Project ECHO: Improving Care Transitions 


Beth Israel Deaconess Medical Center (BIDMC), with support from the D.W. Reynolds Foundation, developed ECHO-Care Transitions (ECHO-CT) to address the gaps in care quality when a patient transitions from the inpatient hospital setting to skilled nursing facility (SNF) care.  The goal is to promote safe and effective transitions for complex older patients by improving communication between the hospital and the SNF providers.   

Within one week of discharge, hospital providers meet with providers at the SNF to discuss the patients’ transitional and medical issues using teleconferencing technology.  The BIDMC and the SNF teams include physicians, nurse practitioners, nurses, pharmacists, social workers, and occasionally the primary care physician.  Our multi-disciplinary teams allow us to discuss a wide range of issues that affect patients transitioning to SNF care; our sessions focus on medication reconciliation, critical laboratory/imaging, follow-up after discharge, and social work issues.  As part of our education initiative, we frequently have internal medicine residents lead the videoconferencing discussions as part of a broader transitional care curriculum.

Clinical

ECHO-CT enables the hospital and the post-acute care facility to work as one team to optimize patient care shortly after hospital discharge. Patient safety is enhanced as careful medication reconciliation identifies discrepancies between hospital discharge and facility admitting medication lists. Important issues flagged during hospitalization are tracked post discharge, including pending test results and follow-up appointments. These are just a few examples of ways in which ECHO-CT strives to optimize patient care. 

Educational

ECHO-CT is part of a required transitional care curriculum for medicine residents, care transitions training for hospitalists and an elective experience for medical students. Residents and hospitalists learn to identify and manage transitional issues identified by either the hospital or post-acute care facility. The learner is actively engaged as they lead the videoconferencing session between the hospital and facility, eliciting and receiving feedback regarding discharge summaries.

Hospitalist AGE Scholars Lecture Series

The ECHO-CT program has a robust teaching initiative focusing on issues relevant to transitions of care and medically-complex, older patients. One part of that initiative is AGE Scholars, a monthly interactive curriculum designed for hospitalists as part of their continuing medical education. 

Monthly didactics include:

  • "I Am Not Going to Rehab": Understanding Options for Caring for Elderly in the Community - Robert Schreiber, MD
  • Two Years Later: Cases in Surrogate Decision Making/Advanced Care Planning and a Review of the Data - Lauge Sokol-Hessner, MD
  • Falling Through the Cracks: Perils of the Post-Discharge Period - Anita Vanka, MD
  • Medication Management in the Elderly - John Marshall, PharmD

Meet Our Research Team

Lewis A. Lipsitz, MD
Chief, Division of Gerontology
Co-Director, ECHO-CT, Division of Gerontology

Lewis A. Lipsitz, M.D., is chief of the Division of Gerontology at Beth Israel Deaconess Medical Center (BIDMC) and a Professor of Medicine at Harvard Medical School.  He is also director of the Institute for Aging Research at Hebrew SeniorLife (HSL), where he holds the Irving and Edyth S. Usen Chair in Geriatric Medicine.  

Dr. Lipsitz serves as principal investigator of the Reynolds Foundation “Next Steps” program to improve geriatric education at Harvard, and two research grants from the National Institute on Aging focused on the cerebrovascular mechanisms of falls and the effect of Tai Chi training on functional outcomes and costs in elderly people.

 

Jonathan Bortinger, MD

Hospitalist, ECHO-CT, Department of Medicine
Dr. Jonathan Bortinger has been a hospitalist in the division of General Internal Medicine at BIDMC since 2011. He currently is one of the Core Education Faculty in the Department of Internal Medicine Residency training program at BIDMC.  He completed his medical residency at Massachusetts General Hospital and earned his M.D. at the University of Pittsburgh School of Medicine. He is one of our facilitators for our weekly ECHO-CT session.

Sabrina Carretie
Program Manager, Project ECHO, Division of Gerontology
Sabrina Carretie serves as the program manager for the Extension for Community Healthcare Outcomes (ECHO) projects in the Division of Gerontology at BIDMC. Ms. Carretie has a strong background in program management and financial administration in higher education

Grace Huang, MD
Hospitalist Education, ECHO-CT, Department of Medicine
Dr. Grace Huang is an Associate Professor of Medicine at Harvard Medical School, a hospitalist in the Department of Medicine at BIDMC, and an associate program director with the internal medicine residency at BIDMC. She is the Director of Assessment, Co-Director of the Rabkin Fellowship in Medical Education, and Co-Director of the BIDMC Academy of Medical Educators. Dr. Huang serves as the evaluation leader on the ECHO-CT project; she is active in designing the assessment tools for our learner groups.
 
Marisa Jupiter, MD
Hospitalist, ECHO-CT, Department of Medicine
Dr. Marisa Jupiter works as a hospitalist in the division of General Internal Medicine at BIDMC. She completed her medical residency at the University of Massachusetts where she spent an additional year as Chief Resident. Dr. Jupiter serves as one of the Core Education Faculty in the Department of Internal Medicine Residency training program at BIDMC.  She is also the coordinator for the hospital medicine CME series, Seminars in Hospital Medicine. Dr. Jupiter is one of our facilitators for our weekly ECHO-CT session.

Amber Moore, MD
Co-Director, ECHO-CT
Hospitalist, Department of Medicine
Dr. Moore has been involved in ECHO CT since 2015 as a hospitalist during the weekly clinic sessions and leading the curriculum development and dissemination to the hospital medicine team. In addition to her knowledge of the program and commitment to the improvement of issues surrounding transitions of care, Dr. Moore is passionate about medical education. She works as a hospitalist at BIDMC where she continues to teach residents and medical students as a member of the core education faculty. She currently teaches the hospital medicine elective to residents, the high value care elective to students, serves on the residency application committee, is the medical director of one of the inpatient medical floors and is also a member of the Society of Hospital Medicine’s patient experience committee.

Anita Vanka, MD
Associate Program Director, Internal Medicine Residency Program
Medical Resident Education, ECHO-CT, Department of Medicine
Dr. Anita Vanka works as a hospitalist in the Division of General Medicine & Primary Care, is an Associate Program Director in the Internal Medicine Residency Training Program, and is an instructor of medicine at Harvard Medical School. She completed the Rabkin Fellowship in Medical Education in 2012 and developed a Transitions in Care Curriculum for medical residents during this year. After being piloted for two years, it was formally integrated into the residency training program as part of the ECHO-CT project.