JAMDA xxx (2015) 1e7
JAMDA journal homepage: www.jamda.com
Original Study
Effect of a Novel Interdisciplinary Teaching Program in the Care-continuum on Medical Student Knowledge and Self-Efficacy Amanda Lathia MD, MPhil a, *, Michael Rothberg MD, MPH b, Mitchell Heflin MD, MHS c, Kelly Nottingham MPH b, Barbara Messinger-Rapport MD, PhD, CMD a a
Center for Geriatric Medicine of the Medicine Institute, Cleveland Clinic, Cleveland, OH Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH c Center for the Study of Aging and Human Development at Duke University Medical Center, Durham, NC b
a b s t r a c t Keywords: Medical student education care transitions levels of care competencies in systems-based care
Objectives: Medical students report that they receive inadequate training in different levels of care, including care transitions to and from post-acute (PA) and long-term care (LTC). The authors implemented the Medical Students as Teachers in Extended Care (MedTEC) program as an educational innovation at the Cleveland Clinic to address training in the care-continuum, as well as the new medical student and physician competencies in PA/LTC. Design: MedTEC is a 7-hour interactive program that supplements standard geriatric didactics during the medical student primary care rotation. This study evaluated the performance of the program in improving medical student knowledge and attitudes on levels and transitions of care. Setting: The program occurs in a community facility that includes subacute/skilled nursing, assisted living, and nursing home care. Participants: Five to 8 students completing their primary care rotation at the Cleveland Clinic are required to participate in the MedTEC program each month. Intervention: The program includes up to 3 hours of interactive discussion and opportunities to meet facility staff, residents, and patients. The highlight of the program is a student-led in-service for facility staff. Measurements: With institutional review board approval as an exempt educational research project, preand postactivity surveys assessed self-efficacy and knowledge regarding levels of care for students who participated in the program and a student comparison group. The post-program knowledge test also was administered to hospital medicine staff, and test performance was compared with medical students who participated in the MedTEC program. Results: Between October 2011 and December 2013, approximately 100 students participated in 20 sessions of MedTEC. All students reported improved self-efficacy and attitudes regarding care of older adults and care transition management. Mean percentage correct on the knowledge test increased significantly from 59.8% to 71.2% (P ¼ .004) for the MedTEC participants but not for the comparison group students (63.1%e58.3%, P ¼ .47). There was no significant difference in mean percentage correct on the post-program knowledge test between MedTEC medical students and hospitalists (71.0% versus 70.3%, P ¼ .86). Students led 8 in-service sessions for facility staff on various topics relating to the care of older adults in PA/LTC. Conclusion: The MedTEC program appears to be a successful innovation in medical student education on levels of care. It could serve as a model for building competency of health professionals on managing care transitions and determining appropriate levels of care for older adults. Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The present affiliation of KN is Office of Research and Grants, Ohio University Heritage College of Osteopathic Medicine, Athens, OH. The MedTEC program was supported by a Geriatric Academic Career Award (K01HP20511) from the Health Resources and Services Administration (HRSA) to the corresponding author. The authors report no other conflicts of interest. http://dx.doi.org/10.1016/j.jamda.2015.04.001 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
* Address correspondence to Amanda Lathia, MD, MPhil, Center for Geriatric Medicine, 9500 Euclid Avenue, X10, Cleveland, OH 44195. E-mail address: [email protected] (A. Lathia).
