Closing the Referral Loop

Referrals have long presented challenges to many medical practices. When one physician is managing the care of most patients, ensuring continuity of care is fairly straightforward. But the introduction of a referral—or several referrals—can complicate patient care.

Furthermore, the advent of medical technology, an increase in the number of specialists, and the ability of patients to self-refer—often without their primary care physicians’ knowledge—create additional challenges. According to one analysis, the average Medicare beneficiary sees 5 to 7 specialists in a year, introducing many opportunities for miscommunication, delayed care, duplicate services, and lack of coordination that can compromise quality of care and increase health care costs.

An inefficient referral process can also expose practices to the possibility of legal problems, especially primary care offices, says Nick Fabrizio, principal consultant with MGMA Health Care Consulting Group. “Practices need to have a process that ensures the referral process is followed—to close that loop."

Carol Greenlee, MD, an endocrinologist in a Colorado-based private practice, believes that making sure referrals go well is part of delivering high-value care and meeting patient needs. She’s had many patients come to her office without enough information for her to make effective use of the appointment.

As health care reform evolves, there is a growing emphasis on improving referrals, says Ann O’Malley, MD, senior fellow at Mathematica Policy Research. “As we move toward more accountable care and value-based payment, there is going to be an expectation that both primary care physicians and specialists communicate effectively with one another and that they track referrals and consultations.”

To solve common challenges in the referral process, an increasing number of practices—including Greenlee’s—are building referral networks and establishing agreements about expectations. Focus on the following areas to improve the referral process.

Open Lines of Communication
Several years ago, Fabrizio conducted a study of why referrals were not going to the intended physicians. “The number one reason was because the office was not accessible,” he says. If a staff member or a patient can’t obtain an appointment with the intended physician, then he or she may go to someone else—or to no one at all.

He suggests designating a staff member to be the primary contact for referrals from other physicians. A dedicated referral line can reduce time spent navigating telephone trees, waiting on hold, or playing “telephone tag.” He also advises practices to research alternatives to telephone communication, including e-mail or texting, to facilitate appointment scheduling among offices.

Exchange Essential Information
The exchange of information is a critical part of the referral process. In a 2011 study, O’Malley found that both referring physicians and specialists overestimate the extent to which they send information and underestimate how much they receive from one another. Setting up expectations about preferred communication practices among physicians could enhance the coordination of care for patients.

To improve the quality of information she receives from referring physicians, Greenlee developed a list of what she needs to provide a “high-value” referral.

“It took some time,” she admits, “but I started getting better and better information.” The referral request should also include the level of care that is expected, such as a one-time consultation for diagnosis and treatment, co-management, or a transfer of care.

Missing records is a common challenge in referrals, but getting too much information can also be a problem, O’Malley says. In addition to a clear description of the reason for referral, a referral request should include pertinent medical history, a current problem list, medications and allergies, test results, and any social circumstances that may affect the patient’s health.

O’Malley points out that most electronic health records include a template for creating a referral, but it may need to be customized to meet the needs of the specialist and the reason for referral. The process can become even more challenging when 2 practices use different electronic health record systems and must rely on faxed records.

For their part, referring physicians should also specify the information that they need from the specialist, including next steps. For example, should the patient return to the primary care physician after receiving the specialist’s findings?

Engage Patients in the Process
In the absence of a clear referral question and medical history, an informed patient can help fill in the gaps.

But, Greenlee says, often patients themselves don’t know why their primary care physician referred them to the specialist. She urges primary care physicians to discuss the reason for referral with patients, as well as the referral process.

This allows patients to get involved in making sure information gets exchanged between the practices—something that’s especially important if the patient self-refers to a specialist.

Track Referrals
In the past, most primary care practices have relied on the patient or the specialist to close the loop on referrals. Now, O’Malley says, patient-centered medical homes are starting to devote staff to ensure that the patient follows through with appointments.

She points out that the Centers for Medicare and Medicaid Services has recently recognized the time and effort that goes into this care coordination with a new Current Procedural Terminology code (99490) for chronic care management, although the code applies only to select patients.

Several medical associations and health care organizations can provide resources to help improve the referral process. For example, Greenlee helped develop the High Value Care Coordination Toolkit for the American College of Physicians that contains checklists and other information about establishing care-coordination compacts among practices.