Warm Handoff Research Articles

Randomized controlled trial of twelve-step volunteer linkage for women with alcohol use disorder leaving jail

BackgroundAlcohol use disorder predicts poor health outcomes among women returning to the community from jail. Twelve-step self-help groups are free and accessible to women leaving jail, but reaching out to strangers can pose a barrier. Pilot work suggested that a volunteer-led “warm handoff” may increase post-release twelve-step self-help group attendance. MethodsThis randomized trial evaluated the effectiveness of a warm handoff intervention on post-release twelve-step attendance and alcohol use. Participants (189 women with alcohol use disorder) were recruited in jail and followed for 6 months after release. Participants were randomized to: (1) a warm handoff, in which a female twelve-step volunteer met with each woman individually in jail and the same volunteer attended the woman’s first twelve-step meeting with her after release; or (2) enhanced standard care (a list of meetings and community resources). Outcomes included days abstinent from alcohol, drinks per drinking day, alcohol-related problems, twelve-step attendance, twelve-step affiliation, network support for abstinence, number of unprotected sexual occasions, and drug using days. ResultsAmong intervention participants, only 66 % were aware that the volunteer tried to contact them after jail, only 38 % reported post-jail contact with their volunteers (typically phone), and only four went to meetings with their volunteers post-release. Of 8 post-release outcomes, intervention effects differed on only one (alcohol-related problems). ConclusionAlthough twelve-step self-help group attendance predicted alcohol abstinence, the volunteer-led warm handoff intervention did not increase twelve-step attendance. The twelve-step tradition of Attraction may inhibit the active outreach required to connect women to services after jail release.

Innovation in germline and somatic tumor testing pathways for ovarian cancer patients

<h3>Objectives:</h3> New approvals for upfront maintenance therapy with parp inhibitors in ovarian cancer now indicate a need for germline genetic testing and potentially somatic testing including homologous repair deficiency (HRD) within several months of diagnosis. However, national rates of germline testing are approximately 30%1 despite being recommended for all patients. Current practice now indicates that it is even more important to obtain results quicker and more efficiently at the time of a new diagnosis of ovarian cancer. We sought to apply novel healthcare innovation techniques to this problem space to improve rates of germline and somatic tumor testing in ovarian cancer patients. <h3>Methods:</h3> A total of 4 pilots ranging from "low to high touch" were performed in an experimental rapid cycle model, each lasting approximately 2-3 weeks. In Pilot 1, providers were "nudged" via email, text or electronic medical record (EMR) alert as per their preference that an upcoming patient was missing either genetic testing or tumor testing (HRD or somatic testing). In Pilot 2, choice architecture was used to pend orders for genetics consultation into the upcoming patient encounter in the EMR. In Pilot 3, a "Concierge Approach" was applied to capture patients in real time who were approached in person at the clinic appointment and offered immediate genetic counseling/testing. In Pilot 4, a text messaging platform was used to schedule patients for a counseling/testing appointment. Descriptive statistics were performed. <h3>Results:</h3> Results: Pilot 1: 30 "nudges" were placed but only 50% of encounters documented discussion or ordering of genetic testing. Pilot 2: 75% of pended orders were signed, with 7/12 (58.3%) of patients scheduling a genetic counseling appointment. Pilot 3: 4/6 (66.7%) of patients completed a genetic counseling appointment when offered in real time at the visit and 3/4 (75%) completed testing. Pilot 4: If patients consented to texting for scheduling (50%), the majority of patients were scheduled for counseling or obtained outside testing results (n=8/9, 88.9%). Attendance rates at appointments scheduled via text were 100% (n=5/5). Potential trends in racial disparities were identified within the n=59 patients missing germline or somatic testing, with an increased proportion of Black patients (27.1%) and Asian/Other (13.6%) missing testing, higher than the baseline practice demographics. <h3>Conclusions:</h3> Behavioral economics can be utilized to improve rates of genetic and somatic testing for ovarian cancer patients. Patients typically complete genetic counseling/testing if an appointment is offered in real time. A ‘warm hand-off' is needed for outreach via text for awareness and engagement, however once enrolled, patients participated via text for scheduling and discussion of prior results at high percentages. A ‘concierge approach' is highly successful but not scalable for all but could be used to ‘rescue' missed patients. Potential racial disparities need further exploration to ensure solutions are equitable and applicable to all patients. The growth of precision medicine could benefit from automation and choice architecture utilizing the EMR. This would allow for surfacing of missing clinical data by removing the mental burden of the work required to complete genetic and somatic testing.'

