Centering health equity during handoff communications

Despite increasing attention to health disparities, inequities in health outcomes continue to plague our society.1, 2 The Joint Commission notes that communication breakdowns are the leading factor contributing to sentinel events, which disproportionately affect historically marginalized populations for reasons including implicit bias and systemic racism, among other possibilities.3 Verbal and written handoffs between hospital clinicians offer a unique but underutilized opportunity to collaboratively and explicitly advance health equity while improving patient safety. Most handoffs happen at the end of a busy day, with limited protected time provided for such a crucial step in patient care. Equal is not equitable for patients with complex social needs: they may require additional resources including physician time. Adding information about health equity to handoffs will require leadership commitment and health system buy-in. For example, funding and staffing a meaningful overlap between day and night shifts would allow for a more comprehensive handoff, as opposed to the status quo where handoffs are unfunded, lightning-fast, brief, and unstructured, when the day team is rushing to exit, and the night team has just arrived. This commitment from leadership could enhance the quality of care for all populations, including for our most vulnerable patients. In this piece, we outline a novel framework to acknowledge and advance equity during handoffs at critical transitions of care. The "Quintuple Aim"4 proposes designing quality improvement efforts to explicitly promote health equity among other important priorities in healthcare. In applying the health equity lens to end-of-service handoffs, we recommend explicitly discussing and documenting barriers to care, with a particular emphasis on unique social determinants of health like limited English proficiency, health literacy, trust in healthcare, medication adherence, and safety. Issues such as patient comprehension of medical conditions, their goals, and the societal context of their lives need adequate representation when framing their care trajectory for the next clinician. Clinicians must be adept in candid conversations about patient's individuality, while also being mindful of avoiding perpetuating stigma and bias. Improving equity extends beyond interventions with obvious health equity implications. Handoffs may appear to be an element of care transitions that focuses on the diagnosis and management of disease, but it is also the moment when two or more clinicians are creating and sharing a mental model with patient centered in the complex milieu of illness, healthcare systems, and society. The framing of each patient has important consequences for subsequent steps in diagnosis and management, yet there is little empirical research to inform best practices for communication on nonclinical information. Clinical data transfer is usually the primary focus during end-of-shift or end-of-service handoffs. The social aspects of a patient's care—critical to shared decision-making with the patient—are deprioritized due to time constraints, cognitive load, or perceived lack of importance.5 The widely used end-of-shift handoff method I-PASS6 is being used for end-of-service handoffs. It does provide a common structure for handoff between clinicians: illness severity, patient summary, action list, situation awareness, and synthesis by the receiver. Although "patient summary" in the I-PASS handoff framework might include both clinical and nonclinical information, most explanations of this framework focus heavily on clinical information to the functional exclusion of key social, psychological, and emotional information about the patient. This is an important oversight given that marginalized populations including women, nonwhite, immigrants, LGBTQ (lesbian, gay, bisexual, transgender, and questioning) patients, and those with intersecting identities are the most likely to have these essential components of their care plan lost amid clinical data at critical transitions in care.7 The stakes are particularly high during hospital stays, where these populations may be skeptical about recommendations from the care team due to longstanding histories of community mistreatment by the larger health system.8 In addition to the I-PASS framework, other structured communication tools have been developed for other transitions of care, such as the ICU-PAUSE9 framework for the intensive care unit (ICU)-to-ward transition. The ICU-PAUSE framework does prominently include the patient's "family contact" and "goals of care" in a designated position. However, like I-PASS, this tool also lacks a specific equity lens. Refining existing communication practices to systematically include social data, could be pivotal in aligning handoffs with the larger conversations in healthcare on advancing equity. We acknowledge that perhaps attempting to fit patients with unique needs in rigid frameworks like I-PASS and ICU-PAUSE may be suboptimal, and perhaps we need a tool that is standardized, yet flexible: one that could emphasize components of the discussion based on patient characteristics like high illness burden versus high socio-behavioral burden vs both. Ideally, a handoff framework would highlight resources in terms of family support, outpatient infrastructure, and availability of home-based services. Ongoing efforts at prior authorization, durable medical equipment requests, and communication status with outpatient providers should be listed and managed in partnership with pharmacists, case managers, and social workers, as often these services are arduous or unavailable for marginalized patients.10 Much work remains in identifying best practices to structure handoffs for each unique patient that is also inclusive, antiracist, and trauma informed. Well-intentioned interventions designed to mitigate bias may paradoxically introduce bias if not considered throughout its development and implementation. Attention to how a patient is identified during handoff is a double-edged sword; it may promote our attention to equity but also threatens to elicit the subconscious bias of providers. For example, the inclusion of the patient's preferred language in the "one-liner" to describe the patient to colleagues could potentially replace the inclusion of race as a descriptor for patients, even when neither race nor language is ostensibly related to their condition or its management. Yet, the standardized inclusion of race as a descriptor across all patients may well be the first step in advancing an antiracist approach to care: to name the identities that contribute to the risk of hospitalization, decompensation, and readmission as any other feature in their medical history. Pulse oximetry failing to detect lower oxygen saturation in patients with darker skin is one example where we often feel comfortable bringing in race to question the accuracy of our diagnosis. By examining what we do not say (or write) about our patients, we can uncover hidden biases and disparities. Careful consideration of how an intervention could exacerbate health disparities is essential in the ongoing effort to advance equity without reinforcing prejudice and is a bottleneck for health equity policy implementation. Providers desire information on complex social issues but what if we don't take this crucial step?11 Just as medical conditions, habits, and age serve as triggers for diagnostic cognitive processes, we must broaden our perspective to encompass elements such as sexual orientation, ancestry, health literacy, and language when considering our patients as complete individuals. However, beyond passive acknowledgment, we must begin by actively incorporating all social determinants of health into our problem representations, we posit that by including these important layers of patient identities into our handoff practices, we can generate focus on these important aspects, as we know inclusion can often signal to providers how much we value this information. To achieve health equity, the Quintuple Aim needs to be applied broadly to all aspects of patient care, such as equitable coronavirus disease vaccine outreach and handoff process.12 These efforts need thoughtful design, or we risk perpetuating bias unintentionally or ignoring social determinants of health that impact patient care and outcomes. Collectively, we must advance equity during handoff and transition of care explicitly. Reframing handoffs by underscoring ongoing efforts and consideration of equity goals, while partnering with the incoming provider through humility around unfinished tasks, and welcoming creativity, perspective, and collaboration can be transformational. Together, we can transform handoffs from merely a simple "box to be checked" at the end of the day into a meaningful dialog that centers our patients' experiences while providing valuable clinical information. The authors would like to acknowledge Dr. Archna Eniasivam, Director, Social Medicine at University of California San Francisco, for helpful guidance. The authors declare no conflict of interest.