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►► FAST FORWARD►►

ROUNDS

A Transitional Care Curriculum for Medical Students and Medical Residents

FACILITATOR GUIDE

Developed by the Division of Geriatrics and Gerontology

Weill Cornell Medical College/NY Presbyterian Hospital in collaboration with the Primary Care Residency Program and with Support from the Donald W. Reynolds Foundation

June 2007

Index

Page(s)

Overview 3-4

Learning objectives 5

Assessment and evaluation 5

Intended audience(s) 6

Instructor qualifications 6

Timeline and Materials 7-8

General Strategies for Getting Started 9-10

Strategies for successful implementation 11-13

List of references 14-15

Citation 16

Copyright information 16

Feedback form 17-18

Appendices

Discharge summary evaluation form and instructions

Small group discussion points

FFR game chance event cards

I. Course overview

Purpose: Fast Forward Rounds (FFR) is an innovative transitional care curriculum for medical students and medical residents. Transitional care is defined as the set of actions necessary to ensure the seamless coordination of care as patients transfer between different locations or levels of care. A successful transition between care settings requires timely communication of a comprehensive care plan between sending and receiving providers, appropriate patient education and medication reconciliation.[1] Without adequate cross-site communication and patient preparation, adverse events including medication errors occur.[2] Unfortunately, medical trainees are not equipped with the knowledge and skills necessary to ensure safe transitions.

Older adults are often under the care of several providers for multiple chronic illnesses and are particularly vulnerable to poor outcomes following hospitalization. To address the needs of both the geriatric population and the Cornell medical trainees, the Cornell Geriatrics faculty created a curriculum which asks students to “fast forward” in time, anticipate patients’ medical and psychosocial needs upon discharge from the hospital, and utilize an interdisciplinary team approach to safely transitioning patients to the next care setting.

Course description: FFR uses multiple teaching modalities to highlight the key components of transitional care. Comprised of two 90-minute sessions, the course combines interdisciplinary lectures, an educational DVD, small-group discussion, a written assignment, an interactive board game, and a web-based participant manual. The course targets medical students beginning their clinical rotations and utilizes medical residents as adjunct faculty.

Session one begins with an overview of the transitional care literature. Next, learners view a DVD showing a hypothetical clinical vignette in which a resident physician hurriedly discharges a patient recently admitted for an acute myocardial infarction. The DVD highlights the resident’s inattention to transitional care. She fails to provide clear follow-up instructions, an explanation of the important changes in his medications, or referrals for critical home care services. The DVD is paused briefly to allow participants to predict the patient’s post-hospital course. When the video resumes, the resident is shown re-admitting the patient to the hospital with congestive heart failure. Over the two sessions, interdisciplinary panelists representing nursing, social work and physical therapy demonstrate how a team-approach to the patient depicted in the video would have ensured a safer transition from hospital to home and likely would have prevented his re-hospitalization. The interdisciplinary panel covers the following topics: Medicare/Medicaid reimbursement, home care services, functional assessment, rehabilitation options, and housing options for older adults.

Equipped with these competencies, all of which are essential to delivering good transitional care, learners are given a discharge summary assignment in which they must develop a comprehensive care plan for a hospitalized patient and submit it prior to the second session. In session two, participants receive written and verbal feedback about their discharge summaries from geriatrics faculty in a small-group setting (see appendix for “Discharge Summary Evaluation Form” and suggested small group discussion points). The small groups become teams for the FFR board game, an exercise that reinforces the major content domains presented in the course.

Resident training session: At Cornell NY Presbyterian Hospital, the primary care residency has four to six members in each class. Third year primary care residents served as adjunct faculty in the course. Their responsibilities included delivery of large group lectures (transitional care or housing options for older adults), reviewing and evaluating the discharge summary assignment and facilitating a small group discussion. Both second and third year residents completed a four hours training session taught by the course creators and core geriatrics faculty. The training session covered all of the content described above for the student sessions in addition to reviewing small and large group teaching strategies (adapted from the Stanford Faculty Development Program[3]).

