There are not enough primary care providers educated in geriatrics to deliver age-sensitive care to older adults, making chronic disease management and optimal function promotion a challenge. According to the 2008 Institute of Medicine (IOM) Report, Retooling for an Aging America: Building the Health Care Workforce, the current healthcare system is ill-equipped to deal with the challenging combination of increased aging demographics and long-term care needs of the aging population.1 The National Academy of Medicine (formerly the IOM) recommends that all healthcare professionals be educated to care for older adults and that there needs to be increased recruitment and retention of geriatric specialists in all fields of practice.
Furthermore, healthcare professionals need to embed their curricula with interprofessional didactic content and clinical experiences to reinforce that an interprofessional, team-based approach is essential to caring for older adults.2 The National Academy of Medicine also recommends that health educators and leaders adopt a mixed-methods research approach for evaluating the impact of interprofessional education.3
In 2008, only 268 NPs graduated from gerontological and adult-gerontology NP programs nationwide.4 Historically, the overwhelming numbers of NPs providing primary care to older adults are prepared as family and adult NPs. As is the case with physicians, few NPs are prepared to manage the multiple chronic illnesses faced by their older primary care patients.
In response to this deficit and to build the capacity of the workforce to care for an aging population, the Advanced Practice Registered Nurses (APRN) Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee developed the 2008 Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (APRN Consensus Model).5 Endorsed by 48 nursing organizations, the APRN Consensus Model defines APRN specialty practice and population foci.
Within the structure of the APRN Consensus Model is the APRN role of the NP, for whom one population focus became the combined adult-gerontology primary care NP.3 Shortly after, the American Academy of Nurse Practitioners Certification Board (AANPCB, http://www.aanpcert.org) and American Nurses Credentialing Center (ANCC) Certification Center (http://www.nursecredentialing.org/certification.aspx) changed their individual adult NP and gerontology NP national certification exams to one combined adult-gerontology NP certification exam (primary or acute care).
Previously, certified adult NPs with either a lapsed certification, those moving to a different state where the new combined certification is required, or those whose employers require the new certification had a gap in geriatric and clinical content on their academic transcript; therefore, these adult NPs were ineligible to meet the new certification requirements.
To address this development, the Hartford Institute of Geriatric Nursing at New York University (NYU) Rory Meyers College of Nursing, in partnership with the NYU School of Medicine, developed an innovative approach to prepare NPs to gain competencies in team-based primary care of older adults with multiple chronic conditions. The Advanced Certificate in Gerontology is a post-master's certificate program option of the Adult-Gerontology Primary Care Nurse Practitioner Program.
The purposes of the program are to develop NPs with the knowledge, skills, and attitudes to manage complex, community-dwelling older adults with multiple chronic conditions in an interprofessional model; implement effective care for this growing population within a high-functioning, interprofessional team that utilizes evidence-based practice to achieve quality outcomes; and promote an interprofessional, team-based approach, applying shared didactic technology (e-learning, interactive web-based content) and clinical technology (online case studies) learning opportunities.
The Post-Master's Advanced Certificate in Gerontology, a technology-enhanced blended curriculum, is most applicable for adult NPs (prepared prior to the APRN Consensus Model) who need the gerontology content to meet eligibility requirements for the national Adult-Gerontology Primary Care Nurse Practitioner certification exam; NPs who want to further their ability to provide comprehensive interprofessional primary care to older adults with multiple chronic conditions; and NPs who want to further their knowledge in gerontology and geriatrics.
Conceptual framework
The Chronic Care Model serves as the conceptual framework for the curriculum.6 The Chronic Care Model identifies six areas that together lead to effective chronic disease management: self-management support, delivery system design, decision support, clinical information systems, organization of healthcare, and community.6
The six areas of the Chronic Care Model are not measured as programmatic outcomes in the advanced certificate program because of the difficulty in linking the program participants to patient outcomes. Nonetheless, the model serves to help learners gain insight into the macro systems of health and community and consider how an interprofessional team may deliver individual-based care to older adults within those systems.6
Curriculum
The Advanced Certificate in Gerontology Program is a minimum 1-year, 12-credits (four courses) post-master's certificate program focusing on interprofessional primary care to older adults with multiple chronic conditions. The program includes four courses: advanced pathophysiology, pharmacotherapeutics, and physical assessment for older adults; primary care of the older adult with multiple chronic conditions focusing on common chronic illnesses in older adulthood; primary care of the frail older adult with multiple chronic conditions focusing on geriatric syndromes and long-term care; and a 1-week, executive format, clinical intensive in interprofessional care of older adults course in collaboration with the NYU School of Medicine. All courses are built on a foundation of adult learning principles.
If a learner is interested in taking the ANCC or AANPCB Adult-Gerontology Primary Care Nurse Practitioner national certification exam, it is important to assure that the course of study fulfills eligibility requirements. Prior to program entry, a gap analysis is completed to make sure the program courses are sufficient for certification or if additional courses are needed.
Learners need to complete a minimum of 250 precepted clinical hours in primary care gerontology to meet the competencies. The program director increases these hours if the gap analysis indicates previous clinically precepted experiences with older adults are insufficient and/or if more clinically precepted time is needed to meet competencies. A curriculum guide has been developed for implementation at other academic institutions and may be accessed online (https://consultgeri.org/sites/default/files/curriculum-guide-2017.pdf).
Educational innovation
The innovative aspect of this program is a series of the six interprofessional education and practice (IPEP) learning resources available both online as online learning modules and on iTunes as free eBooks.7-13 The self-directed learning resources aim to instruct healthcare providers in caring for older adults in interprofessional teams.
