An Interprofessional Course on Improving Older Adults’ Care Transitions

for Advanced Learners

Mitchell T. Heflin, MD, MHSEleanor S. McConnell, PhD, RN, GCNS, BC

Durham VA Geriatric Research, Education & Clinical Center

Duke University

Objectives

• Describe a course for interprofessional students on improving transitions of care– Objectives for the experience– Educational philosophy– Design and implementation– Evaluation

• Future directions

Why a focus on interprofessional education & transitions ?

• 1 in 4 transitions are complicated and require a return to a higher-intensity care setting

• Patient perspective– Patient and caregiver

frustration– Adverse health events

• Health system perspective– Duplication of tests and services– Increased costs– Patient dissatisfaction

Patients Patients and and

CaregiversCaregivers

Challenges: Education

“Once in practice, health professionals areasked to work in interdisciplinary teams,often to support those with chronicconditions, yet they are not educatedtogether or trained in team-based skills.”

Health Professions Education:A Bridge to Quality. IOM 2003

Physical therapists

Social workers

PhysiciansAssistants

Nurses

Physicians

Pharmacists

Patients and

Caregivers

Educational Philosophy

REALWORK!

Course descriptionDate Theme Core Content

Sept 8 It takes a village Teamwork

Sept. 22 Understanding the challenge:

Problems in transition

Oct. 6 Designing solutions QI methods

Oct. 20 Bridging the gaps & setting the bar

Settings and systems

Nov. 3 Breaking down barriers: Interprofessional communication

Nov. 17 Improvement in action Patient-Provider communication

Dec. 1 Closing the loop Feedback from stakeholders

Target Problem: Congestive Heart Failure

• Common, important problem• Large evidence-base• Institutional interest and activity• Core issues:

– Teamwork– Transitions– Quality

Project work

Date Theme Core Content Project workProject work

Sept 8 It takes a village Teamwork Form teamsForm teams

Sept. 22 Understanding the challenge Problems in

transitionInterview patientsInterview patients

Oct. 6 Designing solutions QI methods Research innovationsResearch innovations

Oct. 20 Bridging the gaps & setting the bar

Settings and systems

Select outcomesSelect outcomes

Nov. 3 Breaking down barriers

Interprofessional communication

Design innovationsDesign innovations

Nov. 17 Improvement in action Patient-Provider

communicationTest innovationsTest innovations

Dec. 1 Closing the loop Feedback from stakeholders

Present proposalPresent proposal

Evaluation

Peer and self assessment of team work

Pre- and PostSelf-efficacy

QI proposal rubric

Learner EvaluationCore Content Project workProject work

Teamwork Form teamsForm teams

Problems in transition

Interview patientsInterview patients

QI methods Research innovationsResearch innovations

Settings and systems

Select outcomesSelect outcomes

Interprofessional communication

Design innovationsDesign innovations

Patient-Provider communication

Test innovationsTest innovations

Feedback from stakeholders

Present proposalPresent proposal

Observe teams, form project team

Interview pts, Identify problems

Design QI proposal

Final Course Grade

Learner Evaluation 2008-2009

• 22 students from 6 professions– Medicine, Nursing (ABSN & APN), PA,

Pharmacy, PT, Nutrition• Self efficacy:

• 2008: Significant gains in 3 of 4 domains• 2009: Significant gains in all domains

• Teamwork– High ratings by peers

• Project work

Student Self-Efficacy Gains- Fall 2009

3.112.7333.27

4.074.244.134.38

0

1

2

3

4

5

IP Care Transitions QI Cultural Comp

Mea

n Se

lf-Effi

cacy

Rati

ng

Pre Postp< 0.01 for all categories.

ProjectsDischarge Instruction for Patients with Congestive

Heart Failure

HEART FAILURE ACTION PLAN

Name: DOB: MRN My target weight is:

Symptoms GREEN: What I should do

YELLOW: What I should do.Call provider at:______________________

RED: What I should doCall provider immediately:Day phone:________________Night Phone: _______________

Usual amount of swelling

Increased amount of swelling in ankle or up to shin

Increased swelling up to knee area

Weigh yourself each morning immediately after you get up.

Weight from ________ to _________NO WEIGHT GAIN

Weight from _______ To _______WEIGHT gain of 2-3 lbs overnight or 5 lbs in 1 week

Weight from______ To _______ WEIGHT change of more than 5 lbs in one week

No shortness of breath with usual activity

Increased shortness of breath with usual activity

Shortness of breath at rest

Provider Action No change in treatment

May increase fluid pill

May refer you to ED or clinic

Shortness of Breath

Each morning check for swelling

Morning weight after Discharge ____ lbx

My Heart Failure Passport

Successes

Through interactive, multi-modal learning, students:– Engaged in real teamwork– Examined real transitions– Identified and proposed solutions to real

problems

REALWORK!

Challenges

• Teaching and learning:– Finding the right balance between faculty and

students – Coordinating didactics and project work– Accounting for viewpoints of all professions– Including a broader array of professions

• Turning real work into real improvements

REALWORK!

Next steps

• Continue IP faculty development and teaching• Reach more students in more places

– Geriatric Education Resource Hub

• Collaborate with faculty, learners and clinical partners on QI initiatives– Transitions in cognitively impaired patients

• Mobilize expertise and resources to teach patients and caregivers