Managing Risk During Patient Referral and Transfer

Patients are often referred to the care of other specialists or health care providers, or transitioned from one care facility to another as their conditions and care needs change. For both multi-disciplinary and multi-facility complex care delivery models  to be effective, it is necessary that activities of the variety of health care providers and provider organizations encompass important mechanisms of coordination and integration, such as productivity, efficiency, and quality of care.

“In the United States, more than a third of patients are referred to specialists each year, and specialist visits constitute more than half of outpatient visits.  Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both PCPs and specialists.”[1]

Medical errors often occur when patients are transitioned from one physician to another. Liability is created when time-sensitive information and necessary follow-up treatment slip through the cracks.  It is therefore important to have a clear, organized process in place to ensure continuity of care when a patient is referred to a specialist or transferred to another physician.

Referral processes are prone to breakdowns and inefficiencies resulting in lack of continuity of care, delays in service delivery, and dissatisfaction among practitioners and patients. Making the referral process easy for patients increases the chances they will follow through, and the likelihood that clinicians will get all the information needed. Additionally, by giving appropriate attention to detail, physicians and their staff will enhance patient care, prevent errors, and reduce the chance of lawsuits.

Referral is the process, with the intention of initiating care transfer, and can take several forms:

• Request referral letter/document or referral message for management of patient’s problems.
• Identify, develop, and maintain relationships with those to whom patients are referred.  It is the responsibility of the physician accepting the referral to maintain appropriate and timely communication with the referring physician.
•  Cease to refer patients to clinicians who do not send information back or fail to coordinate care.
• Help patients understand the need for the referral and what information is required
• Provide patients with language assistance needs.
• Provide clear easy-to-understand instructions.
• Follow-up on referrals by confirming patient successfully completed the referral.

Critical components in a referral/transfer process are solid communication and good documentation. It is essential to have direct person-to-person communication between the physicians, or staff on behalf of the physicians, when there is a time-sensitive referral to a specialist or with the covering/on-call physician.

Additionally, documentation is a very important aspect of the referral/transfer process. Many referrals do not include a transfer of information, and when they do, it often contains insufficient data for medical decision making. Documentation can be a narrative summary or a standardized checklist. The minimum information  that should be communicated is:

• Date
• Referring physician’s name
• Diagnosis, problem list
• Reasons for referral
• Urgency of referral (stat, urgent or routine)
• Service requested (consult only, testing only, follow-up, or consult and treat)
• Test results, current treatments
• Current medications, allergy/Intolerance and Adverse Reactions
• Pending laboratory/diagnostics tests with contact information
• Discharge instructions

Other information  that could be provided is:

• History and summary of significant findings
• Patient and family education
• Consents and patient registration/fact sheet information
• Telephone conversations or meetings between physicians
• Physician and family/other contact information

Regardless of the method preferred, paper based or an electronic health record (EHR), develop a standardized form or system to track referrals. Learn to manage referrals efficiently and effectively  to curb the fragmentation of care patients experience when they are bounced back and forth between physicians. Your practice situation will decide what works best, and consistency will make the process run more smoothly.

Author Diana Douglas (CPHRM) is Vice President of Risk Management and Patient Safety for the Cooperative of American Physicians, Inc. (CAP).

If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.