Training requirements for higher specialist trainees in geriatric medicine in community liaison and practice

Community liaison and practice

As a consequence of the ageing population in the UK and increasing pressures on acute hospitals there is a renewed emphasis on shifting the balance of care to the community and providing care closer to home in a more patient-centred way. This has led to closer joint working across primary and secondary care, with social care and the third sector. Many initiatives have evolved into novel services involving Geriatricians in new roles in the community. This has created a breadth of new community training opportunities. All future geriatricians will need to be able to undertake comprehensive assessments out of hospitals, in care homes and in the patient’s own home.

Services providing Comprehensive Geriatric Assessment in the patient’s home have been developed in an effort to avoid unnecessary emergency hospital attendances. These are evolving at different rates. Trainees should gain experience of different approaches, assessing older adults with frailty in their home environments, investigating and providing treatment and supporting patients and their carers by liaising with social care and voluntary sector services.

Community Hospitals may provide facilities for step-up care from the community and step-down care from acute hospitals. They may serve other roles including slower stream rehabilitation, palliative care, interventional procedures such as IV fluids, antibiotics, and other treatments. They may provide short-term respite admissions. Different models of supervision exist involving GP’s, hospital based teams and community Geriatricians. Trainees should try to gain experience as to what these facilities can provide and how they can develop to support the changing provision of healthcare for older adults with frailty closer to home.

In most areas, general practitioners take responsibility for patients living in care homes . You should be aware of how the ongoing medical care of such patients is organised and the opportunities and limitations of looking after patients in this setting. Some GPs organise care by performing regular visits to the homes for which they have responsibility.

Geriatricians work both as hospital-based specialists, working closely with colleagues from other specialties, and community-based specialists, working closely with colleagues in primary care and community services. All geriatricians should have the knowledge and skills required to manage older adults with frailty in a community setting. The 2022 Geriatric Medicine Curriculum highlights the importance of community liaison and practice

Geriatric Medicine Curriculum 2022

The new geriatric medicine curriculum details a number of high level curriculum outcomes known as Capabilities in Practice (CiPs). The capabilities in practice (CiPs) describe the professional tasks or work within the scope of Geriatric Medicine. These are articulated in six generic CiPs, eight IM clinical CiPs and seven Geriatric Medicine specialty CiPs which have been mapped to the relevant GPC domains and subsections to reflect the professional generic capabilities required. Each CiP has a set of descriptors associated with that activity or task. Descriptors are intended to help trainees and trainers recognise the minimum level of knowledge, skills and attitudes which should be demonstrated for an entrustment decision to be made.

Community liaison and practice are key to four of the geriatric medicine specialty CiPs: CiPs 1-3 and 5. These are detailed below along with the key descriptors pertaining to community geriatric medicine. Evidence to inform the entrustment decision might take the form of CbD, Mini-CEX, ACAT, SCE, and reflection on clinical cases. Trainees must be able to provide evidence of all capabilities in a community setting as well as a hospital setting. In addition, NHS services require trainees to have capabilities in selected areas of specialist practice at the time of appointment to a consultant post, and trainees will therefore undertake one module for an additional time period of 3 months – designed to ensure the output of geriatricians with the appropriate skills to meet service needs. Additional ‘themes for service’ capabilities will be integrated into the final 3 years of geriatric medicine training. Community practice is an additional theme.

Geriatric Medicine Specialty CiP 1

Performing a comprehensive assessment of an older person, including mood and cognition, gait, nutrition and fitness for surgery in an in-patient, out-patient and community setting.

Geriatric Medicine Specialty CiP 2

Managing complex common presentations in older people, including falls, delirium, dementia, movement disorders, incontinence, immobility, tissue viability, and stroke in an in-patient, out-patient and community setting.

Geriatric Medicine Specialty CiP 3

Managing older people living with frailty in a hyper-acute (front door), in-patient, out-patient and community setting.

