Department of Family & Community Medicine

Enhanced Skills Program: Care of the Elderly Goals and Objectives

PROGRAM Goals and Objectives

By the completion of the program, residents in the DFCM Care of the Elderly Program must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centered care and service to an elderly population. Residents will be ready for independent interdisciplinary special interest/focused-practice in care of the elderly in all its diverse settings.

In this program residents will:

  • Establish relationships with older patients, their families, caregivers and substitute decision makers that are professional, meaningful and effective, within the primary care setting and within specialized geriatric care systems.
  • Learn comprehensive clinical assessment and management skills related to care of the older adult, including assessment of mental function, atypical presentation of illness and the management of common geriatric and psychogeriatric problems.
  • Expand their administrative skills, knowledge and leadership abilities to work effectively with interprofessional team members in a range of care settings, including acute hospital, long-term care homes and in the community, including the older patient’s home.
  • Deepen their scholarship as it relates to care of the older adult, including education and research.

Residents will be encouraged to set personal learning objectives that may include perceived or previously identified areas of interest.

PROGRAM OBJECTIVES:

Residents will acquire the following key competencies through graduated responsibility:

MEDICAL EXPERT

Physicians are skilled clinicians who provide comprehensive, continuing care to patients and their families within a relationship of trust. Care of the elderly physicians apply and integrate medical knowledge, clinical skills and professional attitudes in their provision of care, with an understanding of how care needs change for the older adult. Their expertise includes knowledge of their patients and families in the context of their communities, and their ability to use the patient-centered clinical method effectively. As family medicine experts they integrate all the CanMEDS-family medicine (CanMEDS-FM) roles in their daily work.

ME.1.  Integrate all the CanMEDS-FM roles in order to function effectively with a special interest/focused practice in care of the elderly

ME.2.  Establish and maintain clinical knowledge, skills and attitudes required for care of older adults

ME.3.  Demonstrate proficient assessment and management of older adults using the patient-centered clinical method

ME.4.  Provide comprehensive and continuing care to older adults incorporating appropriate preventive, diagnostic and therapeutic interventions

ME.5.  Attend to complex clinical situations in the care of older adults effectively.

ME.6.  Demonstrate proficient and evidence-based use of screening instruments and performance-based measures in the care of older adults

ME.7.  Coordinate patient care, including collaboration and consultation with other health professionals and caregivers

COMMUNICATOR

As Communicators, physicians facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. COE physicians recognize the changing communication needs of older adults, their family, caregivers, and substitute decision-makers.

CM.1. Develop rapport, trust and ethical therapeutic relationships with older patients, their families, caregivers, and substitute decision-makers

CM.2.  Elicit and synthesize accurate information from, and perspectives of, older patients, their families, caregivers, substitute decision makers, colleagues and other professionals

CM.3.  Convey needed information and explanations accurately to older patients, their families, caregivers, substitute decision makers, colleagues and other professionals

CM.4.  Develop a common understanding on issues, problems and plans with older patients, their families, caregivers, substitute decision makers, colleagues and other professionals to develop, provide and follow-up on a shared plan of care

CM.5.  Convey oral and written information effectively to older adults, their families, caregivers and substitute decision-makers, as appropriate.

COLLABORATOR

As Collaborators, physicians work with patients, families, healthcare teams, other health professionals, and communities to achieve optimal patient care.

CL.1.  Participate in a collaborative interprofessional model in the care of older adults

CL.2.  Maintain a positive working environment with consulting health professionals, health care team members, and community agencies involved in the care of an elderly patient population

CL.3.  Engage older adults as active participants in their care, with the support of their families, caregivers and substitute decision-makers.

MANAGER

As Managers, physicians are central to the primary health care team and integral participants in Health care organizations. They use resources wisely and organize practices that are a resource to their patient population to sustain and improve health, coordinating care with other members of the health care system.

MG.1.  Participateinactivitiesthatcontributetotheeffectivenessoftheirownpractice,healthcare organizations and systems

MG.2.  Manage their practice and career effectively

MG.3.  Allocate finite healthcare resources appropriately

MG.4. Serve in administration and leadership roles, as appropriate

HEALTH ADVOCATE

As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.

HA.1.  Respond to individual patient health needs and issues as part of elderly patient care

HA.2.  Respond to the health needs of the communities they serve

HA.3.  Identify the determinants of health for the elderly population they serve

HA.4.  Promote the health of individual older patients, communities and populations

SCHOLAR

As Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of knowledge.

SC.1.  Maintain and enhance professional activities through ongoing self-directed learning based on reflective practice

SC.2.  Critically evaluate medical information, its sources, and its relevance to one’s own practice, and apply this information to practice decisions about care of an elderly patient population

SC.3.  Facilitate the education of older patients, their families, caregivers, substitute decision makers, trainees, other health professional colleagues, and the public, as appropriate

SC.4.  Contribute to the creation, dissemination, application, and translation of new knowledge and practices

PROFESSIONAL

As Professionals, physicians are committed to the health and wellbeing of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.

PR.1.  Demonstrate a commitment to their older patients, profession, and society through ethical practice

PR.2.  Demonstrate a commitment to their older patients, profession, and society through participation in profession-led regulation

PR.3.  Demonstrate a commitment to physician health and sustainable practice

PR.4.  Demonstrate a commitment to reflective practice

The competencies developed by the DFCM Care of the Elderly Program are based on previous work by Dr. Andrea Moser (Northern Ontario Family Medicine Program) and Dr. Michelle Gibson (Queen’s University). We gratefully acknowledge and thank them for their generosity.