The Portal of Geriatrics Online Education

25 HOSP: Communicate a discharge plan

25. Communicate the key components of a safe discharge plan (e.g., accurate medication list, plan for follow-up), including comparing/contrasting potential sites for discharge.

PATCH (Palliative Access Through Care at Home) Match: Virtual Training in Geriatric Palliative Home Visits

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
1
Abstract: 

PATCH Match is a competency-based, virtual training experience in geriatric palliative home care, accessible online and suitable for a wide range of health care professionals such as medical and nursing students, residents, fellows, and others. Through simulated home visits, PATCH Match aims to teach learners to recognize that visiting frail older adults in their homes provides a more comprehensive understanding of patients, and that palliative care can be delivered effectively on home visits. Learners visit up to 4 homebound elderly patients, and face decisions about assessment and treatment relating to issues in: dementia with acute agitation, dementia with pain, falls at home, and transitions of care (from hospital to home). 

Educational objectives: 

After "visiting" the PATIENT WITH DEMENTIA AND PAIN, learners should be able to:

  1. recognize atypical ways in which pain may present in patients with advanced dementia,
  2. assess pain in patients with advanced dementia,
  3. identify options for pain treatment in patients with advanced dementia, and
  4. discuss the caregivers' role in caring for patients with advanced dementia and pain.

After "visiting" the PATIENT WITH DEMENTIA AND AGITATION, learners should be able to:

  1. recognize that agitation can be a symptom of emotional or physical distress in patients with advanced dementia,
  2. explain how the environment can have a positive or negative effect on agitated patients with dementia,
  3. describe behavioral and communication strategies for managing agitation in patients with dementia.

After "visiting" the PATIENT WITH RECENT FALLS, learners should be able to:

  1. report common causes of falls at home,
  2. name components of a falls risk assessment,
  3. recognize that most falls are the result of multi-factorial causes,
  4. explain how medications may contribute significantly to falls, and
  5. identify strategies for falls prevention that maximize patients' function and minimize injury.

After "visiting" the patient recently discharged from the hospital (TRANSITION OF CARE), learners should be able to:

  1. recognize problems that occur in the transition from hospital discharge to home relating to medication use and communication about hospital care and follow up,
  2. explain the teach-back method of communicating with patients and families, and
  3. discuss how a multi-disciplinary team and social support system may be engaged during transitions from hospital to home
Date posted: 
Fri, 11/12/2010
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Fri, 11/12/2010
Contact Person/Corresponding Author:



Suggested Citation:
, and . PATCH (Palliative Access Through Care at Home) Match: Virtual Training in Geriatric Palliative Home Visits. POGOe - Portal of Geriatrics Online Education; 2010 Available from: https://pogoe.org/taxonomy/term/173

Texas Tech Medcast Reynolds Geriatric Step 2 CK Test Prep Series 09-10: No. 38--Determined Diana

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
1
Abstract: 

The Step2CK Test Prep Series was created by fourth-year students at the Texas Tech School of Medicine in Lubbock as a project of the fourth-year geriatrics rotation. It was developed as part of the Reynolds Geriatrics Podcast series, which is supported in part by an Aging and Quality of Life grant from the D.W. Reynolds Foundation. The episodes in this series are based on questions that have geriatrics content and patient vignettes from the 2009 Step2CK Sample Exam. 

Educational objectives: 

This episode is based on Question 38 of the 2009 Step2CK Sample Exam.

Learning Objectives: the third-year medical student studying for the Step2CK exam should be able to:

  • List the requirements for informed consent
  • Describe the patient's right to autonomy and refusal of care
  • List the basic guidelines for determining patient competency
  • Describe the difference between beneficence, non-malfeasance and autonomy
Additional information/Special implementation requirements or guidelines: 

For more information on the series, go to http://www.ttuhsc.edu/som/fammed/ttmedcast/gerseri....