2
A. Lathia et al. / JAMDA xxx (2015) 1e7
The importance of education and training of health professionals in geriatrics is well recognized by the medical community. The rapid growth of the older population in the United States magnifies the need for improved training in geriatric medicine.1 The American Geriatrics Society addresses this concern by endorsing 26 minimum competencies in geriatrics for medical students.2 One competency that is challenging to incorporate into medical student curriculum is “comparing/contrasting potential sites for [hospital] discharge” (competency number 25). Association of American Medical Colleges (AAMC) surveys of medical school graduates conducted in 2007 and 2010 demonstrated that approximately one-third of graduates felt that their medical school preparation to care for older adults in the home and long-term care (LTC) settings (including assisted living and nursing home facilities) was inadequate.3 In another study, focus groups of medical students and residents identified the need for improved understanding of the discharge process, of the differences between sites of care, and of determining appropriate levels of care for patients.4 The inadequate training in competency 25 for medical students leads to resident and attending physicians who are uncomfortable with differentiating levels of care and could potentially lead to unsafe discharges, poor care transitions, prolonged hospital stays, and avoidable readmissions. Focus groups of academic general internists and hospitalists revealed that physicians also felt ill-prepared to manage transitions between different levels of care for older adults.5 Patients discharged from the hospital to post-acute (PA) care (subacute/skilled nursing units) suffer from increased mortality and adverse events compared with patients discharged home.6,7 To enhance the quality of care provided in the PA/LTC settings, the American Medical Directors Association: Society for Post-Acute and Long-Term Care Medicine developed competencies for attending physicians. The systems-based competencies (3.3 through 3.6) address levels and transitions of care, payment models, and interdisciplinary team roles.8 Improved training for medical students in competency 25 may strengthen future attending physician competency in systems of care and ultimately raise the quality of care for older adults discharged to different PA settings. The traditional training offered at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine lacked formal curriculum in PA and LTC. We developed the Medical Students as Teachers in Extended Care (MedTEC) program to improve medical students’ knowledge of and comfort with different levels of care, using the medical student and physician competencies as a guide. This program also addresses other AAMC geriatric competencies for students, such as self-care capacity (competencies 10 and 11), atypical presentation of disease (competency 18), and palliative care and hospice (competencies 20 and 21). This article describes program development, content, assessment, and lessons learned. Methods Development Process Before implementing the MedTEC program, we conducted an internal needs assessment. Students identified levels of care as an area with which they did not feel comfortable. They stressed the need for clinically relevant, interactive experiences. In addition, feedback from their geriatrician preceptors confirmed that students struggled to identify appropriate levels of care for vulnerable elders. Studies have shown that medical students typically prefer multimodal learning experiences over unimodal techniques, such as lectures.9 In addition, sessions that use a combination of teaching methods, such as case discussions, role play, and hands-on practice, are more effective at changing behaviors.10 Therefore, we designed
MedTEC to be interactive and to include a mixture of teaching and learning modalities. These modalities included pre-program suggested readings, small group discussions, on-site tour of facilities providing different levels of care, and opportunities to talk to and learn from facility staff and patients. Based on the belief that teaching others solidifies knowledge, we also incorporated a student-led teaching opportunity into the MedTEC program. This approach capitalized on facility needs to educate LTC and PA staff, patients, and family members. The objectives of the program are that the learner will be able to (1) list the levels of PA and LTC, (2) differentiate specific levels of care, (3) define transitions of care, (4) articulate ways to improve care transitions, and (5) teach geriatric principles and other topics relevant to the care of older adults in PA and LTC to interdisciplinary facility staff members (nurses and nurse assistants). Program Structure and Curriculum All medical students are required to complete a geriatrics experience at 1 of 3 clinical sites during their clinical rotations. Approximately 37% of students will rotate through geriatrics at the Cleveland Clinic. We designed MedTEC as a required component of our geriatric medicine rotation, which consists of 3 days in the geriatric medicine clinic and 1 day for the program. The course director