University of Utah School of Medicine
OSVEs (Objective Structured Video Examinations) may be used to teach principles of effective interdisciplinary team-based transitional care. First introduced at the Medical College of Wisconsin in the mid-1990s, the OSVEs were used as brief “trigger videos” demonstrating ACGME competencies to which trainees would respond by completing multiple-choice or fill-in-the blank questions. The Geriatric Transitions OSVE (GT-OSVE) replaces the individual, paper-based exercise with an experiential, team-based exercise focused on transitions of care. The GT-OSVE also addresses interprofessional (IPE) competencies, including the importance of understanding the roles of other health care professionals. A series of three GT-OSVE cases was developed with HRSA Geriatric Academic Career Award support (#K01HP20487) to meet an unmet need in care transitions education. Most existing care transitions educational materials focus on the time of hospital discharge. The three GT-OSVE cases focus instead on post-hospital transitional care in various settings, including the outpatient primary care clinic, skilled nursing facility and assisted living facility. The GT-OSVE case presented here (“Hospital to Outpatient Care Transition”) is the first case in this series and addresses the first post-hospital primary care outpatient visit. The GT-OSVE “Hospital to Outpatient Care Transition” case is a required component of the Patient-Centered Medical Home (PCMH) rotation for third-year family medicine residents at the University of Utah. These residents work with clinical pharmacy residents and physician assistant students to complete the GT-OSVE exercise. The GT-OSVE was designed to be applicable to health professions trainees ranging from novice (e.g. preclinical medical student) to advanced (e.g. senior medical resident), and to be equally relevant to both interdisciplinary teams and teams whose members are all of the same discipline.
Upon completion of this material you will be able to:
1. Understand best practices in post-hospital transitional care.
2. Acquire practical experience in formulating a high-quality, team-based transitions plan.
3. Discuss the contributions of other health professions trainees in formulating effective transitions.
Order of Resource Files
First, trainees should complete the pretest and self-efficacy survey.
Second, faculty facilitator(s) should consider emailing trainees the links to the online transitions and team functioning modules found in the optional advance preparation assignment document. This content may be reviewed on each trainee’s own time prior to the didactic session. The “Geriatric Interdisciplinary Team Training (GITT)” module is freely available; permission has been granted from the author of the “Transitions of Care: Leaving the Hospital” module to use this module as an advance preparation assignment for the GT-OSVE.
Third, faculty should deliver the care transitions didactic presentation to trainees prior to the GT-OSVE exercise. This didactic reinforces and expands upon the care transitions and team leadership content of the optional advance preparation assignment.
Fourth, on the day of the GT-OSVE exercise, faculty should ask each team member to discuss his or her role (e.g. resident, physician assistant, pharmacist, nurse, social worker). A team leader (not necessarily the medical student or resident) should be identified. Faculty should review the faculty and team leader instructions and discuss them with the team (see also “Facilitation Schema” below). Trainees should then be provided with the hypothetical patient chart corresponding with Mr. John Coleman so that they have access to the same information as the resident physician depicted in the video. Trainees should also be provided with the after-visit summary template that prompts them to consider Coleman’s “four pillars” of transitional care as well as barriers to transitional care.
Fifth, the video file, “Hospital to outpatient care transition,” should be shown. The team leader should facilitate team discussion and should elicit the contributions of each team member. After the team discussion, the team leader should present to faculty the transitions plan agreed upon by the team. The faculty checklist of care transitions and team leadership domains should be used by faculty to help track the extent to which the team leader addresses key care transitions domains and identifies barriers to the transitions plan during his or her presentation of the transitions plan, and also the extent to which the team leader facilitates the transitions plan among the team. Finally, each trainee should complete the post-test and self-efficacy survey.
