Bridging the Gap: Enhancing Care Transitions through a Student-Led Warm Handoff Initiative

Title: Bridging the Gap: Enhancing Care Transitions through a Student-Led Warm Handoff Initiative
Authors: Maggie Hale, Tyler Drummond, Georgia Veverka
Date: 1/27/2025
Abstract: Care transitions between inpatient and primary care settings are critical yet prone to information loss, especially for patients without a primary care provider (PCP). This gap can lead to missed follow-up appointments, medication errors, and unmet healthcare needs. In collaboration with Rose Park Primary Care Clinic and University of Utah Hospital inpatient teams, the Warm Handoff initiative aims to establish a student-led warm handoff team to improve continuity of care, reduce barriers to preventative care, and foster meaningful learning experiences for medical students. The Warm Handoff team pairs MS1 students with patients at discharge who lack a PCP. MS1s, supervised by MS3/4 students, create care coordination documents summarizing the patient’s hospital course, new diagnoses, and follow-up needs. Follow-up appointments at Rose Park Clinic are scheduled within one to two weeks of discharge, with dedicated Warm Handoff slots arranged to facilitate this process. Coordination documents are entered into EPIC and emailed to the follow-up provider for seamless communication. A two-week pilot of the Warm Handoff Project evaluated 21 hospitalized patients lacking a PCP and collected data on their hospital discharge status, follow-up appointment outcomes, and barriers to care. Preliminary implementation data revealed that 47.6% of patients successfully attended their first appointment at the clinic, while 38.1% were no-shows. Additionally, 9.5% of patients canceled before their scheduled appointments, and 4.8% were unable to coordinate follow-up visits. Despite these challenges, 10 patients (47.6%) have now established primary care relationships through the Rose Park Clinic. These results underscore the potential of the program to increase continuity of care for a vulnerable population, though challenges related to appointment adherence remain. This Warm Handoff initiative demonstrates a promising model for bridging inpatient and primary care gaps, benefiting both patients and medical trainees. A symposium will provide an opportunity to share insights, engage stakeholders, and refine this model for broader implementation, ultimately advancing patient-centered care and medical education.

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Bridging the Gap: Enhancing Care Transitions through a Student-Led Warm Handoff Initiative by Maggie Hale, Tyler Drummond & Georgia Veverka