conducted the day-long program with 5 to 8 students at a suburban community facility that includes subacute/skilled nursing, assisted living, and nursing home units. The program began with a 120- to 150-minute roundtable discussion, during which the course director reviewed PA and LTC levels, transitions of care, and financial systems (including Medicare and Medicaid). Each student received a customized MedTEC pocket card summarizing the different levels of care (see Appendix 1). Students were given the opportunity to ask questions throughout the discussion and to share their own patient-care experiences involving patient transitions to and from different levels of care from previous clinical rotations. After the discussion session, students were led through the different care units, and they observed care provided to patients by various staff members, including nurse assistants, nurses, activity directors/volunteers, and physical and occupational therapists. Following lunch, the course director prepared the students for the in-service by reviewing the topic and how to teach it to the facility staff, including the teach-back method. The course director chose in-service topics with input from the nursing staff educator. These topics often reflected problems encountered by the facility staff since the previous in-service. Two to 3 days before the MedTEC program, students received an informational handout via e-mail that outlined the topic, usually a general medical concept that was not new to the students. Nurses and nurse assistants attended the inservices during one of two 15-minute sessions, either before or after afternoon shift change. Instruction occurred in small groups of 2 to 3 students and 1 to 2 staff members. The students discussed the topic, using the handout as a guide, while allowing the staff to share their own caregiving experiences. Questions were fielded jointly by the medical students and program director. During the remainder of the afternoon, the students each talked with a PA patient or an LTC resident about their experiences with the facility and with transitions between levels of care. The course director concluded the day with a debriefing session to allow the students to discuss and share their experiences from the day. Program Assessment After piloting the program for 6 months, we conducted an evaluation using pre and post surveys, which were approved as exempt educational research by the Cleveland Clinic Institutional Review
A. Lathia et al. / JAMDA xxx (2015) 1e7
Table 1 Demographic Information for Those Who Completed the Pre-Program Survey, for Both the MedTEC Intervention Group and the Comparison Group Characteristic
n Gender: male Mean age (SD) Year of medical school 3rd 4th 5th Career interest Internal medicine Family medicine Surgical specialty Undecided Other
n (%) MedTEC
Comparison Group
82 46 (56.1) 26.2 (2.8)
16 10 (62.5) 24.8 (1.4)
63 (76.8) 17 (20.7) 2 (2.4)
12 (75.0) 4 (25.0) 0
14 0 12 30 26
(17.1) (14.6) (36.6) (31.7)
4 (25.0) 0 4 (25.0) 4 (25.0) 4 (25.0)
3
care pocket card. These students completed the same pre and post surveys (with references to MedTEC removed). We used paired t tests to compare differences in pre and post responses only for those students who completed both surveys. The IRB considered the use of a comparison group to be exempt research because the students all received the same information but in different formats. Also, the students in each group could not be identified by their responses on the pre and post surveys, and their responses did not affect their grades or evaluations for the rotation. Furthermore, to compare students’ knowledge on levels of care after completing MedTEC to the knowledge of hospital medicine staff, we invited hospitalists to complete the online post-survey knowledge questions. We compared the mean number of correct responses on the knowledge test by the hospitalists with those of the MedTEC students using repeated measures analysis of variance to generate pairwise means comparisons. Results
Board (IRB) in March 2012. The surveys were administered electronically using REDCap (Research Electronic Data Capture).11 To measure levels 1 and 2 of the Kirkpatrick hierarchy of educational outcomes, the surveys assessed students’ self-efficacy, attitudes, and knowledge regarding transitional care across settings.12 The pre-program survey consisted of 3 components: demographic information, self-efficacy/attitude, and knowledge. Students rated their attitudes and self-perceived ability to care for older adults in different community settings and to manage to transitions of care using a 5-point Likert scale (see Appendix 2). The knowledge test consisted of multiple-choice case-based questions on PA care (5), LTC (5), and Medicare/Medicaid (2). The post-program survey was similarly organized with the addition of 3 qualitative program feedback questions, adapted from Buhr et al.13 We completed statistical analyses using SAS version 9.3 (SAS Institute, Cary, NC) and R 3.1.0 (The R Foundation, www.r-project.org) software. We compared differences in pre and post responses for students who completed both surveys using paired t tests. Because some students completed only the