Consultation & Referral: Enhancing the Process to Improve Outcomes

Transcription

1 Consultation & Referral: Enhancing the Process to Improve Outcomes Mary Jo Goolsby, EdD, MSN, NP-C, FAANP, FAAN Georgia Regents University College of Nursing Institute for NP Excellence 1 Disclosure MJ Goolsby has nothing to disclose Institute for NP Excellence 2 Objectives On completing this program, you will be able to : Differentiate between terms consultation and referral Develop appropriate requests for consultation or referral, as indicated Coordinate the consultation or referral process, to optimize outcome Institute for NP Excellence 3 1

2 Consultation & Referral Referrals and consultations: Tickets of safe passage for patients travelling to seek further care Visible currency of sanctioned cooperation among healthcare providers (Lingard et al, 2004) Terms relate to two distinct process Not interchangeable Both processes important to enhancing outcomes Both fraught with opportunities for mistakes Institute for NP Excellence 4 So What s the Difference? Institute for NP Excellence 5 Consultation Request for advice or opinion Usually regarding diagnosis or treatment Does not transfer ongoing care Appropriate terminology: Consultation requested for evaluation of chronic heachache Please see this patient on consultation for recommendations regarding improved blood pressure control Consultant assesses and renders opinion, provides report Institute for NP Excellence 6 2

3 Curbside Consultation Providers often seek guidance through informal, curbside consults Specialists respond to specific question(s) regarding diagnosis or treatment Over phone, electronically, at meetings, etc Extremely important to present well-phrased question with adequate patient details Not appropriate for complex needs Institute for NP Excellence 7 Referral Transfer of care to another provider Involves request that receiving provider accept ongoing care for one or more conditions PCP usually maintains ongoing responsibility for overall care Terminology: Referral for management of seizures Please accept this referral for ongoing management of asthma Institute for NP Excellence 8 Coding Requirements Differ Consultation: Coded as consultation Requires report be provided to the initiating provider Referral: Coded as new patient visit (established if previously seen by accepting provider) Report not required, but necessary for continuity Institute for NP Excellence 9 3

4 Consultation & Referral: Commonplace Practices increasingly prevalent Probability that outpatient visit resulted in referral increased from Primary care--4.8% to 9.3% Specialist 2.9% to 7.3% and phone consultation rate increased Barnett, M. (2012) Institute for NP Excellence 10 NP Referrals Primary Care NP Survey (PCNPS) Conducted 2006 & 2007 by AANP Network for Research (AANPNR) PCNPS designed to describe individual encounters, randomly selected Adaptation of NAMCS (National Ambulatory Medical Care Survey); items regarding referrals/consultations Each iteration ~800 encounters ~11% of encounters resulted in a referral or consultation Most commonly for: diagnostic study/assessment, medical treatment, surgery, and mental health counseling. Institute for NP Excellence 11 Common Reasons for Consultations & Referrals Primary care provider seeking advice for diagnosis and/or treatment Failed conventional or standard treatment Medicolegal concerns Need for treatment by specialized provider Patient request Third party request Institute for NP Excellence 12 4

5 Hesitancy to Consult Concerns regarding: potential loss of patient potential secondary referral or consultation lack of communication and timeliness Institute for NP Excellence 13 (Gandhi, et al, 2002) Problems with Process Surveyed physicians within managed care setting, following completion of a consultation or referral PCPs and specialists identified problems encountered in the process, from list provided Institute for NP Excellence 14 Rankings: PCP Perspective Delays in receipt of information from specialist Redundancy in referral process Time necessary to write/transmit referral Problems locating necessary specialist Problems encountered with medical management: Inadequate knowledge of medical management role Time required to obtain approvals Institute for NP Excellence 15 5

6 Rankings: Specialist Perspective Problems with timeliness of information from referring/consulting provider Time required to obtain approvals: Medical management Insurance Inadequate/unclear information from PCP Time needed to write/transmit adequate note Redundancy in the process Institute for NP Excellence 16 What PCPs Want in Reports Answers to their specific questions Specialist s assessment of the patient Results of all testing and procedures Description of recommended and/or implemented therapy Institute for NP Excellence 17 What Specialists Want in Consult/Referral Request Problems to be addressed specified Questions to be answered Information that patient unlikely able to provide List of all health problems and medications Institute for NP Excellence 18 6

7 Reasons for Choice of Referral Provider Primary care physicians: ease of communication Specialist physicians: shared record system Barnett, M. et al (2012) Institute for NP Excellence 19 Essentials of Consultation Reports Berta et al (2009) Systematic review followed by modified Delphi involving physicians and NPs Identified 15 essential elements from original list of 74 Several are basic but essential 1-4: patient details (name, DOB, contact, etc) 5-6: specialist s name and contact 15: date report prepared Institute for NP Excellence 20 Minimum Essential Elements (8) Reason for the consultation/request as understood by specialist Problem as described by the referring provider Results of specialist results: exam, tests, procedures Proposed or initiated therapy Answers to specific questions Primary/secondary diagnoses Plan of action including therapies and education of patient Follow-up plan Institute for NP Excellence 21 7

8 Risks Associated with Inadequate Communication Repeat visits Redundant or inappropriate tests/evaluation Delayed or inappropriate treatment Increased costs Loss to follow-up Patient harm Institute for NP Excellence 22 Asking Adequate Question Appropriate consultation requires adequate question Becomes critical in informal (curbside) consults Suggested model: PICO format P: Patient I: Intervention C: Comparison O: Outcome Institute for NP Excellence 23 PICO Examples Four-Part Model Questions: PICO Patient/Population include characteristics of specific patient or patient population Intervention/Exposure include the intervention that is being considered Comparison include any alternative being considered (not always applicable) Outcome what is the intent/goal (pain relief, diagnosis, safety) Institute for NP Excellence 24 8