Integrating Physical Therapists Into Primary Care Within A Large Health Care System.

Bellin Health in Wisconsin has pioneered the colocation and integration of physical therapists into primary care pods. This is an observational study based on one in-person visit and several interviews. For patients with musculoskeletal complaints, providers make warm handoffs to the physical therapist, who is a few steps away. The physical therapist performs most of the visit, providing diagnosis, treatment, and patient education. Research studies show that-compared with physician management-appropriate patients managed by physical therapists have better outcomes, lower costs, and higher patient satisfaction. In a fee-for-service environment, the business case for this innovation requires an increased number of follow-up referrals to the physical therapy department. In the Coronavirus disease 2019 (COVID-19) era, physical therapists can provide video visits with equal quality compared with in-person visits. The Bellin Health program is a blueprint for other primary care practices to integrate physical therapists into primary care teams.

Researching warm hand-offs: Should we give a WHOot?

This article discusses warm hand-offs (WHOs) in behavioral services and PCBH models. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Service Coordination to Address Maternal Mental Health, Partner Violence, and Substance Use: Findings from a National Survey of Home Visiting Programs.

Maternal risks such as poor mental health, partner violence, and substance misuse can undermine child health and development. Maternal and early childhood home visiting programs address these risks primarily through referral and coordination with community-based services, yet effects on these outcomes have been small. This study assessed the strengths of local home visiting sites' systems to support coordination of mental health, partner violence, and substance use services. Investigators recruited home visiting sites (N = 88) representing diverse models from a national practice-based research network, the Home Visiting Applied Research Collaborative (HARC). Web-based surveys assessed five implementation system supports for coordination and nine coordination activities drawn from the Measurement Framework for Coordination developed earlier in the project. Surveys also assessed seven coordination barriers identified in previous research. Sites varied in their implementation supports and coordination activities; on average, sites had stronger systems in place to support screening and referring families than to support linkage and follow-up. Implementation supports and activity scores were higher for mental health and partner violence than for substance use. Across all service needs, scores were highest for offering a referral and documenting the caregiver's agreement for exchange of information between providers. Scores were lowest for offering a warm handoff. Lack of open slots and lack of transportation were major barriers to successful coordination for all three services. Results suggest that home visiting coordination could be strengthened by focusing on infrastructure for linkage and follow-up with services in the broader system of care.

Research Participant Recruitment Strategies Among Individuals with Acute Spinal Cord Injury and Their Caregivers: A Pre-Post Study.

Pre-post study. To evaluate the efficiency of a series of recruitment strategies in a longitudinal study of individuals with SCI and their informal caregivers. Primary strategies included (a) rapport building in advance, (b) warm handoffs from another healthcare provider who already had a relationship with the potential participant, (c) ensuring the potential participant had information about the study prior to the initial contact by the research coordinator (RC), (d) attempting informed consent only when both the patient and informal caregiver were present, and (e) ensuring the RC had at least 30 minutes to explain the study when attempting recruitment. While a fairly large body of research has been conducted on general recruitment strategies for clinical trials, very little has examined the efficacy of these strategies within neurological conditions and almost none within SCI. Individuals with an acute SCI and their informal caregivers were recruited from acute spinal cord rehabilitation units with a Veteran's Affairs medical center and an academic medical center in the same urban area. Of 49 eligible dyads, 41 were approached for consent, with 27 consenting to join the study (9 from the academic medical center; 18 from the VA). There was a significant difference in enrollment rates after implementing the recruitment strategies, χ2(1) = 7.572, P = 0.006, with the per month participant enrollment rate nearly doubling after implementation. Using a multiteam and multidisciplinary approach to recruitment may increase the likelihood that individuals with an acute SCI and their caregivers enroll in research.Level of Evidence: 3.