Time requirement: The FFR curriculum requires 3 hours of learner contact with the medical students. At Weill Cornell Medical College, the course was integrated into the 12-week internal medicine clerkship starting July 2006. The first FFR session occurred during week 4 and the second session occurred during week 8 of the 12-week rotation. Sessions were timed to ensure students’ familiarity with the inpatient medical service and allow sufficient time to complete the assignment and implement the transitional care concepts learned.

Findings: Quantitative and qualitative pilot data demonstrate that the course can be feasibly implemented, is well received by students and residents, and is highly effective.

II. Learning objectives

The purpose of the Fast Forward Rounds course is to teach medical trainees how to effect safe transitions when caring for hospitalized older adults. The educational goals of the course are to improve participants’ transitional care knowledge, attitudes and behaviors. The learning objectives emphasize critical transitional care competencies.

Student learning objectives

• Participants will report improved understanding of:

o the roles of interdisciplinary team members (nursing, social work, physical therapy, occupational therapy)

o home care and community resources

o the variety of care settings and housing options for older adults

o the importance of performing a thorough functional assessment

o Medicare and Medicaid reimbursement policies for various home, community, and housing services

• Participants will report increased proficiency in:

o Performance of functional assessment

o Communication with physician and non-physician providers (e.g., home health care workers, nurses, and other interdisciplinary team members)

o Education of patients, families and caregivers

o Medication reconciliation to prevent medication errors

o Management of the discharge process of complex patients

Resident learning objectives

• In addition to the student learning objectives listed above, resident learners will report

o Increased understanding of the transitional care literature

o Improved competency in teaching in small and large group settings

o Enhanced confidence in managing the discharge process of complex patients

III. Assessment and evaluation

Assessment tool: A 35-item evaluation tool was created to assess participants’ knowledge, attitudes and behaviors within the domains of transitional care, functional assessment, interdisciplinary team, community resources and reimbursement. Designed by the Weill Cornell Medical College Geriatrics faculty, the instrument was used in a pre-post-test design and revised based on qualitative participant feedback.

In order to track performance on the assessment tool by individual as well as by group, we assigned each learner a randomly-generated number and asked them to record this number on their tests. Residents completed a slightly longer version of the student test. The resident pre-test was given at the resident training session and each participant completed a post-test at the end of the second student session in which he/she participated.

IV. Intended audience

The Fast Forward Rounds curriculum targets third year medical students beginning their clinical rotations. Third-year clerks were chosen because they work intimately with residents in caring for hospitalized patients and routinely assist in the discharge process by completing discharge paperwork and preparing patients for transitions.

Senior primary care medical residents comprised a second group of learners. Because they work intimately with students on the inpatient medical service, the course creators felt they comprised an ideal group to act as role models for students and effect culture change. As described above residents underwent a separate training session and then served as adjunct teachers of the course.

The Fast Forward Rounds course is appropriate for any group of medical trainees who care for patients along the continuum of care e.g., in an acute care hospital, a sub-acute rehabilitation facility, a skilled nursing facility or in a home-care setting. Diverse groups of learners who could benefit from the curriculum include medical students during their clinical years, resident physicians, geriatrics fellows, physician assistants, and trainees within the disciplines of nursing and social work.

V. Instructor Qualifications and Responsibilities

Course facilitators: Fast Forward Rounds course facilitators should have expertise in geriatrics and/or chronic illness care in order to establish credibility with the intended audience(s) and address any content questions that may arise. Instructors need not have previous expertise in transitional care but should review the transitional care literature before implementing the course. Course facilitators should also have experience in large and small-group facilitation and development and administration of assessment tools.

Expert panelists: The Fast Forward Rounds course requires an interdisciplinary panel representing the fields of nursing, social work, and rehabilitation. These panelists serve as adjunct teachers and are extremely critical to the success of the educational intervention. At Weill Cornell Medical College our expert panel included an inpatient geriatrics nurse practitioner, an outpatient geriatrics nurse practitioner, a physical therapist who was also the Director of Rehabilitation at a sub-acute rehabilitation facility, a social worker with inpatient and outpatient geriatrics experience and primary care internal medicine residents. All of the panelists were experienced in delivering large-group lectures and facilitating small group discussion.

