residents and only 13 percent of graduating internal-medicine residents felt very prepared to care for nursing-home patients (Blumenthal et al., 2001). Still, clinical experiences in alternative sites of care have increased somewhat from past years (Cheeti and Schor, 2002; Matter et al., 2003). For example, Weill Cornell Medical College implemented a clerkship in which third- and fourth-year medical students accompanied a geriatrics team on home visits to patients living with chronic illness; when interviewed about the experience, 84 percent of recent graduates felt that it had had a positive effect on their delivery of care (Yuen et al., 2006).

Among the obstacles to expanding training sites is a lack of funding to cover the expenses of residents while in non-hospital settings. As described above, Medicare distributes GME funds, primarily to hospitals, to support the training of residents. However, the Balanced Budget Amendment of 1997 allows for other providers, including federally qualified health centers, rural health clinics, and managed care organizations to receive GME funds directly (AAMC, 2007c). Furthermore, since 1987 hospitals have been allowed to count the time that residents spend in settings outside the hospital, such as nursing homes and physician offices, subject to certain agreed-upon conditions between the hospital and the outside entity. Still, this does not happen often enough. Since most care of older patients occurs in non-hospital settings, more needs to be done to ensure that professionals are fully trained in how to care for patients in these settings.

The committee concluded that comprehensive care of older patients should include training in non-hospital settings.

Recommendation 4-1: The committee recommends that hospitals should encourage the training of residents in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patients’ homes.

Residency program directors need to ensure that their residents’ schedules include adequate time rotating through these alternative settings, and the directors and hospital administrators need to be willing to collaborate with the outside entities to reach mutually agreeable conditions for partnership.

Board Certification

Physicians may pursue voluntary national board certification in many major specialties and then become certified in the subspecialties of geriatric medicine or geriatric psychiatry. It was in 1988 that the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine

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