Department of Medicine physicians (Drs. Jennifer Lee, Fran Ganz-Lord, Judy Tung and Tara Bishop) have published a pivotal paper on patient care transitions in Academic Medicine (November 2013). Based at an outpatient primary care practice, Weill Cornell Internal Medicine Associates (WCIMA), the study evaluated findings from a resident-staffed early post-discharge program. A goal of any academic medical center is to ensure a patient's safety after discharge from the hospital. This often includes visits and follow-up care at outpatient practices that are staffed by residents-in-training. However, residents may not always be comfortable managing patient care transition.
To address this concern, as well as to ensure safety for patients who are being discharged from the hospital, the authors of the paper designed a quality improvement initiative in 2011. This initiative involves patient visits termed, "bridge visits." A unique appointment template was created and added to the outpatient electronic health record in order to guide residents-in-training during the visits. After the visits, both residents and patients completed surveys regarding their satisfaction with the new program. Survey results included the good news that the majority of patients felt the program reinforced their discharge medication instructions, and they did not mind seeing an interim physician for expedited post-discharge care. The paper proposed "next steps" for the formulation of a new curriculum for residents that will enhance their learning experience in the area of patient care transition – a national quality goal.
For the past two years, Drs. Lee and Ganz-Lord, in conjunction with colleagues from both the Division of Hospital Medicine and WCIMA, have been working with NewYork-Presbyterian Hospital to improve patient care transitions, especially for medically high-risk patients. This latest advancement represents a win-win collaboration not only for Weill Cornell and NewYork-Presbyterian, but for residents and patients alike.
An Assistant Professor of Medicine in the Division of Hospital Medicine, Dr. Lee serves as Quality and Safety Officer for the Department and as Co-Chair of the Quality Improvement/Safety Committee. Dr. Fran Ganz-Lord is an Assistant Professor of Medicine and on staff with WCIMA. Dr. Judy Tung is the Acting Chief of the Division of Internal Medicine and Medical Director of WCIMA. Dr. Bishop is an Assistant Professor working with WCIMA, Department of Medicine, and the Division of Outcomes and Effectiveness, Department of Public Health. The novel study included collaboration with staff members of NewYork-Presbyterian who work in the areas of patient safety and social work.
Dr. Lee, along with staff from the Division of Hospital Medicine including the division's Chief (Dr. Arthur Evans) and Co-Chief (Dr. Sean Pickering), as well as faculty from the Department of Public Health and the Hunter School of Nursing, have published yet another paper on care transition. Appearing in the November edition of the Journal of Hospital Medicine, it addresses the need to reduce hospital readmissions while simultaneously ensuring patient safety during care transitioning. A multi-method study, it is entitled: "The Patient Care Circle: A Descriptive Framework for Understanding Care Transitions."
Results from the study emphasized that care transitions are optimized by a well-coordinated multi-discipline support system, known as the "Patient Care Circle." Through interdisciplinary and patient interviews and focus groups, Issues related to hospital readmissions were also identified and classified.