Workshop Guide

Open Workshop
Guide

 


 

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Open Instructor
Guide

Challenging Patients Curriculum Instructor Guide^

Older Patient with Multiple Co-Morbidities, Advanced Session


Goals:

A PGY-3 resident will be able to develop strategies for managing complex elderly patients, using the principles of the Patient-Centered Clinical Method.

Objectives:


Patient Care

  • Develop a differential diagnosis for a patient’s problem(s)
  • Develop a plan for management that incorporates an understanding of the patient’s feelings and  ideas about their illness, functional state and expectation as well as an understanding of the whole person
  • Identify gaps in knowledge of these areas (patient’s feelings and ideas, etc. and their proximal and distal context)

Medical Knowledge

  • Describe which functional assessment tools would be appropriate in management of the patient
  • Demonstrate a knowledge of the patient’s disease process
  • Describe the patient-centered clinical method

Interpersonal Communication

  • Demonstrate an ability to contribute positively to group discussion

Systems-Based Practice

  • Describe the potential roles of other health professionals in the care of the patient
  • Identify community resources that would be appropriate for care of the patient

Professionalism

  • Demonstrate a sensitivity to the needs of the older patient
  • Recognize ethical issues encountered in these scenarios
  • Demonstrate respect of the older patient in discussion of these scenarios

Practice-based learning and improvement

  • Provide a scenario based on a patient you have seen, as well as several questions that have arisen for you in the care of this patient

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Session Guide^

 

Time needed: 2 to 3 hours, depending on the how many scenarios are discussed

Equipment needed: 

  • Tables and chairs for small group discussion
  • Flip charts and markers
  • LCD projector and computer is optional
  • White board with markers is optional.

Suggested Readings:

This reading discusses principles that may be helpful in caring for older patient with multiple co-morbities:

Patient-centered care for older patients with multiple chronic conditions: A stepwise approach from the American Geriatrics Society. J Am Geriatr Soc. 2012;60:1957-1968.

More resources available at:

3 or more: Managing multiple health problems in older adults. Availabe at: http://www.americangeriatrics.org/health_care_professionals/clinical_practice/multimorbidity

Recommend readings that address the conditions in the case scenarios. Sample readings below (taken from the JAMA series Care of the Aging Patient: From Evidence to Action)

Reuben, DB. Medical Care for the Final Years of Life: “When You’re 83, It’s Not Going to Be 20 Years.” JAMA. 2009;302(24):2686-2694

Carr, DB, Ott, BR. The Older Adult Driver with Cognitive Impairment: “It’s a Very Frustrating Life.” JAMA. 2010;303(16):1632-1641

Tinetti, ME, Kumar, C. The Patient Who Falls: “It’s Always a Trade-off.” JAMA. 2010;303(3):258-266

Breitbart W., Alicia, Y. Agitation and Delirium at the End of Life: “We Couldn’t Manage Him.” JAMA. 2008;300(24):2898-2910

Kleerekoper. Clnical Crossroads: A 73-Year Old Woman with Osteoporosis. JAMA. 1999;282(18):1723

Goode, PS, Burgio KL et al. Incontinence in Older Women

JAMA. 2010;303(21):2172-2181

Arroyo, JG. A 76-Year-Old Man with Macular Degneration. JAMA, May 24/31, 2006; Vol 295, No. 20:2394-2406


Instructor script and notes:


NB:
1 to 2 weeks prior to session, ask residents to identify an older patient they have cared for that has posed a difficult management issue for them. Ask them to draft a brief scenario describing the case, and two identify at least 2 questions they have regarding management of the patient.  As instructor, you will need to collect these responses, edit them and collate them for the session.

