Ariel Cole, MD, and John Fleming, MD, Family Medicine Residency and Geriatric Fellowship Programs, Florida Hospital, Orlando, FL

History
Prior to 2010, the Family Medicine Residency and Geriatric Fellowships at Florida Hospital had longstanding relationships with two nursing homes: an independent upscale continuing care retirement community, The Mayflower, and a nursing home owned by the overall health system, Florida Living. The relationship with The Mayflower was reported in the STFM Messenger Education Column, March 2011. The residency moved to a smaller, community-based hospital (from the larger, tertiary hospital), providing an impetus to reevaluate our relationship with Florida Living due to the increased distance from the new teaching site. The Gardens at DePugh was found to be close to our new location (and therefore patients requiring emergent care would be taken to our new hospital), and the facility is a good balance in size and resources to The Mayflower.
The Gardens at DePugh was started as a nursing home in 1956 and has a long history serving the community. At only 41 beds, it is a small and family-like facility with primarily long-term Medicaid-funded patients. To provide the patient numbers needed for teaching, we needed to take over as medical director and serve as attending physicians for nearly all patients there. The Board of Directors of The Gardens at DePugh agreed to transfer care, as nearly all patients were under the care of a soon-to-be retired physician. Negotiating a contract for the medical director services was the first hurdle, as The Gardens is a not-for-profit facility with limited resources, so we accepted below average compensation considering this status.

Conversion to a teaching facility by the patients and staff at The Gardens was fairly smooth. Patients and families appreciate the ready availability and communication with physicians. Nursing staff is primarily accustomed to managing patients with only telephone support by physicians, so there was a change in communication pattern to a residency-based system with residents on call off hours. Some staff turnover, including the executive director and the director of nursing, was noted in the first year after the transition, possibly related to the changes.

The Program
The residency assumed the position of medical director as well as primary care physician for all of the patients. This arrangement affords the opportunity to provide clinical geriatric experience for resident physicians as well as administrative and regulatory experience for the geriatric fellows.

All of the patients are assigned to senior family medicine residents to follow longitudinally during years 2 and 3. These patients are examined by the residents and reviewed in depth monthly with geriatric faculty and the assigned fellow. Key facility personnel participate and contribute from their respective disciplines. The geriatric fellows also round weekly and follow a panel of patients at the facility.

Additionally, monthly block rotations at the facility are provided for the affiliated internal medicine residency program at Florida Hospital, thus supporting their requirement for clinical geriatric experience for senior internal medicine residents. The family medicine residents complete their block rotation at The Mayflower.

Our three geriatric fellows rotate through DePugh for 4 months each, acting as assistant medical director, attending Q/A meetings, Board of Director meetings, and regularly interacting with facility staff in a multidisciplinary approach to patient care.On-call duties are covered by residents with faculty back up. Internal communication regarding patient events via our electronic record system is required.

Summary
The partnering between an existing skilled nursing facility and our family medicine residency program is described. The transition was challenging, primarily for the facility and staff. We noted a significant staff leadership turnover following the change. The nursing staff had to adjust to communicating with a panel of residents after hours, and the challenge for the residents and attendings is to assure that information is thoroughly communicated. The twice monthly afternoons when residents appear to examine and write new orders on their longitudinal patients must place an unusual burden on the staff. And the concern remains that nurses will lose skills as physicians are present on a daily basis to evaluate and treat new symptoms. Finally, residents accustomed to hospital care must learn to adjust their expectations to an appropriate level for a long-term care facility regarding promptness and availability of labs, imaging, etc. Although there have been some challenges with the culture change from usual care to a teaching model, we feel that this association has benefited patient care, facility reputation, staff competence, and geriatric education for all levels of learners.