Teaching the Geriatric Psychiatry Core Competencies

American Association for Geriatric Psychiatry (AAGP) Steering Committee members:
Susan Lieff, MD, MEd; Iqbal "Ike" Ahmed, MD;
Blaine Greenwald, MD; William Orr, MD; David Sultzer, MD

The following recommendations are a synthesis of training directors’ suggestions of teaching methods that can be used to meet the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements. The ACGME requirements precede each section (Patient Care; Medical Knowledge; Practice-Based Learning and Improvement; Interpersonal and Communication Skills; Professionalism; and Systems-Based Practice) in italicized text.

Patient Care
Management Skills
Medical Knowledge
Interpersonal and Communication Skills
Practice-Based Learning and Improvement
Professionalism
Systems-Based Practice

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

• communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families
• gather essential and accurate information about their patients
• make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment
• develop and carry out patient management plans
• counsel and educate patients and their families
• use information technology to support patient care decisions and patient education
• perform competently all medical and invasive procedures considered essential for the area of practice
• provide health care services aimed at preventing health problems or maintaining health
• work with health care professionals, including those from other disciplines, to provide patient-focused care

Recommendations:

Interviewing Skills – Review the unique aspects of interviewing the elderly, address the issues of transference to the elderly and how that might have an impact on the evaluation using:

• Observation should be done early in the year. Use multiple observations of initial interviews judging both content and interpersonal skills. Make observations in multiple settings. Review the interview by discussing observations.
• Traditional methods include classroom teaching; faculty demonstrations, case conferences; and modeling. Use initial faculty demonstration. Interview all new patients seen with attending physicians.
• Innovative methods may include videotaped interviews; clinical trial training; or simulated patients.
• Include assessment in specific areas – Formal interview assessments used in clinical trials, such as the Cornell, Geriatric Depression Scale (GDS), Brief Psychiatric Rating Scale (BPRS), Neuropsychiatric Inventory (NPI). Include evaluation of Activities of Daily Living (ADLs), apraxia, aphasia and evaluation of gait/balance.
• Formal assessments may include:
  • Use of a mock part II of board exam.
  • A videotape review of interviews with different types of patients.
  • Formal feedback from patient and family.

Mental Status Examination (MSE) – Present didactics early to teach MSE, especially cognitive mental status.

• Use simulation with the fellow.
• Use simulated patients.
• Use teaching videos that demonstrate MSE with different types of patients.
• Observe fellows performance of mental status examination of patients. Note observation skills.
• Discuss specific tests, rationales for use of Mini Mental Status Exam (MMSE), Modified Mini-Mental State (3MS) Exam, Clock test, Frontal Assessment Battery (FAB), Executive Interview (EXIT). Review testing manuals.
• Observe neuropsychological testing.
• Use comprehensive dementia assessments to assess multiple aspects of MSE skills.

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Competency Assessments – Provide opportunities to become familiar with competency tools.

• Provide competency evaluations during Consultation Liaison service (Acute hospital, Long-Term Care (LTC) facility, outpatient).
• Assign court- or county-initiated requests for evaluation.
• Participate in local forensic psychiatry teaching programs on issues of competency in the elderly.
• Review testimony in court or mock trials.
• Watch forensic experts interview and testify on competency.
• Suggest tutorials with elder law experts.
• Arrange for home visits with adult protection agencies.

Family and Caregiver Assessments

• Encourage participation in dementia clinic family meetings.
• Teach principles of geriatric couples/family therapy.
• Provide opportunities for home visits.
• Encourage participation in caregiver teaching groups.
• Demonstrate the use telemedicine evaluations.
• Arrange for observation of social work family and caregiver evaluations.
• Require attendance or deliver a lecture at an Alzheimer Association caregiver meeting.
• Encourage participation in impotency clinic evaluations of elderly couples.

Functional Assessment

• Arrange for observations in occupational therapy assessments (e.g. Kohlman’s Evaluation of Living Skills or KELS, Allen Cognitive Levels Assessment or ACL, driving).
• Encourage participation in rehabilitation medicine clinic and assessments (e.g. for traumatic brain injury or TBI, spinal cord injury or SCI).
• Encourage participation in geriatric medicine or GEM clinics.
• Arrange for observations of physical therapy (PT) assessments.
• Insure familiarity with instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessment tools.
• Arrange for observations of speech therapy assessments.
• Encourage participation in Impotency/Sexuality assessments.

