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Teaching Transitions of Care to Residents Using A Post-Hospitalization Patient Visit


Teaching Transitions of Care to Residents Using A Post-Hospitalization Patient Visit

Boston University School of Medicine
Megan Young, CT, Serena Chao, CT, Victoria Parker, CT, Sharon Levine, CT
Health Resources and Services Administration (HRSA)
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With the goal of learning key components to a good hospital discharge of an older patient, residents at Boston Medical Center participated in a structured teaching exercise adapted from University of Rochester's Hospital to Home program in which they made a home or nursing home visit to see a patient whom they cared for during the hospital admission. This exercise effectively enhances the medical resident's self reported ability to assess and implement post-discharge care for complex older patients. Specifically residents expressed an increased awareness of the need to tailor post-discharge plans to a patient's health literacy level, functional status and psychosocial factors. This exercise is a promising intervention for teaching transitions of care.

Educational objectives: 
  1. Identify the discharge summary as a vital communication tool in the handoff between hospital and post-hospital care teams.
  2. Explain the role of community agencies and services, such as Community Home Health Agencies (CHHA), in providing post-hospital care.
  3. Perform medication reconciliation in order to lessen medication errors at the time of transition.
  4. Identify the psychosocial factors that impact a patient's implementation of his/her discharge plan.
Additional information/Special implementation requirements or guidelines: 

BU Internal Medicine residents who participate in the Geriatrics Ambulatory Rotation are required to complete a post-hospitalization visit on a patient that they cared for (rounding, admission, or discharge) on the inpatient geriatrics service during their weekend coverage duties. This visit may happen in either the home or the nursing home setting. While accompanied by a geriatrician, residents will conduct a brief interview of the patient and his/her family to assess their perspective of the discharge. They will also perform medication reconciliation while in the patient's home or at the nursing home. After the visit, they will critically review the discharge summary to determine if the discharge plan was appropriate for the patient. They will then reflect on ways the discharge plan could have been altered to better fit the patient's needs. The geriatrics attending will evaluate the resident's performance on the post-hospital visit by evaluating skills that correlate with the core competences.

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Estimated time to complete: 
1 hour 30 minutes
Conflict of Interest Disclosure: 
No, I (we) have nothing to disclose.
Already Expired Email Date: 
Wednesday, February 28, 2018 - 8:57am
Already Expired Email 1 month date: 
Thursday, March 15, 2018 - 7:35pm
Expired Email Date: 
Friday, March 30, 2018 - 11:23pm
Contact Person/Corresponding Author:
Dr. Megan Young

Suggested Citation:
Teaching Transitions of Care to Residents Using A Post-Hospitalization Patient Visit. POGOe - Portal of Geriatrics Online Education; 2013 Available from: