Managing referrals amid minefields, breakdowns

Referral management is an essential part of providing high-quality, coordinated care, but poor communication can lead to fragmented care, unnecessary testing, wasted time, and delayed treatment.

The flow of patients between primary care and subspecialist and back again can be challenging to both sides. For the patient who is being referred, it can be frustrating and scary. The idea is that the patient goes to the subspecialist with the information the subspecialist needs and gets the needed diagnosis and care, the information flows back to the referring physician in a timely manner, and the patient gets the best and most appropriate care. Sounds simple, right?

The referral process is a minefield for communication breakdowns, so establishing a system to keep track of referrals can minimize errors and duplication and maximize efficiency for both clinicians and the patient. It is all part of effective care coordination. Consulting practices get what they need when they need it from primary care practices, and referring clinicians get what they need back in a timely manner. Communication flows in both directions.

Establishing good referral management processes provides additional benefits by satisfying requirements for the Merit-based Incentive Payment System (MIPS), as well as National Committee for Quality Assurance (NCQA) requirements for becoming a patient-centered medical home (PCMH) or a patient-centered specialty practice (PCSP). For MIPS, there are five medium-weighted Improvement Activities related to referrals. For the NCQA, there are both core and elective competencies related to Care Coordination (for PCMH recognition) and Initial Referral Management (for PCSP recognition).

Referrals are often made to further investigate a condition or to search for a diagnosis for a range of symptoms that need the expertise of a subspecialist. Coordination between the primary care clinician and subspecialist is critical to good-quality care. Patients may (or may not) schedule themselves to see a subspecialist and, if they do, may not tell your office when or with whom the appointment is, thus you don't have what you need the next time the patient comes in to see you. For the consulting practice, patients may make an appointment with you but not really understand why they are there and, because they didn't tell their primary care practice they were coming, your staff has to make a call to get the records needed for the visit.

Referral management is an essential part of providing high-quality, coordinated care. Poor communication can lead to fragmented care, unnecessary testing, wasted time, and delayed treatment. All of this can be frustrating both to the patient and to the clinicians involved. Much of this can be prevented by establishing some systems to help with transitions.

Here are a few things practices can do to improve their referral processes:

  • Identify the practices to or from whom the most patients are referred. For the primary care practice, look at commonly used multispecialty groups or individual subspecialists, whatever the case may be. For subspecialists, look at the primary care clinicians or groups who refer the most patients to your practice.
  • Create a spreadsheet that includes which clinicians participate with which insurance plans, including names, addresses, phone numbers, and web addresses.
  • Use referral guidelines and referral response checklists to ensure high-value and effective referrals.
  • Establish a “compact” or agreement that sets protocols for the clinical and demographic information needed for the subspecialist (specialty- and condition-specific), what information should go back, and the ideal means of communication or data exchange. Set guidelines regarding how quickly patients can be seen and when the primary care practice can expect a report back.

To further address communication and data exchanges, use ACP's pertinent data sets, to establish clinical data needed for commonly referred conditions. This ensures both the timeliness and appropriateness of the referrals.

In addition, create a paper or electronic logging system to help staff keep track of incoming and outgoing referrals, including the date the referral was initiated, so that staff can follow up with the patient or the subspecialist's practice if no report is received within a certain time frame. Subspecialist reporting on testing, medication changes, and treatment plan can reduce duplication of tests and services and ensure that the primary care practice as well as family and caregivers are all on the same page regarding a plan moving forward.

As you make adjustments to your policies and procedures, it is important to include staff so that there is consistency in how referrals are managed. ACP's High Value Care Coordination Toolkit provides resources to facilitate the transfer of patients back and forth between primary care and subspecialty clinicians. It includes sample referral request and response checklists, care coordination agreements, and pertinent patient data needed by subspecialists for specific conditions before or after referral, such as lab and radiographic testing, medications, comorbidities, relevant clinical history, and other information regarding symptoms or relevant history.

In addition, ACP's Practice Advisor includes care coordination and referral management modules with sample policies and procedures, referral packages, logs, and many additional resources that can be adapted to your practice.