- Email: [email protected]
What is the Diagnosis? Familial Hypocalciuric Hypercalcemia or Primary Hyperparathyroidism with Vitamin D Deficiency
Poster Abstracts / JAMDA 14 (2013) B3eB26
antipsychotic rather than a pain medication. In our case, the unmet need was rectal discomfort from constipation. Laxatives, rather than antipsychotics completely resolved the distressing behavior. In a case series of 14 older patients with dementia and scatolia, all of them had constipation and scatolia resolved with laxatives. In residents with dementia it is important to evaluate disruptive behavior as a symptom of an unmet need rather than as a primary diagnosis. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
B9
research presents evidence for a new dementia-care provider e the Board Certified Behavior Analyst. These clinicians provide an innovative, nonpharmacological, and person-centered approach to dementia care. Behavior services can be incorporated into any interdisciplinary team approach and in any setting, including assisted living facilities, nursing homes, PACE and other community-based programs. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
VA Long Term Care and Violence: It Isn’t Easy Using the Behavioral Model to Manage Behavioral and Psychological Symptoms of Dementia Presenting Author: Maranda A. Trahan, Johns Hopkins University Geriatric Medicine and Gerontology Author(s): Maranda A. Trahan, SungWoo Kahng, Jeanne Donaldson; and Matthew McNabney
Introduction: Behavioral and psychological symptoms of dementia (BPSD) are known to occur in nearly all diagnosed. BPDS affects a patient’s quality of life, risk of institutionalization, caregiver burden, and cost of care. Pharmacological interventions are commonly prescribed, but are associated with significant adverse events (e.g., movement disorders, stroke, death). There is a general agreement that an individual’s physical and social environment influences the occurrence of BPSD. The behavioral model has an established reputation for delivering effective non-pharmacological interventions to individuals with neurological impairments, not related to dementia. The purpose of this poster is to review the first four clinical cases referred to a Board Certified Behavior Analyst for behavioral services to manage BPSD. Case Description: Any member of the interdisciplinary team (e.g., social workers, recreational therapists, transportation services, occupational therapists or medical staff) at one site of the Program of the All-Inclusive Care of the Elderly (PACE) could refer participants for behavioral services. All referrals had a diagnosis of moderate to severe dementia, aged 80 years old or older, were nursing home eligible, and exhibited two or more ADL impairments. Staff could refer participants for any BPSD and the first four included bizarre speech, communication impairments, excessive crying and noncompliance. Medical staff examined all participants who exhibited BPSD before behavioral services began. Various behavioral assessments were completed by a Board Certified Behavior Analyst to identify the environmental triggers or reinforcing rewards that influenced BPSD. Individualized non-pharmacological interventions were implemented in the setting in which these behaviors occurred in order to manage BPSD and/or increase adaptive behaviors. Single-subject designs were used to evaluate the effectiveness of all interventions. Behavioral clinicians identified environmental influences for all BPSD. Results showed that when these factors were modified, BPSD decreased or adaptive behaviors increased. Behavioral services have either stopped or in maintenance for all participants. Discussion: Several lessons were learned from these few cases. First, standard behavioral assessments need to be modified to capture the environmental events that influence BPSD. Standard behavioral assessments were developed with other cognitively-impaired populations (e.g., developmental disabilities), and the clinical cases presented in this poster provide the first empirical evidence that the progression of dementia affects the way environmental variables influence BPSD. Secondly, the unmet needs model, a prominent conceptual framework to explain BPSD, presumes that these challenging behaviors occur as a way to communicate unmet wants or needs. Results from one of the clinical