Date posted: 
Fri, 08/12/2011
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Tue, 01/22/2013
Contact Person/Corresponding Author:



Suggested Citation:
, , , , , , and . Texas Tech Medcast Reynolds Geriatric Step 2 CK Test Prep Series 09-10: No. 38--Determined Diana. POGOe - Portal of Geriatrics Online Education; 2011 Available from: https://pogoe.org/taxonomy/term/173

Fast Forward Rounds - An Innovative and Effective Transitional Care Curriculum

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Abstract: 

Fast Forward Rounds (FFR) is a 3 hour course created to teach medical students how to safely transition patients between different health care settings. The course combines interdisciplinary lectures, an interactive DVD with a clinical vignette, small-group discussion, and a team-based learning exercise. FFR emphasizes the use of functional assessment to identify patients at risk for poor discharge outcomes, promotes interdisciplinary collaboration to link vulnerable patients with appropriate services, reviews Medicare/Medicaid reimbursement, and teaches students to develop comprehensive care plans. The course evaluation tool assesses participants' knowledge, attitudes and behaviors within the domains of transitional care, functional assessment, interdisciplinary team, community resources, and reimbursement. For more information about the FFR course at Cornell University, go to www.cornellaging.com/medical/.

Educational objectives: 

After completing the Fast Forward Rounds course, learners should possess greater knowledge of transitional care, improved attitudes toward promoting safe transitions and increased performance transitional care behaviors. Participants will report improved understanding of: - the roles of interdisciplinary team members (nursing, social work, physical/occupational therapy) - home care and community resources - the variety of care settings and housing options for older adults - the importance of performing a thorough functional assessment - Medicare and Medicaid reimbursement policies for various home, community, and housing services Participants will report increased proficiency in: - Performance of functional assessment - Communication with physician and non-physician providers (e.g., home health care workers, nurses, and other interdisciplinary team members) - Education of patients, families and caregivers - Medication reconciliation to prevent medication errors - Management of the discharge process of complex patients

Additional information/Special implementation requirements or guidelines: 

Please see the facilitator guide for details regarding implementation requirement and guidelines.

Publications from, presentations from, and/or citations to this product: 

Citations: Ouchida, K, LoFaso V, Capello, C, Ramsaroop, R, and Reid, MC Fast Forward Rounds: An Effective Method for Teaching Medical Students to Safely Transition Patients Across Care Settings J Am Geriatr Soc 2007;55:s185 Presentations Northeast Group on Educational Affairs Annual Educational Retreat June 2007 Society of General Internal Medicine Annual Conference April 2008

Date posted: 
Thu, 09/24/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Mon, 09/17/2012
Contact Person/Corresponding Author:



Suggested Citation:
, and . Fast Forward Rounds - An Innovative and Effective Transitional Care Curriculum. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/173

Fourth-Year Medical Student Care Transitions Curriculum

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Abstract: 

The Emory Care Transitions curriculum is a monthlong module directed toward third or fourth year medical students, which makes students aware of the important issues surrounding this topic, and teaches students valuable skills, such as the preparation of discharge summaries. 

Educational objectives: 

Upon completion of the curriculum, students will be able to:

  1. Enumerate and discuss the discharge options available in a particular case scenario;
  2. Write a complete discharge summary, given a patient being discharged from the hospital; and
  3. Communicate the elements of a safe discharge plan, including a medication list and follow-up plans.
Additional information/Special implementation requirements or guidelines: 

In order to achieve the educational objectives, the module is divided into three parts.

  • Part I: Didactic sessions on the most important issues surrounding care transitions, followed by discussion of a hypothetical case, which is presented through two discharge summaries. The documents entitled "Care Transitions Case for Discussion" and "Care Transitions Slide Presentation" belong to this section.
  • Part II: A tutorial on the preparation of discharge summaries, which students can use to prepare their own discharge summary, for one of their own patients. The documents "Discharge Summary Tutorial" and "Discharge Summary Template" are part of this section.
  • Part III: Students will perform a post-discharge phone call for one of their patients, using a checklist from the Society of Hospital Medicine. "Safe Discharge Checklist" and "Post Discharge Call" are used for this part.

The course consists of activities involving direct patient care, classroom lectures and discussion, as well as online lectures and collaboration. For online learning activities, students and faculty members collaborate using Blackboard educational software. For all three of the above activities, students discuss their work with their classmates using Blackboard software. This module could alternatively be taught with up to four face-to-face small group sessions, instead of using online collaboration.

