Michael Richman, a fourth-year medical student at NYU, recently spent a month rotating at the Camden Coalition of Healthcare Providers to expand his exposure to strategies for successfully managing complex patients with chronic diseases. He is currently applying to internal medicine residencies and plans to work as a primary care physician in medically underserved urban areas.

As a medical student, I’ve often seen that despite discharge plans crafted by inpatient care teams, the same patients end up back on the wards weeks—or even days—later. For all the excellent instruction I’ve received over the past few years about how to address the needs of patients while they are admitted, I’ve learned comparatively little about what happens once a patient leaves the hospital or clinic doors and how we as health care professionals can do to ensure that discharge plans become reality.

In just four weeks rotating at the Coalition, I was quickly struck with how much this gap in medical education can have a significant effect on patient care. Leaving behind the walls of the hospital and getting a glimpse into care from a new angle illuminated issues I never before would have considered. A home visit to one patient revealed her pills for the day hidden beneath her pillow—a fact I imagine she would not have disclosed over the phone or at a routine office visit—and subsequent discussion helped us to gain insight into why she wasn’t taking the medication and what information was important to relay to her doctor for making treatment decisions in the future.

Another patient called his care transitions nurse claiming he needed an appointment with his primary care provider. We learned he was running low on his insulin and wanted to see the doctor to get more. Thanks to our ability to access his record, however, we saw that he actually had many prescription refills left on his insulin and determined the true issue was that the patient lacked education about how to figure out if he had refills and how to order them from his pharmacy. In the end, five minutes on the phone saved what would have been an unnecessary office appointment at best and a patient going without insulin at the worst. Instances such as these highlight cracks in current care delivery that are filled by the work of dedicated care transition teams.

Following my month here, I am convinced more than ever of the potential for medical teams to achieve better outcomes for patients through improved coordination of care. I am hopeful the model I’ve been privileged to observe and participate in this month will continue to be refined, expanded, incorporated into training for health care professionals, and exported to other areas of the country that face health care challenges.

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