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Gerontology & Geriatrics Education Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wgge20

An Assisted Living Facility Curriculum to Introduce Geriatrics to First-Year Medical Students a

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Iris L. Tong , Kimberly A. Dodd , Sarita S. Warrier , Louis J. ab

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Pugliese , Naomi Y. McMackin

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& Julie Scott Taylor

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Alpert Medical School, Brown University, Providence, Rhode Island, USA b

Department of Health Care Administration and Management, Salve Regina University, Newport, Rhode Island, USA c

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Department of Medicine, St. Mary Medical Center, Langhorne, Pennsylvania, USA Accepted author version posted online: 09 Sep 2014.Published online: 06 Oct 2014.

To cite this article: Iris L. Tong, Kimberly A. Dodd, Sarita S. Warrier, Louis J. Pugliese, Naomi Y. McMackin & Julie Scott Taylor (2015) An Assisted Living Facility Curriculum to Introduce Geriatrics to First-Year Medical Students, Gerontology & Geriatrics Education, 36:1, 79-95, DOI: 10.1080/02701960.2014.954041 To link to this article: http://dx.doi.org/10.1080/02701960.2014.954041

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Gerontology & Geriatrics Education, 36:79–95, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2014.954041

An Assisted Living Facility Curriculum to Introduce Geriatrics to First-Year Medical Students IRIS L. TONG, KIMBERLY A. DODD, and SARITA S. WARRIER

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Alpert Medical School, Brown University, Providence, Rhode Island, USA

LOUIS J. PUGLIESE Alpert Medical School, Brown University, Providence; and Department of Health Care Administration and Management, Salve Regina University, Newport, Rhode Island, USA

NAOMI Y. MCMACKIN Alpert Medical School, Brown University, Providence, Rhode Island; and Department of Medicine, St. Mary Medical Center, Langhorne, Pennsylvania, USA

JULIE SCOTT TAYLOR Alpert Medical School, Brown University, Providence, Rhode Island, USA

Many U.S. medical schools have developed curricula in geriatric medicine to address the growing older adult population. At our university, the authors have integrated an assisted living facility (ALF) program into a required first-year clinical skills course. During the 2011 to 2012 academic year, an electronic survey was distributed to 109 first-year medical students prior to and after the program. Eighty-eight percent and 85% of students completed the pre- and postintervention survey, respectively. Students reported a positive attitude toward caring for older adults (92.5% postvs. 80.2% preintervention), an understanding of the medical and social needs of older adults (89.2% post- vs. 38.5% preintervention), an acquisition of the skills to assess the health of older adults (71% post- vs. 14.5% preintervention), and an understanding of ALFs as nonmedical supportive housing (92.5% post- vs. 70.8% preintervention). The authors’ curriculum offers an innovative method to integrate geriatrics education early in medical education and to involve medical students in their community. Address correspondence to Iris L. Tong, Alpert Medical School, Brown University, 146 West River Street, Providence, RI 02904, USA. E-mail: [email protected] 79

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KEYWORDS medical curriculum, medical education, medical students, senior mentor programs

As the population of older adults in the United States grows, it is imperative for future physicians to gain the knowledge, skills, and attitudes to care for the elderly. Given the lack of adequate training in geriatric medicine (Blanchette & Flynn, 2001), many medical schools have developed more robust curricula. Individual schools have used various strategies to introduce geriatrics into existing medical school curricula, ranging from independent clerkships in geriatric medicine to vertical integration of aging-related content (Anderson, 2004; Eleazer, Doshi, Wieland, Boland, & Hirth, 2004; Eleazer, Egbert, Caskey, Richeson, & Thornhill, 2006; Szenas, 1998). Since 2000, several medical schools have implemented programs in which medical students partner with older adults in the community to learn about their health issues and their lives (Bates, Cohan, Bragg, & Bedinghaus, 2006; Bernard, McAuley, Belzer, & Neal, 2003; Fitzpatrick, Musser, Mosqueda, Boker, & Prislin, 2006; Roberts, Richeson, Thornhill, Corwin, & Eleazer, 2006). These programs introduce geriatric medicine early in medical school and have fostered more positive attitudes among medical students toward older adults (Eleazer et al., 2009). Established senior mentor programs vary in structure, ranging from social activities to more formal curricula, and in duration, ranging from a brief curriculum to a vertically integrated model throughout all 4 years of medical school. Most existing senior mentor programs have recruited volunteers from local primary or geriatric care practices, retirement communities, churches, and volunteer organizations. At our institution, we have partnered with community-based assisted living facilities to create a program in which first-year medical students are matched with assisted living facility (ALF) residents and then interact longitudinally with the residents and facilities throughout the academic year. Our ALF curriculum has seven goals with respect to geriatric care during the first year of medical school: (a) to develop a positive attitude toward caring for older adults, (b) to have the opportunity to practice interviewing and physical examination skills, (c) to develop skills in time management while performing medical interviews and physical examinations, (d) to gain a better understanding of the aging process and medical needs of older adults, (e) to develop skills to assess the health of older adults, (f) to understand the role of ALFs, and (g) to appreciate the contribution of longitudinal relationships in patient care. Here, we describe the development, implementation, and initial evaluation of our ALF program.

