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Hospitalized Adult Care-Transitions/Home visits
*Do you ever wonder what happens to a patient after discharge from the hospital?
*Are you ever confused about what medications a patient is actually taking?
*Have you ever seen a patient in clinic who informs that he/she was hospitalized and you have no
idea what for and what was done?
Physicians are currently poorly trained in several important aspects of the discharge
process and have limited understanding of the transition to the next site of care. Patients
are also poor at negotiating these processes and may be rehospitalized, experience a
medication error, or miss much needed follow up due to the confusion that surrounds this
time. During this educational experience, you will receive this much needed education
and learn about some of the barriers in a quality transition from both the medical and
patient perspectives. Additionally, it is our hope that you will develop skills in
interprovider communication and patient hand-offs.
Objectives:
1. Students will identify the critical components of care transitions and the common
obstacles to quality of care in transitions from the inpatient setting.
2. Students will identify and describe the important role of healthcare providers in
assuring quality of care during transitions of care from the inpatient setting.
3. Students will perform thorough medication reconciliation between hospital discharge
and home/assisted living/skilled nursing facility.
4. Students will gain confidence and skills in inter-provider communication necessary for
quality care in transitions from the inpatient setting.
Student expectations:
Project:
Students will perform at least one NON-MEDICAL post-discharge visit to a patient they
cared for while in the hospital. The visit will be at a patient's home, in the nursing home,
in hospice, or in an assisted living facility. Students are encouraged to make this visit
with another student, a resident or a faculty member.
Timeframe:
 Home/nursing home/assisted living visit should be completed or scheduled within
the first 4 weeks of clerkship.
 A small group session discussion regarding issues of transitions in care will occur
on the Thursday afternoon of Intrasession.
Safety issues: Take a functioning cell phone and only visit during daylight hours. Be sure
to tell your team where you are going, when you are going and that you may need to call
them (the attending or resident) if any problems arise. Follow your gut reaction, if you
need to leave, leave. If you are uncomfortable with going to a home, consider a nursing
home visit. Consider going with another student. If the patient is unstable, call 911. Carry
your attending’s and resident’s pager number with you as well as the phone number for
the primary care provider or other transition provider (i.e. nursing home or hospice
physician) if you have other questions.
Patient selection recommendations:
1. Patient admitted and discharged during Hospitalized Adult Care clerkship within
the first four weeks, AND
2. At least one prior admission in the last year OR
3. One or more of the following diagnoses:
a. cardiac arrhythmia
b. heart failure
c. acute coronary syndrome (unstable angina or acute myocardial infarction)
d. diabetes mellitus which is poorly controlled or has complications
e. acute exacerbation of chronic obstructive pulmonary disease
f. hip fracture within the last year
g. HIV disease
h. active lung, breast, or colon cancer
i. chronic liver disease
AND
4. Lives within the local Denver area (30 mile radius).
5. Discharged to home, assisted living, nursing home, hospice, rehabilitation facility,
or skilled nursing facility.
6. Cooperative primary care provider OR does not have a primary care provider.
7. Age 65 years or older OR low literacy.
8. Has a telephone to confirm home visit follow-up.
Home visit goals:
 Compare the medications the patient was discharged with to those patient is
actually taking (medication reconciliation).
 See how the illness has progressed in the patient (education only).
 See how the patient negotiates obstacles despite any disabilities.
 Encourage the patient to make/keep follow-up appointment with PCP.
 Relay (NOT ANSWER) patient questions to follow-up provider.
Items to complete (see attachments for templates):
1. Read attached article (Coleman, The Care Transitions Intervention). This article
will help you understand the key issues you are likely to encounter on your home
visit.
2. Discharge phone call to PCP (you should do this for all patients you care for, not
just the home visit patient)
3. Discharge phone call to patient (you should consider doing this for all patients
you care for as well)
4. Home visit form (use as a guideline for visit)
5. Medication reconciliation form (turn in)
6. Follow-up form/phone call for provider (turn in)
Debriefing small group:
 Thursday during intrasession, small group format with clinicians


Discuss visit findings, surprises, problems, interactions, etc.
Discuss EBM article, Coleman, The Care Transitions Intervention