Clinical Training

The trainee will gain proficiency in evaluating, diagnosing and establishing a comprehensive care plan. The patient mix will also include many who are generally healthy and require primarily preventive health care measures. Fellows will enhance communication skills with family members of diverse cultural backgrounds and expectations and also with the members of the interdisciplinary team. Fellows will follow a panel of patients over the course of their training. Thus, when their patients are admitted to the acute care facility, the fellows will be expected to act as back-up geriatric consultants to the inpatient health care team and to participate in the plan of care including discharge plan with the interdisciplinary team and other subspecialty teams involved in the patient's management. They will become adept at using various functional assessment instruments and as team leaders, actualize a comprehensive multidisciplinary geriatric assessment. They will understand the administrative aspects of running an effective continuity clinic and learn how to utilize community resources.

Clinical sites:

Kings County Hospital Geriatric Medicine Clinic. The ethnic background of the patients is approximately 90% black, of whom half are US born African Americans and the others are African Caribbean; the remainder of patients are divided among Caucasians and Latinos. There are approximately 4,000 patient visits per year. The Kings County Hospital Geriatric Clinic is a primary care clinic staffed by geriatric fellows and attending physicians, a gerontologic nurse practitioner, along with nursing and social work services. All referral services needed in the care of this population including audiology, optometry, physical rehabilitation, podiatry, dentistry, nutrition, and pharmacy are available within the hospital campus. Geriatric Medicine fellows receive on-site precepting by attending geriatricians, and interact with other members of the health care team in developing and achieving goals for the patient, such as maintaining function and independence, obtaining health care screening, and receiving ongoing treatment of chronic and intercurrent medical problems. Geropsychiatry and dental fellows on rotation work closely with the geriatric medicine fellows who provide primary care in a longitudinal continuity care rotation. Emphasis is also placed on developing well-coordinated care and continuity of care for patients who have not previously achieved this goal. Supervision is provided by 3 board-certified geriatricians (Drs. Reid-Durant, Price, and Lawrence). All medical subspecialty consultants and clinics are readily available. This clinic was recently expanded and now includes an experienced full-time geriatrician, Dr. Marie Reid-Durant.

Brooklyn VA Comprehensive Geriatric Assessment Clinic. In the Comprehensive Geriatric Assessment clinic, the Geriatric Medicine fellows participate in an interdisciplinary multidimensional evaluation of frail elderly patients with geriatricians, a geropsychiatrist, a social worker, and other trainees. One geriatrician also has a Spiritual Care background. Patients, who generally have multiple geriatric syndromes or psychosocial problems, are referred from the primary care clinics for a geriatrics consultation and return to their primary physicians for follow up. Other trainees in the clinic may include geropsychiatry or dentistry fellows, psychology interns, and 4th year medical students, giving the fellows a teaching role as well. The emphasis of this experience is understanding and application of multidimensional aspects of geriatric care, including medical, functional, psychological, social, spiritual, and environmental, developing consultative skills, and working with the multidisciplinary team.

Brooklyn VA Wound Care Clinic. Focus is on management of leg and pressure ulcers, as well as skin care of ostomy sites. A Gerontologic Nurse Practitioner with special expertise in Wound Care, precepts fellows and provides formal didactic presentations during this rotation.

Homeless Program: The Bowery Residents' Committee. The Bowery Residents' Committee- (BRC) is located in lower Manhattan and operates in residential sites in Brooklyn. BRC includes a senior program funded as a nutrition program by the Department for the Aging, Food for Survival and City-Meals-On-Wheels. The center provides on-site and home-delivered meals, the latter focusing primarily on the older men who live in Bowery Lodging Houses. Members of the center are at least 60 years old. The Senior Center provides extensive case management, entitlement services, advocacy, first-aid care and access to primary health care services on-site. There is also routine outreach into the Bowery lodging houses and the Lower East Side Streets. The medical component of the service is funded through Department of Public Health Healthcare for the Homeless program and is specifically designed to serve the general medical needs of the indigent and homeless seniors served at the center. The current client population consists of the following:

• 75% are poor, elderly Chinese immigrants, most of who do not speak English and have few options for social support.
• 15% are senior men who live in five of the old Bowery "flophouses." Many have long-standing alcohol abuse or recovery issues, and all live on little or no income. Most of these seniors are homebound and are veterans. Advancing age, combined with a history of homelessness, and another disabling condition (including current and prior substance abuse, HIV/AIDS and other significant medical conditions), make these tenants particularly vulnerable.
• 10% are homeless seniors referred to the center by outreach workers; most have left the shelter system or are turned away because of a lack of capacity to serve elderly persons.

BRC's residential program has a large older population, including Clyde Burton House, Glass Factory SRO, the Palace SRO, and Home Plus Supported Housing. In each of these programs, at least 50% of the tenants are over 55 years old.

Geriatric Medicine Clinic at SUNY Downstate Medical Center. Geriatric fellows have ambulatory geriatrics in faculty practice setting at University Hospital, which serves a largely indigent, and minority population (90%), with 70% female. This rotation provides an experience different from the "clinic" setting at Kings County Hospital Clinic where fellows have continuity clinic( Supervisor: Dr. Everton Prospere).

 

Fellows will be expected to be familiar with the range of biopsychosocial issues pertaining to each patient, gain experience in dealing with the perspectives of family members and significant others and maintain accessibility and accountability to other members of the patient's health care team. Fellows will become well acquainted with the contributions and potential of the physiotherapists, occupational therapists, recreational therapists, speech therapists, pressure ulcer clinicians and other members of the team who impact the progress of the patient. Fellows will be expected to become familiar with the mechanisms whereby the nursing home and other services the patient needs or desires are reimbursed and other financial aspects of eldercare relevant to their patients.

When one of their patients is hospitalized at any of our affiliated acute healthcare facilities, fellows will be expected to follow them, provide geriatric consultation advice when relevant, interact with the subspecialty consultants involved in the care and participate in discharge planning. If the patient requires placement on alternate level of care, the fellow will act as an interface to facilitate a smooth timely transition to the nursing home with appropriate input from the patient, family members and in-hospital interdisciplinary team.

Clinical Sites:

Lutheran Augustana Center for Extended Care and Rehabilitation

This is a 240-bed extended care and rehabilitation facility with access to the sophisticated medical technology of Lutheran Medical Center by way of a connecting skyway. The Rehabilitative Services at Lutheran Augustana Center serves all facility residents and is recognized for its intensive short-term restorative rehabilitation for the treatment of complex orthopedic, neurological and other medical conditions. The Home has formal affiliations with several local health care agencies including Calvary Hospital Hospice, the Sunset Park Dialysis Center and also has numerous academic affiliations with local colleges and universities in all professional disciplines.

Susan Smith McKinney Nursing and Rehabilitation Center.

The Dr. Susan Smith McKinney Nursing and Rehabilitation Center, part of the New York City Health and Hospitals Corporation, is committed to provide efficient quality care to all its resident/registrants. It is a new 305-bed state of the art nursing facility located within walking distance of the medical school. Both medical and rehabilitative services are provided in spacious, tastefully decorated rooms equipped with specially designed bathrooms to accommodate the elderly. Staff includes physicians, nurses, patient care technicians, therapists, psychologists, social workers, psychiatrists, pharmacists, and nutritionists. Together with the patient/family this team collaboratively sets treatment goals and establishes care plans resulting in measurable and achievable outcomes. The care plans include but are not limited to rehabilitation, medical, social and therapeutic services. There is immediate access to the acute care services of UHB or other hospitals elected by the patient. The Pastoral Department is available to offer spiritual counseling. The continuum of services provided includes:

• Subacute services: pain management, intravenous therapy, short-term rehabilitation, fall assessment and wound care.
• Skilled nursing care.
• Adult Day Health Program for community residents. Available to the residents are: an array of consultative services including but not limited to dental, podiatry, cardiology, pulmonary, gynecology, medicine, otorhinolaryngology and ophthalmology.
• Rehabilitative services including physical, occupational, recreational and speech therapy.
• Social Services
• Therapeutic services, including a range of stimulating goal-oriented recreational programs designed to maximize residents'/registrants' full physical and psychological capabilities.
• At the McKinney facility, there is a dental facility specially designed for geriatric patients and is staffed by Drs. Gregory and Berger, and dental fellows rotate through this service. Patients are seen both in the clinic and at bedside. Bedside dental visits are primarily consultation and screening, whereas the clinic is reserved for actual treatment ranging from prophylaxis to minor oral surgery procedures. All invasive procedures are referred to the Dental clinic at King's County. The inpatient residents at this nursing home and rehabilitation facility are approximately 80% African Americans, 15% Hispanic, and 5% Caucasian and other.

Dr. Steven Kaner, a board-certified geriatrician and SUNY Downstate faculty member, is the medical director of the facility and also coordinates the activities of the fellows and medical students rotating there as part of the Primary Care Clerkship in Geriatrics. The medicine fellow works closely with professionals from a variety of disciplines during both the longitudinal and block rotations. The longitudinal experience involves primary care to a panel of 5-6 patients throughout the year, or consultation for individual patients scheduled in specialty clinics, in which the number of patients ranges from 2-6 per session. Interaction with one or more members of the team occurs either one-on-one in the care of an individual patient, in a formal interdisciplinary team or family meeting, or in committee work involving administrative aspects of nursing home care.

St. Alban's Extended Care Center. It is located 10 miles from SUNY Downstate. The center has 386 long-term and intermediate care beds, and includes a domiciliary for homeless persons. The VA Primary and Extended Care Center provides primary care and offers specialized geriatric programs, restorative rehabilitation, and palliative care. Geriatric programs also provide comprehensive evaluation and safe, effective management of elderly cognitively impaired veterans. An outpatient Adult Day Health Care Program and Home Based Primary Care Program exists and cares for physically disabled, medically-complicated elderly veterans who are at risk of nursing home placement or recurrent hospitalization. A comprehensive psychosocial rehabilitation Domiciliary program, providing incentive therapy, vocational counseling and independent living skills training for patients seeking to return to independent living, is provided at the VA Primary and Extended Care Center. The Campus also hosts an Ambulatory Care Center that provides primary care and specialty care, including optometry, podiatry, audiology and dental services. Also provided is sub-acute restorative rehabilitation for the elderly. Fellows perform consults throughout the center and also work on the Dementia Unit that is a 20-bed unit designed for the comprehensive evaluation and management of persons with cognitive deficits, and on the Geriatric Assessment Unit. The center also has an adult day care program, a home care program, and a palliative care program to which residents participate in consult. The center's population is approximately 95% male, 5% female, 45% white, 54% Afro-American, 1% Latino. Patients' mean age is 72 years. Approximately 25% of all patients have dementia. There are approximately 20 - 30 new admissions per month to the entire center, and 5 new admissions per month to the Dementia Unit. Fellows are expected to learn the following: diagnosis and assessment of patients in nursing homes, management techniques including behavioral strategies and pharmacotherapy; skills in consultation to other disciplines; family consultation and support, use of respite services such as day care; instruction in use of group and activity therapies, working with and teaching non-mental health professionals about mental health in the aged, and learning about bioethical demands of the very old. Fellows carry an average caseload of 20 patients on the Dementia Unit, and perform 10 - 15 consults per week of patients in the remainder of the center. There are two weekly case conferences. Faculty is always available for on-site consultation. Supervision is provided in the case conferences and in 1hour individual supervision with on-site faculty. Faculty consists of 1 full-time geriatric psychiatrist (former HRSA fellow in geropsychiatry), 1 half-time geriatric psychiatrist (also boarded in family practice and geriatrics), 5 internists (several with added qualifications in Geriatrics), 1 neurologist, 1 psychologist, 6 social workers, 6 activity therapists, 2 physical therapists, and 2 occupational therapists available for consultation.