  1. Briefly review the goal for the session. You will review the objectives in more detail before beginning the discussion. For example, “Today we are going to apply the principles of the patient-centered clinical method to some difficulty patient situations that you have encountered.”
  2. Review the patient-centered clinical method – 20 minutes
    1. Recommend drawing the outline of the method on a white board, and “filling it in” – ask the residents to describe the various components. Or, you can project a slide with an outline of the method on a smart-board, ask the residents to describe the various components and “fill it in.” Or you can project a slide with the method fully diagrammed and discuss the various components. Or you can handout a sheet with a diagram and discuss.
  3. Case discussion
    1. Provide an overview of the structure: we will break into X groups (of 3 to 4 residents, depending on the number present).  Each group will discuss X number of cases (depending on time and number of residents), and will then present the results of your discussion to the entire group.
    2. Describe the format for group discussion, using the guidance below:
    3. As a group, identify:
      1. Medical conditions involved
      2. Include differential diagnoses
      3. Functional domains you need to assess and how you would assess them (which instrument)
      4. Which medical conditions pose greatest threat to functional status
      5. Other health professionals that might help you gather information, assess function, and help you implement a management plan
      6. Community agencies that might be helpful in management of the patient
      7. Review the patient-centered clinical method below, identify potentially useful (needed) information from:
        1. Understanding patient’s feelings and ideas about illness, functional impacts and expectations.
        2. Understanding the whole person (the person, their proximal context and distal context).
      8. Envision what common ground would look like for this patient
        1. What are the problems that could be agreed upon?
        2. What would your roles/patient’s roles/family or caregiver roles be?
        3. What are goals that might reasonable be held in common?
      9. Identify potential resources to help with medical decision making and medical management.
      10. Identify and prioritize unanswered questions/issues.
    4. Break the larger group into smaller groups of 3 to 4 residents.
      1. Give each group a flip chart and markers
      2. Give each group at least once copy of the Discussion Guide and the diagram of the Patient-Centered Clinical Method
      3. Give each group at least one copy of the cases
      4. Instruct the group to identify the cases provided by that group’s members. That group will discuss those cases. Have group select a case to discuss.
      5. Ask the group to discuss a case, using the Discussion Guide, and to write their key findings on a flip chart.
      6. Clarify that everyone understands the instructions.
      7. Give the groups about 10 to 15 minutes to discuss each case.
    5. Monitor groups’ progress, answer questions, and keep them on track.
    6. Group presentation: Once done with small group discussion, each group should present their case and their discussion to all of the groups. Give each group 5 to 7 minutes to do this. Keep track of important concepts, and highlight them at the end of each discussion.
    7. Repeat steps d through f until all cases are discussed or until group runs out of time. Give feedback to groups, especially after the first set of case discussions, to help them stay on task with use of the Discussion Guide.
  4. Summary and wrap –up
    1. Review some of the important points and questions that arose during the case discussions, with particular emphasis on understanding and assessment of the patient’s function, and on key elements that would facilitate the finding of Common Ground between patients and physicians.

Extra tips:  If there are certain conditions that you want to highlight (e.g. driving assessment), include some illustrative cases in the list of cases, in the event that the condition is not included in the cases generated by the residents. Be sure to let residents know that these cases will be included ahead of time. Also be sure to let residents know that there may not be time to discuss all of the cases.  Don’t spend too much time at the beginning on discussion of the patient-centered clinical method – this is a “refresher, and the case discussions will help to give residents a better understanding of the method.


Handouts and Teaching Materials:

  • Outline of the Patient-Centered Clinical Method (handout and PowerPoint slide)
  • Diagram of the Patient-Centered Clinical Method (handout and PowerPoint slide)
  • Discussion Guide (handout)
  • Cases (sample list of cases provided)

Instructor Reference Materials:

  • Review chapters 2, 3, 4, 5, 6, 7, 8, 9 and 10 in Patient Centered Clinical Method, 2nd Edition, Stewart, M, Brown, JB, Weston, et al., Radcliffe Medical Press, 2003.
  • Be familiar with the diagrammatic representation of the Patient Centered Clinical Method.

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Open Outline of Patient
Centered Clinical Method

Outline of the Patient Centered Clinical Method^

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Open Diagram of Patient
Centered Clinical Method

Diagram of the Patient Centered Clinical Method^

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Open Case
Discussion Guide

Case Discussion Guide^

 

As a group, identify:

  1. Medical conditions involved
    1. Include differential diagnoses
  2. Functional domains you need to assess and how you would assess them (which instrument)
  3. Which medical conditions pose greatest threat to functional status
  4. Other health professionals that might help you gather information, assess function, and help you implement a management plan
  5. Community agencies that might be helpful in management of the patient
  6. Review the patient-centered clinical method below, identify potentially useful (needed) information from:
    1. Understanding patient’s feelings and ideas about illness, functional impacts and expectations.
    2. Understanding the whole person (the person, their proximal context and distal context).
  7. Envision what common ground would look like for this patient
    1. What are the problems that could be agreed upon?
    2. What would your roles/patient’s roles/family or caregiver roles be?
    3. What are goals that might reasonable be held in common?
  8. Identify potential resources to help with medical decision making and medical management.