Community and Environmental Assessment

• Encourage participation in home assessments.
• Encourage participation in hospice visits.
• Arrange for observation of social work assessments (inpatient, outpatient, home).
• Obtain Complete Adult Protection Services assessments.
• Demonstrate the use of telemedicine assessments and conferencing.
• Participate in long-term care visits and interact with Directors of Nursing, Medical Directors, etc.

Medical assessment – working with other medical disciplines such as neurologists in geriatric neurology clinics, and with geriatric medicine in a multidisciplinary geriatric evaluation or consultation clinic is key.

• Work with geriatric medicine fellows in multiple settings such as clinics, wards, and home visits.
• Integrate didactic seminars in medicine and neurology taught by geriatric medicine and neurology departments into the geriatric psychiatry seminar series.
• Suggest attending geriatric medicine, neurology and neuroradiology seminars in those departments.
• Consider a one-month medicine or geriatric medicine rotation.
• Include sexual functioning assessment.

Ancillary investigations; laboratory tests; radiology/imaging, electroencephalography (EEG)

• Arrange a visit to the EEG laboratory and brain imaging services.
• Review EEG and scans of all patients.
• Assign reviews of actual scan books to promote recognition of normal and abnormal scans.
• Require attendance at neuroradiology rounds.

Neuropsychologic tests

• Arrange for an afternoon with a neuropsychologist to observe the neuropsychological testing procedure.
• Review appropriate indications for and use of a neuropsychologist.
• De-emphasize routine use of neuropsychiatric testing, especially if appropriate neurocognitive testing is done by the fellow.

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MANAGEMENT SKILLS

Formulation of biopsychosocial information into a comprehensive treatment plan

• Provide individual supervision of trainee cases – presentation and critique of treatment plan.
• Review selected documented biopsychosocial treatment plans, with discussion in supervision.
• Provide group supervision, with focus on treatment planning.
• Present didactic information regarding the elements of a comprehensive treatment plan.
• Perform mock oral boards session.
• Promote grand rounds or case conference presentation, with a focus on comprehensive treatment plan
• Provide multidisciplinary case conferences, to include input and feedback from several clinical care providers (nursing, occupational therapy, geriatric medicine, social work, physical therapy and rehab, etc.).
• Provide clinic, or regular case conferences, that includes cases with multiple and complex diagnoses, and challenging treatment needs.

Pharmacotherapy

• Provide an organized core curriculum that includes each pharmacologic class.
• Include "second-line" treatment strategies for treatment resistant patients in the core curriculum.
• Provide didactic sessions on pharmacokinetic and pharmacodynamic changes over the life span., cytochrome P450 system and drug interactions, psychopharmacologic treatment of dementia, delirium, depression, psychosis and other psychiatric disorders in the elderly, and pharmacologic treatment in patients with common comorbid medical conditions.
• Arrange group supervision, or case conferences, focused on "treatment resistant" cases.
• Provide individual case supervision.
• Hold interdisciplinary conferences with pharmacy.
• Support longitudinal follow-up of patients for supervised management experience in relapse, long term effectiveness, illness morbidity, and residual symptoms.
• Arrange for participation on pharmacy or formulary committee.
• Hold regular journal club or seminar sessions focused on new medical treatment strategies.

Electroconvulsive Therapy (ECT)

• Provide didactic section on indications, risks, procedures, and legal issues in core curriculum.
• Include specific didactics on adverse events, cognitive effects, and the patient with multiple medical problems and medications.
• Arrange a supervised rotation on the ECT service, or during a geropsychiatry inpatient rotation.
• Arrange for observation of an ECT treatment session with review of case notes, and supervision.
• Set up a rotation on ECT consultation service and provide for case review and ECT consideration.
• Brief overview of other potential biologic treatments such as repetitive transcranial magnetic stimulation (rTMS) and Vagal nerve stimulation (VNS).

