![Page 1: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/1.jpg)
Transitional Care Curriculum for Medical InternsLinda DeCherrie, MD
Mount Sinai School of MedicineDepartment of Geriatrics and Palliative Medicine
Department of Medicine
![Page 2: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/2.jpg)
Funding
Scholar of the Hartford Center of Excellence in Geriatric Medicine and Training
There are no other relevant financial relationships to disclose.
![Page 3: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/3.jpg)
Origin of Curriculum
• Resident questions about what happens after discharge
• Faculty feedback that residents were not learning about transitions of care
• No education on discharge summaries• Hospital focusing on transitions of care• ACGME including transitions of care
![Page 4: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/4.jpg)
Transitions of Care Curriculum
• ½ day per week for 8 sessions – divided in 2 week blocks, 4 times a year
• 6-8 interns per block• 1 hour didactic• 2 hours post discharge visits in pairs, with
debriefing
![Page 5: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/5.jpg)
Curriculum
– Introduction to transitions of care/case of a Friday discharge
– Sites of discharge (Home, SAR, Acute rehab, Assisted Living etc)
– Handoffs– Discharge summaries (2 sessions)– Medication reconciliation– Models of transitional care– Transitional care programs at Mount Sinai
![Page 6: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/6.jpg)
Post-Discharge Visits
• Self-identified patients (discharged 1-10 weeks prior)
• Interns schedule themselves• Visits in pairs/triplets• Close proximity to hospital (in Manhattan only)• Review safety prior to visit• Discuss home visit etiquette• Provide “black bag”
![Page 7: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/7.jpg)
Post Discharge Visits
• Partner review discharge summary• Current symptoms• Medication review (look at bottles and where
kept…)• Current function• Current services• Physical exam• Documented in EMR and forwarded to PCP (non
billed visits)
![Page 8: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/8.jpg)
![Page 9: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/9.jpg)
Curriculum Evaluation
• Prediction of patient function and cognitive status vs actual
• Pre-post test of knowledge
![Page 10: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/10.jpg)
Obstacle
• Encourage interns to keep track of patients who may be appropriate for post discharge visits
• Encouraging interns to make sure they have the opportunity to see various sites of discharge
![Page 11: Transitional Care Curriculum for Medical Interns Linda DeCherrie, MD Mount Sinai School of Medicine Department of Geriatrics and Palliative Medicine Department](https://reader037.vdocuments.us/reader037/viewer/2022083119/5a4d1ad27f8b9ab059971bad/html5/thumbnails/11.jpg)
Future Goals
• Review of discharge summaries• Evaluation of patient handoffs• Course dissemination