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

BACKGROUND: Few studies have examined the safety risks of the annual outpatient clinic handoffthat occurs when residents either advance to a higher level of training or graduate ("year-end transfer"). A multifaceted intervention was designed and implemented to identify and improve followup of high-risk patients during academic year-end outpatient transfers in a psychiatry resident continuity clinic.
METHODS: Departing residents identified "acute" patients, who were scheduled on a priority basis for longer appointments during the first month after the transfer. In addition, standardized written and face-to-face sign-outs occurred, incoming clinicians contacted every patient in the first week, and specialized didactics were provided.
RESULTS: For the three intervention years combined, the odds ratio of hospitalization for acute patients compared to nonacute patients was 9.2 (95% confidence interval [CI]: 2.43, 34.7; p = .001). Compared to Year 1, the proportion of acute patients seen within 31 days in Years 2 and 3 increased by 32.2% (from 64.3% to 85.0%, p < .0001). The median time-to-first visit for acute patients decreased by 42% (from 24 days in Year 1 to 14 days in Year 3, p = .001). Finally, resident perception of the quality of the handoffim-proved in all areas compared to baseline, including resident-to-resident communication (2.8 to 3.0, p = .03), accuracy of caseload lists (2.8 to 4.1,p = .003), identification of high-risk patients (2.1 to 3.7, p < .0001), and usefulness of supervision during the transition (2.7 to 4.3, p < .0001).
CONCLUSIONS: Categorical designation by the outgoing clinicians effectively identified patients at higher risk for hospitalization during the transition. Relatively low-cost interventions may significantly improve patient safety and resident training in not only psychiatry, but also other disciplines and specialties.