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Psychotherapy

• Include the structure of available psychotherapeutic strategies, and appropriate choice of patients in the core curriculum.
• Incorporate didactic sessions related to developmental issues of aging and common developmental challenges.
• Include didactic sessions on note-taking, coding, billing, privacy, and ethics in psychotherapy.
• Supervise individual psychotherapy cases including brief, crisis-oriented, cognitive-behavioral, interpersonal, or insight-oriented.
• Oversee longitudinal psychotherapeutic treatment plans; working with individuals over the course of one-year minimum.
• Videotape a review of resident’s individual casework or seminar including teaching videotapes.
• Set up a group psychotherapy experience, with supervision and co-leader.
• Review patient logs and case mix.
• Provide experience with couples therapy, family therapy, and caregivers.

Behavioral treatments

• Include specialized behavioral treatments in the core curriculum.
• Provide a supervised rotation in a behavioral program.
• Encourage attendance at specialized workshops in behavioral treatment.
• Require participation in a dementia behavioral management group session.
• Arrange for liaison with nursing staff and multidisciplinary staff in the nursing home.
• Encourage development and presentation of a behavioral management program to staff.

Ability to effectively communicate with patients, families, and caregivers

• Provide case supervision that includes attention to communication skills.
• Observe in outpatient, inpatient, and consultation settings.
• Encourage fellow to recognize own feelings and attitudes.
• Provide patient survey questionnaires that request feedback on provider communication skills.
• Arrange for fellow’s participation in support groups and family meetings.

Ability to manage ethical and legal issues pertinent to geriatric psychiatry

• Include legal issues such as capacity to consent, conservatorships, involuntary detention and treatment, driving privileges, patient’s rights, advanced directives in the core curriculum.
• Include lectures by an elder law attorney in the core curriculum.
• Encourage discussion of legal issues and involvement in legal proceedings related to clinical activities.
• Encourage attendance at mental health court proceedings.
• Encourage participation in hospital ethics committee.
• Hold ethics case conferences.
• Encourage fellow’s role as a leader, not a junior trainee without responsibility for legal and other administrative tasks.
• Require maintenance of an "Interesting Ethical Dilemmas" case notebook.

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MEDICAL KNOWLEDGE

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:

1. demonstrate an investigatory and analytic thinking approach to clinical situations
2. know and apply the basic and clinically supportive sciences which are appropriate to their discipline

Recommendations:

• Offer a comprehensive geriatric psychiatry core curriculum that includes areas related to geriatric medicine, neurology, neuropsychology, social and anthropological perspectives, ethical-legal issues, spirituality etc.
• Teach through a multiplicity of methods including traditional lectures, seminars, and case conferences. In addition, use participatory methods of teaching such as literature searches, problem-based-learning, journal clubs, and evidence-based-medicine (EBM) methods.
• Provide clinical supervision and case conferences that apply theoretical knowledge to day-to-day clinical care in an integrative fashion.
• Encourage real-time literature searches based on clinical cases and application of the literature to the clinical care of patients.
• Teach principles of EBM and apply these in day-to-day clinical practice. Consider holding EBM case conferences.
• Apply EBM to journal clubs to promote educated consumers of the medical literature.
• Promote review of evidence-based guidelines and expert consensus statements.
• Use problem-based learning (PBL) to solve clinical problems, thus promoting participation in more active learning and less didactics. Encourage development of life-long learning using a PBL approach.
• Teach through other innovative approaches including games such as Jeopardy, Weakest Link, etc.
• Require case reports for journals.
• Address interpretation of industry-sponsored information, including possible biases in industry sponsored research and publications.
• Consider holding quarterly meetings of training programs, video conferencing, journal clubs, or joint conferences with nearby programs. Use regional resources to collaborate rather than compete.
• Encourage attendance at national scientific meetings such as the American Association for Geriatric Psychiatry (AAGP), American Geriatric Society (AGS), American Psychiatric Association (APA), etc.

