Health Literacy Universal Precautions Toolkit, 2nd Edition

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Overview

Primary care practices refer patients to specialists, ancillary health care clinicians, labs and screening facilities, and elsewhere. Making the referral process easy for patients increases the chances that they will follow through, and that both you and the referral destination get all the information you need.

Action

Refer patients to clinicians who coordinate care with you.

• Identifying, developing, and maintaining relationships to whom you refer patients can make the referral process run smoothly.
• Try to establish formal referral agreements with key specialist groups and other clinicians.
• Don't continue to refer patients to clinicians who do not send information back to you, don't provide timely appointments for your patients, or otherwise fail to coordinate care.

Don't rely on patients to relay information.

• Share important information directly with the other office, such as the reason for the referral, pertinent medical history, and test results.
• Explore making electronic referrals. Check whether your EHR has the capability to make referrals directly to other clinicians. If not, self-standing referral management systems are commercially available for purchase.
• Provide a detailed referral to the other clinician that contains all the information needed. The Improving Chronic Illness Site has a guide on Referral Management, which includes a checklist of information to provide to specialists for each referral.
• Get information sent directly back to you. Make sure you get a full report back before your patient's next visit.

Consider language barriers.

• When making referrals for patients with limited English proficiency, identify clinicians who are language concordant or have interpreter services. Go to Tool 9: Address Language Differences for more information on language assistance.
• Include information on your patient's language assistance needs when making the referral.

Make sure the patient understands the reason for the referral.

• Explain why the patient needs to be seen by someone else, and what might happen if he or she is not seen.
• In the case of tests, explain how you and the patient will use the information to diagnose, manage, or decide on treatments for health conditions.
• In the case of screenings, give a clear explanation of the risks and benefits. Ultimately, it's up to the patient as to whether or not to undergo any particular test or screening.
• Use the teach-back method (go to Tool 5: Use the Teach-Back Method) to confirm patient understanding.
• Ask about and address any concerns or fears.

Offer help with the referral.

• Ask patients if they would like your office to make the initial phone call.
• If staff members are making appointments for patients, make sure they first find out when the patients are available.
• Ask patients about transportation and other barriers to their completing the referral. Discuss how they could overcome these barriers. Use Tool 18: Link Patients to Non-medical Support to refer them to other services that could support their completion of the referral.

Provide clear instructions.

• For some referrals, patients will need to prepare in advance (e.g., fast, discontinue a medicine). Provide easy-to-understand instructions verbally and in writing.
• Explain the referral process fully (e.g., how you and the other clinician will exchange information, when the patient should return to your office).
• Give clear oral and written directions to get to the referral location.
• Use the teach-back method (Tool 5) to confirm patient understanding.

Follow up on referrals.

• Confirm and document that the patient successfully completed the referral.
• Obtain information on the result of the referral and document in the medical record.
• Make sure the patient receives the results of any tests or screenings, even normal results.
• Provide patients positive feedback for completing referrals. Let patients see how you use the information obtained from tests or specialist visits.
• If the patient has not completed the referral, reinforce that you feel the patient could benefit, and review barriers.
• Determine whether the patient needs additional referrals.
• Get feedback from patients on the quality of the care provided. Stop making referrals to places that consistently receive negative reports.

Track Your Progress

Select a sample of referrals made during a week. Examine the referral records to calculate the percentage of referrals that included all relevant information. One month later, calculate the percentage of patients whose referral results are in their medical records.

Select a sample of patients who were sent for lab tests during a week. One month later, calculate the percentage of patients who have completed the test and the percentage who have been notified of the test results.

One month after implementing this Tool, ask a sample of patients who have not completed referrals why they did not follow through. Develop and implement an improvement plan to address the reasons they give. Repeat in 2, 6, and 12 months.

Resources

Care Coordination: Relationships and Agreements describes a package of changes, activities, and resources for primary care practices seeking to improve coordination.

Improving Your Office Testing Process: A Toolkit for Rapid-Cycle Patient Safety and Quality Improvement contains tools for referring to patients and following up on tests.

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