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METHOD

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Program Overview At our institution, the Doctoring Course is a required 2-year, preclinical, five-course curriculum combining the instruction in and the assessment of students’ medical interviewing and physical examination skills as well as professional development. The ALF curriculum, which initially began in 2004, has been systematically integrated into the first year of the Doctoring Course. Currently, the curriculum consists of two lectures and five ALF site visits. In academic year 2011 to 2012, 109 first-year medical students were divided into 14 small groups, each consisting of seven to eight students and two faculty members, a physician and a social behavioral scientist. Each small group was assigned to a specific ALF in the local community. At each ALF site, each medical student was then paired with an individual ALF resident. Students and faculty visited their ALF site five times, for 21/2 hours per session, throughout their first year of medical school to perform medical interviews, physical examinations, geriatric assessments, and discussions of end-of-life care. Students also attended lectures with geriatric content and worked with their small-group leaders to learn and to practice their geriatric assessment skills. Students’ skills were continuously assessed by their smallgroup leaders, but their performance in the ALF program was not graded separately. Rather, student performance was a component that was considered in their overall grade in this pass/fail course. Physiologic changes with aging are integrated vertically into the preclinical courses at our institution, and students’ knowledge about geriatrics is assessed outside of the Doctoring Course through periodic multiple choice exams. The program’s schedule, curriculum, and program logistics are summarized in Table 1 and Table 2. Prior to the start of the academic year, an invitation letter is sent to the ALF site coordinators to distribute to their residents. In the letter, we describe the details of the program, the number and dates of the visits, the content of the discussion topics, as well as the content of the medical interview and physical exam that will be performed at each visit. Volunteers contact the ALF site coordinator, and the resident’s cognitive ability to participate in the program is informally assessed by the site coordinator. The site coordinators are administrative staff members at the ALFs, typically the nursing or activities director. Our program coordinator, L.J.P., is one of our small-group faculty members and is a former administrator at two local nursing home facilities in Rhode Island as well as at the Rhode Island Department of Elderly Affairs, where he was responsible for the development of housing and assisted living systems. Our course leaders (I.L.T. and K.A.D.) are physician educators.

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TABLE 1 The Assisted Living Facility (ALF) Program: Schedule and Curriculum Activity

Lecture/ALF visit objectives

Small-Group objectives

Orientation lecture, fall semester: Orientation to the Assisted Living Facility Program

• Lecture on the medical interview of older patients and the complexities of interviewing geriatric patients (Geriatrician) • Review of goals of the ALF program, the role of assisted living facilities within the elderly housing and health care delivery systems, and the financing and regulation of ALFs (Student Program Coordinator) • Review of a video of comments about the ALF program from ALF residents and former students who have participated in the program

• Distribution of ALF site and individual resident assignments • Discussion about the professional relationship, potential transference, and power differential in the patient–provider relationship, and comfort with this differential • Advice on how students introduce themselves to residents, describe their role as first-year medical students, review their time line and the number and dates of their visits throughout the academic year

ALF visit 1, fall semester: Healthcare decision-making and the medical interview

• Orientation to site by the ALF site coordinator: history, financing, physician’s role in the facility, average length of stay, and the services available to the residents • Students meet with their assigned residents for 60 minutes to: ◦ Complete a full medical interview (chief complaint, history of present illness, past medical history, medications, allergies, social history, and sexual history), ◦ Talk with their residents about their experience living in the ALF site, the reasons for which they came to live at the ALF site, and the role of their family and friends in their health care decision making.

