tracer is a 2-week pgy2 block where the resident rounds with the inpatient teaching ward team as the quality officer and follows two to four patients after hospital discharge . the tracer meets the patient on rounds and later returns to discuss the patient 's experience and readiness for discharge . at the time of discharge the resident then meets the patient and nurse within the hour of arrival at the facility or the following day in the home . using standardized tools , the resident assesses the transition and reflects on process ( appendices a and b ) ( 17 , 18 ) . current gaps in resident knowledge are targeted including medication reconciliation , handover of hospital course , and anticipatory advice . the tracer reports their findings to the inpatient team and the pac - performance improvement ( pi ) team . reporting back to the team has improved the awareness for those not on the rotation , including attendings . reports to the pac - pi team have led to changes including condensing the discharge report ; clarifying medications started , stopped , and changed during admission ; and improving access to discharge documents for all visiting nurses . the tracer rotation requires a physician rotation director who orients the resident , leads the pac - pi team in weekly interprofessional meetings , and assesses the performance of the tracer resident . we use semistructured interviews at the end of each year to assess our baystate learner - manager - teacher program redesign . in spring 2010 , pgy3s , who had completed tracer the previous year , were asked to comment about what they had learned being a tracer . end of training teachers / pgy3s were asked the following questions about tracer :  when you were a manager / pgy2 , what did you learn about being a tracer resident? and  did you do anything different in your third year as the result of tracer? these interviews explore the resident experience of tracer 1 year after completing the rotation . the intent is to learn about the tracer program 's sustained effect on learning and practice . sixteen i m residents completed training in 2010 : nine male and seven female ; seven us medical graduates and nine international medical graduates . two trainees had unanticipated schedule changes . using transcripts , the authors , all of whom are also coordinators of the rotation , reviewed and coded each , using a grounded theory approach to develop themes . the authors performed initial coding and several rounds of transcript review and recoding for the following report . tracer is a 2-week pgy2 block where the resident rounds with the inpatient teaching ward team as the quality officer and follows two to four patients after hospital discharge . the tracer meets the patient on rounds and later returns to discuss the patient 's experience and readiness for discharge . at the time of discharge the resident then meets the patient and nurse within the hour of arrival at the facility or the following day in the home . using standardized tools , the resident assesses the transition and reflects on process ( appendices a and b ) ( 17 , 18 ) . current gaps in resident knowledge are targeted including medication reconciliation , handover of hospital course , and anticipatory advice . the tracer reports their findings to the inpatient team and the pac - performance improvement ( pi ) team . reporting back to the team has improved the awareness for those not on the rotation , including attendings . reports to the pac - pi team have led to changes including condensing the discharge report ; clarifying medications started , stopped , and changed during admission ; and improving access to discharge documents for all visiting nurses . the tracer rotation requires a physician rotation director who orients the resident , leads the pac - pi team in weekly interprofessional meetings , and assesses the performance of the tracer resident . we use semistructured interviews at the end of each year to assess our baystate learner - manager - teacher program redesign . in spring 2010 , pgy3s , who had completed tracer the previous year , were asked to comment about what they had learned being a tracer . end of training teachers / pgy3s were asked the following questions about tracer :  when you were a manager / pgy2 , what did you learn about being a tracer resident? and  did you do anything different in your third year as the result of tracer? these interviews explore the resident experience of tracer 1 year after completing the rotation . the intent is to learn about the tracer program 's sustained effect on learning and practice . sixteen i m residents completed training in 2010 : nine male and seven female ; seven us medical graduates and nine international medical graduates . all of whom are also coordinators of the rotation , reviewed and coded each , using a grounded theory approach to develop themes . the authors performed initial coding and several rounds of transcript review and recoding for the following report . sixteen i m residents completed training in 2010 : nine male and seven female ; seven us medical graduates and nine international medical graduates . using transcripts , the authors , all of whom are also coordinators of the rotation , reviewed and coded each , using a grounded theory approach to develop themes . the authors performed initial coding and several rounds of transcript review and recoding for the following report . five themes emerged from review and coding of 14 interviews : seeing things from the other side , the ah ha moment of fragmented care , team collaboration , patient understanding , and passing the learning on . overall , tracer residents describe the transition of care from the patient perspective rather than the traditional physician perspective ( table 1 ) . five themes of the transition of care rotation ( tracer ) residents become aware of how the transition looks from the other side , both the facility and the home . for a facility transfer , the tracer resident appreciates that the nurse has poor access to the hospital team and is gathering information from the written documents only . tracer residents identify with this admission process ; they see the similarity to the hospital admission process . they learn that the medication list on transfer is used immediately to call in