Improving care coordination through virtual warm handoffs in telepsychiartry

Problem: Community telehealth psychiatry often experiences inconsistent handoffs between providers and nurses. This can result in missed nursing assessments, delays in lab work or vital-sign checks, and fragmented follow-up care, especially for patients on medications like lithium, valproate, or clozapine that require specific monitoring as per guidelines. Purpose: This QI/EBP DNP project assessed whether implementing a structured provider-to-nurse SBAR handoff would enhance the completion of nursing assessments in a community outpatient behavioral health clinic. Methods: This intervention was implemented at a single CNS Healthcare clinic through three sequential Plan-Do-Study-Act cycles over 12 weeks, starting with small-scale testing and expanding to four nurse-provider pairs. The workflow used Doxy.me call transfer to move patients from provider visits to nursing follow-up, supplemented by standardized SBAR communication. If a live handoff was not possible, SBAR messages were sent via Microsoft Teams. Nursing follow-up was tracked using telehealth T1002 billing codes, comparing a 53-business-day baseline to post-implementation performance. Results: Baseline follow-up was 20.9% (362/1,731 provider encounters). After implementation, the combined follow-up rate across PDSA cycles increased to 73.5% (642/873), a 52.6 percentage-point improvement (p < .001). Performance improved across all cycles, though variation persisted between nurse-provider pairs. Conclusions: Implementing a structured telehealth handoff with call transfer and SBAR communication significantly improved the reliability of nursing follow-up in community psychiatry. Standardizing this workflow may enhance team-based care, decrease care fragmentation, and strengthen care continuity in telehealth settings.

Author dc:creator

• Gines, Spencer

Contributors dc:contributor

• Jones-Brown, Natalie

• Community mental health services
• Medical telematics
• Nursing assessment

Statement dc:rights

• In Copyright

Language dc:language

English

Identifier

dnp:97
oclc:1601633871
local:R_5oQIwzlLcFmqTuQ

OAI identifier oai:identifier

oai:d.lib.msu.edu:dnp_97