This is a multi-center exploratory study (each site got local IRB approval) of the impact of an educational toolkit combined with a practice-performance self-evaluation instrument (ABIM Care of the Vulnerable Elderly Practice Improvement Module) on trainee knowledge, skills, and attitudes about practice-based learning and improvement and systems-based practice in the care of elderly patients.

This is a longitudinal quasi-experimental study. Programs will be randomly assigned to either the comparison or intervention group, stratified based on program size, affiliation, geographic location, and presence of a geriatrics fellowship program.

Faculty will be trained in use of the CoVE PIM and in the development and implementation of a quality improvement plan. Residents in the intervention group will perform the medical record audit portion of the CoVE PIM. Patient surveys will be distributed by the residency clinics. The goal will be to audit the medical records of patients who complete the patient survey. Residents in intervention groups will participate in completing the practice system survey as a group. Finally, the residents in the intervention group will use the data from the medical record audit, patient survey, and practice system survey, working with faculty, to develop a quality improvement project to improve care for their geriatric patients.

Local medical record abstractors will be trained to perform a separate medical record audit of a random sample of the same patients identified by the residents for both the intervention and comparison groups. The abstractors will perform both a baseline and follow-up audit and will target the same patients who are still living from the baseline period. The follow-up audit will occur 12 months after completion of the initial PIM data collection phase, or approximately 18 months after the initiation of the study.

Evaluation of study outcomes will occur on the program, resident, and patient level.

Inclusion Criteria:

• All residents at a resident clinic site
• Preceptors that are selected by the Champion for a particular resident clinic site
• Patients age 65 years or older for whom any of the following measures would be appropriate: falls prevention, identifying urinary incontinence, screening for depression and cognitive impairment, and providing other preventive care.
• Patients who have been in the practice for at least one year
• Patients who are ambulatory
• Patients who have been seen at least once by the practice within the past 12 months.

Exclusion Criteria:

• Patients under age 65
• Patients who have a terminal illness
• Patients with a life expectancy of less than one-year