cases described in this poster demonstrated that we could teach dementia patients to communicate wants or needs using picture cards. This evidence will lead to an exciting and innovative line of research focused on examining practical interventions to increase functional communication in order to decrease BPSD. Given that the number of people with dementia is expected triple over the upcoming decades, it is vital that services be identified and implemented to reduce challenging behaviors as well as increase adaptive behaviors in this population. The clinical cases described in this poster provide further evidence that assessments and techniques derived from the behavioral model can be used to manage BPSD. Additionally, this
Presenting Author: Neha Kalaria, MD, Baltimore VA Medical Center Geriatrics Author(s): Neha Kalaria, MD, Xiangrong Shao, MD; and Abisola Mesioye, MD
Introduction: Resident on resident violence in long term care is an understudied phenomenon. This is important in VA facilities where there are a large number of residents with dementia, traumatic brain injury, and posttraumatic stress disorder as a result of war-time experiences. The presence of these disorders often results in conflict between residents. Case Description: Mr. LB is a 63 year old Vietnam veteran who has posttraumatic stress disorder, traumatic brain injury and traumatic amputation. He was placed in long term care due to progressive dementia. Previously a counselor for disabled veterans, his stay has been characterized by aggression from other residents related to his wandering behavior and inherent nature to assist disabled veterans. There were a number of interventions implemented to prevent Mr. LB from wandering. Initially, he was endlessly redirected however this proved to be difficult with his cognitive impairment and poor communication. The next intervention used a black square in front of rooms to give the appearance of a hole since he was likely to have impaired depth perception on account of his advanced dementia. This was followed by placement of police tape on doorways, which was also futile. Mr. LB now requires full supervision to avoid conflict with other residents and wandering. Discussion: Residents confined to a long term care facility are likely to have conflict with each other. Posttraumatic stress disorder from war-time and combat experience is associated with impairments in functioning across a number of psychosocial domains. The combination of these impairments often predisposes residents of long term care to resident on resident violence. A relationship exists between level of cognitive function and the type of aggression in demented older adults. Residents with moderate to severe decline in cognitive function are likely to feel threatened more easily with invasion of personal space which has also been found to be the case in residents with posttraumatic stress disorder. It has been shown that there is a higher rate of disputes when demented and non-demented residents are living together. It is essential to assess and determine the cause of aggressive behavior between residents to establish interventions. The high rate of dementia in older adults in addition to posttraumatic stress disorder and traumatic brain injury in the veteran population predisposes this group to resident on resident violence. More studies are needed to better characterize and explore solutions to this phenomenon. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
What is the Diagnosis? Familial Hypocalciuric Hypercalcemia or Primary Hyperparathyroidism with Vitamin D Deficiency Presenting Author: Bikram Saini, MD, University of Maryland Geriatrics Author(s): Bikram Saini, MD; and Abisola Mesioye, MD
Introduction: Elevated calcium levels are a common finding in elderly patients. The most common causes are PHPT (Primary Hyperparathyroidism) and malignancy. FHH, which is also a cause of hypercalcemia, occurs less commonly. It is important to differentiate FHH from mild PHPT with concomitant vitamin D deficiency as both conditions have elevated serum PTH and calcium levels as well as normal or low 24-hour urinary calcium excretion. Serum 25-OHD should be measured in both cases. In mild PHPT with concomitant vitamin D deficiency, urinary calcium excretion increases with vitamin D repletion, thereby distinguishing it from FHH.