pretest, we compared the mean pretest responses for these students with the responses of students who completed both pre and post surveys. In an attempt to measure changes in behavior and whether students are able to put their new knowledge into practice (the third and fourth levels of the Kirkpatrick model), we asked the students to use their required patient logs to identify and discuss the appropriate level(s) of care for one patient who they see in the geriatric medicine clinic after participating in the MedTEC program. To strengthen the evaluation of the MedTEC program, we incorporated a student comparison group. Between July and September of 2013, we replaced the MedTEC program by a day in the geriatric medicine clinic plus a 30-minute didactic session about levels of care. The comparison group students did not receive the MedTEC levels of
Between October 2011 and December 2013, the program was conducted on 20 occasions. Eighty-two of 87 students, who attended MedTEC and who were invited to complete program surveys, completed the pre-program survey. Table 1 shows demographic characteristics for these students, as well as 16 of 19 comparison group students who completed the pre-program survey. Most students in both groups were in their third year of medical school and were male. The mean age of students was 26.2 (MedTEC) and 24.8 (comparison group) years. Fifty-eight (66.7%) of 87 MedTEC students completed both pre and post attitude surveys and 51 (58.6%) completed both knowledge tests. For the comparison student group, 16 (84.2%) and 14 (73.7%) completed both pre and post attitude and knowledge tests, respectively. Responses on the presurvey attitudes/self-efficacy and knowledge questions between the MedTEC students who only completed the pre survey and the students who completed both pre and post surveys were not statistically different. For both the MedTEC and comparison groups, there was a statistically significant increase in scores regarding their attitudes and self-efficacy beliefs about providing care for older adults in different care settings (Table 2). For the MedTEC students who completed both surveys, there was a statistically significant improvement in knowledge, as noted by number of correct responses, on the post-test for the PA care and the Medicare/Medicaid question sections, as well as for all 12 questions in total (Table 3). For the comparison group, there was no statistically significant change in number of correct responses on any of the knowledge test sections or on all 12 questions in total (Table 3). Twenty-three (35.9%) of 64 hospital medicine staff completed the survey. When comparing the mean number of correct responses on the knowledge test with the students who completed the MedTEC program post survey, there was no statistically significant difference in mean number of correct answers on the test in total and on the
Table 2 Comparison of Mean Responses to the Attitude/Self-Efficacy Questions (on 5-Point Likert Scale) on Pre and Post Surveys for Students in the MedTEC (n ¼ 58) and Comparison Groups (n ¼ 16) Who Answered All 4 Questions on Both Surveys Question
Mean Pre-Score (SD)
Mean Post-Score (SD)
P
2.59 (0.92)
3.90 (0.55)
JAMDA journal homepage: www.jamda.com
Original Study
Effect of a Novel Interdisciplinary Teaching Program in the Care-continuum on Medical Student Knowledge and Self-Efficacy Amanda Lathia MD, MPhil a, *, Michael Rothberg MD, MPH b, Mitchell Heflin MD, MHS c, Kelly Nottingham MPH b, Barbara Messinger-Rapport MD, PhD, CMD a a
Center for Geriatric Medicine of the Medicine Institute, Cleveland Clinic, Cleveland, OH Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH c Center for the Study of Aging and Human Development at Duke University Medical Center, Durham, NC b
a b s t r a c t Keywords: Medical student education care transitions levels of care competencies in systems-based care
Objectives: Medical students report that they receive inadequate training in different levels of care, including care transitions to and from post-acute (PA) and long-term care (LTC). The authors implemented the Medical Students as Teachers in Extended Care (MedTEC) program as an educational innovation at the Cleveland Clinic to address training in the care-continuum, as well as the new medical student and physician competencies in PA/LTC. Design: MedTEC is a 7-hour interactive program that supplements standard geriatric didactics during the medical student primary care rotation. This study evaluated the performance of the program in improving medical student knowledge and attitudes on levels and transitions of care. Setting: The program occurs in a community facility that includes subacute/skilled nursing, assisted living, and nursing home care. Participants: Five to 8 students completing their primary care rotation at the Cleveland Clinic are required to participate in the MedTEC program each month. Intervention: The program includes up to 3 hours of interactive discussion and opportunities to meet facility staff, residents, and patients. The highlight of the program is a student-led in-service for facility staff. Measurements: With institutional review board approval as an exempt educational research project, preand