One unique aspect to the curriculum is that it is delivered through in-person and online learning activities. Students meet with the instructor in person at the beginning and at the end of the curriculum, with intervening learning activities performed through online tutorials and collaboration using Blackboard educational software. Alternatively, the course could be delivered all in person, with up to four face-to-face sessions.

Date posted: 
Wed, 01/13/2010
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Thu, 07/05/2012
Contact Person/Corresponding Author:



Suggested Citation:
Fourth-Year Medical Student Care Transitions Curriculum. POGOe - Portal of Geriatrics Online Education; 2010 Available from: https://pogoe.org/taxonomy/term/173

Discharge Summary Feedback

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Other Learning Resource Type: 
Product Information
Abstract: 

This product was created to help teach medical students how to write a thorough discharge summary. The Pearl card is supplemented by an interactive web module that gives the learner a short concise review of hospital admission orders and care. The checklist outlines features that should be included in the discharge summary. This can be used by the student as a reminder of what to write or it can be used by a faculty member who is evaluating a discharge summary created by a learner. The questionnaire is an easily-completed form which should be filled out by a provider who is reading (and using) a discharge summary written by a learner. It can be returned to the student after completion to help them understand how to improve. These materials help the learner to understand why each element of a discharge summary is needed. Use of the documents along with the web module "closes the loop" on the educational process for the learner.

Educational objectives: 

OBJECTIVES: Upon completion the learner will be able to: 1. List the adverse outcomes of hospitalization 2. Describe the aging physiologic changes that predispose older patients to adverse outcomes. 3. Assess the patients; goals of hospitalizations care preferences & discharge criteria. 4. Describe and contrast POA-HC and guardian and how they relate to inpatient care. 5. Describe the causes of iatrogensis and prevention. 6. Describe the control of blood pressure and the affect of hospitalization on blood pressure in the elderly. 7. List ways to improve oral intake in hospitalized elderly. 8. Describe best practices in daily inpatient care in the elderly. 9. Perform best practices in completion of state of the art discharge summary that improves transitions of care

Additional information/Special implementation requirements or guidelines: 

You will need an internet connection to use the web module.

Date posted: 
Wed, 09/23/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 09/23/2009
Contact Person/Corresponding Author:



Suggested Citation:
and . Discharge Summary Feedback. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/173

Transitions in Care Curriculum for Medical Students

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Abstract: 

This curriculum was developed to educate medical students about how to improve hospital discharges. The curriculum is focused on peri-discharge communication with the patient and follow-up provider. Additionally, the student is expected to make a post discharge visit to the patient's home or care center to do medication reconciliation. The standardized Medication Discrepancy Tool by Eric Coleman is used as a tracking mechanism. A pre and post curriculum confidence survey helps the students and educators see what the student has learned. The students are tested on their ability to develop a discharge plan on their final exam.

Educational objectives: 

Objectives:

  1. Students will identify the critical components of care transitions and the common obstacles to quality of care in transitions from the inpatient setting.
  2. Students will identify and describe the important role of healthcare providers in assuring quality of care during transitions of care from the inpatient setting.
  3. Students will perform thorough medication reconciliation between hospital discharge and home/assisted living/skilled nursing facility.
  4. Students will gain confidence and skills in inter-provider communication necessary for quality care in transitions from the inpatient setting.
Additional information/Special implementation requirements or guidelines: 

The curriculum has been implemented within the Hospitalized Adult Care clerkship to give students the experience of discharging the patient and discovering how the patient functions at home.

Publications from, presentations from, and/or citations to this product: 

CDIM Annual Meeting 10/08

Date posted: 
Fri, 08/07/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Mon, 07/02/2012
Contact Person/Corresponding Author:



Suggested Citation:
and . Transitions in Care Curriculum for Medical Students. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/173

Minimum Geriatric Competencies - Medical Students, Emergency Medicine Residents and IM-FM Residents

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Abstract: 

“Competency-based education prepares trainees to perform tasks occurring within the context of practice. Teaching to competency differs from traditional instruction. It begins by stating the performance we expect of our graduates in the workplace and then designing the medical school curriculum to prepare our learners to achieve that performance through deliberate practice in applying the underlying knowledge, skills, and attitudes.” As the elderly population in America "booms," medical education must address the issue at hand and modify their curriculum and teaching practices to give credence to geriatric principles within medical care. It is imperative for many reasons (socially, financially, etc.) that we ensure competency in the care of older adults for every physician.

