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Service Delivery Innovation Profile

Cross-Training of Medical, Dental, and Psychiatric Fellows Enhances Access to Comprehensive Care for Homeless and Formerly Homeless Older Adults


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Snapshot

Summary

The Harvard Geriatrics Fellowship Program cross-trains medical, psychiatric, and dental fellows to provide comprehensive health care services to underserved older adults. Geriatric medicine fellows complete a 6-week rotation in which they collaborate with their peers to offer consultations and care to homeless and formerly homeless older adults living in group residences on a biweekly basis. Fellows also participate in monthly conferences to review cases and weekly didactic sessions designed to improve their skills and knowledge in serving this population. The program has enhanced access to care for a population that previously had little means of securing such services, and has received positive feedback from both patients and fellows. A formal evaluation of the impact on health outcomes is under way.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on program use and anecdotal feedback from patients and fellows.
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Developing Organizations

Beth Israel Deaconess Medical Center; Harvard Medical School
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Date First Implemented

2004
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Homeless; Impoverished; Mentally ill; Age > Senior adult (65-79 years)end pp

Problem Addressed

Homeless older adults, who make up a significant portion of the homeless population in the United States, are at risk of many physical and mental health conditions and generally have little access to care, often leading to premature death.
  • A growing population: According to the U.S. Census Bureau, 8.9 percent of the nation’s citizens 65 and older live below the poverty line.1 Among this population is a group of individuals who are homeless or at risk of becoming homeless. In 2009, those aged 62 and older made up 3 percent of the nation’s sheltered homeless population, with another 14.5 percent being between the ages of 51 and 61.2
  • More health problems: Older homeless persons are at greater risk of developing a variety of health problems, including high blood pressure, chronic diseases, mental illness, and functional disabilities.3 They are also more likely to be victims of crime than are other homeless people; for example, in 2008, 27 percent of homeless victims of violent crimes were between 50 and 59 years of age.4
  • Sporadic care, leading to early death: Many homeless older adults have health conditions that remain undiagnosed and untreated through years of sporadic care, often leading to early death. A study in seven cities throughout North America and Europe found that homeless persons were three to four times more likely to die than were members of the general population, with premature death most often resulting from acute and chronic medical conditions aggravated by life without a home.5

What They Did

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Description of the Innovative Activity

The Harvard Geriatrics Fellowship Program cross-trains medical, psychiatric, and dental fellows to provide comprehensive health care services to underserved older adults. Geriatric medicine fellows complete a 6-week rotation during which they collaborate with their peers to offer consultations and care to homeless and formerly homeless older adults living in group residences on a biweekly basis. Fellows also participate in monthly conferences to review cases and weekly didactic sessions designed to improve their skills and knowledge in serving this population. Key elements of the program include the following:
  • Fellow rotations: Medical, psychiatric, and dental fellows complete block rotations serving formerly homeless older adults living in residences owned by Hearth, a nonprofit organization dedicated to providing service-enriched permanent housing and health care. The fellows, all of whom have recently completed their residencies, participate in the rotation as a part of larger fellowship programs: medical fellows come from Beth Israel Deaconess Medical Center’s Geriatric Medical Fellowship Program, while psychiatric fellows are based at the Cambridge Health Alliance (a Harvard-affiliated teaching health system) and dental fellows at the Harvard School of Dental Medicine.
  • Monthly onsite health consultations and care: Each month, clinical staff at Hearth identify clients who have the most pressing health concerns. Fellows from all three disciplines, working under the supervision of Harvard faculty, meet with these clients to examine their medical, psychiatric, and oral health status. Fellows also conduct an indepth analysis of each client’s care plan. All consultations take place at the resident's home. Every other week, the fellows see residents under the supervision of an attending physician at an onsite clinic located in the Ruggles Affordable Assisted Living Community, a central Hearth site.
  • Monthly care conferences to review cases: Fellows from all three disciplines come together with faculty and Hearth clinical staff on a monthly basis for an indepth care conference. At this meeting, fellows and faculty review current cases and collaborate to improve the care management plan for the Hearth clients they serve.
  • Weekly didactic curriculum: In support of the fellowship’s direct service component, all fellows receive weekly training sessions. The training curriculum spans all three disciplines, so as to prepare fellows to provide comprehensive care to underserved older adults. Training topics include: oral health issues, conducting a dental examination, diagnosing depression and dementia in minority populations, health literacy, health care disparities, health care financing for low-income patients; Medicare pharmacy benefits, and medical leadership.

Context of the Innovation

The cross-training fellowship program grew out of Harvard’s Multi-Campus Fellowship in Geriatric Medicine, a program that has trained physicians to be leaders in geriatric care since 1979. Doctors completing the fellowship spend 1 year rotating through multiple clinical sites, including an inpatient unit, a rehabilitation center, a Veterans Administration geriatrics outpatient unit, a long-term care facility, and a community-based nursing home. To provide more comprehensive care to underserved older adults (many of whom were experiencing mental and oral health problems in addition to their general medical concerns), the program sought funding from the Health Resources and Services Administration (HRSA) to train medical, dental, and psychiatric fellows together in an interdisciplinary experience.

