Reality Doesn't Bite: Improving Education and Outcomes Through Innovations That Enhance Resident Continuity of Care
We at the University of Massachusetts Medical School/Baystate Medical Center unequivocally agree with Ellman et al1 in the May 2016 issue of the Journal of Graduate Medical Education that enhancing patient continuity through innovation should be a core value for residency training. We have embraced continuity as essential for high-quality care, and therefore vital for residency education.
For residents in our primary care program, ambulatory training accounts for over 50% of their education. Electives, which are yearlong continuity experiences incorporated into ambulatory blocks, facilitate provider-patient relationships and an understanding of disease as a continuous evolving course.2 Our alternating 2-week block schedule ensures regular availability and readiness for ambulatory education and patient care.3
To maximize learning and improve alignment with hospital cycles, we have staggered daily admitting schedules. By increasing the number of residents available to admit between 3 pm and midnight, we have decreased time to initial orders and emergency department length of stay while positioning our learners to take full advantage of a diverse selection of patients.
To increase opportunities for inpatient continuity and patient ownership, we have an every-other-day model of admitting for our geographic ward teams. Our teams are comprised of 2 interns and 1 resident, and each intern is available to admit a patient to his or her respective floor every other day.
To improve resident availability for their primary care patients, we expanded our 2-week blocks to the entire residency in 2015. We alternate rotations with call responsibilities and night float with experiences that do not require call or nights. This model improves availability, educational readiness, and resident quality of life, while decreasing fatigue.
During our 2-week quality improvement TRAnsition of CarE Rotation (TRACER), residents join ward teams as quality officers to cultivate an understanding for transitions in care and alternate care settings, such as assisted living and nursing homes.4 The TRACER resident observes and evaluates the discharge process, “follows” the patient to the discharge facility or the first primary care visit after discharge, and uses formal tools to assess the quality of the transitions. Residents learn about collaboration and communication while experiencing the transition from the patient's perspective.
The TRACER also presents a root cause analysis and participates in our multidisciplinary transitions performance improvement team. The TRACER experience has impacted our institutional processes, leading to better clinical outcomes.
We wholeheartedly agree that determining best practices to enhance continuity and education should take place on a more expansive level, rather than through single site innovations. We look forward to collaborating with our Yale University colleagues and others to revolutionize training to better meet the educational needs of our future physicians and the care needs of our communities.
