This document describes the development of a new curriculum called the Acute Care for the Elderly Transition Program (ATP) aimed at improving medical residents' education around care transitions. The program involves second-year residents conducting in-home visits with two recently discharged patients to assess medication management, follow-up care, functional status, and social support. Initial implementation is planned for July 2011. Preliminary findings indicate the program will need orientation for residents and dedicated time on their rotation. Lessons learned so far show importance of resident buy-in, direct supervision, and evaluating impact on patient outcomes and learning.

1. Development of a Curriculum to Improve Care Transitions Education:
The Acute Care for the Elderly Unit Transition Program (ATP)
Franklin S. Watkins, MD
Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine
Statement of the Problem Description of the Program Findings to Date
 The process of care transitions from the hospital to the  Developed for second-year Internal Medicine residents at  First phase of home visits are planned for July 2011
outpatient setting is often underappreciated in medical WFSM (n=28)
education.  Pilot phase testing will continue through September
 Will take place during their inpatient geriatrics rotation in 2011
 During hospitalization, changes in cognitive function, our Acute Care for the Elderly Unit
physical function and the patient’s social support  In July 2011, a new class of second-year residents will
structure frequently occur.  Each second-year resident will perform a one-time home begin their academic year and will be the first class to
 Medicare beneficiaries have a high likelihood of hospital visit on two different patients discharged from their own participate in the fully implemented program
readmission within 30 days after discharge. patient panel.
 Given the above, specialized curricular attention is  The in-home visit will focus on the process of discharge,
required to bridge the gap to improve medical education emphasizing the following: Key Lessons Learned
in areas of discharge planning and optimization of care  Medication review  We will need to be proactive in reserving the necessary
transitions. afternoon times on the rotation for the learners’ at the
 Follow-up with primary care provider
beginning of the rotation.
 Assessment of functional status through review of the
Objective of the Program patient’s activities of daily living/instrumental activities of  There will need to be an introductory orientation to the
daily living program, its goals, and our expectations of this
 The Acute Care for the Elderly Transition Program (ATP) program as a required component of their rotation.
was developed to provide a novel, “real world” curriculum  Responsiveness of home health providers (nursing,
to teach care transitions. therapy)  Directly demonstrating the potential impact of the
program on both patient outcomes and residents’
 The program will be patient centered and case based.  Assessment of the home environment
understanding of the necessary components of an
 The goals of the program are:  Evaluation of the patient’s social support structure optimal discharge will be important in obtaining resident
 buy-in.
 To increase residents’ understanding of the Interns from WFSM will also participate in the program
importance of care transitions  Will provide peer feedback on both the resident’s  Direct supervision from an attending physician at the
 To emphasize the vital role residents’ play in patient discharge summary and the home visit initial visit in the rotation may help to optimize the
education at discharge learning environment and decrease the anxiety that
 Participants in the program will provide feedback on the some learners may have in both in home assessment
 To identify and address predictors of hospital home visit through an anonymous post-visit survey as well as peer evaluation.
readmission and suboptimal care transitions
This research has been supported through a challenge grant from the Picker Institute and the Gold Foundation