PLANNING A CARE
TRANSITIONS CURRICULUM
2011 Annual Reynolds Meeting
Presenters
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Manuel A. Eskildsen, MD, MPH (Moderator) - Emory
Angela Botts, MD - Harvard/BIDMC
Linda DeCherrie, MD – Mount Sinai
Objectives
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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.
Outline
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Introduction (30 minutes)
Table Exercise (30 minutes)
Wrap-up with experience from presenters’ sites (30
minutes)
A Case
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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
Part #2
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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.
Questions
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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?
Care Transitions – Why do we care?
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Nearly 20% of Medicare
patients readmitted to
hospital within a month (Jencks
et al., N Engl J Med 2009)
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Patients are frequently
confused and dissatisfied by
the discharge process
Communication between
hospitalists and PCPs is
infrequent (Kripalani et al.,
JAMA 2007)
Models Shown to Work
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Care Transitions
Intervention – Coleman
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Centered on patient selfempowerment. Has four
pillars:
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Medication selfmanagement
Patient-centered discharge
record
Follow-up
Red flags
Significantly reduced
rehospitalization (Coleman
et al., Arch Int Med 2006)

Naylor model – Univ. of
Pennsylvania
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High-risk elders with
multiple chronic problems
Intervention
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NPs meet pts in hospital
and follow up with patients
and providers
Reduced readmissions,
days in hospital (Naylor et
al., JAMA, 1999)
The Training Imperative
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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?
AAMC Medical Student Geriatric
Competencies
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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
2010 Health Care Law
Patient Protection and Affordable
Care Act
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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
Community Based Care Transitions
Program
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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
A Growing Field
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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
Training in Care Transitions
Issues to Explore
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What learners to train?
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Settings?
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How to involve interprofessional teams?
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What do we know about effectiveness?
Challenges in “Comparative
Effectiveness” in Education
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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
Systematic Review
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“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
Study Highlights
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Participants:
involved 3rd and 4th year medical students
 53% involved residents
 16% involved interprofessional members
 63%
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Vast majority involved brief, self-limited
interventions
74% were in the classroom
Only 37% assessed learner-perceived benefit
How to Approach a Curriculum
Items to Consider when Thinking about
Your Curriculum
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Learning Objectives
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Learner Groups
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Setting
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Stakeholders to engage
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Possible challenges
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Evaluation
Learning Objectives
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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?
Learner Groups
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Medical students
Medical residents
Interdisciplinary?
The skill sets you are trying to create will be very
different
Setting
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Classroom
Small group
Hospital
Home care
Skilled nursing facilities
Stakeholders to engage
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Rotation director
Residency program director
If interdisciplinary:
 Who
runs training for nursing,
PT, etc?
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May be an opportunity to
perform some needs
assessment
Possible Challenges
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We’ll discuss this in small groups and in final
presentations
Evaluation
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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)
What Comes Next
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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