B10
Poster Abstracts / JAMDA 14 (2013) B3eB26
Case Description: A 51 year old patient with a past medical history of
Conclusion/Discussion: Significance: Health care spending is dispropor-
uncontrolled diabetes was admitted to a VA CLC for the management of a diabetic foot ulcer. On review of his labs, he was found to have elevated serum calcium (10.6 mg/dl). Previous records were reviewed which also showed persistent mild hypercalcemia for 15 years. He did not report any kidney stones or bone fractures in the past and could not recall any family history of a calcium disorder. Additional labs were ordered which showed an elevated PTH level (360 pg/ml), a low 24-hour urinary calcium excretion (3.9 mg/24 hours) and a low serum 25-OH Vitamin D level (17.8 ng/ml). Ergocalciferol was given for 3 months and repeat labs showed normal serum Vitamin D (33 ng/ml)) and normal PTH level (43 pg/ml), Serum calcium remains high (10.7 mg/dl) while urine calcium excretion continues to be low (42mg/24hours) and Ca/Cr <0.01. Discussion: Our patient has familial hypocalciuric hypercalcemia (FHH) which is characterized by low urine calcium excretion, Ca/Cr < 0.01, mild hypercalcemia, normal to mildly elevated PTH and normal 25-OH Vitamin D (25-OHD). These patients usually do not have any symptoms or signs of hypercalcemia. In FHH, serum PTH concentrations are typically inappropriately normal or high (in about 20 percent of cases) in the presence of mild hypercalcemia. One cause of a high serum PTH level in FHH is the presence of coexistent vitamin D deficiency which needs to be replaced first before making a diagnosis of FHH as in this case. Hypercalcemia with ’normal’ serum PTH concentrations occurs in approximately 10 percent of patients with primary hyperparathyroidism (PHPT), which is a much more common cause of hypercalcemia than FHH but the urine calcium is usually elevated (urine calcium > 100mg/24 hours). It is important to distinguish asymptomatic PHPT with Vitamin D deficiency from FHH because FHH is a benign inherited condition that typically does not require parathyroidectomy and will not be cured by it. A high incidence of suspicion, a good family history and pertinent labs findings help to confirm the diagnosis of FHH. Affected family members should be identified and counseled on the benign nature of this condition and, consequently, the importance of avoiding parathyroid surgery. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
tionate at the end of lifed30% of Medicare expenditures are attributed to 5% of beneficiaries who die annually and 78% of costs are incurred in the final 30 days of life (Yu, 2008). Studies indicate a reduction in hospitalizations by increasing the use of advanced directives, surrogate decision makers and do not resuscitate decisions (Levy, Morris & Kramer, 2008; Molloy et al. 2000; Nicholas, Langa, Iwashyna & Weir, 2011). Integration of a CPR video tool (Nous Foundation, 2010) into advanced care planning has the potential to reduce hospitalizations, health care costs, and ensure end of life care is consistent with resident wishes (Aw et al., 2012). Recommendations: Implement CPR video on admission when family is present, in senior centers, family educational events or assisted living to increase family participation. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Education
Cardio Pulmonary Resuscitation Decisions in Nursing Home Residents Presenting Author: Melissa S. Bennett, Wright State University Author(s): Melissa S. Bennett, Gail Moddeman, RN, PhD, Phyllis Gaspar, RN; and Todd L. Sobol, MD, CMD
Introduction/Objective: Cardiopulmonary resuscitation (CPR) performed on nursing home residents, consistently demonstrates poor outcomes with less than 5% survival rate (AMDA, January 30, 2011). Study participants overestimate CPR survival based on television and lack of accurate information (Adams & Snedden, 2006; van Mil et al., 2000). This project evaluated use of a video decision tool on CPR choices in nursing home residents over three months. Design/Methodology: A CPR video decision tool was added to advanced care planning discussions to educate nursing home residents and their decision makers. Nurse Practitioners (NPs) documented the resident’s choices in the electronic health record (EHR). Clinical metric reports, based on the EHR, were used to measure the change in CPR decisions over three months in seven nursing homes. Results: The mean percentage change following implementation of the CPR video tool was 5.5% with p¼.226. One facility closed during the pilot, one facility with a new NP showed an increase in residents requesting CPR, one facility showed no change and five facilities had reduced requests for CPR. The decrease in residents requesting CPR was not statistically significant following integration of the CPR video tool. Despite the lack of statistical significance, a 5.5% reduction in residents selecting CPR with an equivalent reduction in hospitalizations would reduce medical expenses by $56,987.