Warm Handoffs for Improving Client Receipt of Services: A Systematic Review.

Warm handoffs intend to improve receipt of services by clients who receive referrals to services that are stigmatized or not easily accessible. Such strategies are characterized as the handoff or transfer of an individual between two service providers through a face-to-face, phone, or technology-assisted interaction. This approach may be useful for maternal and child health home visitors who provide direct services and facilitate connections to community resources for client families. However, little is known about the effectiveness of warm handoffs. A systematic review of the literature on warm handoffs was conducted with studies identified in four databases. Full text was reviewed for studies for which abstracts met inclusion criteria or for which abstracts were not available. Evidence tables summarizing study characteristics, outcome measures and data sources, intervention descriptions, intervention components, and study results were constructed. Of the 42,816 unique articles identified, 32,163 titles/abstracts were screened, 227 qualified for full text review, and five comprised the study sample. Three studies examined referrals from substance use treatment centers to self-help groups, one from federally qualified health centers to community mental health clinics, and one from a mobile needle exchange program to substance use treatment/intake. Three studies showed increases in receipt of services by clients following referral between the warm handoff intervention and control group. Current evidence regarding the effectiveness of warm handoffs is limited. An examination of the effectiveness of warm handoffs in the context of home visits is needed to assess whether they facilitate client referrals.

"Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology".

Social and environmental factors have an outsized effect on one’s health. Children are particularly impacted by the adverse effects of poverty. While social determinants of health (SDH) screening in healthcare settings has proliferated there remain gaps in best practices for screening processes. As research has shown that patient navigation leads to an improvement in unmet social needs and family-reported child health, warm handoffs may be a key factor in assuring that the social needs of families are effectively addressed. Using quality improvement (QI) methods our pediatric clinic worked to increase the warm handoff rate between Community Health Workers (CHWs) and patients with unmet social needs. CHW warm handoff rates increased two-fold over the intervention period. Our results illustrate that QI methods can be used to optimize workflows to increase warm handoffs with CHWs. This is important as health centers work to improve their social needs screening and referral programs.

Integrating physical and mental healthcare: Facilitators and barriers to success.

Introduction:Effective and appropriate provision of mental healthcare has long been a struggle globally, resulting in significant disparity between prevalence of mental illness and access to care. One attempt to address such disparity was the Patient Protection and Affordable Care Act (PPACA), 2010, mandate in the United States to integrate physical and mental healthcare in Federally Qualified Health Centers (FQHCs). The notion of integration is attractive, as it has demonstrated the potential to improve both access to mental healthcare and healthcare outcomes. However, while the PPACA mandate set this requirement for FQHCs, no clear process as to how these centers should achieve successful integration was identified.Methods:This research employed case study methods to examine the implementation of this policy in two FQHCs in New England. Data were obtained from in-depth interviews with leadership, management, and frontline staff at two case study sites.Results:Study findings include multiple definitions of and approaches for integrating physical and mental healthcare, mental healthcare being subsumed into, rather than integrated with, the medical model and multiple facilitators of and barriers to integration.Conclusion:This study asked questions about what integration means, how it occurs, and what factors facilitate or pose barriers to integration. Integration is facilitated by co-location of providers within the same department, a warm hand-off, collaborative collegial relationships, strong leadership support, and a shared electronic health record. However, interdisciplinary conflict, power differentials, job insecurity, communication challenges, and the subsumption of mental health into the medical model pose barriers to successful integration.

