Planning a care transitions curriculum

1. Planning a care transitions curriculum 2011 Annual Reynolds Meeting

2. Presenters • Manuel A. Eskildsen, MD, MPH (Moderator) - Emory • Angela Botts, MD - Harvard/BIDMC • Linda DeCherrie, MD – Mount Sinai

3. Objectives • Compare different models for training in care transitions • Know the key elements that could be included in a care transitions curriculum, and individualize these to different types of learners • Apply appropriate outcomes metrics to measure the success of their care transitions curricula.

4. Outline • Introduction (30 minutes) • Table Exercise (30 minutes) • Wrap-up with experience from presenters’ sites (30 minutes)

5. A Case • You are a member of a ward team caring for an 83-year-old male patient with multiple problems, admitted with CHF exacerbation. You diurese him well with IV furosemide, and in five days, he appears euvolemic and ready for discharge. • The resident manages discharge plan, writing prescriptions and talking to patient

6. Part #2 • Within ten days, your team is notified that the patient is readmitted to the hospital with another CHF exacerbation, and is back on the team. The patient says he was confused about medications and did not take his diuretic.

7. Questions • Could this have been preventable? • Could this have been prevented by better hospital procedures? Or do the housestaff require better training? • What could be done to train housestaff better?

8. Care Transitions – Why do we care? • Nearly 20% of Medicare patients readmitted to hospital within a month (Jencks et al., N Engl J Med 2009) • Patients are frequently confused and dissatisfied by the discharge process • Communication between hospitalists and PCPs is infrequent (Kripalani et al., JAMA 2007)

9. Models Shown to Work • Care Transitions Intervention – Coleman • Centered on patient self-empowerment. Has four pillars: • Medication self-management • Patient-centered discharge record • Follow-up • Red flags • Significantly reduced rehospitalization (Coleman et al., Arch Int Med 2006) • Naylor model – Univ. of Pennsylvania • High-risk elders with multiple chronic problems • Intervention • NPs meet pts in hospital and follow up with patients and providers • Reduced readmissions, days in hospital (Naylor et al., JAMA, 1999)

10. The Training Imperative • Care transitions haven’t traditionally been part of medical education/training • Growing awareness of need to improve care transitions outcomes • Evidence exists for some clinical models… but what about training doctors to do transitions better?

11. AAMC Medical Student Geriatric Competencies • Developed in 2007 • Eight different content areas (e.g., med management, cognitive disorders) • Related to transitions: • #25: communicate the key components of a discharge plan • #13: Identify and assess safety risks in the home environment, and make recommendations to mitigate these

12. 2010 Health Care Law

13. Patient Protection and Affordable Care Act • Starting in 2012, will reduce payments to hospitals to account for preventable readmissions • Promotes the growth of accountable care organizations (ACOs) by letting them share in cost savings • Pilot program for bundled payments across continuum of care

14. Community Based Care Transitions Program • Also part of the 2010 ACA • Provides funding to test models to improve care transitions for older patients • Joins: • Hospitals with high readmission rates • Community Based Organizations

15. A Growing Field • Growing awareness of need to improve care transitions outcomes • Care transitions haven’t traditionally been part of medical education/training • Evidence exists for changing systems… but what about training doctors to do transitions better? • Large organizations stepping into void

16. Training in Care Transitions

17. Issues to Explore • What learners to train? • Settings? • How to involve interprofessional teams? • What do we know about effectiveness?

18. Challenges in “Comparative Effectiveness” in Education • Most of what’s innovative is not published • Our best teachers and curriculum designers aren’t necessarily researchers • “Gold standard” research models can seldom be applied

19. Systematic Review • “A Systematic Review of Curricular Interventions Teaching Transitional Care to Physicians-in-Training and Physicians” • Buchanan and Besdine, Acad Med 2011 • Analyzed interventions between 1973 and 2010 • Ultimately, found 25 unique interventions

20. Study Highlights • Participants: • 63% involved 3rd and 4th year medical students • 53% involved residents • 16% involved interprofessional members • Vast majority involved brief, self-limited interventions • 74% were in the classroom • Only 37% assessed learner-perceived benefit

21. How to Approach a Curriculum

22. Items to Consider when Thinking about Your Curriculum • Learning Objectives • Learner Groups • Setting • Stakeholders to engage • Possible challenges • Evaluation

23. Learning Objectives • Care transitions education is very likely to be skills based --- less knowledge based • Craft active learning objectives: • What skill do you want your learners to have after they’re done with your curriculum? • Perform medication reconciliation? • Communicate with families? • Dictate discharge summaries?

24. Learner Groups • Medical students • Medical residents • Interdisciplinary? • The skill sets you are trying to create will be very different

25. Setting • Classroom • Small group • Hospital • Home care • Skilled nursing facilities

26. Stakeholders to engage • Rotation director • Residency program director • If interdisciplinary: • Who runs training for nursing, PT, etc? • May be an opportunity to perform some needs assessment

27. Possible Challenges • We’ll discuss this in small groups and in final presentations

28. Evaluation • Very important to know what is/isn’t working in curriculum • Important to turn your work into scholarship • Possible measures: • Satisfaction • Knowledge assessment • Direct measurement of skills • Proxy measurements (confidence in skills)

29. What Comes Next • We’ll meet in three groups • You’ll use a template to come up with a plan for designing a curriculum • Share it with your group