TRANSITIONS OF CARE TEACHING PROJECT

Donald W. Reynolds Foundation Dedicated to Geriatrics Education

Teaching Geriatrics broadly so that care of the older patient is improved

Emphasis on Quality of Life Interprofessional Education

ObjectivesUpon completion of the TCTP regarding care and transitioning of the hospitalized older adult, students should be able to:Relate general geriatric principles of care Recite at least three potential pitfalls that can occur with hospital dischargeExplain critical minimum steps that need to occur for safe transition from hospital to skilled care Cite examples of common rehabilitation management issuesDiscuss benefits of interdisciplinary team care for older adultsAppraise contributions that can be made from the other healthcare disciplines (other than one’s own) for improved geriatric careDescribe impediments to interdisciplinary discharge planning communicationDemonstrate ability to manage clinical problems in this unfolding case

Geriatric Competency Domains Cognition

Falls

Atypical presentation

Health care planning

Defining care goals

Medication management

Hospital care

Self-care capacity

Orientation The interactive case system is designed to engage teams composed of

individuals from multiple disciplines in an extended web-based unfolding case exercise.

At the start of each segment of the unfolding case, each discipline receives

information specific to the typical role of that discipline.

Team members from other disciplines each receive different, discipline-specific information, thus mirroring real life.

To succeed, team members must share their clinical information through the system’s electronic chart and then problem solve together.

Learners will be provided instruction, through the case system, on addressing functional impairments, quality of life issues, behavioral issues, and family concerns for a simulated older female patient as she is followed through her hospitalization for a hip fracture, transition of care to a skilled care facility, and the subsequent skilled care stay.

Case

Collaboratively “manage” the care of an elderly woman through three episodes of care (modules of case).Week one/inpatient moduleWeek two/module transitioning from hospital to a skilled nursing facility (SNF)Week three/module in SNF as the patient is preparing to be discharged home

Teams

Senior Nursing students Medical students in Internal Medicine sub-I Pharmacy students Social Work student OT students PT students

Tasks 1: Chart 2: Learn from

other disciplines. Interact!

3: Review questions, read and ask to learn more

4: Complete answers as able

Grading

Pass-fail Determined by proctor in your

discipline Proctor will be viewing interactions

“Adequate interaction with team” You are expected to log on twice daily

and contribute at least 2 substantive posts or replies daily

Module Closing Dates (2015)

Module Close Date (11:59 PM)

1 Tuesday, November 3rd

2 Tuesday, November 10th

3 Tuesday, November 17th

Feedback session

Set optional time to come give feedback at the end of session.

Evaluations must be completed for you to pass. Online or in person

Access case on Blackboard https://bb.kumc.edu/ Log in using your KUMC user name and

password

Blackboard support: dmehling@kumc.edu

Task 1: Enter clinical data, “Chart”

?

Wiki is where you will chart

Chart color by discipline Nursing Purple Medicine Red Pharmacy Green OT Orange PT Brown SW Blue

Please chart by color

Social work BLUE Pharmacy GREEN Nursing PURPLE Medicine RED OT ORANGE PT BROWN

Tasks 2 & 3: Review questions, review with teammates and read to learn

Task 2: Interact with other disciplines to learn what they know and how they approach care

Task 4: Complete answers to questions as able

“Outside my profession's usual practice”

If able, would like you to try to answer questions, even if it is challenging.

Answers to test questions

Final answers to be submitted, then, after midnight of the due date, the acceptable answers to these questions will appear.

Time Management, Review Meet team/introductions Decide responsibilities Each unit lasts 1 week – use time well

Number of questions Add clinical material to case Answer questions by midnight of the next

Monday.

Questions for your team How will you engage team members who are

absent today? How about engaging team members who are

not active during ongoing case work? How will your team communicate? Defined dates for entering clinical information? Dates for entering individual answers? How will you decide about group answers? Who will enter group answers?

Ground Rules

You may use any method of communication you like Case forum is required for team dialogue We will evaluate based on what we see in forum If external dialogue is created

Document discussion inside the case website (like a chart) Use any published resources you like You may meet as a team, in person or in

cyberspace You may not discuss case content with people

outside your team (e.g. learners doing this before or after).

Goals of proctoring Help team with team process

Guide team approaches to interaction Provide feedback on process work and outcomes Counseling, perhaps chasing down team members

who are not contributing satisfactorily Trouble shoot technical issues, find help where

needed Blackboard support: dmehling@kumc.edu

Grade each student’s teamwork after each unit

Proctor responsibilities Supervise students of your discipline

Introduce yourself to the group if you have not yet met

Log in frequency Ensure all of your students are participating

Your students will contribute to the wiki in one color font but you should monitor if each student is contributing (if more than one student in each group)

Be available to guide students regarding content (eg, if there is a question about whether the student should know this content)

Determine and follow through on the “grades” for your students