Transitional Care Curriculum for Medical InternsLinda DeCherrie, MD

Mount Sinai School of MedicineDepartment of Geriatrics and Palliative Medicine

Department of Medicine

Funding

Scholar of the Hartford Center of Excellence in Geriatric Medicine and Training

There are no other relevant financial relationships to disclose.

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

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

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

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”

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)

Curriculum Evaluation

• Prediction of patient function and cognitive status vs actual

• Pre-post test of knowledge

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

Future Goals

• Review of discharge summaries• Evaluation of patient handoffs• Course dissemination