1. Planning a care transitions curriculum
2011 Annual Reynolds Meeting

2. Presenters Manuel A. Eskildsen, MD, MPH (Moderator) - Emory
Angela Botts, MD - Harvard/BIDMC
Linda DeCherrie, MD – Mount Sinai

3. 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.

4. Outline Introduction (30 minutes) Table Exercise (30 minutes)
Wrap-up with experience from presenters’ sites (30 minutes)

5. 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

6. 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.

7. 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?

8. 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)

9. 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)
Was nonsignificant at 30 days

10. 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?

11. 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

12. 2010 Health Care Law

13. 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
Characteristics of ACOs: The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care;
The capability of prospectively planning budgets and resource needs; and
Sufficient size to support comprehensive, valid, and reliable performance measurement. (Berenson, p. 2.).

14. 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

15. 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

16. Training in Care Transitions

17. Issues to Explore What learners to train? Settings?
How to involve interprofessional teams?
What do we know about effectiveness?

18. 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

19. 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
From Pubmed to mededportal, POGOe, society websites. Had to be specific curricular interventions related to care transitions.

20. 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

21. How to Approach a Curriculum

22. Items to Consider when Thinking about Your Curriculum
Learning Objectives
Learner Groups
Setting
Stakeholders to engage
Possible challenges
Evaluation

23. 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?

24. Learner Groups Medical students Medical residents Interdisciplinary?
The skill sets you are trying to create will be very different

25. Setting Classroom Small group Hospital Home care
Skilled nursing facilities

26. 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

27. Possible Challenges
We’ll discuss this in small groups and in final presentations

28. 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)

29. 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