postactivity surveys assessed self-efficacy and knowledge regarding levels of care for students who participated in the program and a student comparison group. The post-program knowledge test also was administered to hospital medicine staff, and test performance was compared with medical students who participated in the MedTEC program. Results: Between October 2011 and December 2013, approximately 100 students participated in 20 sessions of MedTEC. All students reported improved self-efficacy and attitudes regarding care of older adults and care transition management. Mean percentage correct on the knowledge test increased significantly from 59.8% to 71.2% (P ¼ .004) for the MedTEC participants but not for the comparison group students (63.1%e58.3%, P ¼ .47). There was no significant difference in mean percentage correct on the post-program knowledge test between MedTEC medical students and hospitalists (71.0% versus 70.3%, P ¼ .86). Students led 8 in-service sessions for facility staff on various topics relating to the care of older adults in PA/LTC. Conclusion: The MedTEC program appears to be a successful innovation in medical student education on levels of care. It could serve as a model for building competency of health professionals on managing care transitions and determining appropriate levels of care for older adults. Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The present affiliation of KN is Office of Research and Grants, Ohio University Heritage College of Osteopathic Medicine, Athens, OH. The MedTEC program was supported by a Geriatric Academic Career Award (K01HP20511) from the Health Resources and Services Administration (HRSA) to the corresponding author. The authors report no other conflicts of interest. http://dx.doi.org/10.1016/j.jamda.2015.04.001 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
* Address correspondence to Amanda Lathia, MD, MPhil, Center for Geriatric Medicine, 9500 Euclid Avenue, X10, Cleveland, OH 44195. E-mail address: [email protected] (A. Lathia).
2
A. Lathia et al. / JAMDA xxx (2015) 1e7
The importance of education and training of health professionals in geriatrics is well recognized by the medical community. The rapid growth of the older population in the United States magnifies the need for improved training in geriatric medicine.1 The American Geriatrics Society addresses this concern by endorsing 26 minimum competencies in geriatrics for medical students.2 One competency that is challenging to incorporate into medical student curriculum is “comparing/contrasting potential sites for [hospital] discharge” (competency number 25). Association of American Medical Colleges (AAMC) surveys of medical school graduates conducted in 2007 and 2010 demonstrated that approximately one-third of graduates felt that their medical school preparation to care for older adults in the home and long-term care (LTC) settings (including assisted living and nursing home facilities) was inadequate.3 In another study, focus groups of medical students and residents identified the need for improved understanding of the discharge process, of the differences between sites of care, and of determining appropriate levels of care for patients.4 The inadequate training in competency 25 for medical students leads to resident and attending physicians who are uncomfortable with differentiating levels of care and could potentially lead to unsafe discharges, poor care transitions, prolonged hospital stays, and avoidable readmissions. Focus groups of academic general internists and hospitalists revealed that physicians also felt ill-prepared to manage transitions between different levels of care for older adults.5 Patients discharged from the hospital to post-acute (PA) care (subacute/skilled nursing units) suffer from increased mortality and adverse events compared with patients discharged home.6,7 To enhance the quality of care provided in the PA/LTC settings, the American Medical Directors Association: Society for Post-Acute and Long-Term Care Medicine developed competencies for attending physicians. The systems-based competencies (3.3 through 3.6) address levels and transitions of care, payment models, and interdisciplinary team roles.8 Improved training for medical students in competency 25 may strengthen future attending physician competency in systems of care and ultimately raise the quality of care for older adults discharged to different PA settings. The traditional training offered at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine lacked formal curriculum in PA and LTC. We developed the Medical Students as Teachers in Extended Care (MedTEC) program to improve medical students’ knowledge of and comfort with different levels of care, using the medical student and physician competencies as a guide. This program also addresses other AAMC geriatric competencies for students, such as self-care capacity (competencies 10 and 11), atypical presentation of disease (competency 18), and palliative care and hospice (competencies 20 and 21). This article describes program development, content, assessment, and lessons learned. Methods Development Process Before implementing the MedTEC program, we conducted an internal needs assessment. Students identified levels of care as an area with which they did not feel comfortable. They stressed the need for clinically relevant, interactive experiences. In addition, feedback from their geriatrician preceptors confirmed that students struggled to identify appropriate levels of care for vulnerable elders. Studies have shown that medical students typically prefer multimodal learning experiences over unimodal techniques, such as lectures.9 In addition, sessions that use a combination of teaching methods, such as case discussions, role play, and hands-on practice, are more effective at changing behaviors.10 Therefore, we designed
