More than 1.4 million older adults reside in nursing homes, of whom approximately 5% are ≥65 years old and 25.5% are >85 years old (Harris-Kojetin, Sengupta, Park-Lee, & Valverde, 2013; Werner, 2011). Between 2012 and 2030, there will be a 53% increase in the population of Americans age ≥85. The demand for nurse practitioners (NPs) and physician assistants (PAs) to provide care to patients in post-acute and long-term care (PALTC) settings is increasing, particularly in rural areas. The percentage of PALTCs using NPs or PAs increased from 20.4% in 2000 to 35% in 2010 (Intrator et al., 2015). NPs have been documented to improve care for patients in PALTC settings by spending more time with staff and patients (Dwyer, Craswell, Rossi, & Holzberger, 2017) and establishing caring relationships with patients and families (Ploeg et al., 2013). Improved care has been shown to result in improved patient quality of life (Arendts et al., 2018), a reduction in emergency department visits and hospitalizations (Lacny et al., 2016; Rantz et al., 2017), and reduced Medicare expenditures (Rantz et al., 2017). Furthermore, both primary care physicians and PALTC staff report high satisfaction with the level of collaboration and management of chronic and acute conditions that NPs provide (Kaasalainen et al., 2016; McAiney et al., 2017).
Workforce issues can be a major barrier to achieving quality health care in PALTC settings. Barriers to retaining existing and attracting new health care providers and direct care workers include low wages, stigma, poor benefits, and lack of adequate training (Harris-Kojetin et al., 2013). Shortages of health care professionals committed to this population are compounded by the fact that many physicians, advance practice clinicians (e.g., NPs, PAs), and professional nurses who currently provide health care for PALTC patients lack formal geriatric training and certification (Dawson, 2017). A frequently cited reason for the shortage of health care professionals choosing PALTC practice is lack of clinical rotations in nursing homes during professional programs or poor learning environments and deficient curricular quality when students have such clinical rotations (Warshaw, Bragg, Thomas, Ho, & Brewer, 2006; White, Cartwright, & Lottes, 2012; Williams, Nowak, & Scobee, 2006).
Conversely, well-designed PALTC clinical experiences in strong learning environments have shown good outcomes (e.g., learning practice differences such as experiencing more interprofessional communication, opportunities for creativity, and autonomy in PALTC compared to hospital settings) in basic medical and nursing education, as well as graduate residencies (Huls, de Rooij, Diepstraten, Koopmans, & Helmich, 2015; Molema, Koopmans, & Helmich, 2014; Tang & Titler, 2003; Warshaw & Bragg, 2014; Williams et al., 2006). Providing educational programs to direct care workers creates the opportunity for professional growth and increased satisfaction (Stone, 2017). Furthermore, the percentage of total effort that primary care providers invest in PALTC patient care is highly associated with cost and quality outcomes, supporting development of programs to train advance practice primary care clinicians specifically for PALTC–based roles (Intrator et al., 2015; Johnson, Brosseau, Soule, & Kolberg, 2008; Kane, Keckhafer, Flood, Bershadsky, & Siadaty, 2003; Kuo, Raji, & Goodwin, 2013; Ouslander, Bonner, Herndon, & Shutes, 2014; Pepper, Kane, & Teteberg, 1976; Philpot, Tolson, & Morley, 2011; Shield, Wetle, Teno, Miller, & Welch, 2005).
The development of geriatric-specific curriculum is needed to prepare NPs as health care providers in PALTC settings. To meet this need, faculty from the current authors' Health Resources and Services Administration (HRSA)–funded Geriatric Workforce Enhancement Program (GWEP) developed an elective graduate certificate in Gerontology with an emphasis in PALTC. The GWEP is an academic–community partnership formed to enhance health care provider workforce capacity, as well as patient and family engagement, to improve primary care and geriatric outcomes in long-term care in urban and rural environments. One objective of the GWEP is to develop primary care health professionals and direct care workers proficient in addressing the needs of older adults and their families in PALTC settings. A goal of this objective was to prepare NP students enrolled in the Adult/Gerontology Primary Care and Family Nurse Practitioner doctoral programs (herein referred to as NP programs) with the gerontological knowledge and clinical skills necessary for a career in PALTC. This elective certificate program was an option for NP students enrolled in these programs who have an interest in working in PALTC settings.
