Most internists are heavily involved in the management of chronically ill, medically complex patients who may be cared for in a sequence of health care settings during a given illness episode. In particular, general internists, geriatricians, and hospitalists have great responsibility for ensuring that these care transitions are manage competently. One major educational focus of the Geriatrics rotation is transitional care.

At the completion of this rotation, the internal medicine resident will be able to:

  1. Describe the risk factors for poor discharge outcomes, and incorporate this knowledge into the timing of patient discharges and the involvement of ancillary professionals (e.g., social work, home nursing).
  2. Identify patients' medical, nursing, functional, and rehabilitative needs, and properly match these needs to the capabilities of discharge locations.
  3. Construct concise, complete, and timely (<48 hrs of hospital discharge) discharge summaries, which include (among other things) the following key features:
    1. Discharge diagnoses include functional and geropsychiatric diagnoses, in addition to the usual medical ones.
    2. Discharge instructions include any "red flag" signs and symptoms which should be reported immediately, and whom to contact.
    3. Discharge medication list includes:
      • Indication for each drug
      • Regimen reconciliation (which drugs are new, which old ones to stop)
    4. Pending studies requiring follow-up by the receiving clinician or team.
  4. Routinely educate patients and caregivers about medication changes, adverse effects, activity limitations, and “red flag” warning signs.
  5. Elicit goals of care (e.g., life-prolongation vs. comfort-care-only) and incorporate them into transition plans and communications with receiving care team.
  6. Know when a phone call to a receiving team or clinician is appropriate before patient transfer (and how to pithily transmit the important information).