Geriatric Medicine Specialty CiP 5

Managing community liaison and practice:

• Performs a comprehensive assessment (which includes physical, functional, social, environmental, psychological and spiritual concerns) of older people in community settings
• Manages acute illness, comorbidities (including dementia) and other problems safely in community settings, including in patient’s homes and care homes (with or without a hospital at home service)
• Able to discuss uncertainty and balance benefits/burdens of hospital versus home treatment
• Manages rehabilitation in community settings, including patient’s homes, care homes and community inpatient rehabilitation.
• Performs an assessment of mental capacity
• Performs a medication review
• Formulates an appropriate differential diagnosis, problem list, and individualised management plan taking into account patient preferences
• Understands the various agencies involved in community care, (including voluntary, social prescribing and third sector)
• Promotes multidisciplinary team working
• Demonstrates a flexible approach to care which crosses the traditional division between primary and secondary care
• Identifies patients with limited reversibility of their medical condition, is able to discuss end of life, undertake advance care planning conversations (including community DNACPR) and determine palliative care needs

Geriatric Medicine Syllabus 2022

Community practice is a core element of the practice of geriatric medicine and trainees should be expected to undertake a specific attachment to intermediate care and community practice of at least 3 months whole time equivalent duration, either as a single block or over a longer time period. The attachment in community practice should include experience in a variety of settings such as community hospitals, hospital at home schemes, domiciliary assessments, day hospital, interface geriatrics/front door frailty models, continuing care, care home visits. SLEs should be completed to aid reflection and to evidence acquisition of competencies. Trainees wishing to complete the additional theme for service should undertake an additional 3 months whole time equivalent experience.

Core competencies

To have the knowledge and skills required to assess a patient’s suitability for, and deliver careto, older people within intermediate care and community settings, working with multidisciplinary teams, primary care and local authority colleagues.

Knowledge

• Basic Biology of Ageing
• Pathophysiology of frailty and sarcopenia
• Complex common presentations in older people, including falls, delirium, dementia, movement disorders, incontinence, immobility, tissue viability, and stroke
• Diagnosis and management of acute illness in older people
• Diagnosis and management of chronic disease and disability in older people
• Clinical Pharmacology and therapeutics for older people
• Changes in pharmacokinetics and pharmacodynamics in older people
• Principles of rehabilitation
• Nutritional requirements of older adults
• Health promotion and benefits of a healthy lifestyle
• Factors influencing health status in older people
• Models of intermediate care/community geriatrics including evolving role of day hospitals and care home medicine
• Understanding of the various agencies involved in community care
• Opportunities provided by assistive technologies e.g. monitoring devices, technology assisted living, telehealth
• Evidence base for intermediate care and community practice
• Ethics and Medico-legal issues including CPR decisions
• End of Life Care including advance care planning
• Relevant National Publications including Guidelines on Continuing Health Care
• Relevant National Publications including Guidelines on Respite Care
• Understanding of Care Home Structures, Regulation and Inspection
• Role of Independent Sector within intermediate and long term care

Skills

• Establish Diagnosis/Differential Diagnosis
• Recommend pharmacological and non-pharmacological interventions
• Undertake appropriate medication reviews
• Provide team leadership
• Manage time effectively (personal/team)
• Manage acute illness safely within a non-hospital setting
• Discuss uncertainty and balance benefits/burdens of hospital versus home treatment
• Identify opportunities to prevent ill health and disease in patients
• Identify opportunities to promote changes in lifestyle and other actions which will positively improve health.
• Provide palliative care when appropriate – liaising with relevant agencies
• Guide and support patients/staff/relatives/carers through advance care planning – “what if scenarios”. Use of RESPECT forms or alternative
• Liaise effectively with GPs and community professionals including joint management of cases

Attitudes

• Develop an approach to care that crosses the traditional division between primary and secondary care
• Recognise the importance of geriatrician involvement in intermediate care
• Recognise the role of the geriatrician in education and management of community staff
• Ability to work flexibly and deal with tasks in an effective fashion
• Appreciation of the role of rehabilitation in frail older adults
• To work in an empathetic and ethical framework helping patients and relatives/carers to understand and accept or reject medical investigations and treatments
• Promotion of shared decision making
• To recognise the value of a structured, active approach to care in care homes.

