Emory trains students on discharge tasks

Goal to develop DP skills

Health care systems nationwide increasingly are focusing on the care continuum and discharge process as a focal point for improving care, quality, and utilization efficiency. So why shouldn’t medical schools make it a priority to offer coursework related to the discharge process?

"This is an issue that has been identified in many health policy circles as one that is of great importance in terms of the overall health system," says Manuel A. Eskildsen, MD, MPH, CMD, medical director of long-term care at Wesley Woods Center of Emory University and an assistant professor of medicine in the division of geriatric medicine and gerontology at Emory University School of Medicine in Atlanta.

"Readmissions, poor patient communication, poor care coordination plague the American health care system," he adds.

As an educator, Eskildsen decided to do something about this problem.

"I identified it as something of interest and something we could do to improve patient care," Eskildsen says.

"We started this in 2009 with a goal of getting students to develop skills in discharge planning and communication," he adds. "The idea was to do this in a setting that merged some classroom teaching with real-life learning."

In speaking with peers around the country, Eskildsen has found enthusiasm for the idea of including care transition in medical education. The only question was, "What is the best way to do this?"

Elements of the curriculum

So Eskildsen designed a care transitions curriculum that deals with discharge planning and communication, and it’s a requirement for fourth-year medical students at Emory. Eskildsen and co-authors studied the use of the curriculum with 121 fourth-year Emory medical students who participated in a Senior Medicine rotation at either Grady Memorial Hospital, Emory University Hospital, or Atlanta VA Medical Center, all in Atlanta, between August, 2009, and April, 2010.1

The curriculum includes the following:

Discussion of care transitions issues.

This section began with a lecture on transitions of care and why they are important.

"We gave students an initial didactic for an hour on the general concepts of care transitions," Eskildsen says. "One of the nice things about the program is that it limits face-to-face time to the beginning and end of the course, so it saves a lot of time for faculty, as well as students."

The care transitions section includes a definition of different post-hospital discharge options, a list of methods for improving care transition safety, and an explanation of why care transitions are so complex among high-risk populations.1

Students had access to a discussion board that highlighted some care transition challenges through a case study with discharge summaries for a patient with congestive heart failure. An online discussion group gave students the opportunity to report on the strengths and weaknesses of the patient’s management. Then, students posted responses to at least two of their classmates’ reports on this board.1

Preparation of a discharge summary.

This section involves online instruction on how to prepare a discharge summary. It included a lecture online and the use of a discharge summary template based on a guide created by the Boston Association of Academic Hospitalists, which is offered in a toolkit from the Society of Hospital Medicine.1

"The discharge summary is an integral document to patient care, and that happens basically for all hospitalizations, so this form was pretty standard," Eskildsen says. "We tried to follow a formula that was relatively common in the discharge summary, and we tried to use a generic discharge summary that would be useful in a lot of places since these students will graduate and go on to residency programs in other places."

Students could select a patient they saw during their rotation and write a discharge summary for that patient. The summary was posted to the discussion board online, and students commented on each other’s reports. Faculty also gave feedback online.1

Medical students wrote discharge summaries for actual patients, but these summaries were not included in the patients’ charts, Eskildsen notes.

"We had them practice these skill sets and report back to the rest of the group in an online educational program called the Blackboard, which they all shared," Eskildsen says. "They removed any patient identifiers before putting them on the Blackboard for other students to review."

Making a post-discharge phone call to patients.

Each student was asked to make a post-discharge phone call within a week of discharge to the patient who was the subject of the discharge summary. This call was based on a discharge checklist adapted from "Ideal Discharge for an Elderly Patient: A Hospitalist Checklist," issued by the Society of Hospital Medicine.1

The checklist describes elements of a safe discharge plan and could be used in short reports that students filed on the Blackboard.

Students were asked to document patient communication/conversations they had with patients at discharge. In this format they could talk about problems with patients, Eskildsen says.

"At the end of the month, we all met and went over best practices and discussed the unifying process," Eskildsen says.

Investigators looked at several outcomes of the project. For one, they found that student satisfaction with the module was high. About 97.5% of the students rated it good or better, Eskildsen says.

"We also rated the quality of the discharge summaries they prepared and found that 90% of students met the appropriate criteria for their discharge summaries," he adds.

In addition, medical students’ self-confidence in handling discharge summaries improved, and their knowledge improved in the pre-test and post-test.

"They found a benefit in learning about this aspect of medicine," Eskildsen says. "One of the things they appreciated the most had to do with real-life skills like preparing the discharge summary."

Reference

1. Eskildsen MA, Chakkalakal R, Flacker JM. Use of a virtual classroom in training fourth-year medical students on care transitions. J Hosp Med. 2011;Oct. 3[Epub ahead of print].