The purpose of the current article is to provide a detailed description of the steps taken to develop the program of study for an elective graduate certificate in PALTC, including the clinical and didactic requirements. This information can be used as a template for other programs seeking to prepare health care professional students to work within PALTC settings.
A summary of steps involved in the development and implementation of the PALTC graduate certificate follows, including: (a) a history of the internal stakeholders that led to interdisciplinary partnerships and an environment prepared for this type of program; (b) the process by which the graduate certificate was developed; and (c) the authors' approach and implementation, including formative and summative feedback.
The Gerontology Interdisciplinary Program (GIP) at the University of Utah began in 1972 and has been housed in the College of Nursing since 1982. A 30-year history of providing interdisciplinary gerontological education created an environment that fostered a large number of aging-focused course offerings, aging-related research, and faculty with research and clinical expertise in aging. In 2004, with HRSA funding through the Comprehensive Geriatric Education Program, the College developed an online geriatric specialty track through a partnership between the GIP and RN to Bachelor's degree (RN-BS) program. Specialty courses (e.g., Best Practices in Geriatric Nursing and Applications of Research in Aging) were offered through the GIP and specifically built into the RN-BS program of study.
In 2008, the College was funded to develop a Hartford Center of Geriatric Nursing Excellence to expand the number of highly qualified geriatric nurse faculty nationally and in the Mountain West prepared to teach in all levels of nursing programs across academic settings. In addition to supporting two PhD cohorts focused on aging, the Hartford Center provided universal geriatric preparation for all adult clinical care graduate students (MS and NP) and a sub-specialization in geriatrics and gerontology through a partnership with the GIP, which allowed medical students and MS and NP nursing students to earn a graduate certificate in gerontology. Over the 8 years of the funded center, 597 MS and NP students received a minimum of three credits of geriatric education, whereas 58 earned the sub-specialization in geriatrics by completing the gerontology graduate certificate. This process developed a partnership between interdisciplinary faculty with the goal of improving geriatric education for nursing graduates, which paved the way for future innovative approaches to preparing the geriatric workforce.
College of Nursing faculty in the Doctor of Nursing Practice and GIPs reviewed the current literature regarding direct care workforce needs and consulted with local PALTC health care providers regarding the educational and training needs of future NPs working in PALTC settings to provide a foundation for the development of this novel elective PALTC post-graduate certificate in gerontology. The creation of the PALTC post-graduate certificate was based on the Adult-Gerontology Acute Care and Primary Care NP Competencies published by the American Association of Colleges of Nursing (2016) and The National Organization of Nurse Practitioner Faculties, resources from the National Hartford Center of Gerontological Nursing Excellence (2019), curriculum guidelines for PALTC settings provided by the American Medical Directors Association (AMDA; AMDA The Society for Post-Acute and Long-Term Care Medicine™, 2019), and the Gerontological Advanced Practice Nurses Association (GAPNA; 2015) proficiencies for the advance practice RN (APRN) gerontological specialist. The key areas of PALTC education recommended by the latter two groups include, but are not limited to: leadership in the organization, patients' rights, quality management, transitions in care, essential health information tools, working with families, ethics, and regulatory issues.
Based on this preliminary work, faculty decided that the PALTC graduate certificate should include a combination of didactic courses with a focus on geriatric practice in primary care settings (e.g., nursing homes) and clinical rotations within partnering community PALTC settings. The extant graduate certificate programs in gerontology comprise 15 didactic credit hours, which align with the elective course credit options in the NP program of study without requiring that students extend their program of study or take an unreasonable number of credit hours per semester. Expert faculty reviewed existing NP and gerontology courses that would meet the focus of the PALTC certificate. Upon review, faculty selected five courses for certificate program inclusion. Three existing courses were chosen: (a) Physiology and Psychology of Aging, (b) Interdisciplinary Approaches to End-of-Life/Palliative Care, and (c) Elder Health Promotion. In addition, two new courses were developed and offered within the College of Nursing to meet the goals of this certificate program: (a) Foundations of Careers in Long-Term Care and (b) Primary Care Providers in Post-Acute/Long-Term Care. The full program of study and course descriptions can be found in Table A (available in the online version of this article). The syllabi for the two courses (i.e., NURS 6605 Primary Care Providers in Post-Acute/Long-Term Care and GERON 6520: Foundations of Careers in Long-Term Care) were approved through the nursing and gerontology programs curriculum committees. The full PALTC certificate program was approved previously by the College of Nursing and University curriculum committees.
