Silver Book II: Training and development

Good practice guide
Good practices guides focus on providing information on a clinical topic.
(Section editors)
Don Melady
Teresita M Hogan
Date Published:
22 February 2021
Last updated: 
22 February 2021
The Silver Book II was written to address the care needs of older people, specifically older people living with frailty, during the first 72 hours of an urgent care episode. This chapter, edited by Don Melady and Teresita M Hogan, addresses the education, training and workforce considerations of providing urgent care to older adults.

Care of the acutely ill or injured older person takes place over a wide spectrum of settings from in-home community-based care, to in-hospital acute or intensive care, and back.

In some cases, gaining competency will require general enhancements of pre-employment training and education. However,  competency will more likely be achieved through additional field-based, ‘real-life’ on-the-job training. Ultimately every provider continually refines their knowledge and skills to reach expertise, the ability to provide care at the time and in the place where it offers the best care option available for each patient.

It is a common observation that, in most health care education systems, there is little focused education in the specific skills needed to assess, treat, and work with older people. Although older people often make up the bulk of patients seen by health care workers, education in many international systems, treats older people as though they were exceptions or outliers to usual care. It is critical to educate students, trainees, and workers about both general and specific skills needed in older adult care. This chapter will guide educational enhancements to close that competency gap.

To develop competency, it is necessary to develop across three domains – skills, knowledge, and attitudes.

Skills: ‘Hard’ skills which require the appropriate completion of a physical task (e.g. how to transfer a person from wheelchair to bed, how to perform an ultrasound-guided femoral nerve block); and ‘soft’ skills such as facial expressions and touch and body posture (e.g. how non-verbal cues can help to gather information from a person with hearing or cognitive impairment).

Knowledge: This relates to knowing a fact and how to interpret it (e.g. what the normal blood pressure range is for older patients and what it means when abnormal; or the right height for a walker and how to fit one; or what indications for transfer to a higher level of care may be). Other areas of knowledge enhancement include a familiarity with the ways in which older people are different from the general population whether socially, functionally, physiologically, or anatomically. Competent providers have an awareness of community services and resources that others can provide, which may benefit the older person. Additionally all must develop clinical reasoning and assessment skills which might be as basic as identifying when someone ’just isn’t right’.

Attitudes: This relates to feelings or emotions and opinion development, such as changing the way you think or feel about care of older persons resulting in a more positive behaviour. This attitude would manifest as a willingness to spend more time; or an openness to collaborate more intensively with family members or interdisciplinary colleagues. It is the perspective that an older person is an intrinsically valuable and important member of society. Maintaining a positive attitude that one’s own actions, however minimal, have the potential to improve the older person’s life. Excellent providers identify and avoid ageist attitudes which devalue, categorise, or dismiss older people and their issues.

These issues of skills, knowledge, and attitude development exist for all providers across the entire spectrum of care provision for an ill or injured older person, from personal support workers to geriatricians; from doctor’s offices to intensive care units.260

Probably the greatest area of skills enhancement specific to care of older people is communication.

Effective communication skills (the ability to clearly and consistently communicate empathy, compassion, respect, patience and build rapport with patients, families, and caregivers) is another skill set essential at every point along the care continuum.

(Please click the '+' icons below to expand the tables).

Australian resources

Australian Information

Website name



National Ageing Research Institute -training notes for communication

Strategies to enhance staff-resident communication in residential aged care

Ausmed Education

Communicating with older patients

Relationships Victoria

General communication tips with downloadable Good Communication Card and Video

State Government of Victoria, Australia – Health Victoria

Communicating with older people who have diverse needs

Mental Health First Aid

Guidelines for helping the confused older person with dementia

United States resources

United States Information

Arizona Center on Aging: Elder Care - A Resource For Interprofessional Providers

Elder Care Provider Fact Sheets and Care Partner Information Sheets are available in PDF format. Includes a section on Communication

Geriatric Fast Facts

Quick answer/fact sheets on various topics, including family meetings

The Gerontological Society of America

Video on general provider communication and attitudes

National Institute on Aging: Talking with your older patient

Links to PDF chapters of the Handbook, Talking with your older patient

Gerontological Society of America: Communicating with Older Adults

Two relevant publications available for free download

GeroNet UCLA David Geffen School of Medicine

List of national resources and national disease resources. Not perfect because others are CA specific.

