Shana Ratner

Implementation Science Workshop: primary care-based multidisciplinary readmission prevention program.

To define comorbidities including chronic obstructive pulmonary disease or asthma, heart failure, diabetes, hypertension, coronary artery disease, and depression, we required the condition to be listed either on the index hospitalization discharge summary or on the general problem list of the EHR; in addition, an appropriate medication to treat this condition had to be listed in the index hospitalization discharge summary. Cirrhosis and chronic kidney disease required only a mention of this condition in the discharge summary or problem list, and alcoholism was defined to include active problem drinking in the prior 6 months, as noted in the hospital discharge summary or clinic notes.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety

Purpose Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. Method In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. Results Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P < .01), more verbal handoffs (80% versus 38%, P < .01), more patients aware of the handoff (100% versus 74%, P = .01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P =.03), and more ownership of patients before the first visit (56% versus 26%, P =.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P < .01), and more tests were followed up appropriately (67% versus 46%, P = .02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P= .06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P = .06). Conclusions Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

Transfer of Graduating Residents’ Continuity Practices

To the Editors:— We applaud Caines et al.1 for addressing an important patient safety topic, year-end resident continuity clinic handoffs, that has received little attention thus far.2 The high percentage of patients lost to follow-up is astounding, highlighting that clinic handoffs are a vulnerable time for patients. Because very few patients who were lost to follow-up were in fact scheduled for an appointment, it is critical to explore if more effective scheduling may improve this transition of care. In addition to more effective scheduling, we wondered if patient factors or patterns of care may explain why patients did not follow up. For instance, among the 29% of patients lost to follow-up because they did not keep their appointment, it would be important to understand whether these patients had a history of missing appointments. In other words, did they miss the appointment because of the handoff or because they tend to miss appointments? The distinction is important since patients who miss appointments generally may require even more intense follow-up and coaching during the handoff to overcome barriers to visiting their physician. Patients deemed to be high risk may also be more likely to be lost to follow-up in their resident clinic because they present elsewhere to emergency departments or hospitals for acute care. Therefore, understanding the acute care utilization patterns of these patients both before and after the handoff is important to consider for future studies. Lastly, defining high-priority patients as those requiring follow-up within 1 year may be too crude a measure given the chronic illness burden of resident clinic patients. It has previously been demonstrated that US residents take care of underserved populations who are at risk for poor outcomes.3 Moreover, guidelines recommend that patients with certain conditions, such as diabetes, should be seen every 3 months, making certain high-risk patients in need of more frequent care than once a year. Understanding what constitutes a high-risk patient given the increasing complexity of primary care and already high illness burden for resident clinic patients is critical. Rebalancing case loads after a year-end clinic handoff to ensure appropriate workloads and illness burden has been a strategy used in other disciplines.4

Implementation and quality improvement of a screening and counseling program for unhealthy alcohol use in an academic general internal medicine practice

Abstract: Unhealthy alcohol use is the third leading cause of preventable death in the United States. The U.S. Preventive Services Task Force (USPSTF) recommends screening for unhealthy alcohol use but little is known about how best to do so. We used quality improvement techniques to implement a systematic approach to screening and counseling primary care patients for unhealthy alcohol use. Components included use of validated screening and assessment instruments; an evidence-based two-visit counseling intervention using motivational interviewing techniques for those with risky drinking behaviors who did not have an alcohol use disorder (AUD); shared decision making about treatment options for those with an AUD; support materials for providers and patients; and training in motivational interviewing for faculty and residents. Over the course of one year, we screened 52% (N = 5,352) of our clinics patients and identified 294 with positive screens. Of those 294, appropriate screening-related assessments and interventions were documented for 168 and 72 patients, respectively. Although we successfully implemented a systematic screening program and structured processes of care, ongoing quality improvement efforts are needed to screen the rest of our patients and to improve the consistency with which we provide and document appropriate interventions.

Multidisciplinary quality improvement initiative to standardize reporting of lung cancer screening

Structured reporting of lung cancer screening (LCS) results with low-dose computed tomography (LDCT) is necessary for appropriate follow-up and management of lung nodules. We describe processes for standardizing the reporting and tracking of screen-detected lung nodules by increasing documentation of Lung-RADS categorization of lung nodules. Our multidisciplinary team developed a project charter and key driver diagram, revised the radiology reporting template, and provided monthly audit reports to thoracic radiologists. Quarterly from Q1-2015 to Q2-2016, we measured the proportion of screening LDCT reports that included a documented Lung-RADS category. In Q1- and Q2-2015, no LDCT scans contained a Lung-RADS assessment. By the end of Q1-2016, 94% of screening LDCTs contained a Lung-RADS assessment with a recommended follow-up action. We developed systematic processes for lung nodule categorization, documentation, and tracking using Lung-RADS that improved structured reporting at one academic medical center.

Future Directions in Chronic Illness Care

People are living longer with diseases, and the integration of care across multiple diseases will become more complex. Chronic care delivery will evolve toward goal-directed care, underscoring the growing need for clear and ongoing communication about patient values and goals, contributing to more nuanced decision-making. To facilitate a higher order of chronic illness care, cognitively based specialties – particularly primary care – will need to have usable, clear decision support that integrates both treatment and illness consequences across multiple morbidities. The sites of chronic illness care will move outside of the medical exam room, and reimbursement will no longer be transaction based. To help patients negotiate the complexity of health-care delivery and behavior change, integrated health-care systems will need to promote access to care and involve community-based organizations as part of the therapeutic landscape.

Improving the Implementation of Lung Cancer Screening Guidelines at an Academic Primary Care Practice

ABSTRACT Expert groups recommend annual chest computed tomography for lung cancer screening (LCS) in high-risk patients. Lung cancer screening in primary care is a complex process that includes identification of the at-risk population, comorbidity assessment, and shared decision making. We identified three key processes required for high-quality screening implementation in our academic primary care practice: (1) systematic collection of lifetime cumulative smoking history to identify potentially eligible patients; (2) visit-based clinical reminders and order sets embedded in the electronic health record (EHR); and (3) tools to facilitate shared decision making and appropriate test ordering. We applied quality improvement techniques to address gaps in these processes. Over 12 months, we developed and implemented a nurse protocol for collecting complete smoking history and entering that data into discrete EHR fields. We obtained histories on over 50% of the clinics more than 2,300 known current and former smokers, aged 55–80 years. We then built and pilot tested an automated visit-based reminder (VBR) system, driven by the discrete smoking history data. The VBR included an order set and template for documentation of shared decision making. Physicians interacted with the VBR in approximately 30% of opportunities for use. Further work is needed to better understand how to systematically provide appropriate LCS in primary care environments.