Into the Community: Development of a Collaborative Educational Program Between a Geriatric Fellowship and a Community Nursing Home Presenting Author: Nancy Schoenborn, MD, Johns Hopkins University School of Medicine Author(s): Nancy Schoenborn, MD, Monica Sandoval, MD, Jessica Lee, MD, MS, Thomas Edmondson, MD, CMD, Matthew McNabney, MD, CMD, Walter Kowal, MBA, PT; and Laura Gibson
Introduction/Objective: Long term care is critical for geriatric medical education. Many of the frailest and most vulnerable older adults are cared for in nursing homes (NH) where many of the geriatric competencies are easily taught. NHs are also an ideal setting for learning about health systems, interdisciplinary teamwork, and transitions of care. However, there are only a few reports of teaching NHs and trainees’ exposure to long term care is variable overall. We describe the development of a collaborative educational program between a geriatric fellowship and a community NH that enhances the fellows’ education and offers educational opportunities for other post-graduate trainees. Design/Methodology: Beginning in 2012, the geriatric medicine fellowship at Johns Hopkins forged a new partnership with a community Nursing Home (NH) to provide longitudinal experiential learning for the first year clinical geriatric fellows. Both the regional medical director for the nursing home chain and the local facility’s medical director are very enthusiastic. There is also tremendous commitment and support from the facility’s administrator and director of nursing for this educational endeavor. Each fellow is assigned five long term NH residents for whom the fellows serve as primary provider for one year (along with a private attending physician who is board-certified in internal medicine and has extensive experience caring for long term care patients). The patients are selected to be representative of the range of patients seen in long term care. The fellows’ responsibilities include monthly visits and notes, attending to interim issues by phone and making additional visits as needed. Night and weekend coverage is provided by all clinical fellows in the geriatric division on a rotation basis. Nursing home staff has been instructed to direct inquiries and reports to the fellows. The regional medical director and the facility’s medical director are both fellowship-trained and board-certified in geriatric medicine. A monthly didactic was started by the facility’s medical director on NH-related topics. The medical director also provides teaching and supervising opportunities to the fellows in addition to each fellow’s assigned attending. These experiences complement the experiential learning for the fellows so the fellows are well-supported in problem-solving and system-based practice. The one year of longitudinal experience may count towards the requirement to become certified medical director if the fellow is interested in a career in long term care. This experience with community NH has also allowed fellows to teach on the topic to internal medicine residents as part of a separate curriculum on care transitions. Results: Since the program’s initiation in July 2012, the three clinical geriatric fellows have reported positive educational experiences and significant value. They particularly appreciate the exposure to a community NH that offers more realistic experiences and closer ties to the local community.
antipsychotic rather than a pain medication. In our case, the unmet need was rectal discomfort from constipation. Laxatives, rather than antipsychotics completely resolved the distressing behavior. In a case series of 14 older patients with dementia and scatolia, all of them had constipation and scatolia resolved with laxatives. In residents with dementia it is important to evaluate disruptive behavior as a symptom of an unmet need rather than as a primary diagnosis. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
B9
research presents evidence for a new dementia-care provider e the Board Certified Behavior Analyst. These clinicians provide an innovative, nonpharmacological, and person-centered approach to dementia care. Behavior services can be incorporated into any interdisciplinary team approach and in any setting, including assisted living facilities, nursing homes, PACE and other community-based programs. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
VA Long Term Care and Violence: It Isn’t Easy Using the Behavioral Model to Manage Behavioral and Psychological Symptoms of Dementia Presenting Author: Maranda A. Trahan, Johns Hopkins University Geriatric Medicine and Gerontology Author(s): Maranda A. Trahan, SungWoo Kahng, Jeanne Donaldson; and Matthew McNabney
Introduction: Behavioral and psychological symptoms of dementia (BPSD) are known to occur in nearly all diagnosed. BPDS affects a patient’s quality of life, risk of institutionalization, caregiver burden, and cost of care. Pharmacological interventions are commonly prescribed, but are associated with significant adverse events (e.g., movement disorders, stroke, death). There is a general agreement that an individual’s physical and social environment influences the occurrence of BPSD. The behavioral model has an established reputation for delivering effective non-pharmacological interventions to individuals with neurological impairments, not related to dementia. The purpose of this poster is to review the first four clinical cases referred to a Board Certified Behavior Analyst for behavioral services to manage BPSD. Case Description: Any member of the interdisciplinary team (e.g., social workers, recreational therapists, transportation services, occupational therapists or medical staff) at one site of the Program of the All-Inclusive Care of the Elderly (PACE) could refer participants for behavioral services. All referrals had a diagnosis of moderate to severe dementia, aged 80 years old or older, were nursing home eligible, and exhibited two or more ADL