Two-year outcomes of a primary care physician transitions program in a residency continuity clinic

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Aim: Assess the impact of a multifaceted intervention to optimize primary care physician (PCP) transitions on patient outcomes in an internal medicine residency continuity clinic. Subject and methods: Primary care patients in an urban academic hospital-based residency continuity clinic. Several interventions were implemented and received by all included patients beginning in 2021. Graduating resident patient panels were assigned to an incoming intern physician and a chart handoff was documented for approximately 10 high-risk patients per panel. Patients were notified of the PCP transition by letter or portal message and instructed to contact the clinic to schedule an appointment, and the scheduling center contacted high-risk patients to schedule with the new PCP. Interns received education on the handoff program during orientation. The primary outcomes were 30-day emergency department (ED) visits and unplanned admissions. Key results: Thirty-day unplanned admissions had a significant reduction (7.1% vs. 10.3%, p < 0.001) for patients who attended the new PCP appointment compared to those who did not. There were absolute reductions in 30-day ED visits (10.2% vs. 12.7%, p = 0.24). Predictors for ED visits and unplanned admissions included age, atrial fibrillation, end stage renal disease, and schizophrenia. Notably attending the new PCP appointment was not predictive of ED visits or unplanned admissions. Conclusions: The first two years of a thorough intervention to optimize the transition of patients from resident PCPs had benefit on unplanned admissions and possible improvement in ED visits. Attending the new PCP appointment was not predictive in the univariate model suggesting other factors may play a more important role in patient outcomes.

Original languageEnglish
JournalJournal of Public Health (Germany)
StateAccepted/In press - 2024


  • Patient handoffs
  • Primary care
  • Residency continuity clinic
  • Transitions of care


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