MedTEC to be interactive and to include a mixture of teaching and learning modalities. These modalities included pre-program suggested readings, small group discussions, on-site tour of facilities providing different levels of care, and opportunities to talk to and learn from facility staff and patients. Based on the belief that teaching others solidifies knowledge, we also incorporated a student-led teaching opportunity into the MedTEC program. This approach capitalized on facility needs to educate LTC and PA staff, patients, and family members. The objectives of the program are that the learner will be able to (1) list the levels of PA and LTC, (2) differentiate specific levels of care, (3) define transitions of care, (4) articulate ways to improve care transitions, and (5) teach geriatric principles and other topics relevant to the care of older adults in PA and LTC to interdisciplinary facility staff members (nurses and nurse assistants). Program Structure and Curriculum All medical students are required to complete a geriatrics experience at 1 of 3 clinical sites during their clinical rotations. Approximately 37% of students will rotate through geriatrics at the Cleveland Clinic. We designed MedTEC as a required component of our geriatric medicine rotation, which consists of 3 days in the geriatric medicine clinic and 1 day for the program. The course director conducted the day-long program with 5 to 8 students at a suburban community facility that includes subacute/skilled nursing, assisted living, and nursing home units. The program began with a 120- to 150-minute roundtable discussion, during which the course director reviewed PA and LTC levels, transitions of care, and financial systems (including Medicare and Medicaid). Each student received a customized MedTEC pocket card summarizing the different levels of care (see Appendix 1). Students were given the opportunity to ask questions throughout the discussion and to share their own patient-care experiences involving patient transitions to and from different levels of care from previous clinical rotations. After the discussion session, students were led through the different care units, and they observed care provided to patients by various staff members, including nurse assistants, nurses, activity directors/volunteers, and physical and occupational therapists. Following lunch, the course director prepared the students for the in-service by reviewing the topic and how to teach it to the facility staff, including the teach-back method. The course director chose in-service topics with input from the nursing staff educator. These topics often reflected problems encountered by the facility staff since the previous in-service. Two to 3 days before the MedTEC program, students received an informational handout via e-mail that outlined the topic, usually a general medical concept that was not new to the students. Nurses and nurse assistants attended the inservices during one of two 15-minute sessions, either before or after afternoon shift change. Instruction occurred in small groups of 2 to 3 students and 1 to 2 staff members. The students discussed the topic, using the handout as a guide, while allowing the staff to share their own caregiving experiences. Questions were fielded jointly by the medical students and program director. During the remainder of the afternoon, the students each talked with a PA patient or an LTC resident about their experiences with the facility and with transitions between levels of care. The course director concluded the day with a debriefing session to allow the students to discuss and share their experiences from the day. Program Assessment After piloting the program for 6 months, we conducted an evaluation using pre and post surveys, which were approved as exempt educational research by the Cleveland Clinic Institutional Review
A. Lathia et al. / JAMDA xxx (2015) 1e7
Table 1 Demographic Information for Those Who Completed the Pre-Program Survey, for Both the MedTEC Intervention Group and the Comparison Group Characteristic
n Gender: male Mean age (SD) Year of medical school 3rd 4th 5th Career interest Internal medicine Family medicine Surgical specialty Undecided Other
n (%) MedTEC
Comparison Group
82 46 (56.1) 26.2 (2.8)
16 10 (62.5) 24.8 (1.4)
63 (76.8) 17 (20.7) 2 (2.4)
12 (75.0) 4 (25.0) 0
14 0 12 30 26
(17.1) (14.6) (36.6) (31.7)
4 (25.0) 0 4 (25.0) 4 (25.0) 4 (25.0)
3
