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Don't Fumble the Treatment Handoff

September 1, 2008
by David H. Gustafson, PhD, Roger Resar, Kimberly Johnson, MBA, and John G. Daigle
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Organizations need a systematic approach to ensure clients' smooth transition between levels of care

Legendary Ohio State University football coach Woody Hayes once quoted the great Michigan State University coach Duffy Daugherty as saying, “There are three things that can happen when you pass the football, and two of them are bad.” Hayes' teams rarely passed the ball, and that worked out pretty well for him—with a record that included three national championships. Exchanges of the football, especially the type that come from throwing the ball, scared him half to death.

“Handoffs” are critically important in virtually any endeavor. Activities as diverse as day care drop-off and pick-up, relay races, 911 calls, railroad dispatch, and movement of patients from surgery to intensive care require a smooth handoff. A failed handoff disrupts service delivery and introduces errors, sometimes with disastrous consequences:

  • Air traffic controllers “hand off” planes from one region to another. Twenty-five percent of all air traffic control errors occur within 15 minutes of a handoff, according to federal data. The potential cost of poor handoffs can be enormous.

  • In Tampa, Florida, the blackboard to which surgeons refer in the operating room at University Community Hospital listed the wrong leg of a patient for amputation, as did the operating room schedule and the hospital computer system.

  • A total of 167 people died on the Piper Alpha oilrig in the North Sea in 1988 because a message didn't get handed off from one maintenance crew to another during a change in shifts.

Handoffs occur regularly in addiction treatment as well. What happens when a person first calls an addiction treatment agency for help? Does a live person answer the phone, or is the caller directed through an endless cycle of automated prompts? The caller might talk first to a receptionist, who then might hand off the call to somebody else, who then might invite the caller to leave a voicemail message.

How many different people does a client meet with during a first intake appointment? How many forms does the client have to complete during the appointment—forms that request the same information multiple times? Every transition from one level of care to the next in addiction treatment is a handoff that presents a potential interruption or even an end to the client's recovery journey.

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According to a 2004 Treatment Episode Data Set (TEDS) analysis, only 16% of clients discharged from detox programs start a new level of care. Only 30% of clients discharged from residential care start a new level of care, and only 50% of those who start outpatient care complete their regimen. Far too many clients are lost to the system during handoffs from one level of care to another.

We wish to suggest a series of key principles that if followed in the addiction treatment community could dramatically improve the transition of clients between levels of care. These are our eight essential ingredients of a good handoff.

Commitment

Organizations must perceive successful handoffs as essential to service delivery for each client and for the organization as a whole. Securing buy-in from busy front-line staff can be a challenge. To an overwhelmed staff person, a successful handoff might be considered less important than making a bed available for a client in crisis.

The first step in improving handoffs involves all staff members being aware of the important role they play in accepting or transferring a client to or from a level of care. Staff commitment to promoting successful handoffs must accompany this awareness of the critical function they serve in the process. Commitment must begin at the leadership level and be conveyed through all means that leaders have to achieve organizational commitment.

Responsibility

Clients in treatment for substance use problems don't always follow instructions. After all, many patients don't follow doctors' instructions for other types of medical treatment either. The nonprofit Institute for Healthcare Improvement says that “the baton that is being passed bears no responsibility” for whether the handoff is successful.

The idea of caregiver responsibility conflicts with traditional thinking in addiction treatment. Historically we have claimed that clients need to take responsibility for their own behavior. However, organizations that perform handoffs effectively take the position that client noncompliance is the reason for devoting more attention to successful handoffs, not an excuse for failing to do so. In a new paradigm, the caregiver is solely responsible for ensuring that the client with a complicated chronic disease such as addiction gets appropriate care.

Understanding the client

In addiction treatment we are not handing off an inanimate object such as a football or an airplane. While each staff person involved in a handoff needs to have a clear role and responsibility, the process also needs to respect and incorporate each client's unique needs and circumstances. What elements will support or hinder a client's successful transition? Part of a successful handoff involves assessing these needs and understanding a wide spectrum of client characteristics (their physical, psychological, and environmental being).

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