Clinical Experience

Established in 1875, BMC’s Geriatrics Home Care Program is the oldest, continuously operating in-home medical service in the United States, delivering care to those who cannot leave their homes for treatment. Our Home Care Program provides primary medical care to approximately 500 frail, home-bound and isolated older adults in the neighborhoods of Boston. The average age of our patients is 80 years, with a diverse population including 60% identifying as being members of underrepresented groups and 25% who are non-English proficient. Fellows have a longitudinal experience providing primary medical care to a panel of approximately 16 patients during their fellowship.

The home care program also provides opportunities for fellows to instruct Boston University Chobanian & Avedisian School of Medicine students to further develop bedside teaching skills. Fellows work closely with an interprofessional team of providers including physicians, nurse care managers, nurse practitioners, pharmacists, social workers, and community-based allied health care providers (e.g. visiting nurses, physical therapists, home hospice, elder service agencies). Through these experiences, fellows learn how these community resources are both accessed and reimbursed.

The BMC Geriatrics Ambulatory Practice provides primary care for approximately 1500 older adults with multiple chronic comorbid conditions and functional limitations who are able to travel to the clinic. The clinic compromises of an interprofessional team of geriatricians, gerontologically-prepared nurses, medical assistants, a pharmacist, geriatric psychiatrist, registered dietitian and social worker. Fellows participate in a weekly clinic, serving as the primary care physician for a longitudinal panel of patients as well as learning skills around transitions of care and urgent care for older adults.

One of our five multi-level, community-based, skilled nursing facilities in the city of Boston serves as the third clinical site for fellows to provide primary longitudinal and subacute care in a nursing home setting. Each fellow provides primary care to a panel of 10 residents in one facility under the supervision of one longitudinal faculty physician throughout the year. Fellows also have the opportunity to admit and follow subacute rehabilitation admissions. Fellows work collaboratively with one BU Geriatrics nurse practitioner and other members of the nursing home’s interprofessional care team.

Geriatrics fellows rotate through a one-month acute care experience on the BMC Geriatrics Inpatient Service. All patients within our practice, regardless of site of care, are admitted to this service when requiring acute inpatient care. The team is comprised of a BU Geriatrics attending physician, Internal Medicine residents, third and fourth year medical students, a clinical pharmacist, case management team and social work services. During this rotation, fellows gain experience in leading a team caring for medically ill, complex older adults and have a lead role in educating medical students and residents about core inpatient geriatric topics.

Geriatrics fellows rotate through a one-month geriatrics consult experience at Boston Medical Center, performing targeted geriatric assessments on hospitalized patients >65 years old with active geriatric syndromes on Medicine and Surgery inpatient services. The consult service consists of one geriatrics attending and one rotating fellow, with occasional residents and medical students. During this rotation, fellows will serve as the primary point of contact for primary teams requesting consultation and see new consults and subsequent follow-up visits, and staff them with the consult attending.

PACE is a national program for adults age 55 and older who are nursing home certified and living in the community. PACE provides fully integrated, comprehensive, team-based managed care with Medicaid and Medicare financing to keep vulnerable older adults safe and functioning in their homes and communities. Fellows rotate through 2 PACE sites, Upham’s Corner and Harbor Health PACE Centers, where participants can access adult day social services and a full service medical clinic including primary care, nursing, social work, rehab staff and nutrition. The team also provides care at home and follows participants across all care settings (home, hospital, nursing facility).

During this one-month rotation, fellows are under the supervision of two BU faculty geriatricians who serve as PACE attending physicians. They have the opportunity to complete in-home safety and functional assessments with PACE rehab staff, as well as follow and manage patients at the PACE Center. Fellows participate in weekly interdisciplinary meetings as an active member of the PACE team and get a glimpse into the role of the PACE medical director.

Geriatric Fellows rotate through two unique one-month Palliative Care experiences, at BMC and at the VA Boston Health Care Systems Brockton campus.

The BMC Palliative Care Service has provided interprofessional palliative care consultative services for inpatients and their families at Boston Medical Center since September 2007. Patients with a wide range of advanced life-limiting illnesses are seen, including cancer, dementia, heart failure, respiratory failure and stroke. During this rotations, fellows work alongside Palliative Care trained attending physicians, nurse practitioners, and social workers to provide comprehensive consultation in the management of pain, end-of-life related symptoms, and discussions of goals of care. Psychosocial issues, spiritual concerns, and clarifying practical issues about plans of care are also addressed in an interdisciplinary manner. In addition, fellows have the opportunity to spend time in the outpatient palliative care clinic at BMC.

