Aging Q3 End of life Care FacilitatorGuide

When the Patient Care Technician sees a blue sheet on the patient chart, she is reminded to ask the patient the ACOVE questions written on a “blue sheet.” The “blue sheet” is attached to

Facilitator’s Guide Aging Q3

Medical University of South Carolina

Aging Q3 uses multiple strategies to teach residents about geriatric issues and syndromes We address 16 different issues and each issue is covered in a 3 month period The goal is to cover all

16 topics in the Reynolds Foundation grant period of 4 years Since we are aware that it is difficult to reach all of the 100 internal medicine residents every 3 months using only one type of intervention (such as lecture), multiple opportunities are provided Each 3 month topic period is called an “ACOVE” because the teaching content is based on the Assessing Care of Vulnerable Elders (ACOVE) paradigm.1 Aging Q3 has expanded on the ACOVE paradigm to include teaching residents about providing quality care for all adults 65 years of age and older

Each ACOVE has a volunteer “work group” comprised of a chair person and 4-5 internal medicine faculty members The work group begins meeting 3-6 months before their ACOVE starts They develop the quality indicators, goals, objectives, key messages, interventions, and evaluation plan for their ACOVE built on evidence-based best medicine practices identified through literature review The Aging Q3 Principal Investigators, Evaluator, Data Analyst, and Project Directors serve as work group consultants and program management personnel to assist the work group in developing a successful and smooth program

Aging Q3 highlights Soumerai and Avorn’s Academic Detailing model by using rapid and specific teaching interventions with limited interruption in patient care.1The clinical environment is saturated with various visual cues such as posters, detailing sheets, and pocket cards in resident populated areas such as conference rooms and precepting areas

In the clinic, registration staff identify patients who are 65 years of age and over by placing a “blue sheet” on the patient’s chart When the Patient Care Technician sees a blue sheet on the patient chart, she is reminded to ask the patient the ACOVE questions written on a “blue sheet.” The

“blue sheet” is attached to the patient’s chart and cues the resident to address the patient’s responses to the questions and take noted action as necessary Every 3 months the materials are changed for each topic A copy of the “blue sheet” for each ACOVE is included with the ACOVE documents

Included in this product are the principal tools developed and used in the Aging Q3 program ACOVEs to date Additional tools will be added as new ACOVEs are developed If there are

any questions about the details of Aging Q3, content or process, please feel free to contact the chair identified in the ACOVE product or the Aging Q3 project director, Patty Iverson: iverson@musc.edu

1 Soumerai, S and J Avorn 1990: 263(4) “Principles of educational outreach (‘Academic Detailing’) to improve clinical decision making.” JAMA 1990: 263(4) 549-556.

2 Annals of Internal Medicine 2001;135(Suppl.):641-758 is devoted to the ACOVE indicators Articles cover the

project overview, methods for developing the indicators, and the evidence supporting the quality indicators for 11 of the topics.

V End of Life Care

Educational Tools:

1 Aging Q3 End of Life Care Power Point Lecture

The lecture is given to the GIM Residents prior to the start of the ACOVE during

a regularly scheduled meeting time The lecture is presented by the ACOVE work group chair and the power point slides are saved on the Aging Q3

website: http://mcintranet.musc.edu/agingq3 for future reference

The lecture is also presented to the faculty and the nursing staff prior to the ACOVE start date to familiarize them with the topic, key messages, teaching interventions, and process

2 Aging Q3 Blue Sheet

Clinic Registration staff identify patient is 65 years old or older If they are, the Blue Sheet is attached to their chart When the Patient Care Technician takes the patient in to the exam room, she notes the Blue Sheet on the chart and is cued that this patient is 65 or over Before the Resident comes in to see the patient, the Patient Care Technician, asks the patient the questions on the Blue Sheet and records the answers

When the Resident comes into the patient exam room, he/she is cued by the Blue Sheet to address the identified issues and take action as noted accordingly

During precepting, the Resident will review the Blue Sheet answers and action taken with the Attending during patient report

