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The American Journal of Managed Care August 2019
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Tools to Improve Referrals From Primary Care to Specialty Care
Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
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Tools to Improve Referrals From Primary Care to Specialty Care

Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
Data from a national survey of Veterans Health Administration specialists indicate that referral templates may improve the appropriateness, clarity, and completeness of primary care–specialty care referrals.
ABSTRACT

Objectives: Referrals from primary to specialty care are a critical first step in coordination of specialty care, but shortcomings in the appropriateness, clarity, or completeness of referrals are common. We examined (1) whether 3 tools to coordinate specialty care are associated with better referral characteristics and (2) whether greater perceived helpfulness of these tools is associated with better referral characteristics among specialists who use all 3 of them.

Study Design: National online survey about care coordination among medical specialists receiving referrals in the Veterans Health Administration.

Methods: Adjusted odds ratios (ORs) for associations between use and helpfulness of 3 coordination tools (service agreements, referral templates, and e-consults) and perceived frequency of 3 referral characteristics (appropriateness, clarity, and completeness).

Results: Among specialists (N = 497), use of referral templates was associated with perceptions that referrals were more frequently appropriate (adjusted OR, 1.5; 95% CI, 1.0-2.4), clear (adjusted OR, 1.6; 95% CI, 1.0-2.5), and complete (adjusted OR, 1.9; 95% CI, 1.1-3.2). Use of e-consults was associated with more frequent referral clarity (adjusted OR, 1.7; 95% CI, 1.0-3.0). Among specialists using all 3 tools, those reporting that templates were very helpful also perceived more frequent referral clarity (adjusted OR, 3.1; 95% CI, 1.1-8.5) and completeness (adjusted OR, 3.6; 95% CI, 1.5-8.7). Service agreements were not associated with any referral characteristic.

Conclusions: Well-designed referral templates may help improve the clarity and completeness of primary care–specialty care referrals. Existing templates may provide models that can be adapted in collaboration with primary care and broadly applied to improve referrals. Work is needed to improve the impact of service agreements and e-consults on referrals.

Am J Manag Care. 2019;25(8):e237-e242
Takeaway Points

Referrals to specialty care from primary care may be inappropriate, unclear, or incomplete, which can contribute to suboptimal specialist evaluations.
  • In a survey of Veterans Health Administration medical specialists, use of referral templates was associated with specialist perceptions of more frequent referral appropriateness, clarity, and completeness.
  • E-consult use was associated only with referral clarity; service agreement use was not associated with any referral characteristic.
  • Well-designed templates, developed in collaboration with primary care providers, may help improve the quality of primary care–specialty care referrals.
  • Work is needed to improve the impact of e-consults and service agreements on referral quality.
More than 100 million ambulatory care visits resulted in a specialty care referral in 2009, and the number continues to rise.1 As the number of providers involved in a patient’s care increases, so does the risk of care fragmentation. Care fragmentation occurs when patient care and information is shared across multiple providers without accounting for the needs and actions of all involved. Fragmented care can lead to patient and provider dissatisfaction, resource waste, and potentially devastating health consequences.2 Risks to patients include missed and unmet needs,3 duplicated tests,4 medication errors,5 and confusion about their treatment.6 These risks increase exponentially with more sources of medical care,7 raising costs and putting sicker patients in greater danger.2

Referral from primary care to specialty care creates the link between the 2 services and sets the stage for the direction and scope of the patient’s specialty evaluation and care plan. Referrals are therefore a critical first step in coordination of specialty care. Ideally, referrals should reflect a mutual understanding between the primary care provider (PCP) and specialist about when evaluation or care for a condition exceeds a reasonable level for management in primary care (ie, appropriateness for referral). The referral from primary care should also convey a clear question and sufficient historical information about the patient and their condition to focus the consultation (ie, the clarity and completeness of the referral). However, referrals that do not meet these standards are common8 and can result in delayed, duplicative, or incomplete specialty care evaluations, with attendant compromises in the quality of patient care.

Veterans make more than 11 million visits a year to medical specialists within the Veterans Health Administration (VHA),9 which is among the largest integrated healthcare systems in the United States. Preventing adverse outcomes through care coordination is a cornerstone of the VHA’s effort to deliver high-quality specialty care. The VHA has implemented several approaches to improve the clinical appropriateness and content of referrals. Service agreements (ie, care coordination agreements) between local primary and specialty care services outline expectations for each stage of the referral process and include guidelines about clinically appropriate referrals and referral content.10 Referral templates created by specialty services within the shared electronic health record (EHR) are used to structure referrals and guide PCPs in terms of what content to include.3 E-consults are a third coordination tool, intended to shuttle less-complex questions to consultation by chart review so that referrals for face-to-face visits need only be placed for appropriate clinical situations that require a more intense level of service.11 Specialists can request further specification of the referral question or inclusion of additional historical information at the time of e-consult or if they convert an e-consult to a traditional referral.

Specialty services commonly use these tools (service agreements, templates, and e-consults), but little is known about the degree to which any of them improve the appropriateness, clarity, and completeness of referrals from primary care and, thereby, more effectively serve to coordinate care between PCPs and specialists.

We used data from an online survey of VHA specialists’ experience with care coordination to examine the relationships between the use of each of these 3 referral tools and the frequency of desirable referral characteristics. We addressed the following questions: Is the use of referral tools to coordinate specialty care associated with specialists’ perceptions of better referrals? Among specialists who use all 3 tools, are those who rate the tools as very helpful more likely to report better referrals?

METHODS

We used data from an online survey about specialty care coordination among 2533 clinicians from 13 medical specialties across the VHA in 2016 to 2017 (25% response rate).12 The study was focused on the experience of clinicians in medical subspecialties who receive referrals. Participants were recruited using a combination of random sampling, posting the survey link to a VHA specialist listserv, and a convenience sample of facility specialty section chiefs who encouraged their physicians to respond. Email addresses were tracked to avoid participation more than once; responses themselves were anonymous. Incentives were not offered, consistent with VHA policy. The survey was administered using SurveyMonkey.13 The study was approved by the institutional review board at the Bedford Veterans Affairs Medical Center.

Respondents reported on both their use (yes/no) and perceived helpfulness of several tools that could be used to coordinate specialty care. We examined 3 tools that we hypothesized to have a relationship to desirable elements of the PCP’s referral request: service agreements, referral templates, and e-consults. Respondents were asked: “If you used them in the last 3 months, how helpful were these tools in promoting coordination of care with PCPs?” Based on the distribution of responses, and to create meaningful categories, we categorized response options as “not used” (not available to me or available to me but did not use in the last 3 months), “at most somewhat helpful” (not at all helpful, a little helpful, or somewhat helpful), and “very helpful” (very helpful or extremely helpful). Secondarily, we collapsed all ratings of helpfulness to create a category for “used” (vs “not used”).


 
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