Intern Transitions of Care Curriculum Through Posthospital Home and Skilled Nursing Facility Visits

J Grad Med Educ. 2018 Aug;10(4):442-448. doi: 10.4300/JGME-17-00499.1.


Background : Transitions of care pose significant risks for patients with complex medical histories. There are few experiential medical education curricula targeting this important aspect of care.

Objective : We designed and tested an internal medicine transitions of care experience integrated into interns' ambulatory curriculum.

Methods : The program included 1-hour group didactics, a posthospitalization discharge visit in pairs with a home care nurse (cohort 1: 2011-2012; cohort 2: 2012-2013), and a half-day small-group visit to a skilled nursing facility led by a faculty member in geriatrics (cohort 2 only). Both visits had structured debriefings by faculty in geriatrics. For cohort 1, a quantitative follow-up survey was administered 18 to 20 months after the experience. For cohort 2, reflections were analyzed.

Results : Thirty-three of 42 second-year residents (79%) in cohort 1 who participated in didactics and a home visit completed the survey. Seventy-six percent (25 of 33) reported increased knowledge of interprofessional team members' roles and the discharge process for patients with complex medical histories. Seventy-nine percent (26 of 33) reported continued use of medication reconciliation at discharge, and 64% (21 of 33) reported the experience enhanced their ability to identify threats to transitions. Of cohort 2 interns, 88% (42 of 48) participated in the home visit and 69% (33 of 48) in the skilled nursing facility visit. Intern reflections revealed insights gained, incomprehensive discharge plans, posthospital health care teams, and patients' postdischarge experience.

Conclusions : An experiential transitions of care curriculum is feasible and acceptable. Residents reported using the curriculum 18 to 20 months after exposure.

MeSH terms

  • Aged
  • Clinical Competence*
  • Cohort Studies
  • Continuity of Patient Care*
  • Curriculum*
  • Faculty, Medical
  • Geriatrics / education
  • Health Knowledge, Attitudes, Practice
  • Home Care Services*
  • House Calls
  • Humans
  • Internal Medicine / education*
  • Internship and Residency*
  • Medication Reconciliation
  • Mental Processes
  • Patient Care Team
  • Patient Discharge
  • Patient Safety
  • Physicians
  • Problem-Based Learning
  • Skilled Nursing Facilities*
  • Surveys and Questionnaires