• Students meet with their faculty members in a designated conference room to: ◦ Share experiences about interviewing their residents, ◦ Discuss the decision-making process and events that prompted their residents to move to an ALF, ◦ Receive assignment to write-up their medical interview and physical exam, including a summary and problem list.

(Continued)

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TABLE 1 The Assisted Living Facility (ALF) Program: Schedule and Curriculum (Continued) Activity

Lecture/ALF visit objectives

Small-Group objectives

ALF visit 2, fall semester: Medical interview, vital signs, and the discussion of healthcare expectations

• Students have 90 minutes with their resident to: ◦ Obtain a chief complaint and history of present illness of prominent medical concerns, ◦ Perform a nutrition history, ◦ Obtain the review of systems, ◦ Perform vital signs, ◦ Interview their residents about impact of their cultural background on their healthcare decision making—country of birth, primary language, number of languages spoken in the home during childhood, neighborhood, medical care received as a child, health care expectations, and patterns of decision making with respect to healthcare.

• Students and faculty members meet and discuss the impact of their residents’ background on their health and health care

ALF visit 3, spring semester: Introduction to the physical exam (head, ears, nose, throat, neck, cranial nerve, and mini-mental status exams)

• Students have 60 minutes with their resident to: ◦ Obtain a chief complaint and history of present illness of prominent medical concerns, ◦ Obtain vital signs, ◦ Perform a physical exam, including the head, ears, nose, throat, neck, cranial nerve, and Mini-Mental Status Exams.

• Students meet with their faculty members and give a focused oral presentation summarizing the key findings of their interview and physical examination and receive feedback about their presentations • Students are assigned to write-up their medical interview and physical exam, including a summary and problem list in a progress note format (Continued)

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TABLE 1 The Assisted Living Facility (ALF) Program: Schedule and Curriculum (Continued) Activity

Lecture/ALF visit objectives

Small-Group objectives

Geriatric assessment lecture, spring semester: Functional assessment, advance directives, and end-of-life care

• Lecture on the functional assessment of geriatric patients (geriatrician) including review of: ◦ Activities of daily living (ADLs) and instrumental activities of daily living (IADLs), ◦ The Mini-Cog assessment. ◦ Get-Up-and-Go test • Lecture on end-of-life care (palliative care physician) with the goal that students ◦ Appreciate the complex ethical issues involved in end-of-life care ◦ Understand advance directives, including differences between a living will and durable power of attorney for health care

• Students practice the geriatric assessment • Students discuss with small group leaders the challenges of end-of-life care discussions with patients

ALF visit 4, spring semester: The geriatric assessment and end-of-life care

• Students have 75 minutes with their resident to: ◦ Obtain a chief complaint and history of present illness of prominent medical concerns, ◦ Obtain vital signs, ◦ Perform a physical exam, including the eye, motor, sensory, cerebellar, and reflex exams, ◦ Discuss advance directives and plans for end-of-life care with their residents and perform a geriatric assessment.

• Students meet with their faculty to: ◦ Discuss their end-of-life care conversations with their residents, focusing on each student’s own strengths and challenges, ◦ Give a focused oral presentation summarizing the key findings of their interview and physical examination and receive feedback about their presentation, ◦ Receive their assignment to write-up their medical interview and physical exam, including a summary and problem list in a progress note format. (Continued)

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TABLE 1 The Assisted Living Facility (ALF) Program: Schedule and Curriculum (Continued) Activity

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ALF visit 5, spring semester: The physical exam and farewell

Lecture/ALF visit objectives • Prior to the visit, faculty members provide guidance with respect to terminating a professional relationship • Students meet with their resident for 75 minutes to: ◦ Obtain a chief complaint and history of present illness of prominent medical concerns, ◦ Obtain vital signs, ◦ Perform the complete head and neck and neurologic exams. • Present their resident with a certificate of appreciation and bid farewell to their resident

Small-Group objectives • Students meet with their faculty members to: ◦ Give a focused oral presentation of key findings of interview and physical examination and receive feedback on presentation, ◦ Discuss the process of terminating relationship with their residents and the value of a longitudinal doctor-patient relationship to providing patient care, ◦ Discuss potential interest in a field of medicine that provides the opportunity for longitudinal relationships with patients.

