PLANNING A CARE TRANSITIONS CURRICULUM

2011 Annual Reynolds Meeting

Presenters

Manuel A. Eskildsen, MD, MPH (Moderator) - Emory

Angela Botts, MD - Harvard/BIDMC Linda DeCherrie, MD – Mount Sinai

Objectives

Compare different models for training in care transitions

Know the key elements that could be included in a care transitions curriculum, and individualize these to different types of learners

Apply appropriate outcomes metrics to measure the success of their care transitions curricula.

Outline

Introduction (30 minutes) Table Exercise (30 minutes) Wrap-up with experience from

presenters’ sites (30 minutes)

A Case

You are a member of a ward team caring for an 83-year-old male patient with multiple problems, admitted with CHF exacerbation. You diurese him well with IV furosemide, and in five days, he appears euvolemic and ready for discharge.

The resident manages discharge plan, writing prescriptions and talking to patient

Part #2

Within ten days, your team is notified that the patient is readmitted to the hospital with another CHF exacerbation, and is back on the team. The patient says he was confused about medications and did not take his diuretic.

Questions

Could this have been preventable?

Could this have been prevented by better hospital procedures? Or do the housestaff require better training?

What could be done to train housestaff better?

Care Transitions – Why do we care?

Nearly 20% of Medicare patients readmitted to hospital within a month (Jencks et al., N Engl J Med 2009)

Patients are frequently confused and dissatisfied by the discharge process

Communication between hospitalists and PCPs is infrequent (Kripalani et al., JAMA 2007)

Models Shown to Work

Care Transitions Intervention – Coleman Centered on patient self-

empowerment. Has four pillars: Medication self-

management Patient-centered

discharge record Follow-up Red flags

Significantly reduced rehospitalization (Coleman et al., Arch Int Med 2006)

Naylor model – Univ. of Pennsylvania High-risk elders with

multiple chronic problems

Intervention NPs meet pts in

hospital and follow up with patients and providers

Reduced readmissions, days in hospital (Naylor et al., JAMA, 1999)

The Training Imperative

Care transitions haven’t traditionally been part of medical education/training

Growing awareness of need to improve care transitions outcomes

Evidence exists for some clinical models… but what about training doctors to do transitions better?

AAMC Medical Student Geriatric Competencies

Developed in 2007 Eight different content areas (e.g., med

management, cognitive disorders) Related to transitions:

#25: communicate the key components of a discharge plan

#13: Identify and assess safety risks in the home environment, and make recommendations to mitigate these

2010 Health Care Law

Patient Protection and Affordable Care Act

Starting in 2012, will reduce payments to hospitals to account for preventable readmissions

Promotes the growth of accountable care organizations (ACOs) by letting them share in cost savings

Pilot program for bundled payments across continuum of care

Community Based Care Transitions Program

Also part of the 2010 ACA Provides funding to test models to

improve care transitions for older patients

Joins: Hospitals with high readmission rates Community Based Organizations

A Growing Field

Growing awareness of need to improve care transitions outcomes

Care transitions haven’t traditionally been part of medical education/training

Evidence exists for changing systems… but what about training doctors to do transitions better?

Large organizations stepping into void

Training in Care Transitions

Issues to Explore

What learners to train?

Settings?

How to involve interprofessional teams?

What do we know about effectiveness?

Challenges in “Comparative Effectiveness” in Education

Most of what’s innovative is not published

Our best teachers and curriculum designers aren’t necessarily researchers

“Gold standard” research models can seldom be applied

Systematic Review

“A Systematic Review of Curricular Interventions Teaching Transitional Care to Physicians-in-Training and Physicians”

Buchanan and Besdine, Acad Med 2011

Analyzed interventions between 1973 and 2010

Ultimately, found 25 unique interventions

Study Highlights

Participants: 63% involved 3rd and 4th year medical

students 53% involved residents 16% involved interprofessional members

Vast majority involved brief, self-limited interventions

74% were in the classroom Only 37% assessed learner-perceived

benefit

How to Approach a Curriculum

Items to Consider when Thinking about Your Curriculum

Learning Objectives

Learner Groups

Setting

Stakeholders to

engage

Possible challenges

Evaluation

Learning Objectives

Care transitions education is very likely to be skills based --- less knowledge based

Craft active learning objectives: What skill do you want your learners to

have after they’re done with your curriculum? Perform medication reconciliation? Communicate with families? Dictate discharge summaries?

Learner Groups

Medical students Medical residents Interdisciplinary?

The skill sets you are trying to create will be very different

Setting

Classroom Small group Hospital Home care Skilled nursing facilities

Stakeholders to engage

Rotation director Residency program

director If interdisciplinary:

Who runs training for nursing, PT, etc?

May be an opportunity to perform some needs assessment

Possible Challenges

We’ll discuss this in small groups and in final presentations

Evaluation

Very important to know what is/isn’t working in curriculum

Important to turn your work into scholarship

Possible measures: Satisfaction Knowledge assessment Direct measurement of skills Proxy measurements (confidence in skills)

What Comes Next

We’ll meet in three groups You’ll use a template to come up with a

plan for designing a curriculum Share it with your group