VI. Timelines and Materials

Session 1

|Topic |Presenter |Time (minutes) |

|Course overview |Course facilitator |10 |

|Pre-course test | |10 |

|Transitional care |Resident |10 |

|DVD and discussion |Course facilitator |10 (video) |

| | |10 (discussion) |

|Medicare/Medicaid |Social worker |15 |

|Home care services |Nurse practitioner |10 |

|Community resources |Social worker |10 |

|Instructions for assignment |Course facilitator |5 |

|Materials |

|Sign-in-sheet |

|White board and pens to record large group discussion points |

|Fast Forward Rounds DVD, projector and screen |

|Laptop computer |

|Speakers (may be needed for adequate sound quality with DVD) |

|Pre-course assessment tool |

|Pencils |

|Participant handouts |

|Agenda with website information |

|Instructions for written assignment |

|Medicare/Medicaid handout |

|Panelist handouts: agenda |

Session 2

|Topic |Presenter |Time (minutes) |

|Functional assessment |Nurse practitioner |10 |

|Rehabilitation |Physical therapist |10 |

|Housing options |Course facilitator |10 |

|Small group discussion | |20 |

|Game | |25 |

|Post-course test | |10 |

|Review of test answers (optional) |Course facilitator |5 |

|Materials |

|Sign-in-sheet |

|Post-course assessment tool |

|Pencils |

|Written assignments and completed feedback forms |

|List of small-group assignments |

|Signs designating Groups 1 to 4 |

|Laptop computer with power point presentations |

|Projector and screen |

|Fast Forward Rounds game board, team markers, chance cards |

|Handouts for students: none |

|Handouts for panelists: agenda |

VII. General Strategies for “Getting Started”[4]

Integrating any new educational intervention into a pre-existing curriculum requires careful planning. The following is a list of basic elements for creating and implementing a transitional care program at your institution. Although obvious differences will emerge between schools and training programs the following suggestions will prove helpful in most instances.

1. Review the literature

Knowing your topic well makes it much easier to sell to course directors and administrators. Although the topic of transitional care may not seem like a pressing educational item for some course directors they often respond when they understand the breadth of the topic and its broad implications for the health and wellbeing of patients. Transitional care lends itself to teaching about a wide variety of topics including:

- Patient-centered/humanistic medicine

- Medication reconciliation and avoidance of medical errors

- Health economics

- Chronic illness care

- Systems-based care

2. Review competencies addressed by a Transitional Care Curriculum

For example:

- AAMC and John A. Hartford Foundation Consensus Conference- Minimum Geriatric Competencies for Medical Students 2007: addresses competencies in Medication Management, Self-care Capacity, Palliative Care and Hospital Care for Elders.

-ACGME : transitional care curriculums clearly cover competencies in Patient Care and Systems-based Practice categories.

-JCAHO regulations for medication reconciliation covered

3. Choose a learner level

The concepts covered in a transitional care curriculum are probably best targeted at students in 3rd and 4th years or at the resident level. However an introduction to the basics of transitional care in their 1st year Introduction to Doctoring course is also a consideration

4. Choose a venue

The course in which a transitional care curriculum would be imbedded should be chosen carefully. A lot will have to do with the climate of the institution, willingness to give time to the material and support of the faculty. The obvious medical school target would be the medical clerkship where the day to day work involves knowledge of many of the principles of transitional care. Using real patients and real scenarios are always richer than didactics. This material can be taught from an in-patient focus (medicine clerkship) or an out-patient focus (post-hospital discharge visits in a home care program or ambulatory practice).Combining both arenas are ideal but complex logistically.

5. Obtain ’Buy In’

The buy in of course directors and administrators is critical. Some suggestions when approaching them for support are:

-Be excited about the material

-Show how the course will meet required competencies for their learners

-Demonstrate how this may reduce medical errors and legal problems

for the institution-JCAHO “special project”

-Come to the discussion with a clear plan

-Emphasize patient-centered care and humanism

6. Evaluate the depth and availability of faculty

Transitional care projects are a natural venue for teaching team. The more exposure learners have to a multidisciplinary faculty the richer the experience. However, it is crucial that learners see medical role models engaging in the process and stressing the importance of good transitions.

