At its core, the referral and consultation process is about improving patient care, but it has suffered consistent challenges over the years.
Requesting physicians are asking for assistance in diagnosis and management, and responding physicians want to provide this help in a timely and efficient manner. In the past, many of these requests were hallway conversations or phone calls, but as technology use has increased – along with patient volume and acuity – the opportunity for this dialogue has lessened.
The referral/consultation process has not stopped though. It is as important as ever but is overflowing and complex. Research from current and previous members of the Quality Referral Evolution (QuRE) Working Group shows that communication breakdown is one of the leading causes of patient and caregiver dissatisfaction, and this ultimately affects patient safety (Wong et al., 2020). Some factors contributing to this issue include the following:
- Few, if any, formal training programs or mandates are available in Canada on how to develop effective referral/consultation communication.
- Over 1,000 general and specific referral/consultation forms are floating around Alberta’s health care system. On top of every specialist/specialty health service potentially having their own referral form, they all have their own referral/consultation processes, so what they require on a referral and how and when they communicate the outcomes of the patient appointment are unique.
- Family physicians have not been included in planning for improved referral management processes.
- Our IT systems do not talk to each other and are used differently by clinicians, so the information that is gathered about the patient’s story and current condition are not consistently available for successful care transitions.
What this all adds up to is additional chaos and complexity, multitudes of unclear processes, and key members not always being included in an already overtaxed health care system.
What happens when the referral/consultation process does not work effectively?
In 2012, revelations from the Price family concerning the death of their beloved Greg caused his family and health care professionals to review what had happened. The Health Quality Council of Alberta’s (HQCA) Continuity of Patient Care Study (2013) determined that when the circle of care expands beyond the primary care team, a breakdown in the continuity of care can occur if something goes wrong with referral/consultation processes. For continuity of care to be successful, patients must have reliable, accurate information shared between them and their providers; continuity must be maintained amongst providers while managing their patient’s care; providers need to understand and agree on their responsibilities for aspects of their patient’s care; and patients need to know who to contact for assistance, especially in an emergency (HQCA, 2013).
Since Greg’s story was publicly shared in 2013, countless patients still continue to have poor referral and consultation experiences. So, what is being done to improve the referral/consultation process? Several things, thankfully.
In 2015, the Quality Referral Evolution (QuRE) Working Group was formed by a small group of physicians, surgeons, academic and health services personnel. Interested in improving the quality of requests made of medical/surgical colleagues and the quality of their responses, the QuRE Working Group has since developed physician resources, residency workshops and training modules. A QuRE Patient & Caregiver Journal with information and questions patients can ask their care providers has also been developed and is intended to facilitate better two-way communication and information sharing.
Armed with their own research and the findings from the 2013 HQCA study on Greg Price, the QuRE Working Group proposed a motion to the AMA in 2021 for further momentum on referral and consultation changes. A motion was approved and is currently being worked on.
Two current AMA initiatives also exist. One is with the Specialty Care Alliance, which focuses on promotion of the QuRE methodology. The second arises out of the Alberta Surgical Initiative (ASI) but is also considering non-surgical referrals.
Additional initiatives to keep watch for include the following:
- An upcoming AHS Patient Access Management Policy is helping to change this narrative and is recognizing family physicians as the hub of patient care. However, a growing number of patients are without a family physician/primary care access. This variability underscores the complexity that is faced in trying to address these issues and some of the frustrations that have been encountered by users within the system.
- The codesign of provincial referral pathways and forms and subsequent retiring of old referral forms.
- Best practices for EMR vendors to support consistent form structures including tracking referrals and a consistent look and feel for referrals.
- Leveraging community information integration (CII) data elements in the building of the referral forms.
- Change management related to ASI with the development and implementation of central access and intake, for example facilitated access to specialized treatment (FAST), provincial specialist advice (telephone and electronic) programs, and clinical pathways across all surgical specialties.
As many stakeholders are making parallel improvements on the referral/consultation process, the QuRE Working Group hopes these processes can be streamlined, simplified and transparent. Goals should be as follows:
- Patients, primary care physicians, consultants and other referring health team members should all be able to easily track a referral and have a means of updating changes in patient condition or urgency of the request.
- Each referral should not be accompanied by a unique set of rules and forms.
- Whether a request is accepted, denied or more information is required, this should be communicated in a consistent and timely manner.
Where do we go from here?
The development of clear and highly functional pathways for consultation and referral in Alberta is an ongoing challenge. Harnessing the wisdom of health professionals, administrators and the public is essential. The quality of this referral/consultation process needs to be clear, consistent, transparent, and trackable because the process is critical to patient care and safety.
There is still work to be done, and it is essential to have participation of all parties who have responsibilities in Alberta’s health system. It is in everyone’s best interest to look at this change as a quality improvement process. The expectation of the Price family, shared by health professionals, is that no one else should ever be lost in the shuffle and fall through the cracks.
Wong, A., Rizvi, S.K., Aremu, A., & Glassford, J. (2020). Patients' and caregivers' views on communication in the referral-consultation process: A qualitative study. Healthcare quarterly, 22(4), 26-32.
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