Transitions of Care in Continuity Clinic--Lessons Learned and Next Steps.

Abstract

T ransitions of care are associated with increased potential for medical errors, adverse patient outcomes, and reduced patient safety. Acknowledged as one of the largest annual synchronous care transitions in this country, outpatient care for an estimated 1 million patients is transitioned from a graduating third year resident to an incoming intern at the start of every academic year. Patients transitioning care from a graduating resident describe challenges related to establishing a new patient-physician relationship, navigating clinic logistics and care transition processes, and dealing with lapses in care with implications for patient safety. Following these care transitions, high rates of missed appointments, discontinuity with the newly assigned physician, and loss to follow-up have been observed. From the resident perspective, trainees with less clinical experience and limited interaction with local systems of care are expected to assume care for a panel of patients whom they have never met and who often carry a complex burden of medical and social ailments. Not surprisingly, nearly half of residents do not feel personal responsibility for their assigned patients until they are seen by them in clinic. This lack of ownership and accountability for patients almost certainly inhibits timely and efficient responses to patient messages, prescription requests, and other care issues that may be needed in the absence of a clinical appointment. Further, junior residents often have limited clinical calendars as compared to their graduated senior resident counterparts, which likely impedes appointment access, prolongs the establishment of patientphysician relationships, and magnifies the consequences of perceived lack of responsibility. In this issue of JGIM, Solomon et al. report a retrospective cohort study assessing the impact of resident graduation on acute care utilization by residents’ primary care patients. Rates of clinic visits, emergency department (ED) visits, and hospitalizations were assessed before and after the end-of-year transition date and were compared between graduating residents’ patients and non-graduating residents’ patients. As stated by the authors, this is the first study to use a control group of non-transitioning patients to assess outcomes associated with this resident-patient transition. Using this design, the authors found that transitioning patients had no increase or decrease in the rate of clinic visits, ED visits, or hospitalizations relative to non-transitioning patients. While the lack of association between acute care utilization and resident graduation reported in this study is reassuring, the authors appropriately recognize the need for continued efforts to standardize outpatient panel transitions, citing other potential impacts on patients, residents, and clinic staff. Compatible with this approach, several initial efforts to improve end-ofyear panel transitions have been reported. These include reducing the variability in the initial outpatient caseload of incoming residents; integrating patient-centered transition information; standardizing templates for electronic, written and verbal sign-out; and incorporating a multifaceted approach for transition of high-risk patients. Given the high level of medical and social complexity typical of patients seen in resident clinic, targeted interventions aimed at improving care transitions for high-risk patients may be especially relevant. Of particular interest in the study by Solomon et al., high rates of acute care utilization were observed throughout the study including both the preand post-graduation time intervals and at levels that exceeded national averages. Not surprisingly, higher pre-transition visit rates and higher comorbidity scores were independent predictors of posttransition clinic visits, ED visits, and hospitalizations. Precisely what factors contribute to the overall high rates of acute care utilization observed in this study are unknown. The authors postulate that medical complexity, low socioeconomic status, and limited awareness of clinic resources may all contribute, and they appropriately suggest the need for interventions to decrease acute care utilization throughout the year. Consideration could be given to patientcentered interventions aimed at identifying and reducing barriers to obtaining care in the resident clinic setting; systems interventions targeting proactive scheduling and provision of routine preventive care and chronic disease management and facilitating access for acute medical problems; and education interventions designed to improve residents’ skills in outpatient management. Efforts to measure and improve continuity of care could also be Published online May 30, 2015