7. Evaluate your financial support

8. Develop the curriculum

The curriculum can be crafted from existing courses such as Fast Forward Rounds or can be the compilation of ideas from multiple institutions. It is important to use active learning techniques and avoid didactics as much as possible. Have set learning objectives-keep them simple. Role playing, videos, home visits, creating and discussing discharge summaries, small group discussions etc. will add to the experience for learners.

10. Develop an evaluation tool

Evaluating you intervention right from the beginning is very helpful and important for course directors. Knowing early on what is working and what is not can allows for quick adjustments and better learner experiences

11. Anticipate Barriers

The obvious barriers will be about obtaining time in already packed course, finding space, engaging busy faculty, convincing learners that this is important for their medical careers, financial support etc. Problems specific to each institution will also exist and will require creative solutions.

VII. Specific Implementation Strategies for Fast Forward Rounds

Space/room requirements:

The Fast Forward Rounds curriculum is ideally delivered to groups of 20 learners or less. In Session 1, the room should be arranged such that students can view projector screen (for the power point presentations and the DVD) and direct their attention to each panelist.

In Session 2, the students’ chairs should be clustered into 4 small groups but initially aimed at the front of the room so that students can view the projector screen (for power point presentations) and focus on each speaker. The Fast Forward Rounds game board should be laid out ahead of time on a flat surface. We used a table in the middle of the room. After the presentation portion of the session, students will turn their chairs inward to form a circle for the small-group discussion. These groups comprise the teams for the Fast Forward Rounds game. During the game, the teams of students should be able to visualize both the projector screen (game questions and answers) and the actual game board.

Set-up

Allot approximately thirty minutes for set-up prior to each session.

Participant manual

At Weill Cornell Medical College we initially gave each student a printed and bound copy of the participant manual. Based on faculty observations and qualitative feedback from participants, we decided to convert the manual to a web-based format. This allowed for participant self-study and made it easier for faculty to edit the manual. Based on student feedback, however, we did provide some printed handouts for students to be able to follow certain presentations e.g., Medicare and Medicaid reimbursement.

Assessment tool

The initial assessment tool was shortened for the student learners based on participant feedback and the time constraints of each session. Our preliminary data suggest that depending on the previous exposure of the learners to geriatrics topics, some of the multiple-choice knowledge or content-based questions may require modification to increase their level of difficulty.

Game

The Fast Forward Rounds board game reinforces the major content domains presented in the course in a fun and interactive way. The game requires the following materials: the game board, team markers, chance cards (see Appendix for printable version of Chance event cards), and the Powerpoint file which contains an electronic version of all of the game questions.

Before session 2, participants should be randomly divided into four teams. The room should be organized with the chairs arranged in circles before the students arrive. A paper sign can be used to delineate each group and its members. We found it helpful to project a slide with the group lists at the front of the room. For the game, we created a large laminated board that could be placed flat on a table. For team markers, we used common geriatrics-friendly items that could be easily moved around the board (e.g. a tube of extra-protective cream, a roll of paper tape.) One of the course facilitators manages the electronic version of the game and read the questions aloud to the group.

At the start of the game, each team must select one discharge summary to represent their group. The chosen discharge summary should be the one they believe to be the most comprehensive care plan.

The object of the game is for teams to get out of the “Hospital” and reach the area labeled “Home.” In order to be successfully “discharged from the hospital,” each team must answer one question related to their chosen discharge summary. For example, a team might be asked, "Does your discharge summary contain instructions for alarm signs and symptoms that the patient should report to a physician?" Once each team answers a “Hospital” question correctly, they can begin to progress up the board towards “Home.” To do so, they must answer questions stemming from the following 4 categories represented by different colored squares on the board: rehabilitation, home-care, community resources and comprehensive care planning. The “comprehensive care planning” category includes questions about transitional care, poly-pharmacy and health literacy.