Fellows will be located in the acute care hospital settings as geriatrics consultants. They will learn how to do a geriatric consultation in the acute medical, surgical and psychiatric units and gain an appreciation of how to manage the complex needs of the acutely ill hospitalized older person. Interaction with the unit pharmacist will be an important feature, as well as increasing knowledge of pharmacokinetics, pharmacodynamics, drug interactions, problems of polypharmacy and iatrogenesis. Fellows will learn to recognize geriatric syndromes and intervene early, help prevent iatrogenic complications, maintain or improve physical function and shorten the length of hospital stay. Finally, they will come to understand the issues involved in the smooth transition from the acute care facility to subacute care to home or nursing home, help facilitate these transitions, and participate in continuity of care as the patient moves from one level of care to the next.

Clinical Sites:

Lutheran Augustana Center for Extended Care and Rehabilitation. See above for site description.

Maimonides Medical Center. A 705-bed acute care teaching hospital located 3 miles from Downstate. The Division of Geriatrics is headed by Dr. Barbara Paris, a nationally recognized geriatrician with broad expertise in geriatrics and special expertise in elder abuse and end of life care. The Division of Geriatrics at Maimonides has recently begun to host students in the fourth year geriatric medicine clerkship, and SUNY Geriatric Medicine fellows now rotate through the Acute Care for Elders (ACE) unit as part of an exchange program, in which Maimonides geriatric medicine fellows spend a four-week rotation in the Geropsychiatry Program in the Memory Disorders and Geropsychiatry clinics at SUNY Downstate. Fellows from the dentistry program also attend a monthly conference at Maimonides. The rich ethnic diversity of this institution's patient population includes elderly Chinese, Latino, Russian, Korean, Arab, Orthodox Jewish, and many other ethnic groups. The goals of the ACE unit rotations are to enable the fellow to develop an ability to assess and treat acute illness and co-morbid conditions that increase morbidity, length of stay, and re-hospitalization rates; gain knowledge about care of the frail elderly, and participate in education of medical house-staff and students in geriatric medicine.

St Albans Extended Care Center-Consultation-liaison in long-term care setting. See above for site description.

Geroneurology Clinic at SUNY Downstate Medical Center. This clinic is situated at University Hospital of Brooklyn (SUNY Downstate Medical Center) is under the supervision of a behavioral neurologist (Dr. Howard Crystal). The clinic affords fellows the opportunity to see older persons with dementia and neurological disorders, especially persons with movement disorders. Many patients have mixed disorders that include elements of vascular, Lewy-body, Parkinson's disease or Alzheimer's disease. Fellows also see patients with mild cognitive disorders

Fellows will learn the principles and practice of palliative/hospice care including advance care planning, communicating bad news, whole patient assessment, pain management, end of life depression, anxiety and delirium, the goals of care, common physical symptoms amenable to symptom relief rather than cure, and issues related to withholding/withdrawing treatment and the last hours of living. Fellows will gain insights into the current gaps in providing optimum end-of-life care including the inappropriately high percentage of patients whose last days of life are spent in intensive care units, in contrast to their previously stated wishes.

Clinical Site:

Brooklyn VA Hospital (Dr. Beal). See above for site description.

Kings County Medical Hospital Center: rotation: (Dr. Pavel Shulman, Dr. Cho). See above for site description.

 