These electronic resources are based on NYU3T, which is the Teaching, Technology, and Teamwork curriculum originally funded by the Josiah Macy Jr. Foundation. The NYU3T undergraduate level, acute care based modules were adapted in the IPEP modules to focus on the interprofessional primary care of older adults for clinicians at the graduate and postgraduate level in various disciplines.
The six online modules are built on content from the Core Competencies for Interprofessional Collaborative Practice sponsored by the Interprofessional Education Collaborative (IPEC).14 Specifically, the modules address interprofessional collaboration, education, and training of physicians, nurses, NPs, and other healthcare professionals through the IPEC Competency Domains: values/ethics for interprofessional practice; roles/responsibilities; interprofessional communication; and teams and teamwork (see IPEP modules/eBooks).
Additional online modules are offered to provide primary care-based virtual patients for primary healthcare trainees and/or providers to complete and then, as time and schedules permit, discuss as an interprofessional team. Each module takes 10 to 15 minutes to complete and includes the assessment and management of older adults with multiple chronic conditions in an interprofessional manner.
The goal of the collective modules is to increase the number of APRNs, physicians, and other healthcare providers with gerontological competencies and interprofessional expertise to enhance person-oriented primary care to complex older adults with multiple chronic conditions. Objective structured clinical exams, a form of experiential learning and assessment used in graduate health education programs, are used to assess interprofessional provider competencies in care of older adult issues as well as communication and collaboration among team members.15,16
Other program teaching methods include didactic sessions on common geriatric healthcare topics for well and frail older adults, case presentations by trainees, and interprofessional primary care clinical experiences for underserved older adults.
Program evaluation
Funding from a Health Resources and Services Administration, Bureau of Health Workforce, Division of Nursing, Advanced Nursing Education Program grant provided an opportunity to formally evaluate the educational program. Evaluation was done through traditional methods using measurements of students' competencies, course and clinical evaluations, and a mixed-methods approach utilizing the Assessment of Interprofessional Team Collaboration Scale (AITCS), a quantitative, reliable instrument to measure collaboration within teams.17
Additionally, focus groups and reflection questions were used to gather more information related to attitudes, interprofessional education, collaboration, and practice. A mixed-methods approach was chosen, evaluating the interprofessional intervention, with qualitative data as the primary evaluation source and quantitative data providing the supporting data. Because interprofessional education and collaboration are a relatively new phenomenon for study, and evaluation methodologies are still being refined, this work contributes to the development of those methods.3,18
Results
Six NPs completed the program in the first 2 years of the program, along with 15 third-year primary care medical residents joining them for the interprofessional clinical intensive 1-week course. All trainees successfully completed the academic requirements. This was a smaller sample size than initially anticipated, which meant the AITCS responses provided only descriptive data and could not be evaluated statistically to produce meaningful results.
Descriptively, the numbers showed no changes in participant perspectives about teamwork dynamics when measured before and after completing the program. Despite multiple efforts to encourage postintervention survey completion, response rates were low at only 20%; therefore, the pre- and post-responses could not be compared.
By contrast, responses to reflection questions within the IPEP modules demonstrate good alignment with qualitative and quantitative results. Examples of reflection statements included: "This interprofessional education fosters teamwork, effective communication, and respect for each disciplines' knowledge on how to manage a patient" and "In the dyad between doctor and nurse, this is one of the few experiences where I felt like my clinical acumen had weight and was respected."
Notable themes emerged from evaluation of the 1-week intensive course: how previous work and educational experiences influenced perceptions of teamwork, interprofessional education, and collaboration; teamwork dynamics; transitions, with NPs reflecting on the impact of workplace transitions on interprofessional collaboration and physician trainees; promoting understanding, such as learning from each other helps clinicians understand each other's roles in education and clinical practice; and organizational and contextual influences, such as the organization's emphasis to the learners on the importance of developing interprofessional relationships regardless of resources.
Discussion
The program implementation offered multiple lessons for educators seeking to create similar programs; these ranged from the logistics of program management to individual student issues. Scheduling interprofessional activities, including the Clinical Intensive in Interprofessional Care of Older Adults course with joint clinical experiences and objective structured clinical exams, takes time and effort. Scheduling interprofessional educational courses and experiences, though challenging, is possible and should be implemented in all clinical programs. Virtual patients and clinical and objective structured clinical exams may focus on specific geriatric content areas or transitional care issues of older adults with multiple chronic conditions between healthcare settings.
Recruitment challenges include the high cost of tuition and the time commitment to complete clinical hours and course requirements. Prospective students state these as the main reasons hindering them from attending the program despite strong interest in learning more about gerontological nursing and IPEP. Regulatory issues at the university level and between state boards of nursing also pose challenges. Students need to be licensed in the state where they are enrolled in an academic program and complete clinical requirements in the university's state. Rare exceptions may be granted depending upon school and State Board of Nursing approval from both the school's state and the prospective student's home state, if different.19,20
One important and understudied issue emerged from this program. Adult learners bring different life and work experiences to interprofessional education and collaborative learning. Our evaluation captured that the stages of educating of different healthcare professionals appear to influence perspectives on educational and clinical experiences. Even though the program had an andragogical focus, the difference between the NPs and primary care medical residents in terms of their life and work experiences was an underaccounted factor in program planning. The authors recommend that when replicating this model, programs adapt to this factor.
Communication and collaboration
A unique aspect of this program was its effectiveness in fostering communication and collaboration between NPs and other primary care providers through the use of a technology-enhanced blended curriculum. This approach makes it replicable to a larger and diverse group of healthcare professionals. Future planning will focus on continued recruitment of learners into the program, dissemination of the program in other states, and development of new virtual geriatric patients with a focus on interprofessional practice. The Advanced Certificate in Gerontology Program is on track to help develop and refine interprofessional education and advanced geriatric-specific knowledge in primary care.
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