Identify and prioritize unanswered questions/issues.

 

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Open Sample
Case Scenarios

Sample Case Scenarios^

 

Scenario 1

P.W. is a 77-year-old female with a history of upper GI bleed, indeterminate pulmonary nodules, and more recently decreasing functionality at home involving muscle weakness and hand swelling, who presents today for follow-up of her hand swelling and urinary incontinence. She was living in downtown cville and was interested in going to an assisted living facility, but her sons refused to support her in that decision due to poor outcome with another family member. She can no longer comb her hair, and refuses any blood draws and most medication, though is otherwise cognitively intact.

She has, instead, moved out into the country to live with her sons, where she may have less access to med facilities/nursing care. APS have already been involved.

How do I handle her refusing to work things up but presenting over and over with new problems? I’m so frustrated at her sons for not supporting her assisted living facility goals (there may be financial issues here I’m not fully aware of).


Scenario 2

Mr. A is a 78 year old retired Anglican Priest with mild Alzheimer’s dementia. He lives with his wife, who still works. He drives to Barracks Road for lunch every day, and has never had an accident. He has a h/o HTN and Hyperlipidemia, and he is on galantamine for his dementia. He also takes lisinopril and hctz. He has had some trouble with depression, which has responded well to celexa.

When should he stop driving? How do I evaluate him for this?


Scenario 3

Mr. Y is an 84 y/o man whom lives with his wife and daughter. He has issues of stability and falls frequently. He refuses to go to a nursing home – he also refuses home health physical therapy. He also refuses to go to an senior community center with his wife for daytime activities. The last time he did go – he cursed at people and was told he is not welcome anymore if he continues to exhibit this behavior. His family no longer goes out anymore to stay at home to take care of him.


Scenario 4

Mr. C.A. is a 75 y.o. male with a hx of pulm htn, CHF, lymphedema with chronic wounds, HTN, and CKD presenting in WI clinic for follow up on his multiple medical issues.

Items I found challenging:

  1. Sorting through the concerns that were voiced- daughter, wife and patient all  seemed to have differing opinions. hard to tell who was most important to listen to.
  2. Prioritizing his medical issues in the context of his complaint (he was worried about his legs, so was I but I was also worried about his shortness of breath and CKD!)
  3. Digging through his notes to figure out what would be the appropriate next step in his management.


Scenario 5

79 y/o African American lady with long standing, well controlled HTN and questionable pulmonary disease.

She does have a h/o asthma but this has not been active for 30+ years. When I inherited her she had a diagnosis of COPD but given her disposition/age, she has been unable to perform PFTs. Her cxr’s look fine. ECHO shows some diastolic dysfunction.
with this she persistently c/o subjective shortness of breath and nocturnal cough.Sshe is on optimal COPD meds, intermittent lasix, albuterol all offering some relief.

The challenge with her is:

  1. I can’t get PFTs on her: she cannot do them
  2. She is not interested in many interventions/changes
  3. She gets confused easily with medications, changes etc
  4. She lives by herself and comes in by herself so I don’t have a friend or family member to help with her management/insights (though i have been in contact with her daughter who live in Maryland)
  5. She does not want to schedule visits often (2 months is the quickest f/u she wishes to do)
  6. She told me “she’s used to having a male doctor” but is willing to “stick with” me
  7. I am not sure what else to offer her and it seems we are just status quo but she does state that she is doing ok and her SOB is not worse nor much better on meds


Scenario 6

75 y/o female initial visit who has not seen a physician for over 20 years, presenting for progressively increasing confusion and hallucinations. Patient claims to occasionally see small gnomes on the front lawn for which she has called the police. She has full ADLs and is not seem altered or confused during the clinic session. Subsequent consults to neuro feel that patient may have Lewy body dementia but they are not certain. Psychiatry feels that patient should see them regularly and start Seroquel. Patient lives at home alone but close to daughter’s house. Caretaker occasionally visits but patient is predominantly alone. Patient has no significant PMH, no medications, does not smoke, drink alcohol or use any other drugs.  The patient does not wish to see any other doctors other than myself and does not want to take medications.  The daughter is not sure what to do.

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Open Pocket Card

Multimorbidity Printable Pocket Card^