GeriPal A Geriatrics and Palliative Care Blog

Of general interest

Centers for Disease Control and Prevention: Alzheimer’s Disease and Healthy Aging

Health Literacy tools specific to older adults, links to US state and local agencies, and CDC reports

National Council on Aging: Resources for Professional

Up to date topic and webinar links and

Searchable database of their publications

The training of staff who participate in the care of older people during an episode of acute injury or illness is essential for safe and effective care delivery. This is not restricted to medical practitioners but is required across the spectrum. This section explores specific skills relevant to care providers from several specific disciplines.

Considerable work has gone into establishing the Geriatric Competencies in Emergency Medicine. These are specific competencies required by emergency physicians to provide excellent care to older patients. These competencies define the eight highest yield areas where knowledge will most likely impact quality of care provided, for example atypical presentations. Older patients with myocardial infarction (MI) present in a fairly consistent fashion that should be known. The average 80-year-old with MI does not have chest pain, but the primary symptom is usually dyspnoea. The term 'atypical' assumes the bias that practitioners only know the symptoms typical in younger persons. However, each disease/illness presents just as ‘typically‘ or consistently among older persons. Medical staff simply need to learn the differences.

The competencies are grouped within the following domains:

  1. Atypical presentations - These recognise the specific way older people manifest illness and injury are different from (or atypical from) those of younger people (see section on Non-Specific Presentations).
  2. Trauma and falls – These are very different in older people (see sections on Falls and Syncope and Silver Trauma).
  3. Cognitive impairment - Both dementia and delirium are critical aspects of older people's care (see sections on Dementia and Delirium).
  4. Emergency care modifications - ‘Usual‘ emergency care changes to be age- and person-appropriate.
  5. Medication and pain management – Older adult care considers medications in the presence of polypharmacy, comorbidity, and aging physiology (see section on Pain).
  6. Transitions of care – Must be managed differently as older patients move through the care system (see section on Transitional Care).
  7. End of life - Issues such as establishing goals of care, symptom management, and arranging access to palliative care resources (see section on End of Life Care).
  8. Comorbidities – Older adult care requires managing multiple active medical conditions as they impact one another.

Other geriatric educational resources for emergency physicians are available at:

These geriatric domains apply equally well to most physicians and surgeons providing care to an ill or injured older person in hospital. In fact, these competency domains could also provide guidance to any clinician – nurse, physiotherapist, occupational therapist, paramedic, etc. – who wanted to supplement their clinical competency set. Each of these domains probably requires additional education beyond what is currently offered in undergraduate medical or specialty level education; whether this can best be supplemented by off-service geriatric medicine exposures or focussed training on the job will be situation-dependent.

To improve care of older adults in the US by increasing specialty physicians’ competence in geriatrics, the Geriatrics for Specialists Initiative created content to increase competency from the ED through post-operative care. This includes: anaesthesiology, emergency medicine, general surgery, gynaecology, ophthalmology, orthopaedics, otolaryngology, physical medicine and rehabilitation, urology, trauma surgery, thoracic surgery, and vascular surgery. The Geriatrics Competencies by Specialty can be found here, and Geriatrics for Specialty Residents educational toolkits are available here. Many physician training programmes have introduced curricula that cover the geriatric competencies specifically.

Resources: Medical Staff

Nurses Improving Care for Healthsystem Elders (NICHE) provides resources for nursing and interdisciplinary teams. The program has an online Leadership Training Program (LTP) and a long-term care (LTC) educational program, NICHE-LTC.
National nurse organisations around the world provide other nurse-specific tools:
United States
United Kingdom

Early physiotherapy (or physical therapy) after acute illness or injury has potential to maintain or improve physical function and reduce the likelihood of transfer to institutionalisation.261 
Following hospitalisation, physiotherapy is traditionally conducted in inpatient or outpatient rehabilitation hospital settings; however home-based rehabilitation is a viable alternative.262 To enable the older person to accomplish their goals to improve or maintain mobility and independence, the therapy program should be designed to:
  • Increase, restore or maintain range of motion, physical strength, flexibility, coordination, balance and endurance
  • Prevent further decline in functional abilities through education, energy conservation techniques, joint protection
  • Teach positioning, transfers, and walking skills to promote maximum function and independence within the person's capability
  • Improve sensation and joint proprioception
  • Manage or reduce pain
  • Increase overall fitness through exercise programs.
Physiotherapy may also include recommendations for assistive devices to promote independence, adaptations to make the person's home accessible and safe.

