Geriatrics Society: Existing Formal Geriatrics Competencies and Milestones. Available at: http://www.americangeriatrics. org/health_care_professionals/education/curriculum_guidelines_competencies/existing_formal_geriatrics_competencies. Accessed November 29, 2016 Solberg LB, Solberg LM, Carter CS: Geriatric care boot camp: an interprofessional education program for health care professionals. J Am Geriatr Soc 2015; 63: 997−100 Shellman JM, Malcolm M, LeClaire A, Cave A, Rees C: An interprofessional geriatric training and outreach program: student, patient and provider outcomes. Innov Aging 2017; 1:825–826
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