Geriatric Psychiatry Clinic at SUNY Downstate Medical Center. The Clinic population is approximately 75% female; 25% male; 59% white; 37% Afro-American; and 3% Latino. Patient must be age 55 or over. Diagnoses comprise the following: 57% Affective disorders, 14% schizophrenia (early or late-onset), 18% anxiety disorders, 22% personality disorders (primary or secondary), and 6% other disorders. There are approximately 50 new intakes per year, and about 100 active cases aged 55 and over. Fellows are expected to learn the following: diagnosis and evaluation of the geriatric outpatient, individual psychotherapy, family intervention, pharmacotherapy, cognitive behavioral techniques, and consultation skills, working with medically ill patients, working with other disciplines, community resources, and bioethical concerns. The faculty are also always available for on-site consultation. Caseloads are monitored to provide an adequate mix of patients. All residents receive at least 1-1/2 hours per week of clinical supervision. Additional supervision may be provided as required. Faculty consists of 1 full-time psychiatrist with added qualifications in geriatrics (Dr. Cohen), 1 part-time geropsychiatrist (Dr. Casimir) with added qualifications in geropsychiatry, 1 part-time psychologist (Dr. Berzofsky), 2 social workers (Ms Walcott-Brown and Dr. Andreas Adams), and a certified recreation therapist with a specialty in gerontology (Dr. McKenzie-Reece). There is also an additional 5 clinical staff, from various disciplines (e.g., psychiatry, psychology, social work) who work with some of the geriatric patients and who are available for consultation.

Dementia Assessment and Treatment. Brooklyn Alzheimer's Disease Assistance Center (BADAC) at SUNY Downstate Medical Center. It is under the auspices of the SUNY Department of Psychiatry. The center, located in Central Brooklyn, has a patient composition that is comprised of 79% female, 21% male;, 17% white, 75% African American (about one half of whom are African Caribbean), and 8% Latino. The mean age is 73, although patients range from 50 - 95. All patients present with memory or other cognitive problems, and over 95% are found to have an organic condition, usually dementia of the Alzheimer's type (65%) or Vascular Dementia (25%), although probably about one-fourth may have mixed dementias. There are approximately 200 new intakes per year and about 250 patients and their caregivers are followed during the year. Fellows are expected to learn the following: assessment of cognitive disorders, management of dementias including pharmacological and behavioral strategies, to work with caregivers and other family members, home visits, community resources available to patient and families, legal and ethical issues related to dementia, research drugs, consultative skills, and to work with other disciplines. Fellows will typically see 1-2 new intakes per week and follow-up on approximately 5 - 10 patients per week. Fellows spend 1 hour per week in a case conference and 1 hour seminar for 12 weeks devoted to dementia. Fellows will also make home visits with our social worker. Supervision is provided in 1 hour case conference. Faculty is accessible for consultation and will often sit-in on evaluations. Faculty consists of 1 full-time psychiatrist with added qualifications in geriatrics (Dr. Cohen), a part-time neuropsychologist (Dr. Kelly), part-time neurologist (Dr. Crystal), and 2 social workers (Ms Walcott-Brown & Dr. Adams), recreational therapist (Dr. McKenzie-Reece) and a community educator (Dr. Adams).