Teams may also land on a 5th type of square on the board called a “chance” square. On this type of square, teams pick up a CHANCE card. These cards will not have questions but will reveal brief positive or negative clinical scenarios that emphasize the critical components of comprehensive discharge planning. For example, a positive EVENT card reads, "On your recommendation your patient who was admitted with a fall goes to her neighborhood senior center and joins a tai chi class.  Move ahead 1 space." The negative chance cards reveal adverse events adapted from the literature on adverse outcomes following hospital discharge.[5] An example would read, "You discharged your patient who was admitted with pneumonia before he could be evaluated by physical therapy.  He was re-admitted with a broken hip after falling in his bathroom. Go back 1 space."

Once a team reaches the area labeled “Home,” they must answer a case-based question that encourages students to practice their physician-patient communication skills. A typical case-based question might read, “A 65-year-old man is admitted with pneumonia and treated with 3 days of intravenous antibiotics. He is being discharged on one oral antibiotic that he must take for 11 more days. What discharge instructions would you give him?” Each team member can contribute to the group’s final answer. The facilitators judge the answer for completeness and accuracy. For the example above, the team would have to explain the name of the new antibiotic, its purpose, how to take it, the duration of treatment, potential side effects and who to contact if warning signs and symptoms should develop.

To maximize time efficiency and ensure all teams get sufficient play time, we used the team numbers to delineate the order of play, i.e. Team 1 goes first, Team 2 second, etc. We allowed each team to answer one question before moving on to the next team. If a team failed to give the correct answer, they remained on that square and in the next round received another question from the same content area.

References

Transitional Care:

Boockvar et al. Patient Relocation in the 6 Months after Hip Fracture: Risk Factors for Fragmented Care J Am Geriatr Soc 2004;52:1826-1831.

Bowles et al. Patient characteristics at hospital discharge and comparison of home care referral decisions. J Am

Geriat Soc 2002;50:336-342.

Coleman et al. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Jour of Integrated Care 2002;2:1-8

Coleman et al. Preparing Patients and Caregivers to Participate in Care Delivered Across Settings J Amer Geriatr Soc 2004;52:1817-1825.

Coleman and Berenson Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care Ann Intern Med 2004;140:533-536.

Coleman and Boult. Improving the quality of transitional care for persons with complex care needs. J Amer Geriatr Society 2003;51:556-557.

Crotty et al. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Am J Geriatr Pharmacother 2004(4): 257-64. (Abstract only)

Forster et al. Adverse Events among Medical Patients after Discharge from Hospital CMAJ 2004;170(3):345-9.

Forster et al. Adverse Drug Events Occurring following Hospital Discharge J Gen Intern Med 2005; 20:317-323.

Forster et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital Ann Intern Med. 2003;139:161-167.

Landro, Laura. Hospitals Combat Errors at the 'Hand-Off' The Wall Street Journal. June 28, 2006.

Naylor et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA 1999;281:613-620.

Naylor, Mary D. A Decade of Transitional Care Research with Vulnerable Elders. Jour of Cardiovascular Nursing 2000;14(3):1-14.

Rich et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure NEJM 1995;333:1190-5.

Schnipper et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006;166:565-571.

Stewart, S and Horowitz, J. Home-based intervention in congestive heart failure: Long-term implications on readmission and survival. Circulation 2002;105:2861-2866.

Polypharmacy

Colley and Lucus. Polypharmacy: The cure becomes the disease. J Gen Intern Med 1993;8:278-283.

Drake and Romano. How to protect your older patient from the hazards of polypharmacy. Nursing June 1995:34-39.

Forster et al. Adverse Drug Events Occurring following Hospital Discharge J Gen Intern Med 2005; 20:317-323.

FAQs for the 2006 National Patient Safety Goals. Accessed online July 24, 2006.

Harris, Gardiner. Report finds a heavy toll from medication errors. The NY Times July 21, 2006.

Preventing Medication Errors: Quality Chasm Series. catalog/11623.html Accessed online July 24, 2006.

Safran et al. Prescription Drug Coverage and Seniors: Findings from a 2003 National Survey. Health Affairs April 19, 2005. cgi/content/abstract/hlthaff.w5.152v1 Accessed online on July 24, 2006.

