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: link.springer.comJournal of General Internal Medicine 08/2012; 27(11):1395-6. DOI:10.1007/s11606-012-2205-3
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ABSTRACT: 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.Journal of General Internal Medicine 09/2012; 28(1). DOI:10.1007/s11606-012-2206-2
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ABSTRACT: PURPOSE: To improve timely evaluation and management of newly identified, suspected, gastrointestinal (GI) malignancies discovered on radiologic imaging at a safety-net hospital through direct critical results messaging to surgical specialists. MATERIALS AND METHODS: To address delays in evaluating patients for suspected GI malignancies identified on imaging, an enhanced workflow was created--electronically routed critical results messaging to the ordering provider was supplemented with parallel messaging to the surgical oncology clinic. Messaging data obtained for 10 months pre and post intervention were compared. Using chart reviews, time intervals were recorded to assess the impact on (1) being seen by a specialist, (2) completing a diagnostic workup and (3) initiating definitive management. RESULTS: Significant improvements were achieved: (1) patients seen by a specialist increased from 45.9% to 98.0% (p<0.001), with median time decreasing from 35 to 7 days (p<0.001); (2) patients completing a diagnostic workup increased from 77.1% to 93.9% (p<0.05), with median time decreasing from 44 to 18 days (p<0.001); (3) patients with initiation of definitive management increased from 72.1% to 89.8% (p<0.05), with median time decreasing from 62 to 35 days (p<0.05). Further study is needed to assess impact on fragmentation of care and financial implications. CONCLUSIONS: Direct critical results messaging from the radiologist to the surgical oncologist at a safety-net hospital significantly improves the time to complete a diagnostic workup and initiate definitive management with significantly more patients being seen by a relevant specialist.BMJ quality & safety 10/2012; 22(2). DOI:10.1136/bmjqs-2012-001069