In addition to the 15 didactic credits hours, it was deemed important that students have exposure to PALTC environments and direct observation of persons in leadership positions in these settings. NP students are required to spend 80 of their clinical hours observing or participating in leadership activities in a variety of settings, such as primary care clinics, community-based clinics, and long-term care settings. To receive the certificate, NP students are required to complete a final scholarly project that includes at least one committee member with expertise in PALTC settings. The scholarly project focuses on a topic related to practice or quality improvement in the PALTC setting and provides an additional didactic learning experience for students by providing the opportunity for exposure to previous research studies conducted in PALTC as well as future recommendations for clinical, administrative, and policy changes.
NP students in the PALTC certificate program are also required to become members of the GAPNA. Students are required to attend the GAPNA annual conference or similar conference. Students are encouraged to submit an abstract of their scholarly project to be presented at an annual meeting. GAPNA was established in 1981 to provide continuing education conferences for APNs who provide care for older adults in primary, acute, post-acute, and long-term care settings. The stated goals of GAPNA are to: “advocate quality care for older adults; promote professional development; provide continuing gerontological education; enhance communication and professional collaboration among healthcare providers; and educate consumers regarding issues of aging” (GAPNA, n.d., para. 3). The intention for early student membership in GAPNA is to encourage a life-long dedication to gerontology education and the mission of the organization.
In addition, this certificate program assists students in preparing for the newly developed APRN-Gerontological Specialist examination. The focus of the PALTC certificate is to develop the gerontological specialist in the PALTC setting. For example, specialists would apply an evidence-based approach using best practice parameters to the care of older adults with multiple health issues. In summary, to adequately prepare future NPs to work in PALTC settings, an elective graduate certificate was created with core requirements that include a combination of didactic course work (15 credit hours), clinical hours (200 hours), leadership experience (80 hours), a scholarly project with an emphasis in PALTC, and membership in GAPNA.
NP students enrolled in the Family Primary Care and Adult/Gerontology Primary Care program with a stated interest in working in PALTC after graduation were invited to apply for up to 2 years of stipend support from the GWEP to complete the 2-year PALTC certificate program. During this 2-year period, students use their elective course slots to take the required elective courses for the PALTC certificate. In addition, students use this time to complete their leadership and clinic hours in PALTC settings. When possible, students are encouraged to complete their hours with GWEP PALTC partner facilities with medical directors or other nursing staff committed to building primary and geriatric NP competencies as preceptors and mentors. Through the completion of this program, it is hoped that the mentorship, clinical experience, and didactic education will solidify these students to a career in PALTC settings. Another requirement includes facilitating a 1-hour distance-based interprofessional PALTC Learning Community attended by clinicians and staff from GWEP PALTC partner facilities. Students meet regularly with a faculty advisor during their program of study. Students are expected to complete the program requirements by the time they graduate from the NP program.
Currently, the PALTC certificate is only available to University of Utah NP students and mirrors the model of geriatric training for clinicians in PALTC settings, which has been shown to have positive patient care outcomes, including the reduction of preventable hospital readmissions and cost savings. However, the goal is to expand the post-graduate certificate in PALTC to other health science professions, including medicine, pharmacy, dentistry, social work, and physical and occupational therapies. GWEP faculty will work with each program to determine the number of GIP hours required to complete the curriculum and define clinical and leadership activities. The PALTC program will integrate the Interprofessional Education Collaborative Core Competencies for Interprofessional Collaborative Practice (access https://www.aacom.org/docs/default-source/insideome/ccrpt05-10-11.pdf?sfvrsn=77937f972). The four competencies include: (a) interprofessional respect and shared values, (b) knowledge of professional roles to promote and advance health of population, (c) interprofessional communication that supports a team approach to care, and (d) principles of team dynamics. The interprofessional nature of the future program will better prepare students to be contributing members of interprofessional teams that provide person-centered care for older adults in PALTC settings.
