Emory University Care Transitions Curriculum for Internal Medicine Residents
Background
The Joint Commission, American Geriatric Society, ACGME and LCME have all identified care transitions as a core element of patient care and a critical component of health professional education. Only 16% of Internal Medicine residency programs have formal discharge curricula. We describe a comprehensive Care Transitions Curriculum (CTC) for Internal Medicine Primary Care and Categorical residents.
Aim
1. To educate the IM Resident about the risks associated with care transitions and specific strategies to reduce these risks.
2. To facilitate excellent discharge planning behaviors in clinical training.
Participants
PGY 1, 2 and 3 residents so far at the Emory University School of Medicine receive the Care Transitions Curriculum (CTC) during their required 4-week ambulatory rotation.
Learning Objectives
1. Define transitions in care and the roles patients, providers and the system play in safe transitions.
2. Describe the care transitions process and identify potential multilevel factors that are contributory to failure in transitions of care.
3. Describe the effects of unsafe transitions and recognize the key elements of safe transitions.
4. Identify appropriate discharge locations for patients.
5. Identify processes of efficient and effective care coordination that will ensure seamless transition of patients to other care settings.
6. Communicate effectively with accountable care providers at the point of discharge – Interdisciplinary team members, PCP, Home Health team, providers at other health care facilities.
7. Complete an effective pre-discharge patient education on diagnosis, medications and warning symptoms.
Program Description
CTC uses multiple instructional modalities delivered in a 90 minute workshop format including:
– Pre-workshop reading assignment: Falling through the Cracks by Eric Coleman and Society of Hospital Medicine’s Transition of Care for Hospitalized Elderly Patients—Development of a Discharge Checklist for Hospitalists
– Discharge Summary Self Evaluation using a discharge summary checklist adapted from the Society of Hospital medicine
– Power point presentation – Transitions in Care; Why They are Important and How to Improve Them
– Transitions in Care Case Review
– Board Game – Settings of Care
– Handouts given during the workshop for self study include:
– Settings of Care handouts
– Ideal discharge checklist
Evaluations: Evaluations received so far have shown great resident satisfaction with the program.