Geri Models of Care (MOC): An Immersive Preclerkship Curriculum Fostering Student Exploration of Residential Geriatric Models of Care

Abstract

Introduction

Many older adults live in a community-based residential geriatric model of care (MOC; e.g., senior apartments, long-term care nursing facilities). While existing curricula focus on patient transitions to such care, none focus explicitly on MOC features, which are essential for creating effective care plans. We developed the Geriatric Models of Care (Geri MOC) curriculum to guide preclerkship medical students in comparing features of five MOCs.

Methods

On day 1 of the 2-day session, all second-year medical students spent half a day at different sites, interviewing administrators and touring facilities. On day 2, students debriefed and peer taught in small groups with peers who had visited different care models. Students applied their new knowledge to complex patient cases. Students completed retrospective pre/post self-assessments and offered qualitative feedback on the experience. A summative exam essay question assessed student knowledge application.

Results

From 2017 to 2019, 267 students gave the site visit experience a mean rating of 4.6 on a 5-point Likert scale (1 = poor, 5 = excellent). Students’ perceived confidence increased significantly (p < .001) for all four evaluated objectives. On the summative exam question, 89% of students passed. Students commented that the curriculum was a unique and effective learning approach, and 13 sites indicated a strong interest in ongoing annual participation.

Discussion

Community MOC visits were instructive and engaging for students and sites. The curricular materials are novel, adaptable for all levels of medical and health professions trainees, and adaptable for a virtual experience.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Define instrumental activities of daily living and activities of daily living.
• 2.Describe criteria for admission to a long-term care nursing facility.
• 3.Describe criteria for admission to a residential care facility for the elderly.
• 4.Describe criteria for admission to a Program of All-Inclusive Care for the Elderly.
• 5.Compare and contrast five models of care (i.e., senior apartments, residential care facilities for the elderly, long-term care nursing facilities, Programs of All-Inclusive Care for the Elderly, and home-based primary care) based on their residents’ age requirement, level of cognitive impairment, functional impairments, and service options.
• 6.Compare and contrast five models of care based on payment structures.
• 7.Identify at least three challenges that patients and their family members face when choosing and financing models of care for themselves and their loved ones.

Introduction

Providers must consider the medical, psychosocial, and environmental resources available where their older patients reside in order to provide high-quality, appropriate, and supportive patient care.^1–5 An older adult residing in a long-term care nursing facility has both high daily care needs and access to on-site care resources (e.g., medication management, tracking of bowel and bladder function); thus, their health care teams should construct a care plan inclusive of those needs and resources.⁶ On the other hand, a team may incorrectly assume that a patient residing within a senior apartment community has some of the same resources, resulting in an impractical and unsafe care plan. Quality improvement literature demonstrates that patients are at higher risk of incomplete or poor care plans during transitions back to their residential care site if providers are misinformed about the patients’ available resources.^7–9 Providers’ knowledge and appropriate utilization of resources in residential care sites would likely benefit patient safety beyond the transitional period. Given older adults’ complex care needs, understanding a geriatric residential care site's capabilities, resources, similarities, and differences is essential to generating effective care plans that fit an older adult patient's home.^5,10

Medical students have few educational opportunities to learn about residential models of care (MOCs), and even fewer curricula delineate the variability amongst MOCs with respect to their interprofessional teams, payment models, and resources (refer to Table 1 for definitions of key MOCs). Some health professions programs have created small-group, simulation, and role-play-based transitions of care materials for preclerkship and clerkship students and residents that highlight safe discharge planning to post-acute and residential care.^11–15 For example, Little and Gammack designed an immersive, site visit–based, post-acute care session utilizing interviews with the interprofessional post-acute facility team.¹⁶ However, teaching about residential care models solely as part of discharge planning often does not examine their long-term roles beyond acute care transitions. While some medical schools have created structured half days or brief rotations within a home-based care program or residential care community, these programs immerse only clerkship-level students and focus more on student perceptions of older adults following those experiences rather than on describing differences between residential MOCs.^17–20

Table 1. Glossary of Geriatric Models of Care.

Building on these examples, we designed an interactive residential MOC curriculum to teach students the components of different home models, with a focus on MOC costs, services, and resources, as well as to apply how those characteristics could affect patient care, quality of life, and function. This 2-day experience, Geriatric Models of Care (Geri MOC), introduces second-year medical students to common models before their clinical rotations to lay the foundation for safer patient care in their subsequent clerkships and residency training. The curriculum includes an immersive site visit to a local residential care model followed by a student-driven, small-group debrief and discussion. The goals of Geri MOC are to provide students with opportunities to (1) experience firsthand a residential MOC, (2) peer teach about their experiences and facilitate compare/contrast discussions, and (3) reflect upon the challenges older adults face when transitioning to various MOCs.

