Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs

BACKGROUND

While there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern.

OBJECTIVES

The 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country.

DESIGN

Nationwide survey.

PARTICIPANTS

All internal medicine program directors registered with APDIM.

MAIN MEASURES

Descriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs.

KEY RESULTS

Of the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year-End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff.

CONCLUSIONS

Most internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.

Year-End Resident Clinic Handoffs: Narrative Review and Recommendations for Improvement

BACKGROUND

Year-end clinic handoffs in resident continuity clinics are an important patient safety issue.

METHODS

Intervention articles addressing the year-end resident clinic handoff were identified in a targeted literature search. These articles were reviewed and abstracted to summarize the current literature. On the basis of these reviews and consensus expert opinion, recommendations to improve year-end clinic handoffs were developed.

RESULTS

Of 23 identified articles, 10 intervention articles in the fields of internal medicine, internal medicine-pediatrics, psychiatry, and family medicine were ultimately included. The additional 13 nonintervention studies were used as background material. There were 12 clinic handoff recommendations for improvement: (1) focus on patients most at risk during the handoff, (2) educate residents, (3) consider balancing caseloads for the residents, (4) prepare patients for the handoff and perform patient-centered outreach, (5) standardize a written method of sign-out and require verbal communication for a subset of patients, (6) use a standardized template or technology solution for the handoff, (7) identify specific tasks that require follow-up, (8) enhance attending supervision during the handoff, (9) make patient assignments clear after the handoff, (10) have patients establish care with the new provider as soon as possible after the handoff, (11) establish care with telephone contact prior to the first visit, (12) perform safety audits to ensure that sign-out occurs, patients receive appointments, no-shows are rescheduled, and task follow-up is completed.

CONCLUSION

There is emerging evidence for interventions to improve year-end resident clinic handoffs, and the recommendations provided are a starting point to guide training programs.

Residency training in handoffs: a survey of program directors in psychiatry

OBJECTIVE

The purpose of this study was to investigate how psychiatry programs are addressing the new Accreditation Council for Graduate Medical Education (ACGME) training requirements regarding transitions in patient care effective July 1, 2011.

METHODS

An anonymous online survey was distributed to program directors of general psychiatry residencies within the USA. Survey questions pertaining to the 2011 ACGME handoff requirements focused on training modalities, assessment of competence, and oversight of appropriate handoff procedures. In addition, program directors were asked to share specific challenges in implementing the new handoff regulations as well as their view on how the new regulations would impact patient care.

RESULTS

Of the 177 recipients, 108 completed at least part of the survey (61 % response rate). Only 11.4 % of programs indicated that they did not need to make any changes to their program in order to meet the new guidelines. Approximately a third of survey respondents reported that they did not yet have a formal curriculum in handoffs (32.4 %) and/or did not specifically assess competence at handoffs (30.5 %). Program directors cited the challenge of working with a variety of clinical settings with unique cultures, infrastructure, and policies and procedures and suggested that implementation and ownership of handoff training and assessment should be at the level of the clinical services. Despite these challenges, most program directors agreed that the new ACGME requirements would improve patient care and safety.

CONCLUSIONS

The high frequency of programs without established handoff curricula or competence evaluations highlights the potential value of published resources and tools to provide standardized training and assessment in handoffs. The results also underscore the importance of developing training and assessment in close collaboration with the clinical services and recognizing the need to tailor handoff communications to address the types of transitions that occur within each clinical setting.

A survey of primary care resident attitudes toward continuity clinic patient handover

Background

Transfer of clinic patients from graduating residents to interns or junior residents occurs every year, affecting large numbers of patients. Breaches in care continuity may occur, with potential for risk to patient safety. Several guidelines have been developed for implementing standardized inpatient sign-outs, but no specific guidelines exist for outpatient handover.

Methods

Residents in primary care programs – internal medicine, family medicine, and pediatrics – at a US academic medical center were invited to participate in an online survey. The invitation was extended approximately 2 years after electronic medical record (EMR) rollout began at the institution.

Results

Of 71 eligible residents, 22 (31%) responded to the survey. Of these, 18 felt that handover of ambulatory patients was at least moderately important – but only one affirmed the existence of a system for handover. IM residents perceived that they had the highest proportion of high-risk patients (p=0.042); transition-of-care letters were more important to IM residents than other respondents (p=0.041).