This step is done for every patient 65 and over seen in the clinic by a Resident during the ACOVE period (3 months)

3 Aging Q3 Detailing Sheet

During precepting, the Attending will review the key messages noted on the Aging Q3 Detailing Sheet with the Resident The Detailing message is

designed so this content can be covered in a very brief amount of time, usually less than 5 minutes The Attending documents that the Resident has been detailed on the ACOVE topic

4 Aging Q3 Pocket Card

Some ACOVE work groups have designed an ACOVE “pocket card” for

attendings and residents These cards are printed front to back and laminated

to a size comfortable to fit in the coat pocket Pocket cards are currently available for the End of Life Care ACOVE and included in the product

documents

5 Aging Q3 Role Play Introduction Scenarios

Randomly gather residents in small groups of 3-5 Each group is assigned an attending physician One resident is asked to volunteer to act as the “doctor” and others to act as the “patient” or “family member.” The “actors” read

through one of the simulation exercises and they begin conversation The attending physician (evaluator) observes the enactment and using the Role Play Evaluation Tool, grades the “doctor” resident on his performance

6 Aging Q3 Role Play Scenario Evaluation Tool

The Role Play Scenario Evaluation Tool (AKA Simulation Learner Evaluation Tool) is used to guide the evaluator through a consistent measurement of the Resident’s performance on the exercise The Evaluator assigns a “1” (no skill),

“2” (somewhat skilled), or “3” (excellent skill) to each of the 15 measures in the checklist Criteria for skill in each area is defined on the back side of the form

45 total points are possible Based on the score, the evaluator answers “Yes” or

“No, needs more training” to the question: “Do you feel comfortable that this resident can discuss goals and prognosis in a sensitive manner so as to do no harm?” A score of 35 or below indicates that the resident may need more training

If the evaluator feels the resident needs more training in communicating about end

of life issues, he/she will check what problems need to be addressed: verbal communication skills, non-verbal communication skills, professional attitude, or other

After the role play conversation ends, the evaluator shares the evaluation with all

of the group members, pointing out specific good and poor skills in

communicating with patients and/or families about end of life issues Others in the group are encouraged to provide feedback as well

This tool can be used as an evaluation pre and post lecture and/or detailing to measure performance improvement In our time limited (3 months) End of Life Care ACOVE, we only used it once with each learner and provided immediate

individual feedback It can also be used to provide feedback to residents

observed having a “live” conversation with real patients/or families The attending can provide structured feedback and use the experience as a teachable moment while rounding The Pocket Card, “10 Steps of a Family Meeting or Giving Bad News” or the “End of Life Detailing Sheet” can be used as teaching tools

The Simulation Learner Evaluation Tool and instructions for use were adapted from Weissman, D

et al “Standardized Patient Case for Role Playing Exercise/OSCE Station”

7 Aging Q3 Pre-test/Post-test

A short pre/post test (5-6 questions) is administered to the residents to evaluate their knowledge and self-efficacy prior to the ACOVE intervention and after the intervention has ended (3 months) The pre/post test is developed and

administered via “Survey Monkey” a web based survey development program

based on evidence based literature and the knowledge learning objectives chosen by the work group for each ACOVE

The pre test is sent to the resident’s email address 2 weeks prior to the scheduled lecture date and ends prior to the beginning of the intervention The post test (same questions as pre test) is sent at the end of the intervention period Results are automatically tallied using the analysis feature in Survey Monkey Further analysis of the data is conducted by downloading the test results into excel or other spreadsheet data base programs In Aging Q3, the data analyst performs a comparison of all the test takers performance using Generalized estimating equation (GEE) models to test the differences on selecting correct answers on the knowledge items and cumulative distributions to the report of action items between pre and post tests A comparison of matched resident’s performance is also performed McNemar’s tests are used to test the differences on selecting the correct answers to the knowledge items, and Wilcoxon Signed-Rank Test is used for the report of action items between pre and post tests

A report is produced with the results of these analyses and feedback on the

resident’s improvement is presented to the faculty and residents The pre/post test results are used as information gathering only on the student’s knowledge before and after the intervention