The graduate certificate program of study for NP students who plan to work in PALTC settings has been successfully developed and implemented. This novel program includes a combination of didactic, clinical, and leadership training over a 2-year period. This graduate certificate model is associated with positive student learning outcomes. The authors plan to explore the option of offering the PALTC graduate certificate to other health discipline students and currently practicing NPs who desire geriatric professional development to further expand geriatric training in the community.
There are barriers to implementing a certificate program. First, most students do not consider a career in PALTC during their educational program. Due to GWEP funding, the current authors were able to incentivize students to earn the gerontology certificate with an emphasis in PALTC. These students have been asked to be spokespersons for the program and for careers in PALTC, and each year an increased number of applicants have been received for the certificate program.
At this time, due to the newness of the program and limited funding for students, program outcome data for statistical analysis are not available. Additional examination of pre- and post-survey data will be used to refine the clinical and course requirements. The authors also plan to implement a method for collecting formal qualitative feedback from students and stake-holders that will help identify areas of improvement.
Demand for direct care NPs will only increase as the Baby Boomer generation continues to age (Stone, 2017). To provide quality care for patients in PALTC settings, it is essential that health care educators integrate the appropriate curricular programs into nursing as well as other allied health and medical education programs. Furthermore, APNs should consider applying for board certification as a Gerontological Specialist (access https://www.gapna.org/certification).
To the authors' knowledge, this is the first educational opportunity offered for NP students to gain didactic and experiential training to prepare them to practice in geriatrics at the top of their license in PALTC settings. The current article serves as a framework for any nursing programs to reference as they develop individualized graduate certificate PALTC programs in their academic institutions. Additional materials or information regarding the certificate program can be provided by contacting the lead author.
As the U.S. older adult population continues to age, a need for competent health care providers working in PALTC settings is ever increasing. Completion of a graduate certificate in PALTC is an effective model for preparing and recruiting NP students for practice in PALTC settings. Furthermore, this certificate program has the potential to provide graduates with an advantage compared to other applicants as they interview for career opportunities in PALTC settings—they can demonstrate a unique, well-rounded skillset (e.g., didactics, leadership, and clinical experience) in PALTC settings as well as APRNGerontological Specialist credentials.
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Post-Acute/Long-Term Care Certificate Program of Study
|Course Title & Description||Objectives|
|GERON 6520: Foundations of Careers in Long-Term Care (3 Credit Hours)
This course is designed to expand the student's knowledge base of the long term care continuum with a focus on the organization of and interaction with skilled nursing facilities. Students will learn about the roles and key components of the delivery system such as the regulatory environment, quality assurance performance improvement, person-centered care and advance care planning and be able to apply the main components in a variety of course activities.||At the conclusion of the course, the student will be able to:
Explain the organization and roles within skilled nursing facilities.
Apprise the existing regulatory environment of skilled nursing facilities including certification survey process, key domains, and quality measures.
Apply quality assurance performance improvement (QAPI) approaches used in skilled nursing facilities.
Describe culture change movement and apply person-centered care approaches.
Identify critical components for leading advance care planning meetings.
|NURS 6603: Chronic Problems of Adults & Elders (3 Credit Hours)
Management of chronic illness in adults. Focuses on common chronic EENT, respiratory, dermatologic, gastrointestinal, genitourinary, hematological, and musculoskeletal health problems. Less common chronic problems included for students enrolled for 3 credits.||At the conclusion of the course, the student will be able to:
Discuss pathophysiology and clinical manifestations of chronic adult and geriatric health problems.
Identify risk factors associated with specific health problems.
Recommend and interpret diagnostic procedures appropriate for specific patient presentations.
Discuss the differential diagnosis for common health problems and patient presentations.
