Transitions in Care: A Workshop to Help Residents and Fellows Provide Safe, Effective Handoffs for Acute Psychiatric Patients.

Introduction: Focused training in care transitions is an ACGME-required component of resident education. However, there are limited published curricular resources specific to trainees in psychiatry to help develop this crucial skill.
Methods: We developed a 90-minute interactive workshop on care transitions in psychiatry for general adult psychiatry residents (PGY 2-PGY 4), child and adolescent fellows, and consult-liaison fellows. Trainees collaborated in interdisciplinary teams to explore a vignette in which a patient moved through four different venues of care (outpatient, emergency department, inpatient medical, and inpatient psychiatric). Guiding questions prompted discussions of critical issues related to logistics and clinical communication for each transition between care environments.
Results: In a postworkshop anonymous survey, 100% of trainee participants (n = 30) felt the workshop was successful in creating the opportunity to develop relationships with, and learn from, colleagues at other levels of psychiatry training. Ninety percent responded affirmatively that they were able to identify key elements of an effective handoff for an acute psychiatric patient. Eighty-three percent identified being able to describe logistical steps for transferring the care of patients between mental health services at their institution. Discussion: Trainee participants found the workshop beneficial for understanding the steps needed to transfer patients between levels of care safely, discussing and debating gray areas with peers and faculty, and developing interdisciplinary relationships within psychiatry. Faculty participants described an interest in using the workshop as a faculty development exercise. This workshop fills a critical gap in available curricula on transitions in care in psychiatry.

Educational Objectives

By the end of this activity, learners will be able to:

Describe the logistical steps involved in transferring the care of patients between mental health services at their home institutions.

Identify the key elements of an effective handoff for an acute psychiatric patient.

Develop relationships with, and learn from, colleagues at other levels of psychiatry residency training and in other types of psychiatry fellowships, when applicable.

Introduction

The implementation of duty-hour restrictions for residents, which was intended to enhance patient safety and improve learning at training institutions, has led to an increase in change-of-shift handoffs of patients. However, transitions in care have, in turn, been demonstrated to lead to an increased risk of adverse outcomes for patients if essential clinical information is inadequately communicated.[1,2]

The critical importance of training in safe care transitions is reflected in both the ACGME Clinical Learning Environment Review Pathways to Excellence report[3] and the Psychiatry Milestone Project,[4] both of which have identified training in care transitions as a required component of resident education. However, limited resources exist for teaching residents and fellows about care transitions specific to psychiatric patients. Two recent articles have discussed implementation within psychiatry training programs of the I-PASS (illness severity, patient summary, action list, situation awareness, synthesis) system, a transitions-in-care approach developed in pediatrics and associated with a reduction in medical errors and preventable adverse events.[5,6] However, the availability of formal curricula for teaching transitions in care specific to psychiatry is extremely limited. A 2018 review of MedEdPORTAL, the American Association of Directors of Psychiatry Residency Training model curriculum database, and the Association of Directors of Medical Student Education in Psychiatry curricular resources indicated that there were no existing published curricula on transitions in care within psychiatry. Furthermore, a recent survey of psychiatry residency training directors indicated that many programs have yet to develop a formalized teaching approach to handoffs in psychiatry and cited the variations in practice between different clinical settings as a particular challenge.[7]

While psychiatry residents have typically had prior education in transitions in care on medical or surgical services as medical students and interns, the transfer of care within psychiatric services involves additional complexities not typically covered in detail during traditional medical handoffs. Clear communication of a patient's legal status (e.g., whether the patient meets criteria for voluntary or involuntary treatment), history of suicide attempts and psychiatric hospitalizations, trauma history, and history of agitation, aggression, or paradoxical responses to medications are all examples of important details that should be included when transferring care between acute psychiatric services to promote safe, effective treatment and appropriate risk assessment. As these details are specific to psychiatry and are not covered in traditional medical handoffs, focused curricula on psychiatric handoffs are needed to complement the training in medical handoffs that psychiatry residents and fellows typically receive earlier in their general medical training.

This experiential, case-based workshop has been developed to meet the need for curricula on transitions in care specific to psychiatry for general psychiatry residents and subspecialty fellows. The workshop is active in nature and uses a clinical vignette of a patient moving through different phases of psychiatric care as the basis for discussion. Participants follow the transitions in care for this acute psychiatric patient, including from outpatient to emergency room and inpatient settings. Participants are prompted to discuss both the logistical aspects of a safe care transition and the critical clinical information that should be communicated each step of the way. The realistic, case-based format facilitates active participant engagement and the identification of real-life logistical and communication challenges the participants may face within their own health care systems.

