Internal Medicine — Transition to Practice

TTP5 Initiating and facilitating transfers of care through the health care system

Key Features:
- This EPA focuses on the decision to transfer patients with a complex, evolving hospital course from the care of the IM specialist to another acute care institution.
- This EPA includes the medical decision-making about appropriate level of care and builds on the discharge facilitation skills achieved in Foundations.

Assessment Plan:

Direct observation, case discussion or review of clinical documentation by supervisor

Use Form 1. Form collects information on:
- Case complexity: medium; high
- Type of transfer: to acute care setting with high resource intensity; to acute care setting with low resource intensity
- Setting: clinical; simulation

Collect 2 observations of achievement
- No more than 1 simulation

Milestones

• ME 2.4. Determine the setting of care appropriate for the patient’s health needs

• L 2.1. Apply knowledge of the health care resources available in other care settings

• ME 4.1. Assess the need, timing, risk and benefits of transferring a patient’s care to another health professional and/or care setting

• ME 2.4. Anticipate, prevent and manage changes in health status at the time of transition

• ME 2.4. Establish a plan for ongoing care in the local setting and/or for care prior to and during transfer

• COL 1.2. Consult as needed with other health care professionals, including other physicians

• HA 1.1. Facilitate timely patient access to services and resources

• COL 3.1. Organize the handover of care to the most appropriate physician

• COL 3.2. Summarize the patient’s issues, including plans to deal with ongoing issues

• COL 3.2. Recognize and act on patient safety issues in the transfer of care

• P 1.1. Keep the patient and family informed of changes in health status, treatment plan and/or setting of care