Develop a comprehensive management plan that includes pharmacologic and non-pharmacologic therapies.
Integrate patients and families in a psychosocial, cultural, occupational, economic, and environmental context, and health goals into the management plan.
Evaluate outcomes of health care management plan considering treatment alternatives, consultation, referral, and individual variations in response to interventions.
Analyze and apply principles of clinical reasoning in assessing health problems.
|NURS 6604: Physiology & Psychology of Aging (3 Credit Hours)
Biological and psychosocial theories of aging analyzed. Normal physiologic and psychological aging changes presented. Emphasis on distinguishing normal changes from common age-related diseases.||At the conclusion of the course, the student will be able to:
Analyze select theories of molecular and cellular aging.
Differentiate normal aging changes in major organ systems from age-associated disease states.
Analyze selected psychological and social theories of aging.
Differentiate normal psychosocial changes from common mental and emotional illnesses occurring in old age.
Describe how changes occurring with age interfere with or enhance healthy aging.
Discuss ways to promote healthy aging from physiological, psychosocial, and spiritual perspectives.
Explore use of general screening instruments to evaluate physiological and psychosocial changes occurring in older adults.
Demonstrate skills essential for effective interdisciplinary care of clients, families/support systems when working with other health professionals.
|NURS 6605: Primary Care Providers in Post-Acute/Long Term Care (2 Didactic & 1 Clinical Credit Hours)
This course will integrate advanced clinical practice skills with the care of the adult in a post-acute/long-term setting. Problems and issues of adults in these settings will be included in the didactic portion of the class. Students will be placed in post-acute/long-term settings so that they will be able to apply the didactic portion of the class in their placement setting.||At the conclusion of the course, the student will be able to:
Develop proficiency in providing gender inclusive and culturally sensitive age appropriate screening and preventative care to adults in the post-acute/long-term care setting.
Demonstrate assessment of the older adult with complex medical needs in the post-acute/long-term care setting.
Apply and integrate clinical management principles in the care of older adults in a post-acute/long-term care setting.
Utilize leadership skills in an interprofessional team setting in a post-acute/long-term care setting.
|GERON 6002: Services Agencies & Programs for Older Adults (3 Credit Hours)
Analyze the current delivery system of services and programs for the elderly at the national, state, and local levels. Local services and programs specifically examined to determine quality and effectiveness, identify service gaps, and be better prepared to meet the increasing demands of a rapidly aging population. Learn about current concepts in health and social policy reform, and evaluate current public policy recommendations.||At the conclusion of the course, the student will be able to:
Become knowledgeable of the history of social policies for older adults in the United States as they relate to services and programs.
Be familiar with major public health and social service programs available to older adults in the United States and provided locally – including related funding sources, eligibility criteria, services, and public policies.
Students will know how to find information about different services in different locations and will recognize how older adults utilize and understand those services.
Have an understanding of the current trends in reform of the existing system of aging programs and the political, societal, and economic changes driving the evolution of these trends. Based on this understanding, students will anticipate and identify how programs may need to change in the future.
Meet professionals in various fields providing services and programs to older adults and be more aware of career opportunities in the aging sector.
Critically evaluate the access, outcomes, and quality of the delivery system for health and social services to older adults.
|GERON 6050: Best Practices in Geriatric Care (3 Credit Hours)
The course presents an overview of best practices in the care of the older client and his/her family. Included in the course are assessment and management of safety risks, and symptoms, and syndromes common in older adults emphasizing evidence-based practices. Included are detection and management of pain, falls, medication safety, end of life care, and behavioral syndromes. The impact of attitudes, ethical issues, special communication needs, and culture on formal and familial care giving are also considered.||At the conclusion of the course, the student will be able to:
Compare and contrast evidence based practice, best practices, standards of practice, and practice guidelines.
Utilize the appropriate strategies, terminology, and resources to address issues in geriatric care and long-term care.
Apply the evidence for best practices to case studies in the content areas of mobility/exercise, pain/palliation, nutrition/elimination, cognitive/behavioral, and medication safety/polypharmacy.
Apply the quality improvement process, incorporating multiple disciplines and healthcare professionals.