Vik et al. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother 2004;38:303-12.

Williams, Cynthia. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-24.

Health literacy

Institute of Medicine. Health literacy: a prescription to end confusion. April, 2004. Report accessed online July 25, 2006 at: 3775/3827/19723/19726.aspx

Marcus, Erin. The Silent Epidemic –The Health Effects of Illiteracy. N Eng J Med 2006;355:339-341.

Safeer and Keenan. Health literacy: The gap between physicians and patients. Am Fam Physician 2005;72:463-8.

Sorrell, Jeanne. Health literacy in older adults. Journal of Psychosocial Nursing 2006;44:17-20.

Sudore et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc 2006;54:770-776.

Wolf, et al. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165:1946-1952.

Suggested citation

Ouchida, K, LoFaso, VL, Capello, C. Fast Forward Rounds: A transitional care curriculum for medical students and medical residents Facilitator Guide. Division of Geriatrics and Gerontology, Weill Cornell Medical Center, NY Presbyterian Hospital, 2007.

Copyright information

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Peer feedback form

Thank you for taking the time to help us continue to improve Fast Forward Rounds! The information on this form will be kept confidential. Please feel free to contact us with any additional questions or comments.

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Fast Forward Rounds facilitator guide

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Fast Forward Rounds powerpoint presentations

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Home care resources

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Additional comments:

Contact us:

Karin Ouchida, M.D. Veronica LoFaso, M.D.

kouchida@ vel2001@med.cornell.edu

718-920-6722 212-746-1417

Appendix

Instructions for Discharge Summary Evaluation Form:

1. Briefly review the discharge summary to get a sense of the patient’s hospital course

2. Check the box if the student included that particular item e.g. does the list of diagnoses reflect relevant past medical history and diagnoses made during hospitalization

3. If the form doesn’t have a space for the item, point that out so the student understands the limitations of the various hospital forms (e.g. allergies, communication of the plan to the receiving provider)

4. In the comments section, provide constructive feedback to the student – what information was helpful or would have been helpful to the patient’s receiving provider if he/she received this discharge summary?

5. Write the student’s name on the evaluation form and return all evaluation forms and discharge summaries to (insert designated facilitator)

Checklist for evaluating discharge summaries:

□ Complete list of diagnoses

□ Clear, succinct summary of hospital course

□ Relevant test results and labs

□ Complete list of medications (including dose, route, frequency)

□ Allergies

□ Clear and appropriate diet instructions

□ Clear and appropriate activity instructions

□ Follow-up instructions including dates, providers’ names and contact information

□ Instructions about warning signs and symptoms and how to notify a physician

□ Communication of the plan to the receiving provider(s)

□ Communication of the plan to the patient and/or caregiver(s)

|Comments: |

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Suggested Small Group Discussion Points

✓ What are the limitations of the discharge summary?

✓ What happens after you fill out the discharge summary?

✓ How can you use the discharge summary as part of a comprehensive care plan and communication strategy?

✓ Have you ever communicated care plan to post-hospital provider? If yes, was it by phone, paper, email? What was the response?

✓ Discuss what happens specifically when someone goes to a rehabilitation or a skilled nursing facility

✓ What are the key components of good “transitional care” and how can you include them on the discharge summary?

✓ What we looked for when evaluating your discharge summaries:

❑ Discharge diagnoses (including comorbidities and complications)

❑ HPI

❑ Exam (are pertinent findings listed, is there any indication of mental status?)

❑ Tests and results

❑ Patient course and complications (if you were admitting this patient to the rehab facility would you have enough information?)

❑ Medications (doses, timing, duration, indication for prn meds?)