To help achieve this lofty goal, the Minimum Geriatric Competencies have been developed for Medical Students and are being developed for multiple residency disciplines. The files within this product showcase the Medical Student Minimum Geriatric Competencies (published in Academic Medicine, May 2009), Internal Medicine – Family Medicine Resident Minimum Geriatric Competencies (published in Journal of Graduate Medical Education, Sept 2010), and Emergency Medicine Resident Minimum Geriatric Competencies (published in Academic Emergency Medicine, 2010).

Additional information/Special implementation requirements or guidelines: 

The "Side-by-Side" document shows the progression from Medical Student Competencies into resident education.

The documents included with this product are:

  • Emergency Medicine Resident Competencies
  • Medical Student Competencies
  • IM-FM Resident Competencies
  • Side-by-Side Competencies Comparison
Publications from, presentations from, and/or citations to this product: 

Leipzig R M, Granville L, Simpson D, Brownell Anderson M, Sauvigne K, and Soriano R P. (2009). Keeping granny safe on July 1: Consensus on minimum geriatric competencies for graduating medical students. Academic Medicine, 84, 604–610. Also available at http://journals.lww.com/academicmedicine/Fulltext/2009/05000/Keeping_Granny_Safe_on_July_1__A_Consensus_on.17.aspx

Hogan T M, Losman E D, Carpenter C R, Sauvigne K, Irmiter C, Emanuel L, and Leipzig R M. (2010). Development of geriatric competencies for emergency medicine residents using an expert consensus process. Academic Emergency Medicine, 17(3), 316-324. Also available at http://dx.doi.org/10.1111/j.1553-2712.2010.00684.x

Williams B, et al. (2010). Medicine in the 21st century: Recommended essential geriatrics competencies for Internal Medicine and Family Medicine residents. Journal of Graduate Medical Education, 2(3), 373-383. Also available at http://www.jgme.org/doi/abs/10.4300/JGME-D-10-00065.1

Date posted: 
Thu, 01/01/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 06/08/2011
Contact Person/Corresponding Author:



Suggested Citation:
Minimum Geriatric Competencies - Medical Students, Emergency Medicine Residents and IM-FM Residents. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/173

Geriatric Health Care Systems Test

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Abstract: 

This is a multiple choice test used as a pre- and post-geriatrics rotation to assess knowledge and skill in planning health systems use for patient care, such as home care, long term care, hospice, etc.

Educational objectives: 

One of the goals of the one month geriatrics residency rotation is to have residents develop competency in providing care and referring patients across systems of care and understand systems-based geriatrics practice. The rotation provides clinical experience in care of older adults in acute, subacute, long term care, ambulatory, and home care settings with exposure to a multidisciplinary team model of care. Seminars include a session on health care systems and transitions of care. At the end of the one-month rotation residents are expected to attain competency in the following areas: 1. Medical evaluation of the older adult in the emergency room setting When is it appropriate not to admit to the hospital? What can be done to insure a safe discharge from the emergency room? 2. Insurance considerations when planning for hospital discharge What does insurance cover? What are the limitations of the available programs? 3. End of life care What are the goals of care? What services are available for patients and families? 4. Caregiver stress How do we help families plan for the long care of their loved ones? What support is available for families and physicians in making these plans? 5. Community care What kinds of support services are offered in the community after hospital discharge? Who pays for long- term care and how is it arranged?

Additional information/Special implementation requirements or guidelines: 

pre- and post-test

Date posted: 
Thu, 09/24/2009
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 01/23/2013
Contact Person/Corresponding Author:



Suggested Citation:
Geriatric Health Care Systems Test. POGOe - Portal of Geriatrics Online Education; 2009 Available from: https://pogoe.org/taxonomy/term/173

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