Bedside Teaching

Teaching Effective Discharge Transitions Strategies for the Older Adult in the Clinical Setting

The following teaching pearls are used by SHM’s Project BOOST team members to teach residents and students effective strategies for the transitioning of the older adult patient. Submit your own to: BOOST@hospitalmedicine.org .

“In order to optimize the discharge care transition, I ask my residents and students to imagine that he/she was going to see the patient in follow-up and what he/she would want to know for that visit.  It typically results in thinking about the following--

1. What was the primary problem that brought them to hospital?
2. What are the medication changes?
3. What monitoring is required for any of the therapies prescribed?
4. What tests/follow-up is pending?
5. What specific symptoms have I asked the patient to watch out for and have recommended immediate follow-up?
6. What are the on-going self-management concerns that the patient/caregiver may have?”

Lakshmi Halasyamani, MD
Vice President, Quality and Systems Improvement
Saint Joseph Mercy Health System a member of Trinity Health
Ann Arbor, Michigan

“Here are some about Transitions from Johns Hopkins Bayview:

All housestaff participate in rotation focused on providing safe transitions for vulnerable populations. In the curriculum, housestaff are taught to contact the next care provider, and to call all patients after discharge, with a visit to the home or facility of select patients. Housestaff all receive didactic teaching in a noon conference setting about the treachery at transitions, as well as how do complete discharge summaries in a way that facilitates smooth hand offs in care.  We have created a tool for evaluating the accuracy of discharge summaries that attending physicians utilize in providing feedback to residents on summaries they complete.

We also utilize an electronic sign-out system and the Hospitalist service provides orientation to that system during internship orientation. Case managers round with ward teams to help us learn about access to care issues post-discharge.

We also have a noon conference early in the year where someone from The Johns Hopkins Homecare Group educates housestaff about what services are available to assist in transitions.”

Steven J. Kravet, MD, MBA, FACP
Assistant Professor of Medicine
Deputy Director for Clinical Activity
Department of Medicine, Johns Hopkins Bayview Medical Center The Johns Hopkins University

Chief Medical Officer for Patient Safety and Quality Johns Hopkins Bayview Medical Center 

“When teaching medical students, I emphasize the seemingly small things they can do to have a big impact on care transitions.  Hearing the statistics on medication-related adverse events helps students realize the importance of obtaining an accurate home medication list even it requires spending extra time contacting family or the pharmacy.  Similarly, I explain the utility of a brief functional assessment by showing how it can quickly identify a need for home care services and/or determine the appropriate discharge venue. 

At the resident level, I stress the concept that good transitional care is by nature team-based.  A single physician cannot and should not perform the roles of the home care nurse, case manager, social worker and physical therapist but he or she must know when and how to involve these critical team members to ensure a safe discharge.  Most residents feel comfortable interacting with the inpatient interdisciplinary team but are less familiar with home care teams and it is important to review the indications for and payers of home health services.

For both learner levels, I underscore the importance of completing an accurate discharge summary.  Sadly, many students are assigned this task but with little guidance or supervision.  In fact, in a not-so-hidden-curriculum they may be discouraged from spending more than a few minutes completing a document that can ensure the appropriate handoff of key information to the next provider.  As one of my mentors said to me, â  Every discharge is an
admission to another provider.â    I tell students and residents to imagine
that they are on the receiving end of the discharge summary so that they include all of the information they would want in caring for that patient going forward.”

Karin Ouchida, MD
Clinical Instructor of Medicine
Montefiore Medical Center
Albert Einstein College of Medicine
Montefiore Medical Center Home Health Agency Home Care Medical Director

“I always try to tell my trainees that a discharge is a medical procedure every bit as important as a thoracentesis or an LP - it just has a higher complication rate than most other procedures that we perform.  If most of us spent the same amount of time preparing for and performing the discharge as we do for a thoracentesis - assessing for risk factors for poor outcomes and putting services in place when necessary, going over medication changes, self care recommendations, and follow up - our complication rates (readmissions, adverse drug events, or worse) would probably be reduced.  A poor discharge plan can undo every bit of good work that the team spent on the patient during their hospitalization, so doing this final procedure thoughtfully is well worth the effort.” 

Bree Johnston, MD MPH
Associate Professor of Medicine
UC San Francisco and SF VAMC