Use of a warm handoff interprofessional simulation to model asynchronous and patient-centered teamwork

An interprofessional education simulation in an outpatient clinic setting was utilized to allow pharmacy and social work students to practice the warm handoff communication technique. This event included 157 pharmacy and social work students. The primary objective of this encounter was for the learner to better understand the role of the partnering profession and demonstrate an appropriate warm handoff. The simulation included pre-event didactic education, performance of a warm handoff, and faculty-led debriefing. A novel warm handoff evaluation checklist was created to evaluate the performance of the students using the warm handoff communication technique. Students successfully initiated the warm handoff and demonstrated patient engagement by asking permission and using introductions. However, students did not perform as well with the more complex skills of communicating the patient's background, situation, and assessment to their colleagues. Students were asked to complete an anonymous, pre- and post-questionnaire to assess the impact and value of the interprofessional simulation and the likelihood that they would refer a patient to the partnering profession in the future. The post-questionnaire was evaluated both quantitatively and qualitatively using a content analysis of the open-ended questions. The quantitative analysis showed that students valued the simulation and the opportunity to practice and would use the skills gained in the future. The results also revealed an increased likelihood that students would refer patients to the partnering profession post-simulation. The content analysis of the open-ended question asking the learners what they thought was valuable about the simulation demonstrated that students value communicating with another healthcare team member with the patient in the room, learning about the role of other healthcare professionals, and practicing the warm handoff communication tool. Overall, this simulation was shown to be an effective activity to promote interprofessional care between pharmacy and social work students and to practice a warm handoff that promotes integrated patient care in outpatient healthcare settings.

Using Quality Improvement to Increase Access to Palliative Care.

As part of a larger effort to integrate palliative care into a cancer center, we identified barriers to palliative care referral for patients with breast or gynecologic cancer and developed a pilot program to improve access to palliative care services. We developed a multidisciplinary steering committee to uncover barriers to palliative care referral and developed a pilot program, called the Warm Handoff. Through ongoing collaboration and midpilot feedback sessions, we identified several additional barriers and opportunities to increase access to palliative care. Clinicians used the initial Warm Handoff process only 20 times over a period of 7 months. Of those calls, 10 were for issues outside of those that the Warm Handoff pilot was intended to address. During the pilot, we identified lack of access to urgent visits and clinician telephone availability for clinical case discussion as additional barriers to access. Increased collaboration led to the creation of a clinical provider of the day (CPOD) care model, which allowed for a notable increase in the capacity to see urgent consults. After this intervention, we observed an average of 19 patients seen urgently per month. In addition, there was a trend toward increasing referrals from breast oncology after the initiation of the CPOD. A CPOD model, developed via close oncology/palliative care collaboration, resulted in increased utilization of palliative care services.

Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions.

ED-initiated addiction treatment holds promise for enhancing access to treatment for those with opioid use disorder (OUD). We present a literature review summarizing the evidence for buprenorphine induction in the ED including best practices for dosing, follow-up care, and reducing implementation barriers. A literature search of Pubmed, PsychInfo, and Embase identified articles studying OUD treatment in the ED published after 1980. Twenty-five studies were identified including eleven scientific abstracts. Multiple studies suggest that buprenorphine induction improves engagement in substance treatment up to 30 days after ED treatment. Many different induction protocols were presented, but no particular approach was best supported as criteria for induction and initial dosing vary widely. Similarly, transition of care models focused on either a “hub and spoke” model or “warm hand-offs” model, but no studies compared these approaches. Common barriers to implementing induction programs were provider inexperience, discomfort with addiction treatment, and limited time during the ED visit. No studies described the number of EDs offering induction. While ED buprenorphine induction is safe and enhances adherence to addiction treatment, uncertainty persists in how to best identify patients needing treatment, how to initiate buprenorphine, and how to enhance follow-up after ED-initiated treatment.

Finding a Medical Home for Perinatal Depression: How Can We Bridge the Postpartum Gap?

Finding a Medical Home for Perinatal Depression: How Can We Bridge the Postpartum Gap?

