Enhanced Skills Program: Care of the Elderly Home based Primary Care Rotation Goals and Objectives

By the end of the rotation, the resident will be able to:

Manage common medical issues in the homebound and frail older person, including an appreciation of the impact of frailty and the presence of multiple concurrent chronic conditions.
Diagnose, investigate and manage common geriatric syndromes (dementia, delirium, falls, depression, incontinence) in the home setting.
Demonstrate a comprehensive approach to falls including an assessment of underlying etiology, preventive strategies and post-fall needs.
Have an approach to pain management that recognizes the adjustments required in the frail older person with multiple co-morbidities.
Assess the needs of caregivers, including an assessment of caregiver stress.
Assess risk related to elder abuse, home safety, medication, falls, nutrition in the home.
Assess capacity of an individual to make treatment decisions pertaining to medical treatment and housing. Demonstrate a knowledge of the legal acts pertaining to capacity.
Assist a patient in establishing and documenting their advance care directives.
Demonstrate awareness and is able to implement primary care guidelines for prevention and screening in frail older adults.

Discuss the patient and family’s beliefs, concerns, illness experience and specifically focuses on their expectations in terms of goals of treatment and expected outcomes. Attempts to incorporate patient wishes even in situations of diminishing individual capacity.
Demonstrate respect for diversity and difference, including but not limited to the impact of gender, sexuality, race, religion, socio-economic status and cultural beliefs on decision-making.

Participate in a collaborative inter-professional home-based primary care team. Understand, recognize and respect the diversity of roles, responsibilities and competencies of other professionals in relation to their own. Work with others to assess, plan, provide and integrate care for complex homebound patients.
Maintain a positive working environment with consulting health professionals, health care team members, and community agencies. Respect differences, misunderstandings and limitations in oneself and other professionals. Reflect on inter-professional team function.
Engage patients and their families as active participants in their care.

Recognize the importance of appropriate allocation of health care resources in the home, including referral to other health care professionals and community support in the context of limited resources.

Respond to individual patient health needs and issues as part of patient care. Advocate for individual patients around relevant health matters. Implement health promotion and disease prevention (i.e. fall prevention) interventions for individual patients and the patient population served.
Respond to the health needs of the communities that they serve. Describe the practice community and identify opportunities for advocacy, health promotion and disease prevention and respond appropriately.
Identify the determinants of health within their communities including barriers to accessing care and resources. Identify the unique challenges of vulnerable or marginalized seniors and respond as needed.

Maintain and enhance professional activities through ongoing learning. Critically evaluate medical information and its sources and applies appropriately to care for older patients, recognizing the limits of evidence in frail, complex older homebound patients.

Demonstrate a commitment to patients and their families, as well as to their profession and to society, through ethical practice.