VA Boston Healthcare System & New England GRECC

The VA’s Mission is to “fulfill President Lincoln's promise 'To care for him who shall have borne the battle, and for his widow, and his orphan' by serving and honoring the men and women who are America’s Veterans.” The VA Boston Healthcare System is dedicated to serving the needs of America's veterans. It is committed to providing the highest quality health care, to expanding the boundaries of medicine through research, and to training the next generation of health care professionals. VA Boston Healthcare System is a model for the nation in combining exceptional, patient-centered healthcare, innovative research, and outstanding education in a setting that values the contributions of all employees. VA Boston Healthcare System comprises three campuses: Brockton, Jamaica Plain and West Roxbury. The VA is affiliated with Harvard Medical School and Boston University Medical School and teaches students, residents and fellows from many programs at both schools.

The VA’s Geriatric Research, Education, and Clinical Centers (GRECCs) are United States Department of Veterans Affairs (VA) centers of excellence focused on aging. They were established by Congress in 1975 in order to improve the health and health care of older Veterans. They have three main missions: (1) to build new knowledge through research; (2) to improve health care through the development of new clinical programs; and (3) to ensure that "VA" staff are educated about aging-related issues. The GRECCs are located at 20 medical centers across the country, including the New England GRECC at VA Boston and Bedford, and each is connected with a major research university. Fellows participate in journal club, academic seminars and have the opportunity to meet with researchers and explore potential projects. Additional information can be found on the VA Boston Healthcare System & New England GRECC.

VA Ambulatory Geriatrics (VA-A) Block Rotation

The VA Boston Ambulatory Geriatrics rotation (VA-A) is approximately 5 weeks. This outpatient rotation is designed to introduce fellows to the interprofessional care of older veterans using the Geriatric 5Ms framework (Tinetti M, Huang A, Molnar F. The Geriatric 5Ms: A New Way of Communicating What We Do. J Am Geriatr Soc. 2017; 65(9):2115).

Fellows will gain skills in the following areas during the VA rotation:

Mobility (falls and functional status): Fellows rotate through a geriatrics physiatry clinic, learning about mobility and falls prevention, and rotate with rehab specialists such as physical therapy, occupational therapy, and kinesiotherapy. Fellows may also rotate with specialists in osteoporosis, podiatry and prosthetics, as well as the Driver Rehab clinic.

Mind (memory and cognition): Fellows participate in the evaluation of patients with cognitive impairment in the Neurology Memory Disorders Clinic as well as in the Geriatrics Consult clinic, where they partner with interprofessional trainees to care for older adults with memory disorders, ranging from Alzheimer’s and vascular dementia, to Lewy body, Parkinson’s and frontotemporal dementia and chronic traumatic encephalopathy.  Fellows may also rotate with audiology, optometry or speech and language pathology.

Medications (polypharmacy and deprescribing):
VA Geriatrics Consult Clinic: Pharmacists embedded in multidisciplinary geriatrics clinic participate in medication reviews and provide guidance in deprescribing and simplifying medication regimens, as well as adherence to guidelines for older adults.

Multi-morbidity (prioritizing and prognosticating):
VA Geriatrics Consult Clinic: Fellows join an interprofessional team in the VA Boston Geriatrics consultation clinic consisting of geriatricians, nurse practitioner, pharmacists, social worker, with cognitive testing by embedded neuropsychology team. The clinic is designed to conduct comprehensive geriatric assessments integrating evaluation of functional status, fall risk, cognition, multi-morbidity and other geriatric syndromes in light of appropriate disease/syndrome prioritization and prognostication as well as patient values. Patients are seen in person and also virtually through our Telegeriatrics program.

Fellows also rotate through subspecialty clinics such as Geriatric Cardiology and Geri-Renal, as well as the Home Based Primary Care Program.

Matters Most (values, goals of care and advanced care planning): In addition to their inpatient VA palliative care rotation (VA-P), fellows may rotate through the outpatient palliative care clinic or the ALS clinic. Fellows will participate in goals of care conversations in the Geriatrics Consult clinic and will learn about the VA’s life sustaining treatment decisions initiative. Fellows also participate in the My Life My Story program to document a veteran’s life story and values.

VA Boston Healthcare System  (VA BHS)  Palliative Care Block Rotation

The VA BHS Palliative Care rotation is approximately 5 weeks. Geriatric fellows on this rotation will work with the palliative interdisciplinary team to complete new consults and follow up visits on inpatients at the West Roxbury VA acute care hospital. Consults in this 120-bed hospital are received from medical, surgical, spinal cord injury, neurology, cardiology and intensive care settings. Fellows will have an opportunity to interact with medical and surgical residents from HMS training programs including Boston Medical Center, Beth Israel Deaconess Medical Center, and Brigham and Women’s Hospital. Fellows will work closely with their attending and the team to learn advanced communication skills, conducts family meetings, goals of care discussions, manages pain, and other symptoms in older adults. Fellows will participate in interdisciplinary team meeting and assist in home and inpatient hospice referrals. Fellows will also have the opportunity to follow palliative care patients on the acute inpatient hospice and palliative care unit at the West Roxbury VA while on the consult service. In addition, Fellows may choose to spend some of their elective time seeing chaplaincy consults, or working with the palliative care chaplain at the West Roxbury VA, or working on the 15-bed hospice and palliative care unit at the Brockton Campus of VA BHS.