Tools and Strategies to Enhance Care Coordination

University of Chicago: EPOCH- Engineering Patient Oriented Clinic Handoffs

EPOCH: Engineering Patient Oriented Clinic Handoffs
The overall aim of this project is to redesign the end of year handoff process in an internal medicine residency clinic to become more patient-centered by incorporating the patient perspective and their suggestions into this process. To facilitate this redesign, our objectives for this project include: developing an understanding of the ways in which clinic patients perceive the end-of-year handoff process, developing an intervention for internal medicine training that supports a patient-centered end of year handoff, and evaluating the impact of this type of handoff on resident satisfaction, patient satisfaction, and patient outcomes. 

Improving Patient Rounds (IPR)

Improving Patient Rounds
The IPR project goal was to initiate patient- and family-centered care (PFCC) rounds in a general medicine unit in an adult-care inpatient setting. The project initially followed and measured the performance of one service team practicing PFCC Rounds on a general internal medicine unit with the aim of studying the impact on patient, family, staff, and doctors-in-training satisfaction; unit costs; residents’ and unit efficiency; quality; and safety. Educational effectiveness and team performance in PFCC Rounds were assessed through the use of the PFCC Rounds observation checklist; written evaluations by students, residents and attending physicians; and student debriefing during focus group sessions. Participating nursing staff were debriefed to ascertain their perceived benefits and challenges associated with their rounding with the medical team. Debriefing patients and families following the rounds encounters provided additional insights into the patient/family experience and the value of patient/family engagement during rounds.

Patient-Centered Training of Residents on a Medical Ward

Patient-Centered Training of Residents on a Medical Ward:
The patient-centered training project established, integrated patient-centered care teams of project faculty and nursing staff to direct residents on a dedicated patient-centered care ward. Dr. Frankel worked with project faculty, nurse teachers and hospital administration, with a focus on strategies for becoming successful change agents. Success of patient-centered care delivery will be determined by descriptive and patient-specific data. 

Improving Transitions of Care for Older Adults through Interdisciplinary Education for Medical Residents

Improving Transitions of Care for Older Adults through Interdisciplinary Education for Medical Residents
This project proposes to develop an Acute Care for the Elderly Unit Transitional Program (ATP) to teach optimal discharge planning and reinforce interdisciplinary communication through trainee home visits to vulnerable older patients after hospital discharge. The ATP will provide a “living laboratory” to enhance the medical trainees’ understanding of the importance of appropriate discharge planning, communication with the patient, family and caregivers, as well as impact a culturally and socioeconomically diverse population. Additionally, the ATP will meet the stated missions of both the Picker Institute and the Gold Foundation and will provide an innovative educational curriculum for continued measurement of important markers of medical residents’ knowledge, their attitudes regarding both transitions of care and interacting with older adults and their families, and patient outcomes. Successful hospital discharge and transitions of care can be considered Always Events, as all patients experience at least one (and often multiple) care transition following hospitalization.


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