Methods

Setting/Context

The 2-day immersion and small-group debrief sessions of Geri MOC were housed within the required University of California, San Francisco (UCSF), second-year medical student course, Life Stages, which focused on physiology, pathophysiology, and clinical skills across the life span (e.g., reproductive physiology, obstetrics, pediatrics, geriatrics). Geri MOC began in the 2017–2018 academic year and took place annually. The session and all companion materials were pilot tested by second-year medical students completing a quality improvement project with the UCSF Division of Geriatrics. The UCSF Institutional Review Board approved the curriculum evaluation study as exempt.

Participants

Three groups participated in this curriculum: learners, sites, and faculty facilitators. The target learners were all UCSF second-year medical students (approximately 150 per year) who were 12 months into their 18-month preclerkship training. These students went to 20 diverse residential MOC sites representing five categories of residential MOCs: (1) home-based primary care programs (HBPCs), (2) long-term care nursing facilities (NHs), (3) Programs of All-Inclusive Care for the Elderly (PACE), (4) residential care facilities for elders (RCFEs) including adult group homes (AGHs) and assisted living facilities (ALFs), and (5) senior apartments. Sites were mostly located within San Francisco city limits to allow ease of transportation to and from sites. While not a residential MOC site, we included HBPCs because they demonstrated novel outpatient models of health care delivery. During the day 2 small-group debriefing sessions, the curriculum utilized 12 UCSF Division of Geriatrics faculty members as small-group facilitators. These facilitators taught the session on a voluntary basis as part of educational service to the institution. Time commitment for facilitators included 1 hour for an optional, but encouraged, preparation session and 2 hours for the required small-group session itself.

Presession Preparation

We recruited 20 residential MOC sites, evenly distributed across all five categories, 6 months ahead of the session. HBPCs identified patients willing to have provider-led student visits. We communicated primarily with site executive directors/administrators, social service directors, and owners of smaller residential care facilities (e.g., AGHs).

Students received the Immersion Experience Student Guide (Appendix A), MOC Interview Questions (Appendix B), and MOC Tour Checklist (Appendix C), which included prerequisite background reading, prior to the site visits. HBPC student site guides had slightly different instructions given their different structure.

All sites were emailed session materials (Appendices B and C) and the names of students prior to their site visits.

Geri MOC Day 1

We assigned each student one MOC to visit for a 3-hour half-day session (either morning or afternoon). Utilizing existing longitudinal course small groups (12–14 students per group), we divided each small group into pairs and ensured that each group's pairs visited at least four of the five MOCs to guarantee a robust debriefing experience. For example, in a small group of 14, there were seven pairs of students who visited seven different sites encompassing at least four MOCs. All second-year students completed their site visits on the same day. Site size determined the number of students attending (e.g., smaller sites had smaller student groups). Some sites were willing to have two separate student group visits (morning and afternoon).

Students interviewed site administrators and available interprofessional team members utilizing the interview guide (Appendix B). Interviews included questions about the site's mission, admission criteria, cost, and available services; we provided sites with the interview guide prior to the visits to help them prepare. Administrators took students on site tours; HBPC primary care providers took students on a patient home visit. During tours or home visits, students completed a checklist designed to help guide observations within the facility or home (Appendix C). After their visits, student pairs completed a postvisit assignment (Appendix A) in which they prepared a 5-minute, structured presentation to be shared in their small groups the following day.

Given the intensive logistics of this experience, there was no opportunity to make up the immersion site visit; students absent from site visits on day 1 still attended the small-group debriefs on day 2 to learn with their peers.

Geri MOC Day 2

The following morning, students met in their small groups, along with a faculty/fellow facilitator, to debrief and apply what they had learned to hypothetical patient cases. Students received the Debrief Student Guide (Appendix D), and faculty received the corresponding Debrief Facilitator Guide (Appendix E), which included all content in the student guide as well as discussion prompts and case answers. Student small-group sessions were not recorded since they were conducted live and in person. After brief introductions (5 minutes), the 110-minute session was divided into four parts: (1) peer teaching and discussion (70 minutes), (2) patient case review (10 minutes), (3) patient case discussion (15 minutes), and (4) reflections (10 minutes), as detailed below.

Part 1: peer teaching and discussion

Student pairs each spent approximately 5 minutes presenting their visit reflections while highlighting the following MOC features: model type, mission, admission criteria, services, costs, and how residents paid for the model. These presentations were not graded, as they were intended to facilitate peer sharing and discussion. We encouraged students to compile these site visit details into an online, shared document (e.g., GoogleDocs) for ease of discussion; we have included an example of how to set up such a document in Appendix F. Facilitators guided the discussion comparing and contrasting the major differences between sites and what students found most surprising about their visits (Appendix E).

