- Jessica Goodman, PhD, Postdoctoral Fellow, University of Rochester, Rochester, NY
- Lauren Decaporale-Ryan, PhD, Assistant Professor, Departments of Psychiatry, Medicine, & Surgery, University of Rochester, Rochester, NY
- Joseph Nicholas, MD, MPH, Associate Professor, Department of Medicine, University of Rochester, Rochester, NY, Medical Director, Highlands at Brighton Transitional Care Facility, Rochester, NY
The transitions of care from hospital to post-acute rehabilitation and then to home are complex, particularly given the biopsychosocial stressors of aging and social determinants of health that are often present for those with numerous underlying chronic conditions. While psychosocial factors are known to impact success with discharge, unmet needs and concerns are frequently voiced by patients and their families during transitions of care. At the same time, limited physician education and training experiences have historically been available in geriatrics, particularly with older adults transitioning between clinical settings. Previously, our facility ran the Hospital to Home Program as a model of geriatric training for internal medicine residents emphasizing the complicating role of psychosocial factors, including social determinants of health, and importance of interdisciplinary collaboration. In 2018, our facility shifted focus to address another high-risk transitional area, hospital to rehabilitation. The post-acute rehabilitation setting offers a unique opportunity to gain feedback around clinical skillsets necessary for collecting psychosocial information to support effective discharge planning, communication between care teams, and shared decision-making with patients to address complex care needs and social determinants of health. This presentation will outline the structure of the Hospital to Rehab program, as part of a university internal medicine residency.. Particular emphasis will be given to the psychosocial interview portion of the rotation, which serves multiple purposes, including (a) collecting baseline information on residents’ communication skills with patients and families; (b) providing modeling and feedback to residents around the psychosocial factors that play an important role in discharge planning; (c) how to facilitate a collaborative conversation around these factors with patients and their families; (d) an opportunity for residents to contribute to successful discharges through documentation that provides a biopsychosocial picture of the patient and their needs. Qualitative data from residents’ reflections on their experiences with the program overall and psychosocial interview in particular will be shared. Recommendations for building interdisciplinary support to facilitate a program such as this will be offered.
- Identify the impact of social determinants of health on transitions of care across clinical settings.
- Describe the biopsychosocial interview and coaching component of the Hospital to Rehab program and thematic feedback from medical resident participants
- Establish ideas for how to build teaching/training protocols to enhance physicians' communication and biopsychosocial interviewing skills at audience members' facilities