Custom comic strip helps residents hand off patients

Where: The University of Chicago's outpatient resident clinic.

The issue: Improving the handoff of patients at the end of the residency year.

Background

A few years ago, the resident clinic at the University of Chicago had a fairly typical process for transferring patients from graduating residents to entering ones.

“We encouraged the residents to sign out their patients to the other residents and to notify [the patients] about the transition, but it wasn't necessarily always enforced and no one definitely knew what happened,” said Amber T. Pincavage, MD, FACP, assistant professor of medicine.

But then she and other program leaders began studying these handoffs.

“We did some research and saw that this is a risky time for patients,” she said. “A lot of them didn't return for care. ... Many of them after the handoff didn't see the right resident, the one who was supposed to see them and may have gotten information about them. In addition, they had quite a high rate of emergency room visits and hospitalizations during the 3-month period after the handoff happened. Also, there were test results that weren't followed up.”

Based on their research, including interviews of patients, the University of Chicago team developed a packet of information intended to smooth the transition and reduce gaps in care.

How it works

The packet, which was sent to patients 2 months before their handoff, contained a goodbye letter from the departing resident and a certificate recognizing the patient's contribution to resident training. The incoming resident provided a welcome letter with a photo, the phonetic spelling of his or her name, and some personal details, such as hobbies and hometown.

The team had learned from patient interviews that “There was a lot of anxiety that patients experienced about meeting a new provider and not having a rapport with them,” said Dr. Pincavage. “One of the things they mentioned that helps them establish rapport with their doctors is actually knowing personal information about each other, just little things about their family or where they're from.”

The packet also included a visit preparation tool (“listing things like what medications they needed, telling their doctor specifically what's most important to them, thinking about any tests that they hadn't heard results about,” said Dr. Pincavage), clinic contact information, and more unusually, a comic strip.

The comic, “Ms. B. Changes Doctors,” describes the handoff in a way that is easily comprehensible to patients with low health literacy.

“We knew of a comic artist who's a nurse, M.K. Czerwiec. We saw some of her work and contacted her to collaborate with us on this project,” said Dr. Pincavage. “We really wanted to do something to help educate the patients about what was supposed to happen and also try to empower patients to be more actively involved in the transition.”

Results

The comic succeeded in improving patients' awareness of the transition, according to surveys of some of the clinic's high-risk patients. Forty-four percent of patients who were sent a packet with no comic in 2012 remembered it, compared to 64% of those who got the comic version in 2013, according to results published in the February Journal of General Internal Medicine. And almost all (99%) of the patients who received the comic were aware of the handoff.

“Often people get things in the mail from the medical center and they think it's a bill. They don't pay any attention. We had a sticker with the logo from the comic on the outside of the envelope,” said Dr. Pincavage. “A lot of patients specifically said how helpful it was to them, and it actually made them read the other materials. It drew attention to them.”

The packets also decreased the likelihood that a high-risk patient would miss his or her first visit with a new resident. That rate dropped from 43% before the packet to 31% with the 2012 packet to 26% with the 2013 packet with the comic.

“We were really pleased,” said Dr. Pincavage. “The one concern was could this be taken the wrong way? We didn't find that there were any complaints.”

Challenges

The team also didn't find any improvement in their patients' satisfaction with the handoff, however. It continued to hover in the 60% to 70% range, which may be because that's hard to improve upon, Dr. Pincavage speculated.

“Our satisfaction was already pretty high,” she said. “Some of that may be just changing physicians overall. There's always going to be some dissatisfaction with that.”

The initial development of the packet was also a time- and labor-intensive challenge, she noted. The team not only interviewed patients to find out what information would be helpful but also took the first draft back to a select group of patients for their feedback before making revisions.

Next steps

Conveniently, though, other clinics that want to provide a similar resource to their own patients don't have to start from scratch. “We've done a lot of workshops at national conferences and have shared these with other educators,” said Dr. Pincavage. “A lot of them can be used just as is. [With] the comic ... if it's not specific to how they do things, it may not be as applicable, but definitely they could use these tools.”

The University of Chicago packet is available online through the Association of American Medical Colleges' MedEdPortal (registration required) or by contacting Dr. Pincavage.

Words of wisdom

Whether other residency clinics choose to follow their exact model or not, they should focus attention on year-end handoffs, Dr. Pincavage advised. “Think what's going to work best for your clinic,” she said. “Having some kind of structure in place is very important.”