1. An Interprofessional Course on Improving Older Adults’ Care Transitions for Advanced Learners Mitchell T. Heflin, MD, MHS Eleanor S. McConnell, PhD, RN, GCNS, BC Durham VA Geriatric Research, Education & Clinical Center Duke University

2. Objectives Describe a course for interprofessional students on improving transitions of care – Objectives for the experience – Educational philosophy – Design and implementation – Evaluation Future directions

3. Why a focus on interprofessional education & transitions ? 1 in 4 transitions are complicated and require a return to a higher-intensity care setting Patient perspective – Patient and caregiver frustration – Adverse health events Health system perspective – Duplication of tests and services – Increased costs – Patient dissatisfaction Patients and Caregivers

4. Challenges: Education “Once in practice, health professionals are asked to work in interdisciplinary teams, often to support those with chronic conditions, yet they are not educated together or trained in team-based skills.” Health Professions Education: A Bridge to Quality. IOM 2003 Physical therapists Social workers Physicians Assistants Nurses Physicians Pharmacists Patients and Caregivers

6. Educational Philosophy REAL WORK!

7. Course description DateThemeCore Content Sept 8 It takes a village Teamwork Sept. 22 Understanding the challenge: Problems in transition Oct. 6 Designing solutions QI methods Oct. 20Bridging the gaps & setting the bar Settings and systems Nov. 3 Breaking down barriers:Interprofessional communication Nov. 17 Improvement in action Patient-Provider communication Dec. 1Closing the loopFeedback from stakeholders

8. Target Problem: Congestive Heart Failure Common, important problem Large evidence-base Institutional interest and activity Core issues: – Teamwork – Transitions – Quality

9. Project work DateThemeCore Content Project work Sept 8 It takes a village Teamwork Form teams Sept. 22 Understanding the challenge Problems in transition Interview patients Oct. 6 Designing solutions QI methods Research innovations Oct. 20 Bridging the gaps & setting the bar Settings and systems Select outcomes Nov. 3 Breaking down barriers Interprofessional communication Design innovations Nov. 17 Improvement in action Patient-Provider communication Test innovations Dec. 1 Closing the loop Feedback from stakeholders Present proposal

10. Evaluation Peer and self assessment of team work Pre- and Post Self-efficacy QI proposal rubric Learner Evaluation Core Content Project work Teamwork Form teams Problems in transition Interview patients QI methods Research innovations Settings and systems Select outcomes Interprofessional communication Design innovations Patient-Provider communication Test innovations Feedback from stakeholders Present proposal Observe teams, form project team Interview pts, Identify problems Design QI proposal Final Course Grade

11. Learner Evaluation 2008-2009 22 students from 6 professions – Medicine, Nursing (ABSN & APN), PA, Pharmacy, PT, Nutrition Self efficacy: 2008: Significant gains in 3 of 4 domains 2009: Significant gains in all domains Teamwork – High ratings by peers Project work

12. Student Self-Efficacy Gains- Fall 2009 p< 0.01 for all categories.

13. Projects Discharge Instruction for Patients with Congestive Heart Failure HEART FAILURE ACTION PLAN Name : DOB:MRNMy target weight is: Symptoms GREEN: What I should do YELLOW: What I should do. Call provider at: _______________ _______ RED: What I should do Call provider immediately: Day phone:_____________ ___ Night Phone: _______________ Usual amount of swelling Increased amount of swelling in ankle or up to shin Increased swelling up to knee area Weigh yourself each morning immediately after you get up. Weight from ________ to _________ NO WEIGHT GAIN Weight from _______ To _______ WEIGHT gain of 2-3 lbs overnight or 5 lbs in 1 week Weight from______ To _______ WEIGHT change of more than 5 lbs in one week No shortness of breath with usual activity Increased shortness of breath with usual activity Shortness of breath at rest Provider ActionNo change in treatment May increase fluid pill May refer you to ED or clinic Shortness of Breath Each morning check for swelling Morning weight after Discharge ____ lbx My Heart Failure Passport

14. Successes Through interactive, multi-modal learning, students: – Engaged in real teamwork – Examined real transitions – Identified and proposed solutions to real problems REAL WORK!

15. Challenges Teaching and learning: – Finding the right balance between faculty and students – Coordinating didactics and project work – Accounting for viewpoints of all professions – Including a broader array of professions Turning real work into real improvements REAL WORK!

16. Next steps Continue IP faculty development and teaching Reach more students in more places – Geriatric Education Resource Hub Collaborate with faculty, learners and clinical partners on QI initiatives – Transitions in cognitively impaired patients Mobilize expertise and resources to teach patients and caregivers