Survey Design During the 2011 to 2012 academic year, students were asked to complete an anonymous, online pre- and post-ALF program survey consisting of seven close-ended questions (see Table 3) with a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree), one week prior to the first session and one week after the final session of the ALF program, respectively. Survey questions corresponded to the seven stated goals of our ALF curriculum and were developed to assess the degree to which we achieved these goals. The postprogram survey included two open-ended questions regarding aspects of the program that students most enjoyed as well as aspects that they felt could be improved (see Table 4). The open-ended questions were developed for program evaluation. Students’ responses help course leaders determine which program components to retain and which to improve and/or alter for the next academic year. Course leaders use similar openended questions to evaluate the entire Doctoring Course at the end of the academic year. A representative from the Institutional Review Board (IRB) at our university determined that this required curriculum development, implementation, and evaluation process did not meet the federal definition of human subjects

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TABLE 2 Program Logistics

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Role

Responsibilities

ALF program coordinator

• Our program coordinator (LJP) serves as the liaison between the first-year doctoring course leaders and the ALF site coordinators. • Prior to the first ALF visit in the fall, our program coordinator contacts each site coordinator to review the program objectives, to provide guidelines for appropriate resident selection, and to identify an onsite meeting room for students and faculty. • Throughout the academic year, our program coordinator, course faculty members, ALF site coordinators, and students are in regular contact regarding all aspects of the program. • Our program coordinator serves as the primary contact in the case of either a student or resident absence on the day of a visit. ◦ If a resident is not available on a scheduled visit (off site, illness, or even death), then our program coordinator and ALF site coordinator arrange for the student to meet with another resident or to join another student–resident pair. ◦ In the event that a resident dies, our program coordinator is notified immediately. He then notifies the appropriate small-group faculty members who can then counsel and support the student accordingly. • At the end of each academic year, our program coordinator visits each site after the last scheduled student visit and elicits feedback about the program from residents and site coordinators to ensure continuity and consistency as well as performance improvement. • For each subsequent academic year, our program coordinator rotates each faculty pair to a different ALF site to maximize their perspective on differences among participating ALFs. ◦ Faculty members are then able to bring this perspective into their small group discussions with students and to highlight potentially significant differences in ALF services, costs, configurations, and programming.

ALF site coordinator

• Each of the 14 ALF sites in our program has a designated site coordinator, typically the nursing or activity director. • Site coordinators play a vital role in the implementation of the program, monitoring their residents’ participation and providing visit reminders and general information necessary for seamless visit activity. • Site coordinators are also provided with a schedule of the student visits to the ALF sites and greet students and faculty upon each arrival to ensure that visits occur in a timely fashion.

Senior volunteers

• All senior volunteers who are cognitively able to participate in interviews and physical examinations are eligible to participate in the program. • Prior to volunteering, ALF residents receive a written description of the course format and objectives, including a schedule of all site visits.

ALF = assisted living facility.

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TABLE 3 Pre- and Postintervention Student Responses to Assess the Objectives of the Assisted Living Facility Curriculum Question

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My attitude toward caring for older adults is positive. Pre Post

Strongly disagree Disagree Neutral Agree

Strongly agree

p Value

0% 0%

4.2% 1.1%

15.6% 6.5%

53.1% 47.3%

27.1% 45.2%

p = .0195

I have the opportunity to practice my interviewing and physical exam skills. Pre Post

5.2% 0%

6.3% 2.2%

25% 3.2%

43.8% 45.2%

19.8% 49.5%

p < .0001

I have skills in time management while performing medical interviews and physical examinations. Pre Post

