Journal of General Internal Medicine

, Volume 28, Issue 1, pp 41–50 | Cite as

Passing the Baton: A Grounded Practical Theory of Handoff Communication Between Multidisciplinary Providers in Two Department of Veterans Affairs Outpatient Settings

  • Christopher J. Koenig
  • Shira Maguen
  • Aaron Daley
  • Greg Cohen
  • Karen H. Seal
Original Research



Handoffs are communication processes that enact the transfer of responsibility between providers across clinical settings. Prior research on handoff communication has focused on inpatient settings between provider teams and has emphasized patient safety. This study examines handoff communication within multidisciplinary provider teams in two outpatient settings.


To conduct an exploratory study that describes handoff communication among multidisciplinary providers, to develop a theory-driven descriptive framework for outpatient handoffs, and to evaluate the strengths and weaknesses of different handoff types.


Qualitative, in-depth, semi-structured interviews with 31 primary care, mental health, and social work providers in two Department of Veterans Affairs (VA) Medical Center outpatient clinics.


Audio-recorded interviews were transcribed and analyzed using Grounded Practical Theory to develop a theoretical model of and a descriptive framework for handoff communication among multidisciplinary providers.


Multidisciplinary providers reported that handoff decisions across settings were made spontaneously and without clear guidelines. Two situated values, clinic efficiency and patient-centeredness, shaped multidisciplinary providers’ handoff decisions. Providers reported three handoff techniques along a continuum: the electronic handoff, which was the most clinically efficient; the provider-to-provider handoff, which balanced clinic efficiency and patient-centeredness; and the collaborative handoff, which was the most patient-centered. Providers described handoff choice as a practical response to manage constituent features of clinic efficiency (time, space, medium of communication) and patient-centeredness (information continuity, management continuity, relational continuity, and social interaction). We present a theoretical and descriptive framework to help providers evaluate differential handoff use, reflect on situated values guiding clinic communication, and guide future research.


Handoff communication reflected multidisciplinary providers’ efforts to balance clinic efficiency with patient-centeredness within the constraints of day-to-day clinical practice. Evaluating the strengths and weaknesses among alternative handoff options may enhance multidisciplinary provider handoff decision-making and may contribute to increased coordination and continuity of care across outpatient settings.


handoff communication outpatient care decision making coordination of care continuity of care patient-centeredness clinic efficiency 




We would like to thank the SFVAMC primary care providers, mental health providers, and social workers that took time to participate in this study. We also thank Dr. Lucile Burgo, Dr. John Chardos, Dr. Brad Felker, Dr. Drew Helmer, and Dr. Steve Hunt for their feedback on the interview guide. We extend a special thanks to Drs. Robert Craig, Karen Tracy, and Daniel Dohan for their theoretical counsel. Finally, we acknowledge and thank all Iraq and Afghanistan veterans for their service to our country.


Department of Defense awards W81XWH-08-2-0072 and W81XWH-08-2-0106 funded this study. The funders had no role in the design, data analysis, writing or approval of the manuscript.

Prior Presentations

A version of this article was presented orally at the annual meeting of the International Society of Traumatic Stress Studies in November, 2011.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Christopher J. Koenig
    • 1
  • Shira Maguen
    • 2
  • Aaron Daley
    • 3
  • Greg Cohen
    • 4
  • Karen H. Seal
    • 1
    • 2
  1. 1.Department of Medicine, San Francisco Veterans Administration Medical CenterUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Department of Psychiatry, San Francisco Veterans Administration Medical CenterUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.Department of Surgery, San Francisco General HospitalSan FranciscoUSA
  4. 4.Department of EpidemiologyColumbia UniversityNew York CityUSA

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