74 Using an Observation Unit to Decrease Disparities in Opiate Medically Assisted Treatment Program Follow Up

The opioid use disorder epidemic has increased dramatically in the last two decades. Medication-assisted therapy (MAT) for opioid use is a well-established tool for addressing the opioid epidemic. Despite the proven success there are small studies suggesting that black patients and women are less likely to receive medically assisted treatment during opiate rehabilitation. Even with the rise of emergency department-initiated medically assisted treatment programs (MATP) for opiate dependency, little research exists investigating sex or race differences in enrollment to them. Emergency Department Observation Units (EDOUs) are ideally protocol driven patient care areas where decisions can be made about whether to admit a patient or discharge to home. For patients with opioid use disorder, there may be a confounding ingestion which would complicate withdrawal and thus necessitate an inpatient admission. This decision, made in concert with a toxicologist, can be combined with a warm handoff (invitation to clinic and initiation). Aim: to determine the rate of follow up in a MATP with an EDOU providing a ‘warm-handoff’ and also to determine if there is variance in race and sex from the visits to this EDOU and MATP follow up. Out hypothesis was that patients placed in the EDOU using a ‘warm-handoff’ mechanism in concert with toxicology would have an attrition rate to the MAOT clinic less than 50% and have insignificant race and sex variance in MATP follow up. We retrospectively collected data on patients placed in a protocol driven EDOU from the emergency department, over 22 months (January 2018 and October 2019). While in the EDOU, patients were evaluated for co-ingestants, evaluated by a toxicologist who assessed their level of withdrawal and used this information to initiate suboxone therapy and arrange follow up in the toxicology administered medication-assisted therapy clinic. The association between sex, race, and clinic follow-up was evaluated using a logistic regression which included the main effects of sex and race, and the two-way interaction. There were a total of 101 uses of the EDOU suboxone protocol during the study period of which 88 were unique cases and included full outcome data. 34 patients (38.6%) identified as White and 59 (67.0%) identified as Male. The median age was 39 (IQR: 30 - 54) and the median COWS score was 10.5 (IQR: 6 - 14). Of these 39 (44.3%) followed up in our MATP. Neither sex (OR = 1.0, 95% CI: 0.99 - 1.01), race (OR = 0.22, 95% CI: 0.04 - 1.33), nor the interactions between these factors (OR = 3.46, 95% CI: 0.43 - 27.6) were significant. Although the numbers are small, this single center study suggests that using an EDOU and standardizing the pathway to MAT may help eliminate disparities that have been described in larger populations in systems without a ‘warm-handoff’ mechanism. Further epidemiologic studies to understand this population and prospective studies are needed on the issue to best describe the role of the EDOU in this epidemic.

Reengineering the Discharge Management of Heart Failure Patients Discharged to Skilled Nursing Facilities Utilizing a Multidisciplinary Team Approach Reduces 30-day Readmission Rate

Introduction Value Based Purchasing (VBP) Initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. The challenge is the large volume of hospitalized Heart Failure (HF) patients (4,000/year) with a historically high 30-day readmission rate (27%). HF patients discharged to Skilled Nursing Facilities (SNF) (23%) were at higher risk of readmission, p-value Hypothesis Development of a designated multidisciplinary HF Team (NP, PharmD, Case manager and SNF leadership) approach that integrates a standardized comprehensive pre/post discharge multidisciplinary management plan will decrease 30-Day readmission rates. Methods January 15 - April 1, 2019 was the implementation phase of the SNF Heart Failure Readmission Reduction Initiative (SNF -HFRRI) Pilot Project which included generation of a daily patient list with Primary HF (ICD-10) and HF anticipated discharge list from case management. Daily HF Team morning rounds were conducted to review patient/family education, appropriate medication/adherence, and discharge readiness. HF patients identified to be discharged to a SNF were flagged for further in-depth pre-discharge HF NP consult/PharmD counsel and to develop a warm handoff to SNF leadership. Post discharge HF weekly telephone assessment with SNF senior RN leadership and attendings were conducted. Retrospective review of prospectively collected data was analyzed based on age, gender, NYHA, ACC stage, LOS, Unit of discharge and 30-Day Readmission and included Pre-SNF-HFRRI (June 1, 2018 - January 15, 2019); Implementation Phase (January 15, 2019 -March 31, 2019); Post SNF-HFRRI (April 1, 2019 November 15, 2019). Results We identified 182 HF patients (88-Pre-SNF-HFRRI and 94 Post SNF-HFRRI). Continuous variables (age, LOS) and categorical variables (gender, NYHA, LVEF, ACC stage, reason for readmission, hospital unit discharged and 30-day readmission) were summarized; pre/post groups were compared using Wilcoxon rank, chi square and Fisher's exact test. The groups were comparable to age, LOS, LVEF, ACC class, units discharged. A structured weekly post discharge phone assessment incorporating Guideline-Directed Medical Therapy was statistically significant, p Conclusion Our newly integrated multidisciplinary HF team approach that incorporates a structured post-discharge collaborative approach can prevent avoidable 30-day readmissions and improve discharge preparedness.