Parts 2 and 3: patient case discussion

Students divided into subgroups of three or four and spent 10 minutes reviewing three patient case scenarios and deciding the best MOC option(s) for each case. They returned to the large group and spent 15 minutes debriefing with peers and the facilitator. Students explained which MOC(s) they chose, their reasoning, and what was challenging about each decision they made.

Part 4: reflections

Students reflected on the future of residential MOCs for older adults and their own potential concerns as providers who would be caring for a growing older adult population. At the end of the session, students shared one takeaway from the 2-day experience.

Student Confidence and Experience Evaluation

We administered a retrospective pre/post evaluation (Appendix G) to students on paper at the end of day 2 to evaluate their confidence and experiences. We included an optional comments section for open-ended feedback. Course faculty designed the evaluation based on the educational objectives and prior UCSF curriculum evaluations.²¹

Student confidence

We measured self-reported confidence related to four Geri MOC educational objectives on a 5-point Likert scale (1 = definitely cannot, 5 = definitely can). We used paired t tests to assess for change in students’ self-reported pre/post confidence.

Student experience

We asked students an additional three questions regarding the site visit experience (i.e., effectiveness of site team, utility of materials, overall quality). We compiled descriptive statistics on student assessment of site visits.

Students also chose a qualitative descriptor to complete the following sentence: “I feel [blank] when thinking about the future of older adult care in the community.” This question was designed to encourage students to reflect on the impact the experience had on them and what emotions came to the surface as they discussed the challenges older adults face when navigating different MOCs. We also hoped that the question would create empathy for older adults experiencing the need to move to another model of home. We sorted and tallied student fill-in-the-blank responses for frequency of use and generated a class word cloud that was shared at the end of the course so that students could see the various emotions felt by peers. We did this with the intent to validate and normalize feelings as well as to create a space to acknowledge other feelings students had not considered.

Student Knowledge Evaluation

We included a summative Geri MOC open-ended question (OEQ) on the Life Stages course final exam (Appendix H). UCSF summative exams consist entirely of OEQs. Our question reviewed an older adult undergoing a transition of care as part of a set of questions related to a patient being admitted to the hospital and needing to transfer to a higher level of care at discharge. Students had to explain what MOC they would recommend for the patient and why they chose that model. Course faculty used a rubric reviewed and approved by the UCSF School of Medicine assessment team to score the answers (Appendix H). All UCSF preclerkship courses are pass/fail, and all OEQ exams are scored on a pass/fail system based on the number of questions that result in achievement of a passing grade based on the scoring rubric.

Site Team Experience Evaluation

During year 2 of Geri MOC, we asked all site contacts to complete a brief online survey about their experience participating in the Geri MOC site visit (Appendix I). Author Laura K. Byerly reviewed all written site visit feedback from the postvisit survey. She identified common themes noted at multiple sites and compiled descriptive statistics.

Results

During the first 2 years of Geri MOC, 267 (out of 300) UCSF second-year medical students both participated in the curriculum and completed session evaluations.

Twenty residential MOC sites participated annually in Geri MOC: three senior housing apartments, seven RCFEs, three HBPC teams, four PACE sites, and three NHs. From year 1 to year 2, we had an 85% site retention rate; at the end of year 2, 92% of sites expressed interest in participating again the following year.

Student Confidence

Students’ perceived confidence related to Geri MOC educational objectives increased significantly (p < .001) for all four evaluated objectives, with the average post response being a 3.9 or 4.0 on a 5-point Likert scale (Table 2). Results of paired t tests were comparable between both year 1 and year 2 student cohorts.

Table 2. Student Confidence Self-Assessment (N = 267).

Student Experience

From 2017 to 2019, students’ mean rating of the overall site visit experience and on-site team effectiveness was 4.6 on a 5-point Likert scale (1 = poor, 5 = excellent; Table 3). Student responses suggested that site visit materials were not always useful (Table 3). In the open-ended comments, some students indicated that they did not always use site visit materials (e.g., the tour checklist) because they did not have a formal tour or were more engaged in the conversation with administrators/staff than the checklist. A few students noted that the interview guide was too long. Some commented on logistical challenges related to finding sites or the on-site contact but had no negative feedback regarding experiences during the site visit. Other comments indicated that the curriculum was a unique and effective learning approach.

Table 3. Student Site Visit Experience (N = 267).

Student fill-in-the-blank responses had more negatively than positively associated word choices. The most frequently used negative words were concerned (n = 41), worried (n = 21), and sad (n = 18). However, many students did select more positive words, such as hopeful (n = 20) and optimistic (n = 18), sometimes in conjunction with a more negative word (e.g., sad but hopeful).

Student Knowledge

Over the first 2 years of Geri MOC, 89% of UCSF second-year medical students passed the Geri MOC OEQ based on a scoring rubric. The most common reason for not receiving a passing score was an incorrect or incomplete comparison between the two model options in the question despite choosing the correct MOC.