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PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

• analyze practice experience and perform practice-based improvement activities using a systematic methodology
• locate, appraise, and assimilate evidence from scientific studies related to their patients ’ health problems
• obtain and use information about their own population of patients and the larger population from which their patients are drawn
• apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
• use information technology to manage information, access on-line medical information; and support their own education
• facilitate the learning of students and other health care professionals

Recommendations:

Analyze and assess knowledge and practice experience to ensure highly competent evaluation and treatment of psychiatric disorders in the elderly using a systematic methodology:

• Oral face-to-face faculty-informed self-assessment: Resident meets with Program Director or Program Director’s designated faculty member at entry into the program and every 3 months thereafter to conduct a self-assessment of geropsychiatric/neuropsychiatric knowledge base including evaluation and treatment of psychiatric disorders in the elderly. This process is informed by the resident being asked explicit questions that test current knowledge and by the resident presenting cases utilizing a multi-axial DSM-IV format that incorporates a biopsychosocial formulation. At the conclusion of this process, the resident is asked to self-identify his/her knowledge and practice deficiencies and strengths. Following the resident’s self-assessment, the Program Director or Program Director’s designated faculty member will provide any additional input about perceived knowledge and practice deficiencies and strengths.
• Written self-assessment: At entry into the program and every 4 months thereafter, resident completes a series of multiple choice questions provided by the program that address knowledge about evaluation and treatment of psychiatric disorders in the elderly. Resident scores questionnaire and provides feedback to Program Director about his/her knowledge and practice deficiencies and strengths.
• Resident conducts critical review of the literature to address a knowledge gap or improve a clinical skill.

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Establish knowledge of scientific study designs (including cross-sectional and longitudinal approaches and clinical epidemiology) and biostatistical methods.

• Resident participates in research methodology/epidemiology/biostatistical introductory seminar series.
• Resident is provided or referred to relevant biostatistical textbooks/articles.

Insure application of knowledge about scientific study designs and statistical methods to the critical appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness. Assure assimilation of evidence from scientific studies related to their patient’s health problems to enhance clinical care.

• Resident participates in regular journal club wherein he/she critically reviews assigned scientific articles, including data emanating from the pharmaceutical industry.
• Resident is assigned topic for literature review. He/she conducts extensive literature search and prepares presentation for journal club or other seminar. Resident must critique literature and discuss how new findings may influence clinical practice.
• Resident researches/identifies evidence-based reviews (e.g., meta-analyses by Cochrane group) on relevant geropsychiatric topics and presents findings at journal club or other seminar. Resident concludes how findings may influence clinical practice.

Provide opportunities to use information technology to locate, acquire and manage up-to-date information, access on-line medical information, and support their own education to assist in/enhance the quality care of patients.

• Resident participates in tutorial(s) that are either library-based or office-based on how to locate/retrieve scientific articles via internet-based searches of medical and scientific literature databases (e.g., PubMed). Resident demonstrates capability to supervisor by collaborative topic searches during supervisory session(s).
• Resident learns and utilizes developing electronic medical record capability.
• Resident is introduced to psychiatric informatics applications that include pharmaceutical databases. Resident is issued or purchases a PDA (personal digital assistant) as a tool for organization and improving patient care via portable medical applications. Each handheld computer will be loaded with information to provide decision support at the point of care. Such information includes DSM-IV criteria and numerical codes used to assist in diagnosis and coding; a drug information database (e.g., ePocratesqRx from www.epocrates.com) with the capability to check for drug-drug interactions; clinical evidence databases (e.g., Clinical Evidence at www.avantgo.com or www.unboundmedicine.com/cogniq.htm) and a security program (e.g., Certicom movianCrypt www.moviansecurity.com) that encrypts sensitive patient information to enhance Health Information Portability and Accountability Act (HIPPA) compliance, as well as to prevent unauthorized access.*
  
  *This paragraph adapted from UC Davis Psychiatry Newsletter, Fall 2002.

• Resident is introduced to online user-friendly resources for their own (e.g., Psychiatry.Medscape.com; clinicalevidence.com; psychiacomp.com) and for consumers (e.g., webMD.com; American Association of Retired Persons at aarp.org; Alzheimer’s Association at www.alz.org etc.) education.