2.1% 3.2%

12.5% 9.7%

35.4% 22.6%

45.8% 45.2%

4.2% 19.4%

p = .0069

I have an understanding of the aging process and the complex medical and social needs of an older adult. Pre Post

3% 1%

24% 0%

32% 9%

32% 56%

5% 27%

p < .0001

I have skills to assess the health of older adults. Pre Post

8% 0%

46% 1%

28% 26%

13% 57%

1% 9%

p < .0001

I appreciate the impact of longitudinal physician–patient relationships in providing patient care. Pre Post

1% 0%

0% 1%

10% 8%

36% 38%

49% 46%

p = .9556

I understand the role of assisted living facilities as a nonmedical supportive housing environment. Pre Post

1% 0%

13% 2%

14% 5%

49% 49%

19% 37%

p = .0003

research and therefore did not require a formal IRB review. No participantidentifying information was obtained. Given that the goal of our survey was course program evaluation, informed consent was not required.

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TABLE 4 Curriculum Evaluation by Medical Students (N = 93) Question

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What was your favorite part of the ALF program?

What aspects of the program can we improve?

Themes

Representative quotes

1. The importance of longitudinal relationships

“It was great to develop a long-term connection with the ALF resident, to recall things that were mentioned at previous meetings, and to watch as our mutual trust developed.” “I really enjoyed the longitudinal nature of the program. . . . It was really valuable to learn the benefit of continuous follow-up, especially for older patients who may have many complex health issues.”

2. A personal connection with an ALF resident

“My favorite part was learning from and hearing stories told by people who had been alive throughout an entirely different time in this country and who had had entirely different life experiences.” “[My favorite part of the ALF program was] . . . getting to know what kind of life they led long before I was born. What life was like when they were growing up and how it has changed over the years. The intimate details of their lives that help you piece together how they might experience disease.”

1. Modify required elements of individual visits

“You could stress less physical exam components during the visit. Most ALF patients were not adequately dressed or prepared to be physically examined.” “I think that having more frequent interviews but less time spent discussing would be more helpful. We could have sizable discussions perhaps a couple of times rather than after every visit.” (Continued)

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TABLE 4 Curriculum Evaluation by Medical Students (N = 93) (Continued) Question

Themes

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2. Improve coordination between the sites and doctoring program

3. The need for an end-of-year activity

Representative quotes “The communication [can be improved]: letting the residents know what days we are coming (which in some ways translates into letting the staff know well in advance so that they can help the residents plan their activities for that day) would be helpful, as there were some days when the residents were double-booked when we arrived.” “The last visit should be more of a wrap-up session: asking for advice on caring for older patients, things we can improve on, the ALF residents’ impression of the program, etc.”

ALF: assisted living facility.

Deidentified survey data were compiled. Pretest–posttest responses were tabulated, and frequencies were identified and displayed in a 2 × 5 table for each question. Pre- and postfrequencies of Likert-type responses were compared using Fisher’s Exact Test that returned a chi-squared value. In cases where responses to Likert-type questions were zero, cells were combined for the purpose of analysis. Analyses were using SISA (Uitenbroek, 1997). Free text responses to the open-ended questions on the post-ALF curriculum survey were initially read multiple times by one author (S.S.W.). Major themes were identified and coded using a general inductive approach for qualitative analysis (Thomas, 2006). The data were then organized using Weft QDA v.1.0.1 (Fenton, 2006). An additional author (K.A.D.) independently reviewed and coded the survey responses using the identified themes. Inter-rater reliability analysis using the kappa statistic was performed to determine initial agreement among raters (kappa = .82). All disagreement was resolved through discussion between these two authors (S.S.W. and K.A.D.).

RESULTS Of the 14 ALF sites participating in our ALF program in the 2011 to 2012 academic year, all 14 have continued to participate in subsequent years.

