Outcomes for Resident-Identified High-Risk Patients and Resident Perspectives of Year-End Continuity Clinic Handoffs
ABSTRACT Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.
To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff
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.
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.
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.
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.
SourceAvailable from: Victor O Kolade[Show abstract] [Hide abstract]
ABSTRACT: 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.11/2014; 4(5):25087. DOI:10.3402/jchimp.v4.25087
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ABSTRACT: BACKGROUND Reducing hospital readmissions is a national healthcare priority. Little is known about how readmission rates vary across unique primary care practices.OBJECTIVE To calculate all-cause 30-day hospital readmission rates at the level of individual primary care practices and identify factors associated with variations in these rates.DESIGNRetrospective analysisSETTINGSeven primary care clinics affiliated with the University of California, San Francisco (UCSF).PATIENTSAdults ≥18 years old with a primary care provider (PCP) at UCSFMEASUREMENTSAll-cause 30-day readmission rates were calculated for primary care clinics for discharges between July 1, 2009 and June 30, 2012. We built a model to identify demographic, clinical, and hospital factors associated with variation in rates.RESULTSThere were 12,564 discharges for patients belonging to the 7 clinics, with 8685 index discharges and 1032 readmissions. Readmission rates varied across practices, from 14.9% in Human Immunodeficiency Virus primary care and 7.7% in women's health. In multivariable analyses, factors associated with variation in readmission rates included: male gender (odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.05–1.40), Medicare insurance (OR: 1.31, 95% CI: 1.05, 1.64; Ref = private), Medicare-Medicaid dual eligible (OR: 1.26, 95% CI: 1.01–1.56), multiple comorbidities, and admitting services. Patients with a departed PCP awaiting transfer assignment to a new PCP had an OR of 1.59 (95% CI: 1.16–2.17) compared with having a current faculty PCP.CONCLUSIONS Primary care practices are important partners in improving care transitions and reducing hospital readmissions, and this study introduces a new way to view readmission rates. PCP turnover may be an important risk factor for hospital readmissions. Journal of Hospital Medicine 2014. © 2014 Society of Hospital MedicineJournal of Hospital Medicine 11/2014; 9(11). DOI:10.1002/jhm.2243 · 2.08 Impact Factor
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ABSTRACT: Graduating residents transition their continuity clinic patients to junior colleagues every year, creating a vulnerable transition period for about 1 million patients nationally. We examined a standardized, electronic template for handing off high-risk ambulatory patients by outgoing residents from 7 residencies within a large health care system, and compared handoff quantity and provider satisfaction for handoffs with and without that template. Residents graduating in 2011 from 5 internal medicine, 1 family medicine, and 1 internal medicine-pediatrics residency programs in 1 health care system were randomized to a new electronic handoff process with a standardized intervention template or a free-text handoff. Expert reviewers independently evaluated all handoff notes, and providers were surveyed after follow-up appointments regarding use, helpfulness, and overall satisfaction with the handoffs. Fifty-two of 79 residents (66%) participated, performing 278 handoffs. Eighty-four patients (30%, 17 of 57) failed to follow up within the study period. For patients who followed up, providers read 61% (101 of 165) of the handoffs at the time of the visit. No significant difference existed between groups in the satisfaction of the follow up provider or the quality measure of the handoffs in our process. Expert agreement on which features make the handoff "helpful" was fair (κ = 0.34). A standardized template did not improve handoff quantity or satisfaction compared with a free-text handoff. Practical handoff programs can be instituted into diverse residencies within a short time frame, with most residents taking part in creating the handoff formats.03/2014; 6(1):112-6. DOI:10.4300/JGME-D-13-00139.1