The Brockton VA Palliative care rotation provides care to older adult veterans admitted to the hospice and palliative care unit. This team consists of an attending physician, nurse practitioner, social worker, nurse manager, chaplain, speech pathologist, pharmacist, nutritionist, recreational therapist, and kinesio-therapist. The hospice and palliative care unit accepts patients for both end of life care and for ongoing symptom management and support during palliative chemotherapy or other supportive care. During this rotation the fellow will learn how to run a family meeting, run an interdisciplinary team meeting and develop a comprehensive care plan for patients’ nearing the end of their lives.

During this one-month rotation, fellows are exposed to caring for a wide range of patients representing the full spectrum of cognitive function related to Alzheimer’s and other forms of dementia. Fellows have the opportunity to learn from leading dementia experts at the Bedford and Boston VA campuses, with both geriatrics and neurology backgrounds, performing comprehensive geriatric assessments, consults focusing on the diagnosis and management of dementia, and participating in the care of patients with severe dementia residing on a locked dementia unit.

Geriatric Fellows rotate through a one-month long nursing home and rehabilitation rotation at our Boston VA site on the Community Living Center (CLC) unit. The CLC is designed for frail older adults who manifest multiple medical problems and geriatric syndromes typical of patients in long term care settings. Fellows are responsible for daily rounds on the unit and addressing and treating acute and chronic medical/geriatric problems that arise day to day. The fellow is encouraged to take ownership in patient care including longitudinal geriatric primary care needs, reviewing and updating monthly orders, running interdisciplinary team & family meetings, addressing and updating advance directives, under the direct supervision of an attending physician.

The Hospital in Home (HIH) program is a unique model of care that provides complex care patients with extensive care in the home with goals of reducing hospital admissions, length of hospital admissions, reduce complications of medical care and most importantly provide patient centered care. The HIH team is based on an interprofessional approach to care of patients with nurses, pharmacists, social workers, advance practice clinicians and physicians as the team foundation. The goal of caring for these patients is to maintain complex patients in place and to provide care that aligns with patients’ values and health goals, using the Geriatric 5M’s approach and Patient Priorities Care approach to discussing patients’ values. The fellow will participate in HIH admissions (while patient is in hospital/emergency department or from clinic) and home visits during the month-long rotation. They are expected to attend the daily interdisciplinary team (IDT) huddles and to contribute to care of patients. This rotation takes place at VA Boston Healthcare System located in West Roxbury.

ENRM Bedford VA Medical Center Geriatric Evaluation and Management (GEM) unit is a 24-bed inpatient rehabilitation program specifically designed to help Veterans with active geriatric syndromes return to living an independent and active lifestyle as quickly as possible. During the one-month GEM rotation, Geriatrics fellows help lead an interprofessional clinical geriatrics team, including nurse practitioners and house staff, and work under the overall guidance of the attending physician. Clinicians work collaboratively with skilled nurses, psychologists, pharmacists, care managers, and physical, occupational, speech, and recreational therapists to evaluate and treat Veterans to support maximum independence. Fellows also have the opportunity to teach internal and family medicine residents rotating through the service.

The geriatric psychiatry rotation allows fellows to perform psychiatric consultations on seven of the Community Living Center (CLC) units at the Bedford VA under the direct supervision of a geriatric psychiatrist for a one-month rotation. Common psychiatric problems that are seen are Schizophrenia, Anxiety, Depression, or Dementia with Agitation and other behavioral disturbances. On the units, the fellow learns to manage patients with common presentations including agitation, aggression, depression and withdrawal, wandering and self-injurious behaviors. An interdisciplinary team approach is used to develop a plan involving both pharmacological and non-pharmacological interventions.

Fellows also have the opportunity to rotate through two BMC-based Geriatric Consult experiences at our BMC Shapiro Geriatrics Ambulatory Clinic:

• Comprehensive Geriatric Assessment Clinic: Precepted by Fellowship Program Director Dr. Ryan Chippendale, this clinic allows for fellows to take a deep dive into comprehensive geriatric assessments with one patient scheduled per clinic session and with the assistance of an interprofessional team. Hear Dr. Chippendale discuss more about the Geriatric Assessment Clinic experience on this Boston MedTalks Podcast.
• Memory Disorders Clinic: Precepted by Geriatrics Section Chief Dr. Hollis Day, this clinic allows for fellows to learn the core components of assessing and diagnosing patients presenting with various stages of memory complaints and disorders. Fellows have the opportunity to become more comfortable with performing memory testing, educating patients and families about new diagnoses and connecting them with appropriate resources. Learn more about our Memory Disorders Clinic here.

Fellows participate in overnight and weekend call for our outpatient geriatrics practice alongside our geriatrics attending physicians. Fellows are scheduled for weekend call no more than once per month. They also take one weekday call per month. All call is performed at home and there is NO in-house call required, even when rotating through the geriatrics inpatient service. There is extensive training provided to incoming fellows to ensure appropriate skill development in the area of telemedicine and there is always a supervising attending that can be reached 24 hours a day when the fellow is on call.