admission orders to the on - call physician and , thus , needs to be accurate . they realize the importance of the discharge summary to the receiving team as opposed to its equal relevance to the hospital team for future care . residents experience directly the impact of the transition on  the other side ( the accepting nurse side ) of a facility transfer . the tracer resident comes to have a new appreciation for the transition to home . the residents learn that patients have little understanding of the basic elements of the hospitalization such as the primary hospital diagnosis , the changes in medications , and the follow - up plan . patients are also unprepared for the recovery period challenges as they are still recovering from illness ; how and when to get their new medications , tracking medication changes , and mobility issues . residents have new awareness of the challenges in the transition to home as they see the experience from  the other side ( the patient 's side ) of the handoff . residents describe an epiphany , the moment when they realize that the transition is fragmented for patients and their families . tracer allows the resident to slow down and become an observer of the process of care and reflect . they identify patient education , handoff communication ( written and verbal ) , and team collaboration as keys to a successful discharge . both written and verbal , for both patients and the health care team , is a hallmark lesson learned in this  ah ha moment . they come to see the unique roles and responsibilities of the hospital nurse at discharge , the nurse in the accepting facility , and the nurse in the home . the hospital nurse is responsible for educating the patient on the primary discharge diagnosis and medication changes as well as preparing the patient for the next level of care . the facility nurse relays orders to the accepting physician and assesses the patients appropriateness for this level of care . and finally , the home nurse possesses skills for advocacy , education , and coordination of care . overall , the tracer resident learns the various scopes of practice of the nurse in different settings and describes being more prepared to collaborate in the future . residents also realize that different pac settings ( home vs. facility ) require different transition strategies . for the transition to home , a patient is required to manage independently , including their activities of daily living , medication , and follow - up plans . thus , the home discharge is a handoff to the patient with a home nurse as an advocate , whereas the facility transfer is a handoff to the health care team with patient involvement . the tracer residents gain a deeper understanding of their role in collaborating around discharge as they have more knowledge of the nursing scope of practice and different needs of the patient in the two settings ( table 1 ) . the patients do not understand basic elements of the bedside conversation , for example , their diagnosis , medication changes , and what to expect . the residents see three parts to the problem : too much medical terminology , the hospital physician not appropriately checking or understanding or using teach - back , and an overwhelmed , sick patient . trainees see that communicating at the level of the patient and checking for understanding are key elements of the transition ( table 1 ) . the pgy3 carry the lessons learned from tracer into their physician practice as pgy3 teachers on the wards . the pgy1/medical students bring out the importance of the tracer learning experience as the pgy3 reinforces the value of a good transition of care . as teachers , they internalize the value of the tracer experience and see the importance of teaching this knowledge to their colleagues ( table 1 ) . residents become aware of how the transition looks from the other side , both the facility and the home . for a facility transfer , the tracer resident appreciates that the nurse has poor access to the hospital team and is gathering information from the written documents only . tracer residents identify with this admission process ; they see the similarity to the hospital admission process . they learn that the medication list on transfer is used immediately to call in admission orders to the on - call physician and , thus , needs to be accurate . they realize the importance of the discharge summary to the receiving team as opposed to its equal relevance to the hospital team for future care . residents experience directly the impact of the transition on  the other side ( the accepting nurse side ) of a facility transfer . the residents learn that patients have little understanding of the basic elements of the hospitalization such as the primary hospital diagnosis , the changes in medications , and the follow - up plan . patients are also unprepared for the recovery period challenges as they are still recovering from illness ; how and when to get their new medications , tracking medication changes , and mobility issues . residents have new awareness of the challenges in the transition to home as they see the experience from  the other side ( the patient 's side ) of the handoff . residents describe an epiphany , the moment when they realize that the transition is fragmented for patients and their families . tracer allows the resident to slow down and become an observer of the process of care and reflect . they identify patient education , handoff communication ( written and verbal ) , and team collaboration as keys to a successful discharge . both written and verbal , for both patients and the health care team , is a hallmark lesson learned in this  ah ha moment . residents learn the importance of team collaboration . they come to see the unique roles and responsibilities of the hospital nurse at discharge , the nurse in the accepting facility , and the nurse in the home . the hospital nurse is responsible for educating the patient on the primary discharge diagnosis and medication changes as well as preparing the patient for the next level of care . the facility nurse relays orders to the accepting physician and assesses the patients appropriateness for this level of care . and finally , the home nurse possesses skills for advocacy , education , and coordination of care . overall , the tracer