Resources: Physiotherapists

Occupational therapists are healthcare professionals who use occupations or everyday life activities, to support participation, performance, and function of patients in the home and community.263 The goal of occupational therapy is to identify and overcome barriers that prevent a person from participating in basic and instrumental Activities of Daily Living (ADLs), ranging from toileting and dressing to medication and financial management. When working with older adults who are acutely ill or injured, assessment within the first 48 hours of care is essential because, without timely interventions, a person’s condition may deteriorate rapidly.
OTs should assess and understand how the presenting illness or injury impacts the older adult’s ability to perform daily activities. Treatment can include restoration of physical, cognitive or sensory abilities as well as compensatory strategies for improved functional performance when restoration is not possible. The approach should be guided by CGA, especially early discharge planning.

Resources: Occupational therapists

Paramedics are one of the few healthcare professionals who routinely see patients in their own homes. This in-home assessment informs not only paramedic treatment pathways and transport decisions but also future care and decision-making beyond the acute situation, including discharge planning. Paramedics should understand how illness, acuity, and frailty interact, the common presentations encountered when a person is frail and sick, and how care should be modified in this vulnerable population.
Many older adults will require stabilisation and transportation for urgent care. However all paramedics, regardless of level of training, require the skills and knowledge to manage patients in the home without transport to the emergency department where such pathways exist. Clinical practice guidelines are emerging for palliative or end-of-life care that enable paramedics to provide treatment in the home without the need for emergency transport.264 Other referral dispositions are possible following non-transport in some jurisdictions (e.g. falls referral programs80) or the application of decision-rules to determine safe non-transport.265-6 Paramedics should possess knowledge about the communities in which they work and resources available in order to be able to generate appropriate referrals and work collaboratively with community-based health care teams, particularly in the context of the non-transport.

Resources: Paramedics

Community paramedicine (CP), also known as Mobile Integrated Healthcare, provides opportunities to tailor care for older adults and to offer proactive preventative care prior to a health crisis or better-integrated acute care services. CP is a term used to describe expanded paramedic scope and practice in non-traditional roles where paramedics are viewed as physician extenders,267 recognising that non-physician clinicians are under-used.268 This has meant a shift towards developing models of care that are often ‘care in place’ or referral to another health care service other than the ED. Most CP programs target vulnerable populations such as older adults in social housing269, long-term care,270 or older adults with acute exacerbations of chronic conditions.267 Community paramedic pathways provide treat-in-place, treat-and-refer, or traditional transport to urgent care options that are adjuncts to existing health care services. Community paramedics routinely conduct multi-domain assessments which provide rich information that can inform care planning and goal setting.271

Resources: Paramedicine

Institutions providing care to older adults vary internationally in the type and extent of care offered, the characteristics of the resident population, as well as in naming. The term ‘nursing home’ is common in the United States, Netherlands, Canada, Germany, Australia, Japan and India, less so in other European and Eastern countries.
Focused attention on staff characteristics such as their training, recognition and response to a change in a person’s condition can improve quality of care when a resident becomes acutely ill or injured. Most countries have resources and processes with surveyors or inspectors who oversee care quality, enforce regulations and learn from visits to these facilities.
Key points for providing urgent care in the context of long-term residential care:
  • Leadership support for improving care when a change in condition happens is essential
  • Designate a ‘champion’ on the staff to promote new practices and sustain focused attention on the improvement effort
  • Train all staff in the nursing home on how to recognise signs and symptoms that signal a potential change in resident status
  • Formalise reporting pathways so that all staff know when and to whom to report a change
  • Develop a standard approach or workflow for how a change in status will be evaluated
  • Train all clinical staff on this workflow, particularly staff that are responsible for telephonic coverage during the evening/night/weekend hours
  • When a hospital transfer is necessary, use a standard communication template and have a nurse-nurse or doctor-doctor phone conversation to ensure shared understanding of the reason for transfer and goals of care (see INTERACT transfer document as one example of a useful resource).