Plan age-appropriate communication activities and education with older adults and family caregivers.
Present a quality improvement project incorporating nursing and healthcare research best practices, and impact evaluation.
|GERON 6320: Death, Dying, & Bereavement (3 Credit Hours)
Practical assessment and intervention strategies for working with dying and bereaved individuals and their families. Overview of clinical, philosophical, spiritual, and social issues concerning dying and bereavement. Strategies related to personal growth and awareness of unfinished business emphasized.||At the conclusion of the course, the student will be able to:
Develop an awareness of personal feelings, beliefs, attitudes, unfinished business, misconceptions about death and grief, and confront one's own mortality.
Identify practical strategies and resources for supporting terminally ill or dying individuals and their loved ones.
Acquire an understanding of normal and complicated grief, and identify practical strategies for working with a grieving person.
Learn about death and grief customs of other cultures and religions.
Critique the funeral mortuary experience in American society and its value for survivors.
Complete (own) advanced directives and be able to educate family, friends, or patients about the value of having these documents in place.
Identify practical strategies for working with individuals with life-threatening illness and their loved ones.
|GERON 6390: Geriatric Care Management: Clinical Issues (3 Credit Hours)
Care Management: Clinical Issues provides an introduction and overview of the care management role in the context of interdisciplinary and across systems care management for clients. Care Management: Clinical Issues focuses on skill development in managing care for the lifetime continuum of clients including disease and wellness and developmentally appropriate assessment and planning care management. The content explores the process of conducting a comprehensive assessment of the client, family and support systems, and healthcare systems to establish, implement, monitor, evaluate and document a comprehensive plan of care across healthcare systems.||At the conclusion of the course, the student will be able to:
Identify and articulate the role of the geriatric care manager to clients, families, support systems, other disciplines, and to the healthcare community at large.
Apply current research, guidelines and evidence to the practice of geriatric care management, in particular, regarding pain and symptom management, grief and loss, end of life and palliative care, and other selected geriatric syndrome and disease management guidelines.
Demonstrate appropriate communication strategies when interacting with clients, families, support systems, colleagues, and other systems of care.
Conduct a screening and comprehensive client, family/support system assessment, appropriate to discipline.
Formulate a comprehensive plan, including identifying short and long-term goals, community and other resources, expected outcomes, client, family/support system education, and modification of the plan.
Describe scope and limits of discipline-specific roles in geriatric care management.
Demonstrate skills essential for effective interdisciplinary care of clients, families/support systems when working with other health professionals.
Analyze current research and guidelines for a specific client diagnosis and disease trajectory.
|GERON 6392: Geriatric Care Management: Legal, Financial, & Business Issues (3 Credit Hours)
The Care Management: Legal, Financial, and Business Issues course presents the opportunity for students to gain insight and understanding into the creation, development, implementation and monitoring of a care management business through the development of a written business plan. Over the course the student will learn the necessary steps to building a care management program. At the same time the student will learn basic business skills of marketing, branding, and interviewing. The course is appropriate for individuals who have an interest in the care management field and who are focusing their careers working with populations and individuals over their life-time of care within illness and wellness issues.||At the conclusion of the course, the student will be able to:
Describe the role of a care manager in providing education, support, and advocacy for clients and their families.
Differentiate between various models of care management, namely for-profit, non-profit, and government.
Differentiate between various end of life planning documents and relationships, including a general power of attorney, financial power of attorney, medical power of attorney, living will, conservatorship, and guardianship.
Construct ethical dilemmas that are present within the care management business.
Identify health policy, access, and reimbursement issues relevant to care management.
Compare models of care management, namely for-profit, non-profit, and government.
Develop a care management business plan through a PowerPoint presentation of their business.
Eighty Leadership Hours dedicated to the PALTC environment
PALTC-focused DNP scholarly project with at least one PALTC content expert on the project committee.
Membership with the Gerontological Advanced Practice Nurses Association (GAPNA). Submit an abstract to and attend the annual meeting.
Serve as spokesperson for our GWEP, attending Center and University events when requested.
Quarterly meetings with the Program Advisor and or Project Director to report on progress.