impairments. Staff could refer participants for any BPSD and the first four included bizarre speech, communication impairments, excessive crying and noncompliance. Medical staff examined all participants who exhibited BPSD before behavioral services began. Various behavioral assessments were completed by a Board Certified Behavior Analyst to identify the environmental triggers or reinforcing rewards that influenced BPSD. Individualized non-pharmacological interventions were implemented in the setting in which these behaviors occurred in order to manage BPSD and/or increase adaptive behaviors. Single-subject designs were used to evaluate the effectiveness of all interventions. Behavioral clinicians identified environmental influences for all BPSD. Results showed that when these factors were modified, BPSD decreased or adaptive behaviors increased. Behavioral services have either stopped or in maintenance for all participants. Discussion: Several lessons were learned from these few cases. First, standard behavioral assessments need to be modified to capture the environmental events that influence BPSD. Standard behavioral assessments were developed with other cognitively-impaired populations (e.g., developmental disabilities), and the clinical cases presented in this poster provide the first empirical evidence that the progression of dementia affects the way environmental variables influence BPSD. Secondly, the unmet needs model, a prominent conceptual framework to explain BPSD, presumes that these challenging behaviors occur as a way to communicate unmet wants or needs. Results from one of the clinical cases described in this poster demonstrated that we could teach dementia patients to communicate wants or needs using picture cards. This evidence will lead to an exciting and innovative line of research focused on examining practical interventions to increase functional communication in order to decrease BPSD. Given that the number of people with dementia is expected triple over the upcoming decades, it is vital that services be identified and implemented to reduce challenging behaviors as well as increase adaptive behaviors in this population. The clinical cases described in this poster provide further evidence that assessments and techniques derived from the behavioral model can be used to manage BPSD. Additionally, this
Presenting Author: Neha Kalaria, MD, Baltimore VA Medical Center Geriatrics Author(s): Neha Kalaria, MD, Xiangrong Shao, MD; and Abisola Mesioye, MD
Introduction: Resident on resident violence in long term care is an understudied phenomenon. This is important in VA facilities where there are a large number of residents with dementia, traumatic brain injury, and posttraumatic stress disorder as a result of war-time experiences. The presence of these disorders often results in conflict between residents. Case Description: Mr. LB is a 63 year old Vietnam veteran who has posttraumatic stress disorder, traumatic brain injury and traumatic amputation. He was placed in long term care due to progressive dementia. Previously a counselor for disabled veterans, his stay has been characterized by aggression from other residents related to his wandering behavior and inherent nature to assist disabled veterans. There were a number of interventions implemented to prevent Mr. LB from wandering. Initially, he was endlessly redirected however this proved to be difficult with his cognitive impairment and poor communication. The next intervention used a black square in front of rooms to give the appearance of a hole since he was likely to have impaired depth perception on account of his advanced dementia. This was followed by placement of police tape on doorways, which was also futile. Mr. LB now requires full supervision to avoid conflict with other residents and wandering. Discussion: Residents confined to a long term care facility are likely to have conflict with each other. Posttraumatic stress disorder from war-time and combat experience is associated with impairments in functioning across a number of psychosocial domains. The combination of these impairments often predisposes residents of long term care to resident on resident violence. A relationship exists between level of cognitive function and the type of aggression in demented older adults. Residents with moderate to severe decline in cognitive function are likely to feel threatened more easily with invasion of personal space which has also been found to be the case in residents with posttraumatic stress disorder. It has been shown that there is a higher rate of disputes when demented and non-demented residents are living together. It is essential to assess and determine the cause of aggressive behavior between residents to establish interventions. The high rate of dementia in older adults in addition to posttraumatic stress disorder and traumatic brain injury in the veteran population predisposes this group to resident on resident violence. More studies are needed to better characterize and explore solutions to this phenomenon. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
What is the Diagnosis? Familial Hypocalciuric Hypercalcemia or Primary Hyperparathyroidism with Vitamin D Deficiency Presenting Author: Bikram Saini, MD, University of Maryland Geriatrics Author(s): Bikram Saini, MD; and Abisola Mesioye, MD
Introduction: Elevated calcium levels are a common finding in elderly patients. The most common causes are PHPT (Primary Hyperparathyroidism) and malignancy. FHH, which is also a cause of hypercalcemia, occurs less commonly. It is important to differentiate FHH from mild PHPT with concomitant vitamin D deficiency as both conditions have elevated serum PTH and calcium levels as well as normal or low 24-hour urinary calcium excretion. Serum 25-OHD should be measured in both cases. In mild PHPT with concomitant vitamin D deficiency, urinary calcium excretion increases with vitamin D repletion, thereby distinguishing it from FHH.
