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Authors Institution
Kara Bischoff MD
Jayson Morgan MD
Yimdriuska Magan
Harry Hollander MD
Michelle Mourad MD
Sumant Ranji MD
University of California, San Francisco School of Medicine
Postgraduate Education
Teaching Transitions of Care through Analyzing Readmissions

Nearly one in five Medicare patients is readmitted within 30 days of discharge from the hospital. Many medical centers have developed multifaceted programs aimed at improving transitions of care and reducing readmissions.
Residents have not been fully utilized in these efforts; literature suggests improvements are needed in how we educate and employ residents in efforts to decrease readmissions.
By engaging residents in analyzing their patients’ readmissions, and providing individualized feedback, we aimed to hone residents’ practice of transitions of care. 
Summary of Work


• Residents receive formal education about safe discharge practices.
• Thirty days after completing a wards month, residents receive a list of patients discharged under their care who were readmitted to the hospital within 30 days.
• Using a structured tool, residents collect follow-up information about at least four of their patients. Residents identify systems issues and reflect on how this review will impact their future clinical practice.
• Residents receive formal feedback on their work and are evaluated on their ability to execute a safe transition of care from inpatient to outpatient setting.
Summary of Results
       Residents identified factors that they believed contributed to readmissions. These divided into the following categories.

Discharge counseling for patients: “In the future I will be sure to include written instructions about what to do if symptoms return/worsen and when to return to the ED, and not simply verbal instructions.”

Patient education about medications: “The patient went home with poor understanding of her medications … Med teaching may need to happen many times before it sinks in, but it needs to continue to happen until a patient understands.”

Involving the PMD and family: “We could have involved the PMD more up front or made a point of contacting the caregivers to get input…  I will put more effort into getting information from all parties participating in my patient’s care.”

Motivating patients to care for themselves: “His case is a reminder of how brittle our patients with exacerbation-prone illnesses can be, and also the enormously important role that proper self-care plays in keeping patients out of the hospital.”

Advance care planning: “The patient’s goals of care rapidly evolved during these two admissions… This reminds me how important it is to engage family members and the patient throughout the hospitalization as the patient’s condition evolves in order to provide the most appropriate care.”

Medication availability upon discharge: “I will try to ensure med availability prior to discharge.”

Timely outpatient follow-up: “This case highlighted the importance of close follow-up - our team identified that this patient’s poor baseline functional status put her at high risk for complications at the time of her transition to home. Fortunately, early appointments with her outpatient providers allowed her persistent/recurrent infection to be identified early.”

PCP communication: “With complicated discharges, always make sure to complete a thorough verbal sign-out to the PCP if possible!”


Percentage of residents who agree or strongly agree.

• 72% of residents reviewed more than the required number of cases (>4).
• 55% of residents spent more than the allotted time (>5 hours).
Take-home Messages

• We describe an educational innovation that actively engages residents in analyzing transitions of care.
• Residents identified many important issues that arise around the time of discharge.
• Residents believe this experience will improve their practice, is worth the time and effort it requires, and should be required for all residents.
• Our results suggest that this is a valuable exercise that fills a current educational gap.
• Further study is needed to evaluate if intended changes in practice occur and if residents observations can fuel system changes.
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Summary of Work
Summary of Results
Take-home Messages
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