Specific Learning Methods

• Attachment to intermediate care and community schemes
• Attachment to ‘hospital at home’ services
• Visits to care homes and Continuing Care Hospitals
• Visits to community services
• Short attachment to Primary Care
• Performing/taking part in domiciliary visits.

Geriatric Medicine Specialty CiP (theme for service)

• Able to manage ill or disabled older people in a hospital at home, intermediate care and community setting and is able to provide a comprehensive community geriatric medicine service
• Demonstrates advanced skills in undertaking a comprehensive assessment (which includes physical, functional, social, environmental, psychological and spiritual concerns) of older people in community settings including the patient’s own home and care homes. Performs an assessment of mental capacity, including in challenging circumstances
• Manages acute illness, comorbidities (including dementia) and other problems safely in community settings. Appropriately selects, manages and interprets investigations with special regard to what matters most to the patient. Performs an extended medication review
• Demonstrates excellent risk assessment and management skills in identifying the most appropriate place of care, recognising patient autonomy
• Appropriately manages patients with pre-existing learning disability in a community setting
• Leads rehabilitation in a community setting, and demonstrates advanced skills in managing and contributing to community MDT working
• Understands the various agencies involved in community care, (including voluntary, social prescribing and third sector)
• Delivers a flexible approach to care which crosses the traditional division between primary and secondary care
• Identifies patients with limited reversibility of their medical condition and determines palliative and end of life care needs
• Demonstrates advanced skills in care home medicine
• Demonstrates skills in education and management of community staff
• Possesses the knowledge and skills required to develop a community geriatric medicine service for older people.

Knowledge

• Evidence regarding suitability and effectiveness of different forms of supported care for older people (including retirement villages, highly sheltered housing, and care homes with or without nursing, both general and with specialist designation)
• Current national publications regarding intermediate care
• Current national publications regarding end of life care
• Regulatory bodies with responsibility for care homes
• Understand the role of commissioners of care for English services (if appropriate)
• Understand regulation regarding medicine administration in care homes
• Models of medical care for care home patients including knowledge of evidence base
• Knowledge of pressure relieving and other specialist equipment and their uses.
• Knowledge of criteria for continuing care assessments

Skills

• Excellent risk assessment and management skills in identifying most appropriate place of care
• Excellent communication skills in sharing with patients and their carers decisions about place of care in the light of risk assessment
• Extended skills in medication review in those with frailty and life limiting conditions
• Excellent communication skills including verbal and written and timely communication
• Multidisciplinary team leadership
• Developing community and intermediate services for older people
• Effective interagency working; with social services and the voluntary sector including older people’s representative groups
• Excellent influencing skills in joint working with providers and commissioners of community services for older people

Attitudes

• Works in a context of mutual respect with other health and social care colleagues
• Works in a context of recognition of the older person as central to decisions about their future plan of care whether in their own home or other community setting
• Facilitates the sharing of relevant information with appropriate regard both to patient confidentiality and to the important role of carers

Specific learning methods

• Experience (minimum 3 months full time or equivalent part time)
• Sessional or full-time attachment with intermediate care services at home or in institutional settings both at nursing and residential levels
• Leading a MDT for at least 10 meetings, leading at least 5 complex case conferences and undertaking solo at least 10 home visits to assess older patients
• Attachment to a primary care team and consultant geriatrician with a special responsibility for community and intermediate care
• Attachment to a public health service or commissioners organising and funding care for older people including that in community settings
• Accompany a community geriatrician or GP (or both) on proactive planned visits to care homes (minimum 10 visits).