Provide for continuous evaluation and improvement of knowledge and skills through familiarity with and adherence to "best practices. "

• Resident is exposed to national "consensus statements," "practice parameters," "treatment guidelines," and "expert consensus guidelines" relevant to geriatric psychiatry and geriatric neuropsychiatry.
• Resident is exposed to published assessment and treatment algorithms.
• Resident attends local, regional and national scientific meetings.
• Resident is exposed to mental health evidence-based summaries (e.g., Clinical Evidence; the Cochrane Collaboration; Evidence-Based Mental Health).

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Facilitate learning by providing opportunities to teach other students and health care personnel and community-based consumers.

• Resident prepares a faculty-supervised presentation on relevant topic that has been exhaustively researched and gives lecture(s) to staff.
• Resident prepares a faculty-supervised presentation on a relevant topic and participates in organization’s speaker’s bureau to provide lecture(s) to lay public in community-based setting.

Support participation in an individually supervised research or scholarly activity that translates into tangible academic accomplishment.

• Resident develops individual mentored research project that is modest enough in scope to be completed within fellowship year.
• Resident collects data in first half of year and submits abstract for presentation in "Young Investigator" forum of APA Annual Meeting.
• Resident writes paper based on research findings that is edited by research mentor and submitted for publication.
• Resident writes case report of interesting patient and submits for publication.
• Resident identifies topic for which recent literature review is wanting and undertakes comprehensive literature review and mentored write-up that is submitted for publication.
• Resident submits mentored research grant.

Encourage demonstration of attitudinal behaviors that foster lifelong learning; and development of habits of inquiry that are recognized as a continuing professional responsibility. *

• Program cultivates and resident demonstrates a willingness to pursue continuing education and supervised experiences to keep one’s own clinical practice behaviors commensurate with the community standard of care. Achieved via program support of continuing education opportunities including attendance at local and national symposia and organizational meetings.
• Program cultivates and resident demonstrates a willingness to obtain information from electronic databases and scientific literature in geriatric psychiatry and related fields, ensuring clinical practice is consistent with scientific advances. Achieved through exposure during the fellowship of how-to use/access psychiatric informatics and regular journal club participation.
• Program cultivates and resident demonstrates the recognition that the scientific literature must be integrated in an evolutionary manner, realizing that no one study or theory is likely to address all clinical situations. Achieved via regular exposure during the fellowship of critical appraisal of published scientific studies through journal clubs, individual and group supervision, attendance at lectures and grand rounds presentations, and self-study.
  
  * This section was adapted from Sexson et al, Academic Psychiatry, Winter 2001.

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INTERPERSONAL AND COMMUNICATION SKILLS

Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to:

• create and sustain a therapeutic and ethically sound relationship with patients
• use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills
• work effectively with others as a member or leader of a health care team or other professional group

Recommendations:

• Use family meetings and family counseling, especially with social workers and case managers, and offer feedback. Provide information without jargon, and with empathy, including discussions of the diagnosis of Alzheimer’s disease, poor prognosis, and death and dying issues.
• Use direct observation, especially during dementia evaluations.
• Teach by example.
• Incorporate feedback from other disciplines
• Require presentations to caregivers at dementia evaluation centers.
• Encourage leading a support group for caregivers.
• Encourage attendance at community events and programs for the elderly, e.g., senior centers and day programs.
• Encourage participation in family meetings on the inpatient unit, often with a social worker.
• Promote working with multidisciplinary teams, and demonstrate effective communication of assessment and treatment plans. Provide opportunities to demonstrate the ability to work through disagreements and conflicts with other disciplines.

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PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

• demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development
• demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices
• demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

Recommendations:

• Provide didactics in the basic principles of ethics, and medico-legal issues.
• Provide didactics on the roles of culture, ethnicity, gender, and socio-economic issues in geriatric psychiatry.
• Promote faculty role modeling in their professional interactions with patients, families, colleagues, staff, consultees, students, trainees, employees, etc.
• Hold ethics case conference with different themes and discuss advance directives, competency, end of life, and elder abuse issues.
• Use problem-based format to discuss ethical, business, administrative, managed care, medico-legal, conflict resolution, cultural, resources and rationing of care issues.
• Demonstrate the integration of these issues in case discussions.
• Teach administrative issues through several means including requiring attendance at monthly staff meetings, giving lectures on paperwork management/billing issues, and allow fellows to participate in the billing process.
• Give fellows a title such as Associate Medical Director of inpatient unit, and allow them to deal with issues of managing staff, unit policies, and treating staff, patients and family with respect, compassion, integrity, as well as being responsive to concerns raised.
• Hold discussions of public policy and public advocacy as it impacts psychiatric care issues.
• Discuss the larger context of geriatric psychiatry (e.g., book by Bernard Lo)

