We believe that interprofessional education – where faculty AND learners represent more than 1 profession – creates a more robust training environment. The additional focus on learning “with, from and about” each other leads to higher quality patient outcomes in the health care system and improved preparation for delivering team-based care. This is why fellows will be supervised by faculty representing different professions.
Growing as a specialist in our field requires stepwise building of skills, so we have carefully crafted a year long progressive independence framework that assures fellows get high quality observed feedback early in the year but are practicing how to get indirect support while functioning independently by the end of the year. In addition, fellows will get dedicated training and experience supervising other learners on service.
Blocks
- Inpatient consults in the ICU and hospital floors (approximately 5 to 6 months)
- Home hospice (combined rotation with Bayada Hospice and Visiting Nurse and Hospice of New Hampshire and Vermont; 1 month for advance practice trainees and 2 months for physician trainees)
- Inpatient Hospice Unit (2.5 months at the Jack Byrne Center for Palliative & Hospice Care (JBC))
- Long-term care (2 weeks at Kendal at Hanover and 2 weeks with our Geriatrics team at local skilled nursing facilities)
- Spirituality (0.5 months)
- Pediatric Complex Care Team at Dartmouth Children’s Hospital (0.5 months) – MD/DO fellows ONLY unless pediatrics is within APP’s scope of practice
- White River Junction Veterans Affairs Hospital (1 month) – MD/DO fellows required and elective for APPs
- Vacation (4 weeks)
- Interprofessional rotation with social workers, nurses, and a pharmacist (0.5 months)
Inpatient block
The consult service sees patients in various inpatient settings at Dartmouth Hitchcock Medical Center, including on the medical, oncology, cardiology, pediatric, psychiatric, surgical and critical care units. Daily Interprofessional Team (IPT) meetings are held with:
- Bereavement manager
- Between 1 and 6 learners on rotation
- Chaplaincy
- Administrative team members including scheduling secretary, administrative assistants, and the practice manager
- Healing arts
- Nursing, including advanced practice nurse faculty and fellows, and inpatient and outpatient nurse clinicians.
- Pharmacy
- Physicians, including faculty and fellows
- Social work
- Volunteer manager
IPT meetings are held at Dartmouth Hitchcock Medical Center to comprehensively review each patient and family being followed by the palliative care team.
Fellows take weekend call about 9 weekends per year (including only 1 major holiday), either at the Byrne Center or at Dartmouth Hitchcock Medical Center. Additionally, fellows will cover night home pager call for about 1 night per week to gain experience in responding to palliative care emergencies.
Jack Byrne Center for Palliative & Hospice Care block
Fellows work in this stand-alone hospice and palliative care unit which serves as an extension of Dartmouth Hitchcock Medical Center to collaboratively manage complex end-of-life care in an interprofessional fashion. Patients come from Dartmouth Hitchcock Medical Center, when the focus of care is on comfort, and fellows work in conjunction with local home hospice agencies to both admit and discharge patients. The fellow will gain experience with terminal agitation, pain crises, and existential crises as well as better understand how the system of respite and General Inpatient Admission (GIP) hospice admissions work.
Daily IPT meetings are held with:
- Bereavement manager
- Between 1 and 3 learners on rotation
- Chaplaincy
- Administrative team members including scheduling secretary, administrative assistants, and the practice manager
- Healing arts
- Licensed Nursing Assistants (LNAs)
- Nursing, including advanced practice nurse faculty and fellows, JBC nurse clinician, bedside nursing, and nurse manager
- Pharmacy
- Physicians, including faculty and fellows
- Social work
- Volunteer manager
IPT meetings comprehensively review each patient and family.
Hospice block
The hospice rotation includes time split between Bayada Home Hospice (Norwich, VT) and Visiting Nurse and Hospice for New Hampshire and Vermont (White River Junction, VT). Fellows act as part of the hospice team, learn about the interprofessional support offered, and learn about being a medical director or hospice clinician. Experiencing 2 different hospices allows for a fellow to more deeply understand the hospice system and the variability inherent in that system. Fellows focus on caring for GIP or respite hospice patients at the Jack Byrne Center.
APP fellows additionally focus on gaining an understanding of the APP role in a hospice agency and as a clinician of record.
Long-term care rotation
Fellows are required to spend 4 weeks, or 100 hours, seeing patients with serious illness who reside in a long-term care facility (LTCF). The fellowship uses 2 interprofessional LTCF teams and fellows spend a two-week block with each team.
Kendal-at-Hanover is a Continuing Care Retirement Community (CCRC) with a spectrum of independent to assisted living residences, a secure dementia assisted living unit, and a skilled nursing unit. The Dartmouth Hitchcock Medical Center Geriatrics Team provides medical direction and patient care at local Skilled Nursing Facilities (SNFs) all of which have wide socioeconomic diversity among the patient population. Both sites offer significant opportunities in goals of care discussions, advance care planning and end of life care as well as providing experience in routine geriatric evaluation and management.
The Fellow participates in evaluation and management of patients. Patients range from fully independent to those with various stages of progressive dementia, and late-stage cardiac, pulmonary, and cancer diagnoses. Fellows will have the opportunity to see patients whose goals range from full aggressive interventions to those wanting to focus solely on comfort.
Spirituality block
Fellows will spend 1 week of time with the Department of Spiritual Health and experience the Clinical Pastoral Education (CPE) program run through this department. This experience will include being involved with CPE education, self-reflection and one-on-one reflection with Chaplaincy staff, CPE clinical review and rounding, learning spiritual screening and assessment tools, and observing verbatims by CPE interns. Lastly, HPM fellow and CPE interns will form dyads for 1 week in the spring to practice collaborating and learning from each other more deeply.
Pediatrics block
Fellows will rotate with the Pediatric Palliative Care team as well as other pediatric subspecialty services seeing pediatric patients with multiple medical issues to learn the principles of pediatric palliative care.
White River Junction VA block
Fellows gain clinical exposure to holistic care for patients and their families with advanced serious illness and receiving care through a federally funded VA system. At the VA, fellows will see a mix of inpatient and outpatient palliative medicine consultations. Attention is directed towards pain and symptom management, psychosocial-spiritual issues, and core communication skills in this population with special attention to the unique needs of the Veteran population. Learners are part of daily interprofessional team meetings, team and learner-specific educational sessions, and rounding with an attending or interprofessional team members.
Interprofessional block
To collaborate interprofessionally, fellows must understand the roles and responsibilities of other team members, the optimal ways to communicate with these team members, the relevant ethics and values that are shared or unique between interprofessionals, and the best ways to collaborate through teamwork. In addition, transprofessional team members can practice some of the skills from another profession so they can better serve patients and care partners. This is why we have created this block for fellows to learn directly from our social workers (inpatient consult, JBC, outpatient), our nurses (inpatient consult, JBC navigator, JBC bedside nurses, and outpatient), and finally our pharmacist and bereavement manager. One week is earlier in the year to become familiar with the people and roles, and one week is later to allow more advanced practice of interprofessional collaborate.