Specialty Referral Management/Care Coordination

Improving care coordination between primary care and specialty care to ensure the best possible experience for patients.

Patients are being seen by a primary care physician and given a referral to a specialist for follow up care and diagnosis.    Sometimes a specialist is seeing a patient and referring that patient to another specialist for follow up care and diagnosis.    We are trying to ensure that when that referral is made there is a very efficient and patient friendly process for those follow up visits to be booked in a timely manner within our system.   Sometimes we will book the follow up visit real time, which works.   However, in many instances the patient does not want to book the visit during the current visit and then takes it on themselves to book the follow up specialty appointment.   At that point we sometimes see delay in scheduling, scheduling with the wrong physician or no action by the patient.  We have implemented a variety of different methods to improve this process, but would be interested in hearing examples from others that have implemented good processes that ensure patients who don’t book the referral real time are not getting lost and the follow up appointment gets booked timely and with the right physician?   Also, many times patients following their specialty visits will obtain information that requires further decision making or testing.   At that point we want the original referring physician to be reengaged with the patient along with the information from the specialist to help design a path forward that is efficient and effective and that makes the patient feel like their care is being guided in partnership with their physician as opposed to the patient having to determine next steps.   Again, we have worked hard on this issue, but am interested in others who have processes that can improve upon our efforts.


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Participant comments on Specialty Referral Management/Care Coordination

  1. In a highly complex organization with more than 1200 bed capacity and several tertiary care specialties, care coordination is considered a big challenge, especially with the fact of the low literacy level in the patient’s community and their caregivers’. Our institution created some strategies to cope with this and try to reach the best outcomes in patient coordination and patient/ patient partnership in the below levels of patient referrals:
    1. Within the specialty care ( Combined services such as Medical oncology, Radiation oncology and Oncology Surgery)
    2. Cross specialty consultation
    3. Outside the organization consultation (long term care facility)
    4. Home Health Care referrals and follow ups

    Creating combined clinics for each complicated specialty such as Organ transplant or Cancer Care, where the different specialties discuss the cases in both clinic setting and post clinic conference, this happen in a form of a multidisciplinary approach with the presence of MDs from several specialties, health education, nursing, social workers, and psychologist in some diseases.

    The hospital policy mandate all primary physicians to provide phone handover and verbal approval before referring any new follow up to different specialty, this will take the shape of calling the consultant on call that week and explain the reasons for the referral and the urgency, then the accepting MD will advise the right date and name of the clinic to fit the patient or will visit the patient in the inpatient room if was admitted to the hospital, otherwise case will be rejected and Adverse Occurrence report will be initiated from the receiving service

    The hospital recruited a crew of care coordinators ( Nursing and Clerical) to facilitate patient discharge and referral to outside facility , they take care of the communication, transportation, and financial agreements

    For the in-house care coordination, a leadership team from clinical nursing care coordinators are assigned to each specialty to ensure continuity of care in regard to follow up appointments for MD, treatment , or investigations. This team is granted a direct phone access and can be reached at any time during the day by patients and care givers and by other health care providers, they are also equipped with electronic access to Health Records on tablets and laptops to facilitate the care, and they are expected to reconcile patient’s records ( orders and requests) at the end of each clinic.

    For Home Health Care referrals,
    The MD will evaluate the patient condition and the need to be treated at home for several indications and treatments such as Enzyme replacement, or Home TPN or even end of life care, then will initiate a referral to HHC by both filling the referral criteria form and calling the HHC coordinator to assess patient within set time frame.
    HHC coordinator will then assess the eligibility and fitness and will schedule the patient with proper HHC team according to the geographical location and case acuity.

    In addition to all of that, the hospital created a call center ( Toll Free Number) to contact by patients/ caregivers and to answer any question related to their appointments, travel and logistics.

    Finally, with all the efforts put into place, we are still facing some patients who failed to confirm their appointments or lost the follow up after several no shows to their clinic appointments, and for those we rely on the providers reporting those incidences to try to prevent them from happening in the future due to the seriousness of the consequences that may impact patient health or prognosis.

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