PLANNING A CARE TRANSITIONS CURRICULUM2011 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