Longitudinal Experiences

Geriatric Specialty Clinic: Fellows spend two half-days per week in the Geriatric Specialty Clinic, which is both a consultative and primary care clinic. The clinic serves a very diverse patient population, from retired CEOs to refugees, from residents of the assisted living facility across the street to people traveling three hours to come to the clinic. The clinic has been rated consistently among the top clinics at UNC for patient satisfaction.
The Fellows’ clinic is supported by an interprofessional team including pharmacy and social work. They also have the ability to consult Dr. Ana Felix, a neurologist, and Dr. Julia Lunsford, a geriatric psychiatrist, who each see consult visits in the Geriatric Specialty Clinic. New patients are assessed by the full team of professionals in a 2-hour initial appointment, and fellows see follow-up visits for 45 minutes with the ability to consult the interprofessional team as needed. Fellows inherit a panel of patients from an outgoing fellow, and see one new patient per clinic session.

In the Geriatric Specialty Clinic, fellows learn the comprehensive geriatric assessment and how to counsel patients and families on managing many common geriatric syndromes.

Skilled Nursing Facility: Fellows spend one half-day per week at the skilled nursing facility at one of two local Continuing Care Retirement Communities: Carol Woods or the Cedars of Chapel Hill. The fellows perform subacute care admissions, see regulatory visits, and make acute care visits. Fellows work with Drs. Margaret Helton and Dr. Marvin McBride at the skilled nursing facilities, and receive mentorship in the management of patients in long-term care, including advanced care planning, avoiding hospitalizations, staff education, and billing and documentation in skilled nursing facilities. Fellows work closely with social workers, physical therapists, and nursing staff to provide individualized, goal-oriented, appropriate care for residents.

Home Visits: Fellows will be assigned specific home visit patients to follow through the UNC REACH program. This rapidly expanding home care initiative is housed in the Department of Family Medicine and is staffed with nurse practitioners, pharmacists, nursing, and social workers. The REACH program follows home-bound and frail elderly patients in their homes, and also have an active palliative care patient panel with critical illnesses who may or may not be on home hospice. The learning goal for fellows is to gain comfort in managing patients in more resource-limited situations as part of an interdisciplinary team.

Block Experiences

Inpatient Geriatrics/Med A: Fellows spend two 4-week blocks on the geriatric inpatient service, known as Med A. Med A is housed at UNC Hillsborough, a new UNC Hospital located about 10 miles from Chapel Hill. The Med A team consists of a Geriatrics attending, John Gotelli, our Geriatric Nurse Practitioner, Ronald Davis, our inpatient pharmacist, as well as an Internal Medicine resident, two interns, and students from the School of Medicine and the School of Pharmacy. The nursing and therapy staff have been trained in geriatric principles, and the unit emphasizes the importance of delirium prevention, early mobility, and safe transitions of care. The fellows’ responsibilities include resident and student education in inpatient geriatric principles, in particular functional and cognitive assessment, as well as performing comprehensive geriatric evaluations on new patients with the nurse practitioner. Fellows often lead goals of care discussions with patients and families, and on their second block on Med A are encouraged to serve as a junior attending.

Program of All-Inclusive Care of the Elderly (PACE): Fellows spend one 4-week block at two nearby PACE sites, Pittsboro and Burlington. PACE programs are model programs for care of frail elderly patients who are dual recipients of Medicare and Medicaid benefits. The program is designed to keep nursing home eligible patients at home. The PACE sites have large day programs with busy on-site clinics managing chronic diseases as well as acute issues like volume overload, infections, and wound care. PACE also has rehabilitation services, nutrition services, pharmacy, and recreation services on site. The program has a collaborative and focused interprofessional staff. Fellows spend time in the clinic, make home visits with PACE nursing and therapy staff, and get to perform evaluations on new patients. They also participate in daily IDT meetings and more focused individualized care plan meetings for patients they care for in clinic. By the end of the rotation they are encouraged to be developing and assessing patient goals for the individualized care plan meetings.

Rehabilitation: Fellows spend one 4-week block with the Department of Physical Medicine and Rehabilitation. Fellows split their time between seeing patients in a local subacute care facility after medical or surgical hospitalizations and experiencing a variety of outpatient activities. These outpatient experiences include neuropsychiatric assessment and testing, driving assessment, pelvic rehabilitation, prosthetics and orthotics clinic, physical therapy, occupational therapy, cardiac and pulmonary rehabilitation, home safety evaluations and wheelchair evaluations. The goals of this rotation are for fellows to understand the services and equipment available to their patients to help maintain or regain function.

Inpatient Palliative Care Consultation: Fellows spend one 4-week block with the palliative care consult service. Fellows see inpatient consults from a variety of medical and surgical services at UNC Chapel Hill for end-stage symptom management and goals of care discussions. The service sees a variety of patients with cancer, heart failure, liver disease, dementia, trauma, and other complex diseases. This is an opportunity for fellows to participate in and lead intense and often complex family meetings, understand the planning for outpatient management of terminally ill patients, and to gain skills in symptom management at the end of life.

Outpatient Experiences

Fellows spend four four-week blocks rotating through a variety of outpatient clinics. The introductory month includes a chance to become more familiarized with the Geriatric Specialty Clinic as well as with the area services for older adults. This includes visits to the Area Agency on Aging, local Senior Centers, Adult Day Care Centers, and meeting with Orange County EMS, who provide interesting and innovative services to area seniors.

Fellows spend additional time during these months rotating with our Geriatric Psychiatrist Dr. Julia Lunsford, and Dr. Ana Felix, the Neurologist who sees patients in the Geriatric Specialty Clinic. Other clinic experiences include the Wound Care Clinic with Vascular Surgery, Urogynecology Clinic, Rheumatology Clinic, the Sleep Disorders Clinic, and Heart Failure Clinic.

Many fellows also choose to rotate at Transitions Hospice, spending time at the inpatient hospice unit as well as making home visits with hospice nurses, chaplains, and social workers.

During these blocks fellows also make home visits, teach residents and students, and have discretionary time to work on their quality improvement project and other educational or research pursuits.

Fellows also have two elective months and three weeks of vacation yearly.