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Bridging care transitions: findings from a resident-staffed early postdischarge program
Jennifer I Lee1, Fran Ganz-Lord, Judy Tung
1Dr. Lee is assistant professor, Division of Hospital Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York. Dr. Ganz-Lord is assistant professor, Weill Cornell Internal Medicine Associates, Department of Medicine, Weill Cornell Medical College, New York, New York. Dr. Tung is associate professor, Weill Cornell Internal Medicine Associates, and acting chief, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York. Dr. Bishop is assistant professor, Weill Cornell Internal Medicine Associates, Department of Medicine, and Division of Outcomes and Effectiveness, Department of Public Health, Weill Cornell Medical College, New York, New York. Ms. DeJesus is director, Department of Social Work and Care Coordination, New York-Presbyterian Hospital, New York, New York. Ms. Ocampo is improvement manager, Division of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York. Ms. Tinghitella is improvement manager, Division of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York. Dr. Scott is vice president, Division of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York.
A quality improvement program for early postdischarge follow-up enhanced patient safety and resident education. This initiative improved medication adherence and reinforced discharge instructions for better care transitions.
Area of Science:
- Quality Improvement
- Medical Education
- Patient Safety
Background:
- Academic medical centers face challenges in post-discharge patient follow-up.
- Resident physicians may lack confidence in managing care transitions.
Purpose of the Study:
- To design and evaluate a quality improvement program for early post-discharge follow-up (bridge visits) in a resident primary care outpatient practice.
- To assess the program's impact on patient safety and resident learning.
Main Methods:
- A quality improvement program was implemented in 2011.
- A unique appointment template was added to the electronic health record to guide residents.
- Residents and patients completed post-visit and post-program surveys.
Main Results:
- 31.0% of residents reported medication reconciliation issues and 25.9% adherence problems.
- 47.4% of residents felt the program changed their discharge practices.
- 95.7% of patients reported reinforced discharge and medication instructions.
Conclusions:
- Early post-discharge programs are valuable for patient safety and experiential learning in medical education.
- The findings will inform the development of a formal curriculum in care transitions for residents.
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