9 Example PICO Question In family practice setting, a 25 year old woman who has been on low molecular weight heparin (LMWH) for venous thromboembolism (DVT) presents for pregnancy confirmation. Results of a pregnancy test are positive. This is the first time you have encountered this situation and you are unsure whether it is safe to continue her on LWMH to manage DVT. Institute for NP Excellence 25 Clinical Question- PICO Patient/ Population Intervention/ Exposure Comparison Outcome In a 25 y/o pregnant woman with DVT history is LMWH as safe as unfractionated heparin in terms of adverse reactions to the mother or fetus? Institute for NP Excellence 26 What to Include in Request Patient s name and DOB Payor source Summary of current problems and known diagnoses Pertinent history: medical, surgical, family, social Pertinent physical findings and diagnostic study results Summary of previous (related) consultations CLEAR indication of either consultation or referral Pertinent patient preferences Institute for NP Excellence 27 9

10 What to Expect in Consultant s Report Statement of understood purpose for visit Summary of history and physical findings Results from any diagnostic studies or procedures Summary of any therapy recommended or implemented Response to any treatment provided Assessment of problem and/or diagnosis Recommendations for further assessment or treatment Recommendations for further consultation Summary of instructions provided to patient Indication whether consultation complete or plans in place to see patient further Institute for NP Excellence 28 What to Expect in Referral Report Summary of all relevant points listed on previous slide PLUS Adequate detail to ensure continuity of care As indicated, interim summary reports Institute for NP Excellence 29 How to Enhance Process Standardize process to write requests/reports Forms (paper/electronic) help Prompt required details Indicate referral or consultation Indicate/link any appended information Institute for NP Excellence 30 10

11 E-Consultations Ontario E-consultation service NPs and physicians Standardized form to transmit requests Responses included: Specialist response without visit Specialist request for further information prior to providing advice Specialist request formal consultation visit Could meanwhile request further study, interim treatment Positive response, <10% required visit Liddy et al (2013) Institute for NP Excellence 31 Similar U.S. study E-Consultations Submission of question to consultant or referral request, with relevant information NP or physician in specialist practice reviewed and responded Results included Elimination of inappropriate referrals/consultative visits Expedited urgent cases Ensured necessary work-up was complete before seen Straus, et al (2013) Institute for NP Excellence 32 How to Enhance Process Select appropriate means of transmitting request/report Many options Electronic record allows sharing through system Mail or fax of documents Hand-carried documents by patients Consider necessity of initial phone consult Institute for NP Excellence 33 11

12 How to Enhance Process Understand timing: Time required for necessary documents to reach specialist When patient will actually be seen by specialist Time required to receive specialist s response When to follow-up on the process Ensure patient understands time issues and when should seek advice if delays encountered Institute for NP Excellence 34 How to Enhance Process Consider establishing referral/consultation agreements Murray (2002) describes referral agreements as means to minimize delays and optimize process PCP and specialist define Which conditions will be managed by each Agreed-upon diagnostic workup prior Timeframe for accomplishing visits Type of communications provided in request and reports Institute for NP Excellence 35 Professional Benefits of Optimizing Processes Consultant reports provide opportunity for PCP to learn from the specialist s visit Timely and appropriate requests and reports enhance satisfaction with collegial relationships Smooth process enhances patient confidence in and satisfaction with care provided Institute for NP Excellence 36 12

13 Summary NPs have history of provided care that is safe, effective, and cost-effective. PCP remains responsible for coordinating care Appropriate use of consultations and referrals optimize management Ensure safe passage for their patients Enhance communication Institute for NP Excellence 37 References Akbar, A. et al (2008). Interventions to improve outpatient referrals from primary care to specialty care. Cochrane Database of Systematic Reviews. 2008, Oct 8 (4): CD Available online June at URL: Barnett, M. (2012) Trends in physician referrals in the U.S Archives of Internal Medicine, 172 (2), Barnett, M. et al. (2012). Reasons for choice of referral physicians among primary care and specialist physicians. Journal of General Internal Medicine, 27 (5) Bergus, G., Randall, C., Sinift, S., & Rosenthal, D. (2000). Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Archives of Family Medicine, 9, Berta, W et al (2009). Enhancing continuity of information: Essential components of a referral document. Canadian Family Physician, 54, e1-6. Available online June 12, 2013 at URL: Francois, J (2011). Tool to assess the quality of consultant and referral request letters in family medicine. Canadian Family Physician, 57, Available online June at URL: Institute for NP Excellence 38 References Gandhi, T., Sittig, D, Franklin, M., Sussman, A., Fairchild, D., & Bates, D. (2000). Communication breakdown in the outpatient referral process. Journal of General Internal Medicine, 15, Kuo, D., Gifford, D., & Stein, M. (1998). Curbside consultation practices and attitudes among primary care providers and medical subspecialists. JAMA, 280, Liddy, C et al (2013). Building access to specialist care through e-consultation. Open Medicine, 7(1). Available online June 12, 2013 at URL: Lingard, L. et al (2004). Expert and trainee determination of rhetorical relevance in referral & consultation letters. Medical Education, 38 (2), Murray, M. (200 2). Reducing waits and delays in the referral process. Family Practice Management. Sep 2002, Straus, S et al (2011). Implementation of an electronic referral system for outpatient specialist care. AMIA Annual Symposium Proceedings Archive Available online June 12, 2013 at URL: Institute for NP Excellence 39 13