Conclusion

There is room for improvement in resident acknowledgement of handover processes in continuity clinics. In this study, IM residents attached greater importance to a specific handover tool than other primary care residents. Thus, the different primary care specialties may need to have different handover tools available to them within a shared EMR system.

Transfer of care of psychotherapy patients: implications for psychiatry training

Transfers of care occur routinely in medical training, but the transfer of psychotherapy patients has received relatively little attention. This article discusses important issues concerning these transfers, using case examples and findings from a survey of the experience of psychiatry residents transitioning psychotherapy patients. Residents have difficulty telling patients they are leaving and often delay doing so. Because feelings of closeness and attachment can develop in long-term therapeutic relationships, residents describe feeling guilty, uncertain, anxious, sad, and occasionally relieved as they prepare their patients for transfer. Outgoing residents can feel anxious when recognizing and addressing their patients' and their own positive feelings. Incoming residents experience discomfort at being compared to the previous therapist and often encounter the patient's negative feelings at the transfer and the loss of the previous therapy. Teaching about the two poles of transfer of care is recommended to better understand and respond to this transition for both patient and therapist. This should include addressing the stresses involved and recommendations for management.

Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers

BACKGROUND

It is unclear why systematic training in end-of-residency clinic handoffs is not universal.

PURPOSES

We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors' attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation.

METHODS

We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems.

RESULTS

Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04).

CONCLUSIONS

Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.

What do patients think about year-end resident continuity clinic handoffs? A qualitative study

BACKGROUND

Although Internal Medicine year-end resident clinic handoffs affect numerous patients, little research has described patients' perspectives of the experience.

OBJECTIVE

To describe patients' perceptions of positive and negative experiences pertaining to the year-end clinic handoff; to rate patient satisfaction with aspects of the clinic handoff and identify whether or not patients could name their new physicians.

DESIGN

Qualitative study design using semi-structured interviews.

PARTICIPANTS

High-risk patients who underwent a year-end clinic handoff in July 2011.

MEASUREMENTS

Three months post-handoff, telephone interviews were conducted with patients to elicit their perceptions of positive and negative experiences. An initial coding classification was developed and applied to transcripts. Patients were also asked to name their primary care physician (PCP) and rate their satisfaction with the handoff.

RESULTS

In all, 103 telephone interviews were completed. Patient experiences regarding clinic handoffs were categorized into four themes: (1) doctor-patient relationships (i.e. difficulty building rapport); (2) clinic logistics (i.e. difficulty rescheduling appointments); (3) process of the care transition (i.e. patient unaware transition occurred); and (4) patient safety-related issues (i.e. missed tests). Only 59 % of patients could correctly name their new PCP. Patients who reported that they were informed of the clinic transition by letter or by telephone call from their new PCP were more likely to correctly name them (65 % vs. 32 % p = 0.007), report that their new doctor assumed care for them immediately (81 % [68/84] vs. 53 % [10/19], p = 0.009) and report satisfaction with communication between their old and new doctors (80 % [67/84] vs. 58 % [11/19], p = 0.04). Patients reported positive experiences such as learning more about their new physician through personal sharing, which helped them build rapport. Patients who reported being aware of the medical education mission of the clinic tended to be more understanding of the handoff process.

CONCLUSIONS

Patients face unique challenges during year-end clinic handoffs and provide insights into areas of improvement for a patient-centered handoff.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety

PURPOSE

Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff.

METHOD

In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes.

RESULTS

Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06).

CONCLUSIONS

Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

Current Practice in End-of-Residency Handoffs: A Survey of Internal Medicine-Pediatrics Program Directors

BACKGROUND

End-of-residency outpatient handoffs affect at least 1 million patients per year, yet there is no consensus on best practices.

OBJECTIVE

To explore the use of formal systems for end-of-residency clinic handoffs in internal medicine-pediatrics residency (Med-Peds) programs, and their associated categorical internal medicine and pediatrics programs.

METHODS

We surveyed Med-Peds program directors about their programs' system for handing off ambulatory continuity patients.

RESULTS

Our response rate was 85% (67 of 79 programs). Thirty-one programs (46%) reported having a system for end-of-residency handoffs. Of the 30 that offered detailed information, 22 (73%) formally introduced the program to residents, 12 (40%) standardized the handoff, and 14 (47%) used multiple methods for information exchange, with the electronic health record and oral transfer of information (15 of 30, 50%) the most common. Six programs (20%) indicated they did not offer residents protected time to complete end-of-residency handoffs, and 13 programs (43%) did not identify a specific postgraduate year level for residents to whom patients were handed off. Programs were more likely to have a system for end-of-residency handoffs if another categorical program at their institution also had one (P < .001).

CONCLUSIONS

Fewer than half of responding Med-Peds programs have outpatient handoff systems in place. Inclusion of end-of-residency handoff information in the electronic health record may represent a best practice that has the potential of enhancing continuity and safety of care for patients in resident continuity clinics.

Development of a structured year-end sign-out program in an outpatient continuity practice

BACKGROUND

In an effort to prevent medical errors, it has been recommended that all healthcare organizations implement a standardized approach to communicating patient information during transitions of care between providers. Most research on these transitions has been conducted in the inpatient setting, with relatively few studies conducted in the outpatient setting.

OBJECTIVES

To develop a structured transfer of care program in an academic outpatient continuity practice and evaluate whether this program improved patient safety as measured by the documented completion of patient care tasks at 3 months post-transition.

DESIGN

Graduating residents and the corresponding incoming interns inheriting their continuity patient panels were randomized to the pilot structured transfer group or the standard transfer group. The structured transfer group residents were asked to complete written and verbal sign-outs with their interns; the standard transfer group residents continued the current standard of care.

PARTICIPANTS

Thirty-two resident-intern pairs in an academic internal medicine residency program in New York City.

MAIN MEASURES

Three months after the transition, study investigators evaluated whether patient care tasks assigned by the graduating residents had been successfully completed by the interns in both groups. In addition, follow-up appointments, continuity of care and house officer satisfaction with the sign-out process were evaluated.

KEY RESULTS

Among patients seen during the first 3 months, the clinical care tasks were more likely to be completed by interns in the structured group (73 %, n = 49) versus the standard group (46 %, n = 28) (adjusted OR 3.21; 95 % CI 1.55-6.62; p = 0.002). This was further enhanced if the intern who saw the patient was also the assigned primary care provider (adjusted OR 4.26; 95 % CI 1.7-10.63; p = 0.002).

CONCLUSIONS

A structured outpatient sign-out improved the odds of follow-up of important clinical care tasks after the year-end resident clinic transition. Further efforts should be made to improve residents' competency with regard to sign-outs in the ambulatory setting.

Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs

BACKGROUND

Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.

OBJECTIVE

To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff

DESIGN

Retrospective cohort

PARTICIPANTS

Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009-2011. PGY2 IM residents surveyed from 2010-2011.

MEASUREMENTS

Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.

RESULTS

Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P<0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p<0.001) and those lost to follow-up (21 % vs. 17 % NSR, p=0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as "theirs" until they are seen by them in clinic.

CONCLUSIONS

While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.

An intervention to improve ambulatory care handoffs at the end of residency

INTRODUCTION

The medical literature shows evidence of numerous initiatives to improve inpatient physician handoffs. In contrast, handoffs of ambulatory patients to incoming interns or junior residents at the end of residency are an area of potential concern that has been overlooked.

OBJECTIVES

To examine handoffs of high-risk ambulatory patients by outgoing residents to junior colleagues and to compare current practice to a standard handoff process. We hypothesized the intervention would lead to increases in the number and quality of ambulatory care handoffs.

METHODS

Fourteen graduating internal medicine and combined internal medicine-pediatrics residents who practiced at an academic continuity clinic were randomized to an intervention or a control group. E-mail instructions were sent asking the intervention group to write a handoff note using the clinic's electronic medical record system. The e-mail included a detailed outline of information to incorporate and highlight features of the electronic medical record that would facilitate the process. The handoff notes of the intervention and control group were independently evaluated and scored for quality using a predetermined point system.

RESULTS

Six of the 7 residents (86%) in the intervention group completed 19 handoff notes; none of the residents in the control group completed handoff notes. Most of the handoffs provided a brief paragraph or 2 of background information on the patient and then focused on issues needing short-term follow-up during the coming months.

CONCLUSIONS

The standardized handoff process implemented via simple e-mail instructions increased the number of outpatient handoffs at the completion of residency. Further study with a larger number of residents, identification and removal of barriers to the handoff process, and correlation of handoffs to clinical outcomes are key next steps.