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Between 2004 and 2013, more than 400 residents from approximately 20 different ALF sites in our local community have participated in our program. Approximately 60% of the ALF residents who have participated in our program have volunteered for more than two academic years and have worked with more than one student. In 2011 and 2012, 96 students (88%) completed the precurriculum survey, and 93 students (85%) completed the postcurriculum survey. Students who completed the survey responded to all seven close-ended questions in the pre- and postintervention surveys. Survey results are summarized in Table 3. After completing the ALF program, 92.5% of first-year medical students had a positive attitude toward caring for older adults, compared to 80.2% of students preintervention. At the end of the program, more students felt that they had the opportunity to practice their clinical skills (94.7% postvs. 63.6% preintervention) and that they possessed time management skills (64.6% post- vs. 50% preintervention). In addition, more students felt that they understood the aging process and the medical and social needs of older adults (89.2% post- vs. 38.5% preintervention), that they had skills to assess the health of older adults (71% post- vs. 14.5% preintervention), and that they understood the role of ALF as a supportive housing environment (92.5% post- vs. 70.8% preintervention). Pre- and postsurvey responses indicate that students have an unchanged, strong appreciation of the impact of longitudinal physician–-patient relationships on patient care (88.5% pre- vs. 90.4% postintervention).

Identified Themes With respect to their favorite components of the program, students most enjoyed the longitudinal aspect of their relationship with their ALF resident as well as creating a personal connection with their resident. Many students highlighted the importance of continuity with their ALF residents in establishing rapport, in observing medical conditions develop over time, and in gaining a better understanding of health. Students also enjoyed interacting and connecting with their residents on a social level, often beyond the doctor–patient relationship. Students also identified three major areas of improvement for the program. First, several students noted that the curricular elements of the ALF visits could be modified to accommodate the unique situation of visiting residents in their homes and that the time designated for small-group discussions with faculty during ALF visits could be better utilized. Second, students noted that the coordination of the many ALF site visits was often challenging, as residents were occasionally not present for a site visit due to other personal obligations (e.g., personal physician appointment, family visit, etc.) and felt that communication between the ALF sites and the ALF program

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coordinator could be improved. Third, students felt that it was important to develop a structured, end-of-year activity to show their appreciation to the ALF residents, site coordinators, and staff for participating in the program as well as to provide closure for the students and ALF residents. At the end of the academic year, our program coordinator meets with the site coordinator and some residents at each ALF. At this informal meeting, residents are asked about the number of times that they have participated in our program and if they would like to participate in the program again. Residents and site coordinators are also asked about aspects of the program that they enjoyed and aspects that could be improved. Based on informal feedback elicited by our program coordinator at the end-of-year meeting, older adults stated that they volunteer in our program because they enjoy interacting with students and playing a role in the education of future physicians. ALF residents stated that they understand the importance of educating future doctors and expressed a sense of pride in helping medical students. Many residents volunteered to participate multiple academic years in a row. In addition, the ALF site coordinators view the program as a vital part of the health and well-being of their residents and have made several requests to increase the number of scheduled visits from students.

DISCUSSION At our medical school, we have developed a structured program for first-year medical students involving formal didactics as well as a longitudinal matching of students with residents in local ALFs. As a result of our program, students had not only the opportunity to practice their medical interviewing, physical examination, and time management skills, but also have improved their attitudes toward caring for older adults and gained a better understanding of aging and the role of ALFs for the elderly. One of the strengths of this study is the high response rate to the pre- and postprogram survey. Given that more than 85% of the students responded to the pre- and postsurveys, we are confident that the results accurately represent students’ experiences in our program. Another strength is that we demonstrate that our ALF program makes a statistically significant impact on six of the seven goals described in our curriculum, confirming that our program is achieving the goals which we initially set forth. Additionally, we performed a quantitative as well as qualitative analysis. Our quantitative analysis demonstrated a statistically significant difference in students’ attitudes and perceived knowledge base before and after completing our program, whereas the qualitative analysis provided us with in-depth knowledge regarding aspects of the program that students enjoy and other aspects of the program that could be improved.