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SYSTEMS-BASED PRACTICE

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

• understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
• know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
• practice cost-effective health care and resource allocation that does not compromise quality of care
• advocate for quality patient care and assist patients in dealing with system complexities
• know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

Recommendations:

During the first week of training, the Program Director and other faculty will provide an overview of the local service system including information about how to access – in each clinical environment in which the resident will rotate – the following services for their patients: medical-surgical and subspecialty medical-surgical consultation including geriatric medicine; medical and psychiatric emergency assessment/treatment; neurology consultation; physical medicine and rehabilitation consultation and physical therapy; dentistry; audiology; pain management and palliative care including hospice; laboratory testing including electrocardiograms (EKGs) and acquisition of laboratory results; structural and functional neuroimaging; neuropsychological testing; electroencephalography (EEG); social work including disposition planning; aftercare resources (e.g., partial hospital, outpatient clinic, psychosocial club, etc.); psychiatric rehabilitation (e.g., occupational therapy, activity therapy); home care including visiting nurse services; nutritional assessment and dietary counseling; pastoral counseling; genetic counseling; family support groups; bereavement programs; and ethics committee.

During clinical experiences/rotations in which clinical decision-making is supervised by a faculty member, allow residents to experience first-hand - as the patient’s primary geropsychiatric clinician and as a subspecialty geriatric psychiatry consultant in both psychiatric and medical-surgical settings - the clinical interaction/collaboration with all above intra-organizational services in the context of achieving comprehensive geriatric care of patients and their family members. Provide opportunities for residents to:

• Respond to necessary consults and interact with relevant consultants and support services.
• Order and follow-up on appropriate laboratory testing.
• Function as a consultant geriatric psychiatrist to medical-surgical patients in the acute care hospital setting.
• Working in collaboration with social work and other colleagues, participate in the disposition planning of geriatric psychiatry inpatients, geriatric psychiatry outpatients, and medical-surgical patients to whom they are consulting, such that patients are referred to a comprehensive array of necessary services available within the local health system to ensure that optimal care is accessed and achieved.

Promote an understanding of the local/national priority to provide cost-effective, efficient health care that does not significantly compromise quality, including understanding the Medicare/Medicaid systems, the historical antecedents to Managed Care and Managed Medicare, and the current status of Managed Medicare. Provide opportunities for residents to:

• Receive lectures/seminars.
• Receive relevant articles and books.
• Discuss issues with faculty supervisors or visiting faculty in individual meetings and small group forums.
• In the context of clinical work, interface with case managers of Medicare Managed Care "products" during the pre-authorization and ongoing utilization review process.

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Encourage participation in cost-effective, efficient health care of the elderly utilizing successful time-management strategies. Provide opportunities for residents to:

• Under the auspices of an assigned supervisory faculty member, conduct efficient initial and follow-up assessments within locally mandated time-frames that are consonant with post-fellowship community practice.
• Employ formatted intake forms and relevant geriatric psychiatry assessment scales that promote efficiency of evaluation/treatment.
• Develop efficient mechanisms for communicating with referring and consulting physicians, communicating with patients and family members, and for organizing daily clinical tasks, such as computerized scheduling systems, email communication, personal digital assistants (PDAs), scheduled times per day or week for patient/family questions and feedback.

