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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