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Although we believe that the ALF program is responsible for the improvements in attitudes toward caring for older adults as well as in clinical skills, there are limitations to our project. This was a self-report survey of students, which may be subject to bias, as described in the next paragraph. Given the nature of the data collected, we were unable to adjust for potential confounders such as student age, race/ethnicity, or socioeconomic backgrounds, which may have affected responses. Additionally, these results are reported after only one academic year at one institution, which may affect generalizability. Finally, the first-year students also had a longitudinal experience in a clinical mentor site that may have influenced their perception of caring for older adults. Student’s appreciation of the impact of the longitudinal relationship in patient care remained unchanged prior to and after participation in the ALF program. As their expressed appreciation was high pre- and postintervention, this could be explained from two perspectives. One explanation is the influence of the social desirability bias. It is possible that medical students are rating their appreciation of the longitudinal relationship highly because they believe that a high rating will be viewed favorably by others. However, it is also possible that medical students appreciate the importance of a longitudinal relationship with a health care provider based on personal experience. In a survey of more than 400 premedical students, 89% stated that their reason for choosing medicine as a career was either a desire to help others, a genuine interest in the sciences, or their personal exposure to medicine (Daniel & O’Brien, 2008). Therefore, medical students at our institution may have a strong appreciation for the longitudinal relationship secondary to their personal experience with health care providers. Our qualitative analysis demonstrated that one of the students’ favorite aspects of the program was developing a longitudinal relationship with their resident. Therefore, the ALF experience may have not only served as a concrete example of this concept to our students, but may have also solidified this concept, which might be frequently challenged in their future medical school training. The survey results also indicated that the students had more positive attitudes toward caring for older adults and a better understanding of the medical and social needs of older individuals after participating in the ALF program. This is reinforced by the qualitative analysis, where the students described that their favorite parts of the program, the longitudinal nature and the social aspect of the visits, which allowed them to form relationships that led to a deeper understanding of the health and needs of their ALF residents. When reflecting on aspects of the program that could be improved, students indicated that a modification of activities would be helpful. Despite this recommendation for some changes to the structure of visits, the survey results indicated that the current structure allowed students to practice and improve their skills in the medical interview, physical exam, and time management.

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In response to student feedback described in the qualitative analysis, the ALF program has been expanded to include independent student visits to the ALF sites without small group faculty members. This change allows for more frequent interview and examination practice, fewer discussion sessions, and more flexibility in learning objectives to accommodate examining residents in a home environment. In addition, our program coordinator communicates frequently with all ALF site coordinators during the academic year, prompting site coordinators to provide site visit reminders to their residents and to inform him of any anticipated resident absences. Lastly, each small group of students is now charged with developing an activity for their final ALF site visit to express their appreciation to residents. Activities range from health-related activities (e.g., blood pressure screening) to entertainment (e.g., musical performances by students). Given the complicated logistics and infrastructure required to run a successful program, further evaluation is ongoing. Future plans include a formal evaluation of the program from the perspective of the course leaders, faculty, site directors, and residents. We may also consider having students meet with their residents during their subsequent years in medical school. Another area of interest is to determine if our program stimulates interest among medical students to pursue geriatrics as a career. Although this study does not directly address this issue, a future project could entail following up with medical students who have graduated from our institution and comparing the percentage of graduates who entered into the field of geriatrics prior to and after initiating our ALF program. As our ALF program started in 2004, the first set of primary care providers would have completed their residency training in 2011, and we would have several years of former students to survey. Another potential project is to survey graduates of our institution to determine if they felt that our ALF program affected their career choices. Our ALF program offers an innovative, sustainable method to integrate geriatrics education early in medical education and to involve medical students in their community. Partnering with local ALFs provides medical students with the valuable opportunity to practice new clinical skills with some structured independence in a nonclinical setting. Strong relationships between patients and their health care providers foster trust and open communication, leading to increased patient adherence and engagement, producing maximum positive outcomes (Atlas, Grand, Ferris, Chang, & Barry, 2009). Through our program, students experience the relationship that develops between patient and provider. We have paid close attention to the process of selecting our participants to achieve the goals set forth for students. Students and ALF residents have responded positively to our ALF program which first began in 2004. Since then, the program has been successfully integrated and sustained in the required curriculum. The partnership between our university and local ALFs has benefitted not only our students but also the older adults in our community.

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ACKNOWLEDGMENT The authors thank Richard Doyle, PhD, MA, MS, for his assistance with the statistical analysis in this study.

FUNDING This article was funded by The Donald W. Reynolds Foundation, grant #529081, 2006-2010.

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