Practical implementation advice
The GT-OSVE case, “Hospital to Outpatient Care Transition,” was designed to ease the scheduling demands often inherent in interdisciplinary education. Since this GT-OSVE case presents a videotaped encounter with a standardized patient, programs do not need to compensate or schedule standardized patients. Required materials include a computer with Internet access, PowerPoint slides, and hard copies of ancillary materials including pretest and posttest surveys, faculty and team leader instructions, hypothetical patient chart materials, after-visit summary template and faculty checklist. Optional materials include the advance preparation assignment and a projector and screen, although the video case can be displayed on a laptop with small groups. Trainees will require 40 minutes to review the online modules prior to GT-OSVE administration. Faculty should allow approximately 60 minutes on the day of the GT-OSVE exercise to include the following activities: explanation of the GT-OSVE exercise (10 minutes), viewing of the “Hospital to Outpatient Care Transition” video case (10 to 15 minutes), team formulation of the transitions plan (10 minutes), presentation of the transitions plan by the team leader to faculty (5 minutes), faculty debrief and team discussion (10 minutes) and completion of the posttest survey (5 minutes). At least one faculty member must be present to set up the video and hard copy materials, introduce the case and debrief trainees at the end of the session. Whenever possible, faculty from additional disciplines should participate to enrich the feedback provided to trainees during the debriefing component. Estimated faculty preparation time includes reviewing the online modules (40 minutes), PowerPoint slides and GT-OSVE case (60 minutes), and hard copy materials (30 minutes).
Strategies to avoid potential pitfalls
We have noticed several potential pitfalls when administering the GT-OSVE “Hospital to Outpatient Care Transition” case. First, depending on the personality of the trainees involved, one trainee sometimes dominates the team discussion. In order to ensure that each trainee contributes to the transitions plan equitably, we created the after-visit summary template containing the “four pillars” of effective care transitions as well as a fifth component (barriers to an effective transition). We ask each trainee to jot down notes on this after-visit summary template as they watch the GT-OSVE with the expectation that the team leader will elicit and integrate the contributions of each trainee. This approach has reduced the tendency of one team member to dominate the discussion. Second, we noticed that the 4 minute and 36 second pre-visit planning section section (from 0:00 to 4:36) and the 3 minute and 14 second post-visit planning section of the GT-OSVE “Hospital to Outpatient Care Transition” video (from 12:01-15:15), which depicts a resident physician modeling pre and post-visit planning with a medical assistant and a care manager, can prompt trainees with numerous items to include in the transitions plan. As a result, we generally reserve the pre and post-visit planning sections of this GT-OSVE case for more novice teams of trainees, such as preclinical medical students, who are less likely than more advanced trainees to be familiar with the medical home setting. This reduces the length of the video to 9 minutes and 10 seconds (4:37 – 12:00 and 15:16-17:03). Third, we noticed that stopping the video at 12:00 (just after the conversation with Mr. Coleman and his daughter-in-law) works well since, when trainees viewed the end of the clinical encounter (15:16 – 17:03) before discussing the case as a team, they provided feedback that the office visit was over and that parts of the transitions plan had already been presented in the video before they had an opportunity to formulate their own transitions plan. We now play the last part of the clinical encounter (15:16-17:03) after the trainees present their transition plan. This approach has worked well since the final segment demonstrates that even a carefully crafted transitions plan might not succeed if the patient is not fully engaged in the plan. Finally, there may be instances in which more than one trainee from a single discipline is present (e.g. two physician assistant students). When this occurs, we encourage the “duplicate” trainee to consider attending to aspects of the case they might not often address (e.g. nutritional, psychosocial, or functional issues). We feel this approach helps increase trainees’ appreciation for the roles of other disciplines, even when trainees from other disciplines are not present, and also demonstrates that team members’ roles can often overlap.
Limitations of the resource and opportunities for improvement
The most important limitation of the GT-OSVE involves its videotaped format. Although the videotaped standardized patient encounter ensures lack of variability in the case from session to session, we are unable to reproduce the spontaneity of live interactions between trainees and the standardized patient. However, faculty can rewind the video to replay particularly noteworthy video clips and use this technique as a basis for discussion with their trainees. The GT-OSVE could also serve as a training video to create a live OSCE session dedicated to care transitions. We also recognize that the length of time (25 to 30 minutes) allotted for the team members to watch the video, formulate a transitions plan and present to a faculty preceptor may be longer than the time allotted during a real-world post-hospital primary care outpatient visit. We mention in our faculty debrief to trainees that they may have less time to conduct real-world transitional care visits, and we emphasize that best practices in care transitions taught by the GT-OSVE case can be an organizing principle to help them structure what can otherwise be chaotic office visits following hospital discharge. We also discuss in our faculty debrief to trainees the importance of other team members’ roles and working as a team to best meet the complex needs of vulnerable older adult patients in a timely fashion.
Permissions for Advance Preparation Assignment Materials
The GITT (Geriatrics Interdisciplinary Team Training) modules are freely available online from the Hartford Institute for Geriatric Nursing.
The online module entitled "Transitions of Care: Leaving the Hospital" is used with permission from Kathyrn Eubank, MD.