Most doctors are quite familiar with making referrals. The catch, however, is that the definition of referral differs among individuals and regions of the country. The terms “referral,” “consultation,” and “transfer of care” all mean different things.
According to the AAFP, “A referral is a request from one physician to another to assume responsibility for management of one or more of a patient’s specified problems. This may be for a specified period of time, until the problem(s) is resolved, or on an ongoing basis. This represents a temporary or partial transfer of care to another physician for a particular condition."
On the other hand, a consultation is a request made by one physician to another for an advisory opinion. “The requesting physician utilizes the consultant’s opinion combined with his own professional judgment and other considerations (eg, patient preferences, other consultations, family concerns, and comorbidities) to provide treatment for the patient,” wrote the AAFP.
A transfer of care is a request made by one physician to another to assume management (and responsibility) of one or more patients. These transfers can be for a limited time or can be permanent.
Now that we’ve cleared up some basic terminology, let’s look at some practice-based tips on the referral process. We gleaned these tips from different online health sources.
Tip #1: Reasons for referrals
When you refer a patient, you should have a valid reason. These reasons typically fall into one of four categories:
When you need help making a diagnosis. Keep in mind that getting the help of another physician doesn’t reflect poorly on your clinical acumen. Instead, it meets the goal of treating the patient in the most efficient way.
When you want the opinion of a specialist.
When you feel that a patient may vibe better with another physician. Obviously, you should do your best to work with a patient, but for situations out of your control, you may find a referral a good idea. For instance, if you know that another physician speaks the patient’s native language, and the patient doesn’t speak English, a referral may be a good idea. Please note that referring a patient for such reasons is different from firing one. See this article for more on firing a patient.
You can refer to improve patient access. For instance, if your census is packed and you lack time, a referral may be a good idea.
Remember to document your reasons for referring patients.
Tip #2: Explanations
It’s imperative that your patients understand why the referral is necessary. Explain what to expect during the referral process and from the specialist appointment. Give your patients the opportunity to ask questions, and encourage them to follow-up with questions addressed to the specialist as necessary. Always document that you have informed the patient.
Tip #3: Protocol
After deciding to refer, follow a protocol or use referral management software that includes everyone in the practice.
The protocol should be initiated immediately—especially in cases of high need. Office staff should set up an appointment with the specialist before the patient leaves the office.
Tip #4: Touching base
According to the AAFP, it is the responsibility of the physician accepting the referral to maintain appropriate and timely communication with the referring physician (and to seek approval from the referring physician for treating or referring the patient for any other condition that is not part of the original referral).
However, it is wise for the referring physician to take the lead in communications. Discuss the referral directly with the specialist. Ensure that the specialist has all the necessary medical records and test results, as well as other documents.
Points to address include: the urgency of the referral, length of the process, methods of communication, and management roles during the duration of the referral. To this end, a referral agreement may be a good idea. Such agreements can ensure that the specialist—and not a mid-level provider such as a nurse practitioner or physician assistant—sees the patient first and delivers medical advice. Deadlines can also be established.
Tip #5: Monitoring
Establish a system to monitor referral due dates and institute a system of reminders. Auditing referrals on a quarterly basis may also be a good idea to catch up on anything missed. If the specialist is behind, then consider another provider for future referrals.
A key to proper monitoring is to review the specialist’s results and recommendations in a timely fashion. Remember that neglecting specialist recommendations can make you liable, so feel free to contact the specialist for diagnosis or needs.
Tip #6: Scripts
Referrals for behavioral health can be particularly sticky. You want to ensure that the patient adheres to your guidance, yet, at the same time, doesn’t feel stigmatized or insulted. Managing mental-health referrals requires finesse and a level of anticipation.
The Center for Integrated Healthcare and the VA Healthcare Network Upstate New York makes certain recommendations.
“Avoid creating the impression that you are referring the patient for BH (behavioral health) because you can’t find anything medically wrong with them, rather, emphasize that good health care always involves paying attention to both physical and emotional health and well-being. The key is to frame this as a routine, legitimate part of primary care,” they wrote.
Importantly, developing a script that you routinely follow may be a good idea.
On a final note, remember that you can only recommend and encourage that a patient accepts the referral. Ultimately, it is up to the patient to follow through. Always document when a patient doesn’t follow through with a referral despite your recommendations. Also, document why the patient doesn’t want to follow through with the referral. Remember that the patient can always choose to pursue the referral in the future.