11:00 - 11:05 amSaturday, September 17
Upper Lobby
Patient partners: how a student-driven care transitions and home visit program is transforming medical education and bridging the gap from hospital to home
Upper Lobby
Patient partners: how a student-driven care transitions and home visit program is transforming medical education and bridging the gap from hospital to home
Stanford University
As the health care system rapidly changes to emphasize patient-centered care, quality, and efficiency, transforming medical education to support training in patient self-management and empowerment, health... Read more

Description

As the health care system rapidly changes to emphasize patient-centered care, quality, and efficiency, transforming medical education to support training in patient self-management and empowerment, health care delivery, and innovation is increasingly crucial. Stanford’s Patient Partners (P2) program is a student-driven care transitions program with a two-fold mission: 1) to improve patient outcomes and reduce readmission rates at Stanford Hospital and 2) to provide a hands-on, early clinical education for pre-clerkship medical students to serve as health coaches and lead quality improvement initiatives. This talk will explore successes and challenges of the program and share lesson learned that can inform digital health interventions to improve care transitions programs.

In partnership with Stanford Hospital and the medical school faculty, students work on multidisciplinary teams to support patients hospitalized for pneumonia, hip replacement, or heart failure to transition home from the hospital. The care transitions components are founded on the Coleman model, which empowers patients by providing them with resources for managing their care at home. P2 students first meet with patients in the hospital to understand their values, goals, and barriers to care. They then conduct a home visit and several follow-up phone calls in the month following the patient’s discharge. P2 is designed to reduce readmissions by training medical students, an untapped resource in the health care system, to help empower patients with tools to manage their health.

Patient Partners is a hands-on clinical, leadership, QI initiative that was designed to address gaps in medical education and patient care. Medical students often clamor for increased early clinical exposure and opportunities to add value to patient care and clinical innovation. Through P2, students gain essential skills that are fundamental yet difficult to acquire in the classroom setting, such as health coaching, motivational interviewing, and care management. As students work with patients and visit them in their homes, they learn the many challenges that patients face in understanding physician instructions, managing medications, and adhering to a care plan.

P2 has trained three cohorts of care transitions coaches thus far. The program averages 6 referrals per week, with over 80% of patients enrolling. P2 has evolved to address a variety of challenges. This talk will first address successes and challenges which will then lead into a focus on sharing opportunities for integrating digital health solutions into the discharge follow up process. We have learned that better follow up communication and data management is critical to supporting patients’ care transition and is currently absent from most discharge processes. Capabilities that we anticipate will improve P2 and similar programs range from follow up automated texting and Q&A with care providers, more accessible and easy to use discharge instructions, digital tracking of goal setting and adherence, and closing the feedback loop with EHR integration to improve communication with the care team. Such innovations will be instrumental to both improving patient care by facilitating quicker responses from the health care team, preventing costly readmissions and negative patient outcomes, and contributing to medical student education by training the next generation of patient-centered physicians and health care innovation leaders.

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