Provide information on current Medicare, managed Medicare, and Medi-gap reimbursement processes and methodologies - including coding for appropriate services and in the case of managed Medicare pre-authorization, utilization review and reauthorization processes - in the contexts of hospital-based inpatient and outpatient services, inpatient and outpatient private practice, and nursing home-based service provision. Provide opportunities for residents to:

• Receive lectures/seminars that include basic principles underlying indemnity and managed Medicare programs.
• Receive articles/book chapters to be discussed in supervision, journal club, or other seminar meetings.
• Be exposed either through didactics or on-site visits to private practice geriatric psychiatrists.
• Receive instruction on appropriate billing practices, including invited talks from local finance department personnel and from representatives of local Medicare intermediaries.
• Attend seminars/courses at local/regional/national professional meetings on Medicare billing and coding.
• Interface with Managed Care case managers during the pre-authorization, utilization review, and re-authorization processes.
• Educate patients and family members about the differences between indemnity and managed Medicare systems.

Relate information about the spectrum of extra-organizational (i.e., outside the local health care environment of the geriatric psychiatry residency) community-based, aging-specific resources and agencies available to help serve the elderly and achieve optimal clinical outcomes, including how to advocate for and access such services for patients and their family members. These include geriatric medical and geropsychiatric programs/practitioners not affiliated with the geriatric psychiatry residency program’s parent institution but more conveniently located to the patient’s home; adult and dementia day care including Alzheimer’s disease and related dementia family support groups; advocacy and public education/service organizations such as the local chapter of the Alzheimer’s Association or the local county department for the aging; home care; senior housing options including subsidized housing, assisted living, and nursing homes (including federal regulations governing psychiatric services); senior citizen centers; psychosocial "clubs"; meals-on-wheels; adult protective services; elder-law services and resources including financial planning/counseling; driving assessment programs; and insurance companies/agents knowledgeable re: long-term care insurance. Provide opportunities for residents to:

• Receive lectures/seminars from local and invited faculty.
• Visit off-campus agencies/programs/housing options/nursing homes.
• Have an ongoing supervised experience as a consulting geriatric psychiatrist in a nursing home and participate in multidisciplinary conferences there.
• Receive or be referred to relevant articles/chapters/resource guides/books.
• Attend meetings of local organizations such as the Alzheimer’s Association and volunteer to be a speaker in a family seminar.
• Observe guardianship and related legal proceedings.

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During clinical experiences/rotations in which clinical decision-making is supervised by a faculty member, allow residents to experience first-hand – as the patient’s primary geropsychiatric clinician and as a subspecialty geriatric psychiatry consultant – the clinical interaction/collaboration with all above extra-organizational services in the context of achieving ongoing comprehensive geriatric care of and best outcomes for patients and their family members. Provide opportunities for residents to:

• In collaboration with social work and other colleagues, participate in the disposition planning of geriatric psychiatry inpatients, geriatric psychiatry outpatients, and medical-surgical patients to whom they are consulting, such that patients are referred to appropriate community-based agencies including senior housing options.
• Effectively and collegially collaborate with community-agency(ies) to achieve desired outcome(s) by role modeling senior staff behavior and by being observed and counseled by senior supervisory staff.
• Complete all referral paperwork in a legible and timely manner to ensure efficient transfer of patients to community service providers. Such paperwork will be reviewed by supervisory personnel and feedback provided to the resident.
• Endeavor to achieve aftercare treatment services that are provided by geriatric sub-specialists or clinicians with geriatric expertise.
• Endeavor to achieve treatment services that occur in an environment that is as close to home as possible.
• Endeavor to achieve treatment services that occur in the least restrictive environment possible.
• Through role modeling of senior staff behavior, work in a manner that is mutually respectful of all levels of staff in order to achieve optimal outcomes for patients since optimal geriatric care is dependent upon a multidisciplinary team approach.

Increase residents’ knowledge of the diverse systems involved in the treatment of the elderly, and integrate such multiple systems of care in treatment planning including by collaboration with allied health professionals both within and outside the parent institution of the geriatric psychiatry residency program such that patients access optimal services. Provide opportunities for residents to:

• Develop treatment plans that will be critiqued by senior faculty and staff and then amended accordingly by the resident.
• Through modeling of supervisor behavior, successfully demonstrate in the Team Meeting context a respect for and collaborative approach with allied health professionals to achieve best outcomes for geriatric patients. Supervisory personnel will provide feedback.
  

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