Interventions to improve the effectiveness of transfer btween the inpatient hospital and primary care
| Level | Intervention | Example | Effectiveness |
|---|---|---|---|
| Patient/Family | Patient Involvement: Involve patients and family members as active participants in the handover | Empowering patients to actively participate in the information exchange between the hospital and the primary care setting | Variable: While patient participation in their health care generally has been shown to enhance safety, capacity for participation depends on patients’/families’ sophistication and willingness to accept the responsibilities of the added role. Not suitable for all patients, and requires screening of patients. May reduce patient safety if the (sole) intervention at the system level is the expectation for patient/ family involvement in handovers.16–18 |
| Individual healthcare professionals and healthcare teams | Education and Training: Improve knowledge about handovers, attitudinal change to consider handovers important to safety and teach handover skills | Handover toolbox,20 | Lectures, on-line modules, case based discussions, multi-disciplinary team training, handovers as entrustable professional activities (EPA)24 | Moderate to high, depending on the systems for transfer of training to the workplace and the need for and availability of periodic refresher training: Training in multi-disciplinary teams was considered more desirable by healthcare professionals and may aid in transfer of training to the workplace.21 Mass customization, with local communities of practice adapting generic handover education materials and tools to local circumstances adds efficiency and cost-effectiveness.22 |
| Healthcare Team/Micro-system | Shared Coordination: Shared responsibility for continuity and transfers by considering the professionals involved in the hospital to primary care handover at discharge as a ‘virtual microsystem’ | Discharge planning, shared involvement in follow-up by hospital and community care providers, use of electronic discharge notifications and web-based access to discharge information for general practitioners (GPs) | Effectiveness depends on a shared understanding of roles: Not effective if roles are unclear.9 12 16 Shared coordination requires tools for efficient communication that establish or build on existing ‘common ground’ between microsystem members. Effectiveness can be facilitated by shared information systems, or hampered by lack of shared information or the structure of the information itself.8 9 10 1112 16 |
| Healthcare Team/Micro-system | Local Communities of Practise: Engaging local stakeholders in communities of practise to improve handovers | Potentially high: Facilitated by the creation of systems tailored to local circumstances, although engaging health care professionals in frontline improvement work is time consuming and individuals may lack preparation. Communities of practise are effective in designing or adapting low-cost approaches that effectively address local circumstances.8 20–22 | |
| Within and across microsystems with shared responsibility for continuity | Standardisation: Standardise elements of handover practise between sending and receiving individuals, teams or units. | Standardised paper/electronic handover protocols in intensive care, discharge summaries, medication reconciliation forms | Variable: Sustained benefits are more likely when standardised tools are adapt to local circumstances and are implemented as part of a larger educational strategy that ensures the tools are embedded in local practise and context.23 |
| Institutional ‘meso’ systems and potentially across institutional systems | Records, data support and technology: Create handover data depositories, including handover features as part of the medical record or discharge form. | Electronic tools to facilitate quick, clear and structured summary generation, shared records across micro- and meso-systems that participate in the coordination of care. | Effectiveness depends on shared data systems and seamlessness of information: Lack of fully shared systems across settings hamper efforts to ensure continuity of care.9 12 16–18 Electronic health record (EHR) organisation is moving to narrative structures to make transparent ‘common ground’ in handover communications, and allow interpretation by individuals who are not the primary recipients of information.13 14 |
| Macrosystem | Research Funding: Funding research to improve handovers. | EU Seventh Framework Programme support of the HANDOVER Project effort to improve transitions at the primary care—hospital interface6 7 | Effective in producing initial research to develop and test interventions and assess their financial and societal benefit. Less funding to date for projects focused on post-implementation effectiveness, cost/ benefits analyses or comparative effectiveness.26 |
| Macrosystem | Regulation/Policy: Incentives or sanctions as a force function to improve handover practise. | Payers’ threat of reducing payments for readmissions attributed to suboptimal handovers. | Influences handover practise by creating pressure on/incentives for organisations to improve handovers: Benefits from post-implementation research to identify effective, broadly adaptable approaches, and the ability adapt ‘regulated’ practise to incorporate new knowledge. |