The target audience for this workshop is interdisciplinary groups of trainees in psychiatry, including general adult psychiatry residents of all training years, child and adolescent psychiatry fellows, and consult-liaison fellows. With this target audience, participants have the opportunity to learn from each other in interdisciplinary discussions and build relationships across psychiatric disciplines, as well as to explore nuances of system differences across a spectrum of care settings within their institutions. The incorporation of content relevant to general psychiatry residents as well as subspecialty fellows permits this workshop to fit easily into an annual all-department retreat or orientation. However, the content is also appropriate for individual groups of trainees (e.g., adult psychiatry residents without subspecialty fellows) and can be implemented outside of the interdisciplinary context as needed, depending on institutional size and resources.

Methods

We developed this workshop as an annual orientation activity for all PGY 2-PGY 6 postgraduate trainees in psychiatry at our training institution. Prior to the workshop, we assigned trainees to randomized groups of approximately five to six participants per group, with groups composed of general psychiatry residents from PGY 2-PGY 4 training years, child and adolescent fellows from all training years, and consult-fellows. Given the mix of training years participating, we emphasized the unique contributions of each training level present at the onset of the workshop in order to encourage open collaboration across training years and specialties. No prerequisite knowledge was required prior to participation. However, all residents had preexisting familiarity with internal medicine handoffs from their intern years.

Once assembled in small groups, trainees introduced themselves if they did not already know each other. We then provided a brief overview on the rationale for including this workshop as a part of their training, including the increase in care transitions with limitations in duty hours, the risk of adverse events with increased care transitions, and the ACGME mandate for training in care transitions. We also explained to participants that they would be working collaboratively through a four-part scenario designed to familiarize them with different levels of care within the institution, the logistics of transferring a patient between different levels of care, and the essential clinical content to communicate for an acute psychiatric patient transitioning through different levels of care.

After this brief introduction, participants worked through sequential small- and large-group discussions of a vignette of a patient transitioning through four different levels of care: (1) from an outpatient psychiatric clinic to psychiatric emergency services, (2) from emergency services to an inpatient medical unit, (3) from inpatient medicine to inpatient psychiatry, and (4) from inpatient psychiatry back to outpatient treatment. As we introduced each section of the exercise, we also provided the relevant vignette on paper handouts for all participants to read together (Appendix A). Participants read and discussed each vignette and the associated guiding questions within their small groups. After each small-group discussion, we facilitated a follow-up large-group discussion of guiding questions and associated key points. The overall time line of the workshop was as follows:

Small-group assignment and introductions (5 minutes).

Introduction to and overview of workshop (5 minutes).

Small groups: Read part 1 of scenario, discuss guiding questions (10 minutes).

Large group: Review small-group answers to guiding questions and key points (10 minutes).

Small groups: Read part 2 of scenario, discuss guiding questions (10 minutes).

Large group: Review small-group answers to guiding questions and key points (10 minutes).

Small groups: Read part 3 of scenario, discuss guiding questions (10 minutes).

Large group: Review small-group answers to guiding questions and key points (10 minutes).

Small groups: read part 4 of scenario, discuss guiding questions (10 minutes).

Large group: Review small-group answers to guiding questions and key points (10 minutes).

Guiding questions for case discussion focused on two primary aspects of care transitions: (1) the logistics of care transition (e.g., transportation, any necessary legal paperwork, involvement of supervisors) and (2) identification of critical clinical content to communicate from one provider to the next. Additional details regarding guiding questions and key points to elicit within group discussion were described in the discussion guide (Appendix B). We also instructed participants to practice using the I-PASS mnemonic as they worked through the scenarios and have included examples of this in the discussion guide for institutions using the I-PASS system.

After completion of all small- and large-group discussions, we gave participants an anonymous survey querying them on the effectiveness of the workshop in meeting the stated educational objectives (Appendix C). The survey was created by curriculum developers, who included both faculty and trainee members, based on a review of the literature and consensus agreement of top priority questions. The survey also asked that participants describe the aspects of the workshop that were most useful and offer suggestions for improvement. Based on feedback from the first cohort participating in the workshop, we developed and provided a handout summarizing important contacts within our system (e.g., public safety phone number, legal counsel contacts) to a later cohort of participants the following training year.

Participants’ skill in executing safe, effective transitions in care was subsequently monitored by faculty in the clinical setting via direct observation when clinically applicable, offering the opportunity for feedback within the actual clinical environment, for example, a PGY 2 or PGY 3 resident's postcall handoff to the psychiatric emergency services attending.