Resources: Long term residential care

  • The INTERACT Quality Improvement Program is designed to standardise how a change in health status is recognised and evaluated to prevent potentially avoidable hospitalizations. Also included are tools to standardise communication within the nursing home and with hospital staff.
  • This change package includes multiple strategies and actionable ideas that nursing homes can use to improve quality care.

Many people want to stay independently living in their own home for as long as possible as they age, including during an episode of illness or injury. Personalised home-based community care delivered by nurses, allied health professionals, and personal care workers enables people to retain their dignity while remaining independent in their own familiar environment. Home-based community care can be tailored to individual needs and may include support with:
  • Recovery from an illness or injury, regaining or maintaining independence, managing chronic conditions, or medication management
  • Specialised nursing care in skin and wound care, diabetes, continence, dementia, mental health and palliative care
  • Mobility and rehabilitation
  • Post-hospital care
  • End-of-life care at home
  • Domestic tasks, such as cleaning, laundry and meal preparation
  • Personal care such as bathing and dressing
  • Gardening and home maintenance
  • Transport for appointments and shopping
  • Companionship and social support
Currently, with most older people wishing to age in place, service providers are faced with supporting people with higher levels of frailty and functional dependency. Improvement in assistive technologies ranging from mechanical aids and home modifications to computerised diagnostic/therapeutic devices and sensors, complement home-based care by assisting and monitoring activities of daily living and physiological function.
Specific competencies for home-based community nurses and allied health professionals, such as physiotherapists and occupational therapists, include:
  • Ability to work autonomously
  • Clinical reasoning and holistic assessment skills to identify common conditions, such as delirium, dementia, malnutrition, mental health issues
  • Risk assessment and management skills
  • Knowing when to refer to other health professionals
  • Recognition and management of early changes and potential clinical deterioration.
Recognising clinical deterioration
Functional or sensory decline
Change/alteration in skin integrity
Reduced oral intake
Loss of appetite or unplanned weight loss/gain
Altered blood glucose levels
Altered vital signs
Wound deterioration/failure to progress
Change in urine output or change in bowel habits
Altered cognition or changes in communication
Changes in mental health
Specific competencies for personal care workers include:
  • Skills with enabling and/or supporting an individual’s activities of daily living (ADL) such as eating and drinking, bathing, toileting, skin care, oral hygiene
  • Assisting with domestic ADLs such as light housekeeping activities
  • Assistance with medication support, in accordance with established employer or government policy and scope of practice
  • Companionship and social support
  • Observation skills to recognise, document and communicate changes in physical or cognitive function.

Resources: Home based acute care

Social Workers and Case Managers have an important role in the acute care of older people, offering a ‘collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community.'
Case Management services include resource management, facilitating communication, and directing treatment throughout the care continuum. Goals include maximising healthcare use and access, facilitating health and safety, and optimising self-efficacy. Information for the scope of Case Management services can be found here. Although interrelated, Social Work and Case Management Workers offer distinct and essential services during an episode of acute illness to injury.

Social Workers can be most helpful in managing deteriorating cognition and mental health, inadequate housing, maltreatment neglect and abuse, advance directives, and managing the economics of individual/group benefits and insurance eligibility. They are sometimes responsible for arranging post-acute care placements. Challenges that face Social Workers include both training and staffing of services, which have not kept pace with the increased demands of aging population.273 Social Workers can support patients and families to adapt to evolving roles and responsibilities, particularly during an episode of acute illness or injury.274

Resources: Social work

Areas in which case management can be most helpful include arranging and providing in-home nursing service, medication arrangement and monitoring, maintaining mobility, wound care support, arranging durable medical equipment, and providing bedside care.

Case Managers can be involved with arranging post-acute home services including home nursing, IV infusion management, medication management, durable medical equipment, and physical/occupational therapy. Specific skills required to provide in home Case Management include making initial health evaluations, cleaning and dressing wounds, monitoring vital signs, and supervision of home care workers.

Resources: Home case management

Social Workers, and Case Managers must maintain the perspective that they are also navigating multiple systems. Integrating these systems in an essential component of successful treatment. Patients operate within their family system, community system, and larger cultural system. The expectations on family to manage home care is increasing as longevity increases.273 Beyond the family system, integration of community systems is important to longer term planning.273 Community and cultural system integration allow resources to operate within and beyond certain aspects of the acute hospital stay.

Resources: Social workers and case managers

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