B10
Poster Abstracts / JAMDA 14 (2013) B3eB26
Case Description: A 51 year old patient with a past medical history of
Conclusion/Discussion: Significance: Health care spending is dispropor-
uncontrolled diabetes was admitted to a VA CLC for the management of a diabetic foot ulcer. On review of his labs, he was found to have elevated serum calcium (10.6 mg/dl). Previous records were reviewed which also showed persistent mild hypercalcemia for 15 years. He did not report any kidney stones or bone fractures in the past and could not recall any family history of a calcium disorder. Additional labs were ordered which showed an elevated PTH level (360 pg/ml), a low 24-hour urinary calcium excretion (3.9 mg/24 hours) and a low serum 25-OH Vitamin D level (17.8 ng/ml). Ergocalciferol was given for 3 months and repeat labs showed normal serum Vitamin D (33 ng/ml)) and normal PTH level (43 pg/ml), Serum calcium remains high (10.7 mg/dl) while urine calcium excretion continues to be low (42mg/24hours) and Ca/Cr <0.01. Discussion: Our patient has familial hypocalciuric hypercalcemia (FHH) which is characterized by low urine calcium excretion, Ca/Cr < 0.01, mild hypercalcemia, normal to mildly elevated PTH and normal 25-OH Vitamin D (25-OHD). These patients usually do not have any symptoms or signs of hypercalcemia. In FHH, serum PTH concentrations are typically inappropriately normal or high (in about 20 percent of cases) in the presence of mild hypercalcemia. One cause of a high serum PTH level in FHH is the presence of coexistent vitamin D deficiency which needs to be replaced first before making a diagnosis of FHH as in this case. Hypercalcemia with ’normal’ serum PTH concentrations occurs in approximately 10 percent of patients with primary hyperparathyroidism (PHPT), which is a much more common cause of hypercalcemia than FHH but the urine calcium is usually elevated (urine calcium > 100mg/24 hours). It is important to distinguish asymptomatic PHPT with Vitamin D deficiency from FHH because FHH is a benign inherited condition that typically does not require parathyroidectomy and will not be cured by it. A high incidence of suspicion, a good family history and pertinent labs findings help to confirm the diagnosis of FHH. Affected family members should be identified and counseled on the benign nature of this condition and, consequently, the importance of avoiding parathyroid surgery. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
tionate at the end of lifed30% of Medicare expenditures are attributed to 5% of beneficiaries who die annually and 78% of costs are incurred in the final 30 days of life (Yu, 2008). Studies indicate a reduction in hospitalizations by increasing the use of advanced directives, surrogate decision makers and do not resuscitate decisions (Levy, Morris & Kramer, 2008; Molloy et al. 2000; Nicholas, Langa, Iwashyna & Weir, 2011). Integration of a CPR video tool (Nous Foundation, 2010) into advanced care planning has the potential to reduce hospitalizations, health care costs, and ensure end of life care is consistent with resident wishes (Aw et al., 2012). Recommendations: Implement CPR video on admission when family is present, in senior centers, family educational events or assisted living to increase family participation. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Education
Cardio Pulmonary Resuscitation Decisions in Nursing Home Residents Presenting Author: Melissa S. Bennett, Wright State University Author(s): Melissa S. Bennett, Gail Moddeman, RN, PhD, Phyllis Gaspar, RN; and Todd L. Sobol, MD, CMD
Introduction/Objective: Cardiopulmonary resuscitation (CPR) performed on nursing home residents, consistently demonstrates poor outcomes with less than 5% survival rate (AMDA, January 30, 2011). Study participants overestimate CPR survival based on television and lack of accurate information (Adams & Snedden, 2006; van Mil et al., 2000). This project evaluated use of a video decision tool on CPR choices in nursing home residents over three months. Design/Methodology: A CPR video decision tool was added to advanced care planning discussions to educate nursing home residents and their decision makers. Nurse Practitioners (NPs) documented