The Cambridge Health Alliance Institutional Review Board (IRB) determined that this project did not qualify as human subjects research and did not require a full IRB review.

Results

This workshop has been presented in both local and national settings by a team of interdisciplinary leaders from our institution, including a PGY 4 adult psychiatry resident, a second-year child fellow, and training directors for both general psychiatry and child fellowship training programs. Locally, it has been used as an interdisciplinary training in our annual Department of Psychiatry summer orientation for 2 years, with 30 participants attending each session. The majority of participants have been general adult psychiatry residents in years PGY 2-PGY 4 (22–24 participants per session); child and adolescent fellows (six to nine per session) and consult-liaison fellows (two per session) have also participated.

Participants in the first trainee cohort completing the workshop filled out an anonymous postworkshop survey to assess the benefits and limitations of the workshop and to provide feedback. Of the 30 participants, 100% felt the workshop was successful in creating the opportunity to develop relationships with, and learn from, colleagues at other levels of psychiatry residency training and in other types of psychiatry fellowships; 90% responded affirmatively that they had met the objective of being able to identify the key elements of an effective handoff for an acute psychiatric patient; and 83% stated that they were able to describe the logistical steps involved in transferring patients between mental health services at our institution. Participant responses regarding success in meeting learning objectives are summarized in the Table. Participants felt that the most helpful components of the workshop were “having interdisciplinary conversations,” “learning more about the logistics of transitioning care between different levels within [our care system],” and “discussing/debating gray areas.”

Table.

Summary of Participant Responses to the Postworkshop Survey (n = 30)

In narrative feedback, trainee participants also provided comments on what they found to be their key takeaway learning points. Below, their comments to the prompt “What were the most important takeaways from this session for you?” are broken out by theme.

Appreciation for the complexity of psychiatric care systems:

“Systems are complicated, so reach out for help!”

“How to transfer PT from OP to ED, important resources to consult—faculty back-up, child fellow, support staff, public safety, legal.”

“The need for involving more people in communication of transfers.”

The importance of thorough communication:

“Communication is critical.”

“Conversation between the various levels of care is important and should be as complete as possible.”

“Communication between teams is very important.”

The availability of and importance of asking for help/support for safe transfer:

“There are always resources or someone to discuss cases with.”

“Systems are complicated, so reach out for help!”

“Talk to other providers, there is always support, never worry alone.”

The intersection of relevant mental health law with transitions of care in psychiatry:

“Learning the involuntary detention process and associated legal paperwork.”

“Discussing legal concerns [consent from a guardian, involuntary hold].”

“Had questions about legal guardianship that were answered.”

Areas for improvement noted by trainee participants included a request for more time for discussion and a summary of systems contacts and resources to assist with transfers of care. Based on this feedback, we increased available discussion time in subsequent iterations of the workshop and provided a key-point handout with information on logistical issues specific to our institution, including important phone numbers, reminders of how to reach supervisors within different parts of our institution, and where to find and access legal documents.

Discussion

This workshop was designed to teach psychiatry residents and fellows about the logistics and communication necessary for safe transitions in care between different psychiatric care settings. The case-based, discussion-oriented format permitted active engagement from all participants throughout the workshop, and the realistic nature of the case offered trainees the opportunity for in-depth, detailed discussion of the logistics and communication needed for safe transfer of care between teams. While this workshop could also be flexibly adapted to a noninterdisciplinary setting (e.g., adult psychiatry residents without subspecialty fellows), trainees who participated in the interdisciplinary setting uniformly described the opportunity to build community and learn from trainees at other levels in training as a strength of the workshop. Of note, we did not include PGY 1 psychiatry residents in this workshop, since general psychiatry residents at our institution do not begin their acute psychiatry rotations (i.e., inpatient care, psychiatric emergency services, and inpatient consult-liaison) in earnest until the PGY 2 year. For programs that begin acute psychiatry rotations in the PGY 1 year, this curriculum would be appropriate for delivery to general psychiatry PGY 1 residents.

This workshop was also presented at the American Association of Directors of Psychiatric Residency Training 2018 annual meeting, with the goal of sharing the curriculum with other training programs so that it could be used for transitions-in-care education at other institutions. Verbal and written feedback from participants suggested that in addition to implementation with residents and fellows, this curriculum would also be useful as a faculty development exercise within graduate medical education (GME) training programs in psychiatry. While this option has not yet been formally piloted or evaluated, the workshop curriculum could also be implemented with faculty to solidify faculty understanding of the nuances of transfers of care between settings within their own systems as well as to review how they would advise trainees managing transfers.