Site Team Experience

During year 2, 13 out of 20 sites completed surveys. All reporting sites indicated that the student visit experience was positive (100% agreed or strongly agreed), that they enjoyed teaching students, and that they had a strong interest in ongoing annual participation. Only one site team indicated the visits negatively affected workflow. All sites agreed or strongly agreed that they had adequate communication from course faculty leading up to visits. Regarding preparatory materials (e.g., interview guide, tour checklist), 85% agreed or strongly agreed that the materials were helpful.

In our review of themes noted by site visit teams, the most frequently indicated enjoyable points included the students’ enthusiasm and thoughtful questions and the site teams’ ability to share their experiences of caring for residents:

• •“[We enjoyed] their enthusiasm and interest in learning about different models of senior housing.”—Senior Apartments Executive Director
• •“They were inquisitive and engaged, and talking with them helps me reflect on what we do.”—Veterans Affairs Social Worker
• •“Allowing students to see how cool senior life can be (and how charming our residents are).”—ALF Executive Director

Discussion

Geri MOC provided preclerkship medical students with a unique exposure to common models of residential older adult care, equipping them with the foundations for creating safe and feasible care plans that suit a patient's home. Visiting sites, interacting with sites’ interprofessional teams, and reflecting on the experience with peers increased students’ knowledge of key MOC features and the challenges faced by older adults navigating residential care options. The peer-teaching format of the small-group debriefs encouraged students to be experts within their small groups; small-group discussions included exploration of MOC costs, services offered, and potential barriers to accessing residential care, which led to students co-constructing a shared understanding of the five residential MOCs without having to visit each one. The site visits and small-group sessions led to increased self-perceived confidence related to describing and choosing the MOC that best matches a patient's needs. The high pass rate of the Geri MOC–based OEQ on the final exam demonstrated that students could apply information from their peer-led debriefing session. Students’ fill-in-the-blank responses from their day 2 evaluations suggested they recognized both the concerns and the hopes older adults and families face when moving into an MOC. The feelings students identified suggested that experiencing site visits and learning about different MOCs were successful in creating empathy for older adults navigating to a new home model. Site team enthusiasm and commitment to hosting future students were encouraging for curriculum sustainability.

We learned several important lessons in the first 2 years of Geri MOC. First, we learned the importance of communicating with sites. We recruited sites early, approximately 6 months in advance, and checked in with them 3 months and a few weeks prior to the student visit to provide session materials (Appendices B and C). Despite the preparation, situations such as site team members leaving, state survey visits, and viral outbreaks required last-minute pivoting to alternative sites. We advise maintaining at least one backup site option, whether as an additional visit to an already participating site or an additional site able to accommodate students at the last minute. Additionally, we learned that the interview guide and tour checklists were helpful for some students and sites; however, student feedback indicated that the richness of the discussion between students and site teams went beyond these materials when the discussion was student driven. We therefore modified our instructions in year 2 to make the tour checklist a suggested, rather than required, resource.

There are limitations to Geri MOC's generalizability given that the curriculum was developed and implemented in an urban setting with access to both a variety of MOCs and geriatrics faculty. However, medical schools in other settings or that are smaller may need fewer sites. Geri MOC could be implemented in a more temporally spaced fashion in which students attend fewer sites in total but visits are staggered over multiple days (e.g., multiple student groups visiting one or two facilities over multiple days). Geri MOC's debrief and case discussion benefited from geriatrics faculty facilitators, although outpatient primary care or inpatient/outpatient social work or case management teams could facilitate these discussions as well. In addition, Geri MOC did not include a patient interview in the students’ site visit due to the sites’ request for students to remain nonintrusive to patient care, so as not to interrupt patient daily routines or violate patient privacy.

We see many ways in which Geri MOC can be adapted for future work and new directions. Future iterations of this course could use a true pre- and posttest format in lieu of a retrospective pre/post evaluation given the readily available online assessment tools. We also see value in Geri MOC's content and format for other health professions programs, such as physician assistant, nurse practitioner, social work, and physical/occupational therapy training programs. Students in these disciplines all encounter older adults experiencing care transitions, and increased knowledge of how MOCs affect older adults would help students in a diversity of health professions achieve an appropriate care plan. Although we have focused here on the initial years of 2017–2019, the time period in which we collected student and site team survey data, Geri MOC continued through the 2020–2021 academic year, during which the COVID-19 pandemic required shifting the curriculum to a virtual activity. Students interfaced in small groups with both site administrators and teams through real-time virtual platforms in which they could interview team members and virtually tour sites through audiovisual technologies, followed by virtual, small-group debriefs.

Finally, we see an opportunity to explore application of Geri MOC content during the clerkship years. One way to provide further evidence of the utility of this curriculum would be to include follow-up surveys or interviews with students and their core clerkship preceptors. These could help determine whether Geri MOC prepares students for direct patient care.