✓ Communication

❑ How do you know if the plan was communicated to the patient or caregiver(s)

❑ How do you know if the plan was communicated to the receiving care provider(s)?

| | |Your patient admitted with new atrial fibrillation is going home on coumadin. |

|On your recommendation, your patient who was admitted with a fall goes to her | |You call his PMD and ensure he has follow-up of his INR. Move forward 1 space.|

|neighborhood senior center and joins a tai chi class.  Move forward 1 space. | | |

|You take the time to educate your patient with chronic constipation on an | |Your patient with end-stage dementia has several pressure sores. You discuss |

|appropriate diet prior to discharge. Move forward 1 space. | |with the social worker the need for an alternating pressure mattress at home. |

| | |Move forward 1 space. |

|You discover your patient admitted with hyperglycemia eats a lot of sweets at | |You reconciled your patient’s medication list and changed her inpatient |

|home because he is lonely and depressed. You refer him to a medical model | |Protonix back to Prevacid on the discharge summary. The Prevacid was on her |

|adult day program where they can monitor his blood sugars, regulate his diet | |drug formulary so she saved a lot of money. Move forward 1 space. |

|and screen him for depression. Move forward 1 space. | | |

|You included the urine culture organism and drug sensitivities on your | |You made a packet for the rehabilitation facility that included a copy of your |

|discharge summary for the nursing home. When the patient complained of dysuria| |discharge summary, pertinent labs and studies. The patient arrived at the |

|and the urinalysis was positive, the nursing home doctor was able to start an | |facility at 4pm on a Friday but the admission took only 30 minutes because of |

|antibiotic based on the previous culture results. Move forward 1 space. | |the information you provided. Move forward 1 space. |

|Your patient with a seizure disorder is started on an antibiotic known to alter | |Your patient was admitted with new onset congestive heart failure, and no follow-up |

|levels of anti-epileptic drugs. No monitoring was performed in or out of the | |was arranged at discharge. The patient was re-admitted for CHF due to non-adherence |

|hospital and she has a generalized seizure shortly after discharge. Anti-epileptic | |to therapy. GO BACK 1 SPACE (10) |

|drug levels are found to be sub-therapeutic. GO BACK 1 SPACE (2) | | |

|Your patient had a known allergy to a specific drug but was given that drug despite | |Your patient was prescribed very high doses of steroids and developed a generalized |

|protesting and developed a pruritic rash. GO BACK 1 SPACE (4) | |anxiety reaction. He was not informed of this potential side effect, nor was it |

| | |addressed at a follow-up visit. GO BACK 1 SPACE (13) |

|Your patient developed symptomatic hyperkalemia after being started on | |Your patient was prescribed narcotics with no education about constipation or |

|spironolactone. No lab monitoring was done for 2 weeks. GO BACK 1 SPACE (6) | |co-prescription of a stool softener. The patient returned several days later to the |

| | |ER with severe constipation and vomiting. GO BACK 1 SPACE (14) |

|Your patient was discharged on antibiotics and developed diarrhea. She was not | |Your patient was taking warfarin and was discharged with inappropriate dosing and no |

|informed of signs/symptoms to report and returned to the ER 3 days later with | |follow-up of the INR. The patient fell and developed a subdural hematoma. The INR |

|pan-colitis due to C difficile. GO BACK 1 SPACE (17) | |was found to be 10. GO BACK 1 SPACE (28) |

|Your patient was sent home on an increased dose of diuretics without any evaluation | |Your patient was sent home on IV vancomycin for endocarditis. No drug levels were |

|of gait stability. He developed postural hypotension and fell at home. GO BACK 1 | |monitored and the patient developed a serious rash and renal failure. GO BACK 1 |

|SPACE (54) | |SPACE (71) |

*Numbers in parentheses refer to the adverse events listed in appendix of Dr. Forster’s 2003 Annals of Internal medicine article (Forster et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital Ann Intern Med. 2003;139:161-167.)

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[1] Coleman, EA and Boult C. Improving the quality of transitional care for persons with complex care needs. J Amer Geriatr Soc. 2003;51:556-7

[2] Forster et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2993:138:161-167.

[3] Stanford University Clinical Teaching Program ()

[4] Written by Dr. Veronica LoFaso for SGIM National Meeting April 2008, Pittsburgh, PA

[5] Forster et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital Ann Intern Med. 2003;139:161-167.

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FFR Game Positive Chance Events

FFR Game: Example Negative Chance Events

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