Did It Work?

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Results

Post-implementation data suggest that the program has enhanced access to care for a population that previously had little means of securing such services. The program has also received positive feedback from both patients and geriatric medical fellows. A formal evaluation of the impact on health outcomes is under way.
  • More older adults served: Each geriatric medical fellow provides care and consultations to approximately 100 older adults per year. Approximately half of these patients receive additional care from dental fellows, while a fourth receive treatment from psychiatric fellows. In the absence of the program, it is unlikely that these individuals would receive comprehensive care across all three disciplines.
  • Positive feedback from patients and fellows: Patients express satisfaction with the personal attention they receive from the fellows, as well as the convenience of having medical, dental, and psychiatric care delivered at one central location. In turn, fellows report appreciating the opportunity to experience patient care outside of a hospital setting. In addition to Hearth resident satisfaction, most primary providers express a positive response to the additional attention and recommendations resulting from the interaction of Hearth residents with the geriatric trainees.
  • Ongoing study of impact on health outcomes: An ongoing study is evaluating how the coordination of interdisciplinary fellows improves health outcomes, including whether the program leads to earlier diagnoses of depression in patients with heart disease. Ongoing monitoring of outcomes related to recommendations for the monthly interdisciplinary case conferences has been tracked.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on program use and anecdotal feedback from patients and fellows.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Securing funding: Although project leaders had been interested in pursuing a cross-training fellowship for some time, the emergence of HRSA funding specifically earmarked for such a program enabled them to move forward with planning and implementation. Project leaders sought and received a 3-year HRSA grant, followed by a 5-year HRSA grant.
  • Forming leadership committee: A committee, including the principal investigator, site directors for the geriatric psychiatry and the geriatric dentistry fellowships, and the coordinator of the overall geriatric fellowship program, formed to steer the development of the cross-training fellowship program.

Resources Used and Skills Needed

  • Staffing: Six to seven fellows participate in the interdisciplinary fellowship program each year. A core group of seven faculty created and implemented the cross-training curriculum, with a wide range of faculty members involved as guest lecturers.
  • Costs: Annual grant funding of $600,000 and supplemental funds cover most program expenses. (See Funding Sources section below for more details.) Major categories of expenses include salaries and benefits for the fellows and stipends for the core faculty involved in creating and implementing the program.
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Funding Sources

Health Resources and Services Administration
The program is primarily funded through a 5-year, $1.8 million grant from HRSA, with supplemental funding provided by Beth Israel Deaconess Medical Center and other affiliated partners.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Build on existing model: Rather than start from scratch, utilize the framework of existing programs or fellowships as a launching point for any new initiatives. Harvard developed its cross-training fellowship within the context of its longstanding and reputable geriatric medical fellowship program.
  • Seek targeted funding: The Harvard Geriatrics Fellowship Program was able to secure a significant HRSA grant to support cross-training of medical professionals in an interdisciplinary experience.
  • Establish key partnerships: Build and maintain partnerships with a small number of clinical sites. Faculty and fellows must emphasize strong communication with partner sites to facilitate quality and continuity of patient care.

Sustaining This Innovation

  • Engage a faculty or provider champion: One or more key leaders must advocate for the fellowship program on an ongoing basis, coordinate the didactic curriculum, and facilitate mutually beneficial partnerships with clinical sites.
  • Ensure balance between curriculum and clinical work: Direct patient care and didactic education are both important components of the program, and each should receive adequate emphasis.

More Information

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Contact the Innovator

Alan Abrams, MD, MPH
Beth Israel Deaconess Medical Center - Division of Gerontology
110 Francis Street, Suite 1B
Boston, MA 02215
Phone: (617) 632-8696
Fax: (617) 665-3530
E-mail: aabrams@bidmc.harvard.edu

Innovator Disclosures

Dr. Abrams reported receiving grant funding, reimbursement for travel expenses, and fees for writing manuscripts and other review activities from the Health Resources and Services Administration (HRSA). Information on additional funders is available in the funding sources section.

Footnotes

1 United States Census Bureau. Current Poverty Data. [Web site]. Available at: http://www.census.gov/hhes/www/poverty/
2 United States Department of Housing and Urban Development. The 2009 Annual Homeless Assessment Report to Congress. June 2010. Available at: http://www.hudhre.info/documents/5thHomelessAssessmentReport.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
3 National Coalition for the Homeless. Homelessness Among Elderly Persons. June 2008. Available at: http://www.nationalhomeless.org/factsheets/elderly.html.
4 National Coalition for the Homeless. Hate, Violence, and Death on Main Street USA: A Report on Hate Crimes and Violence Against People Experiencing Homelessness, 2008. August, 2009. Available at: http://www.nationalhomeless.org/publications/hatecrimes/index.html.
5 O'Connell JJ. Premature Mortality in Homeless Populations: A Review of the Literature. Nashville: National Health Care for the Homeless Council, Inc., 2005. Available at: http://www.nhchc.org/wp-content/uploads/2011/10/Premature-Mortality.pdf.
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Original publication: October 28, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 21, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.