Program Training Chief Residents to Improve Care for Hospitalized Older Adults Now Goes National

To better prepare its medical students and residents to care for the growing number of hospitalized older adults, Boston University Medical Center (BUMC) launched a highly innovative program in 2005. The program focuses on chief residents - who not only play important roles in medical student and resident training, but also in mediating among residents, faculty and nursing staff, and in communicating with patients and their families.

The program, Chief Resident Immersion Training (CRIT) in the Care of Older Adults, aims to familiarize chief residents with geriatrics syndromes, the functional assessment of older patients, assessing decision making capacity, preoperative and postoperative evaluation, and management and discharge planning. It's also designed to encourage positive attitudes toward caring for the aging, foster leadership and teaching skills, and improve collaboration among the various specialties and subspecialties involved in elder care. The idea is that chief residents, having completed this training, will put it to use and pass it along to the residents and medical students that they, in turn, help train.

The results of the program have been extremely promising. A case in point: the 16 BUMC chief residents who participated in CRIT last year saw their scores on a test of geriatrics knowledge jump 41% after they completed the two-and-a-half day intensive educational retreat that's at the heart of the Donald W. Reynolds Foundation-funded, BMUC-based program. They also showed significantly greater understanding of multifaceted geriatric health problems and expertise in conducting functional assessment of older patients, and related skills Eleven months following CRIT, most of the chief residents had implemented a project related to geriatrics education or clinical care. They also reported improved care of older patients, better leadership skills, better and more geriatrics teaching, and more collaboration among disciplines.

Now, CRIT in the Care of Older Adults is going nationwide.

In late June, the John A. Hartford Foundation awarded a $2.095 million grant to The Association of Directors of Geriatric Academic Programs (ADGAP) and Boston University for a national demonstration project to replicate the CRIT program at 13 more US medical schools. Through a peer-reviewed application process, five medical schools - at the universities of Colorado, Kansas, Nebraska, Rochester, and South Carolina -- were selected to participate starting this year. Four more schools will be chosen in 2008 and an additional four, in 2009. Each institution will receive a 30-month grant of $114,000 to conduct two intensive CRIT training retreats and follow-up training for their chief residents over two consecutive years.

"This funding allows us to mentor faculty teams from other institutions by having them observe the CRIT in action and to serve as site consultants at their own institutions as they develop their own programs," says Sharon A. Levine, MD, Associate Professor of Medicine and Director of Medical Education and the Geriatrics and Geriatric-Oncology Fellowship Programs at BUMC and Associate Dean of Academic Affairs at Boston University School of Medicine. Dr. Levine developed the CRIT program at the medical center and will serve as Project Director for the new nationwide CRIT demonstration project.

"We will also evaluate the results on a national basis and hopefully continue to show the statistically significant gains in geriatrics and leadership knowledge and skills of this important group of trainees," she adds.

At BUMC, teams that include both a chief resident and a faculty member responsible for residency training in surgical and medical specialties attend the intensive, interactive 2 1/2 -day CRIT retreats. Each team also collaborates on a year-long project -- focused on either geriatric clinical care or education -- that the chief resident completes over the course of the year.

In May, a chief resident and faculty member from each of the five schools selected to participate in the demonstration project this year observed BUMC's CRIT training retreat -- so they can replicate the retreat at their home institutions. The first of the retreats modeled on BUMC's are slated for this coming June. Each chief resident-faculty mentor team also got curriculum, facilitator materials, and a video of the BUMC retreat, and will get ongoing technical help from the BU faculty involved in CRIT.

"The design of the retreat is phenomenal and allows sufficient time to impart geriatrics knowledge, develop leadership skills, and foster relationships and collaboration amongst subspecialty chief residents," says Annette Medina-Walpole, MD, Associate Professor of Medicine and Program Director for the Geriatric Medicine Fellowship at the University of Rochester School of Medicine and Dentistry, one of the five schools chosen to participate in CRIT this year. "By virtue of this, residents are 'geriatricized' and will not only be able to provide more appropriate care for the older adult, but will also be able to impart and model their education and skills in geriatrics to the other residents in their programs."

Each evidence-based CRIT educational retreat includes roughly 15 chief residents and their mentors and BUMC estimates that the demonstration project will train a total of roughly 390 chief residents. These chief residents will, in turn, teach the geriatrics evaluation and management skills they've learned to about 18,000 residents and medical students, Dr. Levine estimates.

"Building on work funded by our good friends at Reynolds, the CRIT team has designed a cost-effective national mechanism to reach crucially located medical educators," says Gavin W. Hougham, Ph.D., Senior Program Officer with the John A. Hartford Foundation.

Trainees versed in the unique needs of older patients are in growing demand. With the graying of the US population, the number of older adults requiring hospitalization has been rising dramatically nationwide. In the last three decades, the percentage of inpatients 65 and older has nearly doubled, from 20% to 38%. Patients 65 and older undergo more than twice as many surgical procedures as those 45 to 64.

"We are at a crossroads in medical education," says Dr. Hougham. "We know the number of older patients is rising, and we are eager to build ever more bridges between geriatrics and the rest of medicine. We can learn a lot from each other."

In addition to scoring significantly higher on tests of geriatrics knowledge and skills after the CRIT retreats, BUMC participants have also reported greater awareness of age-related health problems, and greater competence in evaluating and treating older patients and diagnosing and managing delirium and dementia. In surveys, they've also reported feeling significantly more confident in their ability to both practice and teach residents about geriatrics, and in their administrative and management skills. Just as important, those surveyed also reported that the program gave them invaluable opportunities to collaborate with staff in other medical specialties -- and fostered an interest in geriatrics.

"With only 7,100 geriatricians nationwide, there will never be enough of us to care for the 35 million adults over the age of 65," says Dr. Levine. "Part of our job is to train the surgeons, primary care doctors and medical specialists caring for this population and to help them to communicate with each other, families and patients, and to teach future physicians in their own specialties."

"Chief residents are key influencers in their institutions," Dr. Levine adds. "They are looked up to as role models and when they move on in their careers, often in leadership positions, they will take with them the knowledge and skills that they have learned during training to new practice sites around the country. By focusing on this important group, CRIT is an efficient and effective means of increasing institutional capacity for enhancing awareness, knowledge, and skills regarding high-quality collaborative care of the elderly."

This coming year, Dr. Levine, other project leaders and ADGAP plan to start working on plans for further expansion of CRIT.

Applications for the 2008 CRIT program are available at http://www.americangeriatrics.org/adgap/crit/default.asp. All institutions with full-time academic geriatrics program directors are eligible to apply.