• Seminar in Dementia and other Cognitive Disorders: Review of the evaluation of neurological assessment, neuropsychological assessment, delirium, types of dementia, pathogenesis; symptoms, treatment and management strategies, current research advances, complications of dementia and its identification, e.g., depression, delusions, psychosocial issues for patients and caregivers, community resources, cross-cultural issues. Carl Cohen, M.D., Georges Casimir, M.D., Kim Kelly, Ph.D., Howard Crystal, M.D., Sharon McKenzie-Reece, Ph.D., Lorna Walcott-Brown, MS. 1 hour weekly for 12 weeks.
• Seminar in Common Psychiatric Disorder of Older adults: Depression and Other Mood Disorders, Suicide, Bereavement, Psychoses, Anxiety Disorders, and Personality Disorders in Older Adults: Review of the assessment and management of depression and mania, diagnostic and treatment issues specific to older populations, psychopharmacology, dynamic and supportive psychotherapy, cognitive behavioral approaches to treatment, research advances in pathogenesis and treatment, use of ECT and other somatic treatments, issues of bereavement. Diagnosis and treatment of anxiety disorders including use of CBT. Recognition and treatment of bipolar disorders. Recognition and treatment of schizophrenia and other psychoses in later life. Georges Casimir, M.D., Carl Cohen, M.D., Nancy Talavera, M.D., Michael Berzofsky, Ph.D., Steven Friedman, Ph.D. 1 hour weekly for 9 weeks divided into 2 blocks of 5 weeks and 4 weeks.
• Seminar in Cross-Cultural Aspects of Geriatrics: Review of cross-cultural aspects of aging, growing old in other cultures, review of special populations in Brooklyn e.g., West Indian (French and English-speaking), Latino, Jewish, Russian, and African American. Georges Casimir, M.D., Nancy Talavera, M.D., Carl Cohen, M.D., Jay Sokolovsky, Ph.D., Sharon McKenzie-Reece, Ph.D., Lorna Walcott-Brown, MS, Andreas Adams, Ed.D., MSW,.1-hour weekly for 5 weeks.
• Seminar in Inter-Generational, Aging, Sexuality, and Human Development: Overview of biological, psychological, sociological, theories of aging; theories of life-span development, sociocultural context of families and human development; parenting, cognitive changes over life course; personality development and change, gender issue; grandparenthood, cross-generational interplay of illness and dependency, caregiving; family therapy issues. Carl Cohen, M.D., Barbara Lawrence, Ph.D., Marion Dunn, Ph.D. 1 hour weekly for 5 weeks.
• Seminar in Medical and Oral Health Issues in Older Persons: Topics include: surgical issues, medical assessment, neurological assessment, prescribing issues, oral health care, pharmacokinetics and pharmacodynamics, falls and gait disorders, renal disorders and incontinence, palliative care, end of life decisions, alcoholism. Everton Prospere, M.D., Steven Kaner, M.D., Judith Ahronheim, M.D., Edmund Bourke, M.D., Jacob Dimant, M.D., John Weigan, M.D., Julius Berger, D.D.S., Alfred Joseph, D.D.S. Stuart Lazow, DDS, Allen Carver, M.D., Chris Harghel, M.D., Sarah Egan, M.D., Howard Crystal. M.D., Girardin Jean-Louis, Ph.D., Georges Casimir, MD. 1-hour weekly for 14 weeks.
• Seminar in Ethical, Legal, Health Financing, and Administrative Issues of Elderly Persons. Topics include: ethical issues, administrative psychiatry and health financing, legal issues George Casimir, M.D., Martin Petroff, JD, Judith Ahronheim, M.D. 1 hour weekly for 3 weeks
• Seminar in Educational Methods and Doctor-Patient Interaction with Older Patients. Topics include: doctor-patient interactions, education of patients, teaching methods, development of teaching portfolio. Barbara Lawrence, Ph.D., Gerald Adler, M.D. 1½-2 hours weekly for 3 weeks
• Seminar in IT, Web sites development, use of virtual patients, IV, and embedded lectures. Topics: use of video, webcasting, publishing of web sites, and other IT skills. Faculty include Dr. J Neil
• Seminar in Administration: Topic include health management managing in complex organizations, organizational change, and health policy. Dr. Howard Berliner

Physical Medicine and Rehabilitation

In this experience, fellows learn to understand the categories of impairment, disability, and handicap, and to apply the principles of physical medicine and rehabilitation to the geriatric patient. They will enhance their understanding of the roles of the physiatrist, the physical therapist, the prosthetist, the orthotist and other members of the PM&R team. They will become familiar with the objectives and techniques of various therapeutic modalities, the neurological and musculoskeletal examinations, different settings for rehabilitation, learn to write an appropriate physical therapy prescription including goal setting. Rotation in the prosthetics section will familiarize the fellow with the variety of assistive devices available, their uses and their limitations. Familiarity will also be gained with the approach of the PM&R departments to hip fractures, total joint replacement, amputations, stroke, peripheral neuropathy, disuse atrophy and decreased muscle tone, osteoporosis, osteoarthritis, significant cardiac impairment. The crucial role of the social support systems in effecting rehabilitative potential in such conditions will become apparent as well as the implications this may have in the case of disadvantaged minorities.

Clinical Sites:

Dr. Susan Smith McKinney Nursing and Rehabilitation Center. See above for facility description.

St. Albans Extended Care Center. See above for facility description.

Lutheran Augustan Center for Extended Care and Rehabilitation. See above for facility description.