Risk of Suicide, Unintentional Death Soar after Nonfatal Overdose

Risk of Suicide, Unintentional Death Soar after Nonfatal Overdose

Exploring Predictors of Treatment Engagement in Urban Integrated Primary Care.

Integrated primary care (IPC) is intended to address the gap in access to behavioral health care. This may be particularly true in urban settings; however, there is a paucity of research on treatment engagement in urban IPC. This study explored factors associated with treatment engagement. Data were collected via retrospective chart review for 410 patients of diverse backgrounds who received an IPC referral in an urban primary care site. Patient-related factors included having multiple types of referral concerns, patient primary care show rate, and number of visits with referring clinician. Service-related factors included referral type (warm handoff/ electronic), number of days between referral and intake, and average number of days between IPC treatment sessions. Engagement outcomes included attendance at IPC intake, total IPC sessions attended, overall IPC show rate, and IPC treatment attrition. Of referred patients, 348 (84.9%) were encouraged to or scheduled an intake. Of those, 289 (83.1%) scheduled and 57.2% attended; the average number of sessions attended was 1.73. Patients who had more primary care office visits and higher primary care show rates were more likely to attend an IPC intake. Shorter average duration between follow-up sessions was associated with higher overall IPC show rates for those who initiated IPC follow-up care. Supporting engagement in primary care broadly and building scheduling capacity for IPC treatment may increase IPC service engagement in an urban primary care context.

Warm handoff, or cold shoulder? An analysis of handoffs for primary care behavioral health consultation on patient engagement and systems utilization.

Warm handoff, or cold shoulder? An analysis of handoffs for primary care behavioral health consultation on patient engagement and systems utilization.

“Nice to meet you”: A quality improvement project to increase warm handoffs.

“Nice to meet you”: A quality improvement project to increase warm handoffs.

Improving Use of a Hospital Transitional Care Clinic

In response to Medicare readmission penalties, some hospitals have introduced transitional care clinics (TCCs) to meet the care needs of patients recently discharged from the emergency room or inpatient setting. This study was undertaken to increase the proportion of low-income, medically complex patients using a TCC at a large academic medical center, Northwestern Medical Group Transitional Care Clinic (NMG-TC). This quality improvement study combined interviews and quantitative data analysis to determine how to increase use of NMG-TC. Physicians and patients were interviewed and surveyed to identify opportunities to expand clinic use. Logistic regression analysis of electronic health record (EHR) data was used to identify sociodemographic and clinical conditions influencing the TCC appointment show rate. Provider surveys and interviews suggested that referrals would likely increase via automation of referral guidelines and enhanced transitional care education. Patient interviews indicated that better communication of NMG-TC purpose, emphasizing nonmedical offerings, and warm handoffs could increase engagement. EHR analyses revealed that patients least likely to attend appointments were male, uninsured, non-Hispanic black, or homeless; had documented substance use; or lived > 50 miles from the clinic. Conversely, patients with heart failure, anxiety, or malignancy were more likely to attend appointments. TCC show rates could be improved with better communication of NMG-TC benefits to both patients and referring providers, as well as warm appointment handoffs, particularly for patients least likely to attend scheduled visits.