Wales: Core curriculum of competencies for intermediate care for SpRs in geriatric medicine
In a pioneering step, Wales developed a comprehensive core curriculum of competencies for intermediate care for SpRs in geriatric medicine. While designed for SpRs in Wales, the curriculum has UK-wide relevance.
The changing service models for delivering medical care to older people has been distilled into the areas of:
- Acute medicine - unselected acute admissions and assessment of acute illness in older people in Medical Assessment Units
- Rehabilitation - short-term/long-term programmes delivered either in a hospital or community setting
- Community - planning and delivery of services for older people in the community which could be at home or within a residential or nursing home.
- Sub-Speciality services - e.g. stroke care, orthogeriatrics, falls, etc.
Recognising the important role of geriatric medicine in providing a breadth of comprehensive care for older people, Drs Khanna, Dunn and Bhowmick developed a curriculum of core competencies required by those physicians planning and delivering services in the community (Intermediate Care).
A key strand in developing future services in geriatric medicine has been the development of Intermediate Care (Wanless) and the Welsh Assembly Government document, “Designed for Life”. The theme in these documents is for older people’s health and social care issues to be managed nearer to their home, in the community. At present, the development of Intermediate Care services has been ‘hit and miss’ - fragmented, unevenly developed and delivered with poor integration with main-stream services. The Academy of the Royal Colleges has identified the lack of specialist medical input as being one of the reasons for the failure of development of efficient Intermediate Care services. It recommended that geriatricians be encouraged to undertake well-defined roles in community work, in planning and delivery of Intermediate Care services.
It is noted that current SpRs receive little direct training in non-hospital settings and, with an ever-increasing acute workload, their exposure to longer term rehabilitation, and health promotion, may also be cursory. If these doctors are to be able to realise their ambition (as stated in the Wanless Report), it is important that they are able to access this practical training so that they have confidence in delivering Intermediate Care in the community setting. This will prepare SpRs for the ever-increasing number of consultant posts in Intermediate Care, which are starting to emerge across the United Kingdom.
This will vary according to the interest of the SpR, but should be a minimum of 6 weeks up to a maximum of 6 months, to be decided by the Specialist Training Committee.
SpRs would be attached to hospitals/ trusts/local health board (LHBs)/primary care trusts (PCTs), which have developed a comprehensive Intermediate Care training programme from acute all the way to reablement and continuing care.
This requires a greater emphasis on implementation of a new core curriculum/ competencies for training in Intermediate Care and the following format is suggested -
Acute Care in the community
Competency - assessing and managing acute illness in the Community setting attained by knowledge of:
- facilities and resources available in the community for Acute Assessments
- assessing acute illness in the community in a multidisciplinary setting (rapid response, hot clinics, ECAS, etc.
Demonstrate this knowledge by preparing six case reports: formulation of Care Plan with involvement of members of the Multidisciplinary Team.
Rehabilition in hospital; at home; in residential/nursing home settings
Competency - assessment and management of patients for rehabilitation in the community attained by knowledge of:
- facilities and resources available in the community for rehabilitation (day hospitals, day centres, community rehabilitation teams - reablement)
- assessing rehabilitation needs for the patient and their carers in a multidisciplinary setting - this should include needs assessment and care planning
Demonstrate this knowledge by preparing four case reports and formulation of suitable care plans.
Chronic long-term conditions management
Competency - ability to assess and manage common long-term, disabling conditions in institutional and non-institutional settings attained by knowledge of:
- generic and specialist teams available in the community for long-term condition management and long-term disease management
- current legislation on Continuing Health Care funding
- common long-term disabling illnesses and their attendant complications and the management thereof
- social and health provision
- policy of Welsh Assembly Government (WAG)
- benefits available
This is done by:
- Working with patients with long-term conditions in a locality to ensure continuity and to establish professional and multi-agency lines of communication
- Managing cases and taking an active role in case discussions regarding adults with complex disability in a multidisciplinary setting
- Attendance at clinics of other disciplines
- Involvement in Primary Care team meetings
- Gaining experience of working with specialist nurses in long-term disease conditions, e.g chronic obstructive pulmonary disease/cardiac failure
Demonstrate this competency by preparing 4 case reports
Audit - leading and facilitating the evaluation of services for long-term conditions.
Managing long-term conditions in care homes
Competency - though similar to the competencies required for long-term conditions management, specific areas for developing assessment of processes for falls, incontinence, tissue viability and palliative care attained through knowledge of:
- facilities and resources available in the community regarding care homes
- any pro-active case management teams in the care homes
- Welsh Assembly Government long-term NHS Continuing Care Policy
This is done by:
- assessing and managing long-term conditions in the care homes in a multidisciplinary setting
- demonstrating this knowledge by preparing one case report and formulation of a care plan demonstrating close working across primary/ secondary care interface
- attending Continuing Health Care Panel
- participating in a visit to a care home
- doing one joint visit with community specialist nurse (long-term conditions) e.g. continence advisor, tissue viability nurse, movement disorder nurse and Macmillan nurse
Public health / commissioning / joint planning
Competency - produce a review of effectiveness or demonstrate a case of need attained by knowledge of:
- LHB: Wanless Plans
- local facilities
- different models of care
This is done by:
- Attachment to Public Health Department/ Commissioning in order to complete a project which evaluates the effectiveness of a Health Intervention Programme, including critical evaluation of the data and collection system used
- Attachment to Social Services Department to complete a project that promotes joint-working, including critical appraisal of knowledge base and methodology
- Work with Planning Officers in Health and Social Services using epidemiology and health data to demonstrate a case of need which should be contracted for
- Demonstrate by production of a business case and subsequent action which followed this
- Attend local health board (Joint Health/Social Care) meeting
Competency - ability to use assistive technology to enable patients to reside safely at home or in an institution attained by knowledge of:
- equipment used plus potential funding sources
- life-style monitoring technology
- undertaking assessment of patients with a multidisciplinary team, visiting the SMART Houses and the disabling living centre
This is done by:
- application for funding for equipment for 2 patients and follow-up of these patients
- attend course on useful assistive technology
- demonstrate the knowledge by application for funding for such equipment
- prepare one case report of value of assistive technology