care pocket card. These students completed the same pre and post surveys (with references to MedTEC removed). We used paired t tests to compare differences in pre and post responses only for those students who completed both surveys. The IRB considered the use of a comparison group to be exempt research because the students all received the same information but in different formats. Also, the students in each group could not be identified by their responses on the pre and post surveys, and their responses did not affect their grades or evaluations for the rotation. Furthermore, to compare students’ knowledge on levels of care after completing MedTEC to the knowledge of hospital medicine staff, we invited hospitalists to complete the online post-survey knowledge questions. We compared the mean number of correct responses on the knowledge test by the hospitalists with those of the MedTEC students using repeated measures analysis of variance to generate pairwise means comparisons. Results
Board (IRB) in March 2012. The surveys were administered electronically using REDCap (Research Electronic Data Capture).11 To measure levels 1 and 2 of the Kirkpatrick hierarchy of educational outcomes, the surveys assessed students’ self-efficacy, attitudes, and knowledge regarding transitional care across settings.12 The pre-program survey consisted of 3 components: demographic information, self-efficacy/attitude, and knowledge. Students rated their attitudes and self-perceived ability to care for older adults in different community settings and to manage to transitions of care using a 5-point Likert scale (see Appendix 2). The knowledge test consisted of multiple-choice case-based questions on PA care (5), LTC (5), and Medicare/Medicaid (2). The post-program survey was similarly organized with the addition of 3 qualitative program feedback questions, adapted from Buhr et al.13 We completed statistical analyses using SAS version 9.3 (SAS Institute, Cary, NC) and R 3.1.0 (The R Foundation, www.r-project.org) software. We compared differences in pre and post responses for students who completed both surveys using paired t tests. Because some students completed only the pretest, we compared the mean pretest responses for these students with the responses of students who completed both pre and post surveys. In an attempt to measure changes in behavior and whether students are able to put their new knowledge into practice (the third and fourth levels of the Kirkpatrick model), we asked the students to use their required patient logs to identify and discuss the appropriate level(s) of care for one patient who they see in the geriatric medicine clinic after participating in the MedTEC program. To strengthen the evaluation of the MedTEC program, we incorporated a student comparison group. Between July and September of 2013, we replaced the MedTEC program by a day in the geriatric medicine clinic plus a 30-minute didactic session about levels of care. The comparison group students did not receive the MedTEC levels of
Between October 2011 and December 2013, the program was conducted on 20 occasions. Eighty-two of 87 students, who attended MedTEC and who were invited to complete program surveys, completed the pre-program survey. Table 1 shows demographic characteristics for these students, as well as 16 of 19 comparison group students who completed the pre-program survey. Most students in both groups were in their third year of medical school and were male. The mean age of students was 26.2 (MedTEC) and 24.8 (comparison group) years. Fifty-eight (66.7%) of 87 MedTEC students completed both pre and post attitude surveys and 51 (58.6%) completed both knowledge tests. For the comparison student group, 16 (84.2%) and 14 (73.7%) completed both pre and post attitude and knowledge tests, respectively. Responses on the presurvey attitudes/self-efficacy and knowledge questions between the MedTEC students who only completed the pre survey and the students who completed both pre and post surveys were not statistically different. For both the MedTEC and comparison groups, there was a statistically significant increase in scores regarding their attitudes and self-efficacy beliefs about providing care for older adults in different care settings (Table 2). For the MedTEC students who completed both surveys, there was a statistically significant improvement in knowledge, as noted by number of correct responses, on the post-test for the PA care and the Medicare/Medicaid question sections, as well as for all 12 questions in total (Table 3). For the comparison group, there was no statistically significant change in number of correct responses on any of the knowledge test sections or on all 12 questions in total (Table 3). Twenty-three (35.9%) of 64 hospital medicine staff completed the survey. When comparing the mean number of correct responses on the knowledge test with the students who completed the MedTEC program post survey, there was no statistically significant difference in mean number of correct answers on the test in total and on the
Table 2 Comparison of Mean Responses to the Attitude/Self-Efficacy Questions (on 5-Point Likert Scale) on Pre and Post Surveys for Students in the MedTEC (n ¼ 58) and Comparison Groups (n ¼ 16) Who Answered All 4 Questions on Both Surveys Question
Mean Pre-Score (SD)
Mean Post-Score (SD)
P
2.59 (0.92)
3.90 (0.55)