Feedback from and reflection on the earliest iteration of the workshop provided valuable lessons leading to improvement in subsequent iterations. Most notably, participants wanted a hard-copy reference sheet containing contact information for important contacts related to transitions in care, including public safety, legal counsel, support staff, and supervisors. A sheet containing these resources was therefore developed and provided to participants at the end of the workshop in subsequent sessions. We also found that trainees’ level of interest in learning details about related mental health law was higher than anticipated, as demonstrated by their level of engagement in discussions of legal topics (e.g., guardianship and involuntary holds), questions during the workshop, and identification of legal topics as key takeaway points. Given this level of interest, workshop leaders prepared more detailed answers for questions related to local mental health law for subsequent iterations.

There were several limitations of this curriculum. First, while no prior training in handoffs was required to participate, all of our participants had prior experience in care handoffs in internal medicine. We therefore focused specifically on learning about care transitions among different psychiatric services, which was most relevant to their work as psychiatrists; we intentionally did not include coverage of transitions from or within medical teams, as this was less relevant to our trainees’ work and typically had been covered earlier in their training. Second, we did not incorporate a structured evaluation of learners’ knowledge within or immediately after the workshop session. There were several barriers to this type of evaluation, including the fact that our workshop was conducted during the orientation week at the start of the training year, and we therefore did not have a reliable way to evaluate trainees’ approaches to handoffs prior to receiving the curriculum. Instead, we utilized real-time feedback on handoff practices and outcomes embedded within the clinical learning environment after the workshop. While this strategy did not offer as much quantitative, objective data on what learners gained from the curriculum, it did locate assessment within the most salient learning environment—clinical care of patients—and carried the benefit of evaluating actual practice habits rather than short-term, rote demonstration of knowledge of key concepts outside of a real clinical care environment. Feedback provided to trainees included both qualitative verbal feedback and written documentation of progress on interpersonal and communication skills milestones outlined by the ACGME.[4] Next steps for evaluating the results of this curriculum could include objective changes in the frequency of adverse outcomes during transitions in care within the department, as well as formal assessments of trainee handoff practices following the training.

This curriculum introduces participants to the I-PASS system in only a cursory manner. This reflects the fact that use of the I-PASS system is not universal among health care organizations as well as the fact that the efficacy and applicability of I-PASS to psychiatric patients have not been formally studied. In this context, I-PASS content may not be a high priority for some training programs, and it is therefore not a major point of emphasis in this curriculum. However, programs whose institutions do utilize I-PASS may wish to enhance this component of the workshop, and additional context on the I-PASS system and curricula for implementation is available in a prior MedEdPORTAL publication specifically targeting I-PASS teaching and learning.[8] Similarly, this workshop focuses on verbal handoffs but does not cover another valuable handoff tool, the electronic medical record (EMR), as a detailed verbal handoff is the standard of care within our system for the high-acuity transitions of care depicted in the curriculum vignettes. In our training programs, residents and fellows in psychiatry do clinical rotations in over 15 different sites and services, each with its own institutional practices on use and format of EMR-based handoffs. Given this heterogeneity in EMR handoff practices across sites, we chose not to teach a single EMR handoff approach in this curriculum. Rather, we delegated the teaching of EMR handoff to individual clinical services, with the expectation that competency in verbal handoffs developed through this curriculum and subsequent clinical practice would provide trainees with a solid foundation to provide thorough handoffs using a variety of electronic handoff tools. Programs with fewer sites and/or a more homogeneous approach to EMR handoffs on different rotations may wish to pair this curriculum with an additional module on EMR handoffs for all trainees.

Residents and fellows training in general psychiatry and psychiatric subspecialties work within complex systems of care, in which they may rotate through a variety of acute service and outpatient settings, each of which may have its own protocols, supports, and challenges for safe transitions in care. Residents and fellows are in the position to care for patients whose psychiatric complexities, such as trauma histories, interpersonal sensitivities, interface with mental health law, or maladaptive behaviors, may not fit neatly within traditional medical models for handoffs. In consideration of these nuances unique to the psychiatric context, as well as the ACGME mandates for transitions-in-care training to promote patient safety, this curriculum fills a unique need by providing a psychiatric-specific model for teaching GME trainees about transitions in care.

Case Vignettes.docx

Discussion Guide.docx

Postcourse Survey.docx

All appendices are peer reviewed as integral parts of the Original Publication.