resident learns the various scopes of practice of the nurse in different settings and describes being more prepared to collaborate in the future . residents also realize that different pac settings ( home vs. facility ) require different transition strategies . for the transition to home , a patient is required to manage independently , including their activities of daily living , medication , and follow - up plans . thus , the home discharge is a handoff to the patient with a home nurse as an advocate , whereas the facility transfer is a handoff to the health care team with patient involvement . the tracer residents gain a deeper understanding of their role in collaborating around discharge as they have more knowledge of the nursing scope of practice and different needs of the patient in the two settings ( table 1 ) . the patients do not understand basic elements of the bedside conversation , for example , their diagnosis , medication changes , and what to expect . the residents see three parts to the problem : too much medical terminology , the hospital physician not appropriately checking or understanding or using teach - back , and an overwhelmed , sick patient . trainees see that communicating at the level of the patient and checking for understanding are key elements of the transition ( table 1 ) . the pgy3 carry the lessons learned from tracer into their physician practice as pgy3 teachers on the wards . the pgy1/medical students bring out the importance of the tracer learning experience as the pgy3 reinforces the value of a good transition of care . as teachers , they internalize the value of the tracer experience and see the importance of teaching this knowledge to their colleagues ( table 1 ) . tracer residents are transformed by workplace learning as they can take a step back to observe and reflect on the transition . physician workplace learning is traditionally embedded only in the clinical wards or the ambulatory setting ( 19 ) . this , however , omits learning about handoffs , performance improvement , and pac teams . the tracer resident follows the patient experience through the continuum of care with systems improvement as the focus of workplace learning . for example , the tracer resident may describe an error in medication reconciliation and report emphatically , one small error can lead to significant harm. through the short reflections from each visit and the long reflective essay added to the curriculum in 2012 , we are able to triangulate the data . although the message of accurate medication reconciliation is taught in other venues including orientation , didactics , chart stimulated recall , and direct observation ; it is the tracer experience that seems to have the greatest impact on transition of care learning . tracer residents have the time and intellectual space to step back and reflect in the workplace , focusing on competencies in systems based practice ( sbp ) , practice based learning ( pbli ) , professionalism ( prof ) , and interpersonal and communication skills ( ics ) , specifically subcompetencies sbp 14 , pbli 1 and 2 , prof 1 and 3 , and ics13 . although we have considered moving tracer into the pgy1 curriculum , the pgy1 learner puts greater value into learning competencies in medical knowledge and patient care . we have added case - based learning to our didactics and we have implemented a pgy1 transition of care curriculum for orientation , direct observation , and chart stimulated recall . for tracer , our next steps are to explore the tracer model for other professions and for interprofessional education ( ipe ) . the care transitions education project , a robert wood johnson funded demonstration project of the massachusetts senior care foundation , has applied the tracer curriculum to nursing students and found similar themes ( 20 ) . how do we train physician , nurse , and pharmacist together for the transition ? other next steps for investigation include assessing the clinical outcomes of a tracer experience during and after the rotation . residents describe the tracer experience as an epiphany , an  ah ha moment , with a sustained effect 1 year after they have completed the rotation . they identify with the patient 's experience and the health care team in the continuum of care . accurate written and verbal communication is a hallmark lesson learned in this  ah ha moment of acknowledging the ramifications of fragmented care . they note the importance of open bidirectional communication with the health care team and the importance of owning the handover to insure patient safety . they are able to differentiate the needs of the patient who can go home versus those who require skilled nursing . tracer , in the middle of the training years , gives residents a moment to breathe and open their eyes to the patient 's experience of care in transition and develop physician competencies not easily assessed in traditional rotation .
backgrounda safe patient transition requires a complex set of physician skills within the interprofessional practice.objectiveto evaluate a rotation which applies self - reflection and workplace learning in a transition of care rotation ( tracer ) for internal medicine ( i m ) residents . 
 tracer is a 2-week required i m resident rotation where trainees join a ward team as a quality officer and follow patients into postacute care.methodsin 2010 , residents participated in semistructured , one - on - one interviews as part of ongoing program evaluation . 
 they were asked what they had learned on tracer , the year prior , and how they used those skills in their practice . using transcripts 
 , the authors reviewed and coded each transcript to develop themes.resultsfive themes emerged from a qualitative , grounded theory analysis : seeing things from the other side , the 
 ah ha moment of fragmented care , team collaboration including understanding nursing scope of practice in different settings , patient understanding , and passing the learning on . 
 tracer gives residents a moment to breathe and open their eyes to the interprofessional practice setting and the patient 's experience of care in transition.conclusionsresidents learn about transitions of care through self - reflection . 
 this learning is sustained over time and is valued enough to teach to their junior colleagues .