the resident’s choices in the electronic health record (EHR). Clinical metric reports, based on the EHR, were used to measure the change in CPR decisions over three months in seven nursing homes. Results: The mean percentage change following implementation of the CPR video tool was 5.5% with p¼.226. One facility closed during the pilot, one facility with a new NP showed an increase in residents requesting CPR, one facility showed no change and five facilities had reduced requests for CPR. The decrease in residents requesting CPR was not statistically significant following integration of the CPR video tool. Despite the lack of statistical significance, a 5.5% reduction in residents selecting CPR with an equivalent reduction in hospitalizations would reduce medical expenses by $56,987.
Into the Community: Development of a Collaborative Educational Program Between a Geriatric Fellowship and a Community Nursing Home Presenting Author: Nancy Schoenborn, MD, Johns Hopkins University School of Medicine Author(s): Nancy Schoenborn, MD, Monica Sandoval, MD, Jessica Lee, MD, MS, Thomas Edmondson, MD, CMD, Matthew McNabney, MD, CMD, Walter Kowal, MBA, PT; and Laura Gibson
Introduction/Objective: Long term care is critical for geriatric medical education. Many of the frailest and most vulnerable older adults are cared for in nursing homes (NH) where many of the geriatric competencies are easily taught. NHs are also an ideal setting for learning about health systems, interdisciplinary teamwork, and transitions of care. However, there are only a few reports of teaching NHs and trainees’ exposure to long term care is variable overall. We describe the development of a collaborative educational program between a geriatric fellowship and a community NH that enhances the fellows’ education and offers educational opportunities for other post-graduate trainees. Design/Methodology: Beginning in 2012, the geriatric medicine fellowship at Johns Hopkins forged a new partnership with a community Nursing Home (NH) to provide longitudinal experiential learning for the first year clinical geriatric fellows. Both the regional medical director for the nursing home chain and the local facility’s medical director are very enthusiastic. There is also tremendous commitment and support from the facility’s administrator and director of nursing for this educational endeavor. Each fellow is assigned five long term NH residents for whom the fellows serve as primary provider for one year (along with a private attending physician who is board-certified in internal medicine and has extensive experience caring for long term care patients). The patients are selected to be representative of the range of patients seen in long term care. The fellows’ responsibilities include monthly visits and notes, attending to interim issues by phone and making additional visits as needed. Night and weekend coverage is provided by all clinical fellows in the geriatric division on a rotation basis. Nursing home staff has been instructed to direct inquiries and reports to the fellows. The regional medical director and the facility’s medical director are both fellowship-trained and board-certified in geriatric medicine. A monthly didactic was started by the facility’s medical director on NH-related topics. The medical director also provides teaching and supervising opportunities to the fellows in addition to each fellow’s assigned attending. These experiences complement the experiential learning for the fellows so the fellows are well-supported in problem-solving and system-based practice. The one year of longitudinal experience may count towards the requirement to become certified medical director if the fellow is interested in a career in long term care. This experience with community NH has also allowed fellows to teach on the topic to internal medicine residents as part of a separate curriculum on care transitions. Results: Since the program’s initiation in July 2012, the three clinical geriatric fellows have reported positive educational experiences and significant value. They particularly appreciate the exposure to a community NH that offers more realistic experiences and closer ties to the local community.