Emory University School of Medicine
This product consists of a series of activities conducted as a month-long module among third-year medical students during their ambulatory rotation aimed at educating them about provider-related factors in care transitions and best practices that assure patient safety during transitions. This product is also aimed at educating the students on the critical role of the receiving outpatient physician in care coordination and inter-professional collaboration during the transitions period. The activities are delivered in the context of an interactive case-based learning workshop followed by month-long web-based activities.
On completion, the learner will be able to:
- Structure the post discharge visit and perform post discharge outpatient best practices including medication reconciliation, review of a discharge summary with implementation of critical elements of the discharge care plan.
- Identify patient discharge care needs including factors that present a risk for re-hospitalization; develop a multidisciplinary care plan to address identified needs.
- Identify available community resources for the post discharge patient.
- Identify appropriate care settings for the post discharge patient.
- Apply skills for inter-professional team collaboration and care coordination in the management of a discharged patient.
Blackboard Software for the web-based activities.
The transfer of patient care from the hospital team to providers in the community is a high-risk process characterized by fragmented, non-standardized, haphazard care. The contributory role of provider-related factors to failure in transitions of care is becoming more prevalent as a result of the lack of continuity of care with the emerging role of hospitalists in the care of patients, increasing the need for understanding of the roles of sending and receiving providers in the care transitions process.
The initial workshop consists of an interactive case-based presentation on the issues that occur at the point of transition, followed by recommended care transitions best practices. The workshop also incorporates hands on activities that simulate a patient’s post-discharge office visit with the participants role playing as the patient’s primary care physician. During this activity, the learners are trained on: structuring of the post discharge visit; identification of patient care needs, along with factors that present a risk for re-hospitalization; and, development of a multidisciplinary care plan to address the needs of the patient. This session is followed by a month-long web-based module that consists of participants’ review of web based study materials, completion of assignments along with online peer-peer and facilitator interaction. During the month, the participants continue to role play as the patient’s primary care physician while collaborating with other members of the healthcare team in caring for the patient. This aspect of the curriculum focuses on educating learners about the role of members of the healthcare team, inter-professional team collaboration and care coordination in the management of the discharged patient. It also highlights the role of the patient and family in the care transitions process, identification of available community resources to meet patient care needs, and appropriate discharge care settings.
The rotation is concluded with a wrap up session at the end of the month where interactive discussions are held to reinforce lessons learnt along with a discussion on appropriate discharge care settings, eligibility criteria and funding sources. The students then get to vote on a choice of an appropriate discharge care setting for their patient.