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Academic Pediatrics 2020Nearly a quarter of families of children with need of subspecialty care report difficulty accessing that care. Telehealth is a method to overcome barriers to... (Review)
Review
Nearly a quarter of families of children with need of subspecialty care report difficulty accessing that care. Telehealth is a method to overcome barriers to subspecialty care. However, improving access to subspecialty care through telehealth requires granular identification of specific subspecialty barriers and recognition of the strengths and limitations of each telehealth strategy for addressing identified barriers. Focusing on each sequential step in subspecialty referrals and potential associated barriers, we summarize specific telehealth and technology-enabled strategies to improve access to subspecialty care, including electronic consultations, live interactive telemedicine, store-and-forward telemedicine, tele-mentoring, patient portals, and remote patient monitoring. Intentionally selecting telehealth strategies to target specific subspecialty referral barriers may avoid risks from misapplication of telehealth, may more clearly elevate equitable access as an essential goal within telehealth initiatives, and may also lead to synergistic use of strategies that overcome sequential barriers.
Topics: Child; Delivery of Health Care; Health Services Accessibility; Humans; Mentoring; Monitoring, Ambulatory; Patient Portals; Pediatrics; Physicians, Primary Care; Referral and Consultation; Remote Consultation; Specialization; Telemedicine
PubMed: 31404707
DOI: 10.1016/j.acap.2019.08.002 -
Journal of Medical Ethics Dec 2022The referral is the key source of information that enables radiologists and radiographers to provide quality services. However, the frequency of suboptimal referrals is...
The referral is the key source of information that enables radiologists and radiographers to provide quality services. However, the frequency of suboptimal referrals is widely reported. This research reviews the literature to illuminate the challenges suboptimal referrals present to the delivery of care in radiology departments. The concept of suboptimal referral includes information, that is; missing, insufficient, inconsistent, misleading, hard to interpret or wrong. The research uses the four ethical principles of and as an analytic framework.Suboptimal referrals can cause by hindering safe contrast-media administration, proper radiation protection by justification of procedures, and compassionate patient care. Suboptimal referrals also hinder promoting patient from the correct choice of imaging modality and protocol, an optimal performed examination, and an accurate radiology report. Additionally, patient is compromised from the lack of information needed to facilitate benefit-risk communication. Finally, suboptimal referrals challenge based on lack of reasonable patient prioritising and the unfairness caused by unnecessary examinations.These findings illuminate how suboptimal referrals can inhibit good health and well-being for patients in relation to safety, missed opportunities, patient anxiety and dissatisfaction. The ethical challenges identified calls for solutions. Referral-decision support tools and artificial intelligence may improve referral quality, when implemented. Strategies addressing efforts of radiology professionals are inevitable, including gatekeeping, shared decision-making and inter-professional communication; thereby raising awareness of the importance of good referral quality and promoting commitment to ethical professional conduct.
Topics: Humans; Artificial Intelligence; Beneficence; Communication; Radiology; Referral and Consultation
PubMed: 34429384
DOI: 10.1136/medethics-2021-107335 -
Ophthalmic & Physiological Optics : the... May 2022Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many...
PURPOSE
Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many cases no reply to the referral letter is received, resulting in some patients being re-referred unnecessarily, potentially increasing the number of other patients who lose sight whilst on hospital waiting lists. This study investigated, qualitatively and quantitatively, factors influencing optometric referrals and replies.
METHODS
The three-phase, sequential mixed methods study started with a literature review and qualitative phase, interviewing stakeholders to identify issues for exploration in subsequent phases. The second, quantitative phase, undertook documentary analysis of 349 patient referral records from three optometric practice modalities (domiciliary, independently owned, and corporate chain) in England. A final qualitative phase obtained views from stakeholders to explore unexplained findings from the first two phases.
RESULTS
Phase 1 identified communication, financial, professional and technological issues for further exploration. In Phase 2, the referral rate was 22.2% for domiciliary provider, 2.1% for independent practice and 2.5% for the corporate chain, with the variation most likely explained by patient age and associated ophthalmic disease, illness and disability. The referral reply rate was 5.7% for domiciliary provider, 25.0% for independent practice and 4.9% for the corporate chain. The community optometrist remained unaware of the outcome of their referral in 72.8% of cases. Qualitative analyses indicate the main factors influencing referral reply rates are technology, the General Medical Practitioner, community optometrists' utility to and utility of the National Health Service and patient mobilisation.
CONCLUSIONS
The low referral reply rate creates a break in the feedback loop required to raise the standard of referrals and avoid unnecessary re-referral. Of the factors identified that influence referral reply rates, technology is key in view of the increasing use of online referral platforms. Feedback to the referring optometrist should be embedded in such systems.
Topics: England; Humans; Optometrists; Optometry; Referral and Consultation; State Medicine
PubMed: 35106831
DOI: 10.1111/opo.12948 -
BMC Health Services Research Feb 2022Unnecessary referrals in Danish hospitals may be contributing to inefficient use of health services already stretched and under pressure and may lead to delayed...
BACKGROUND
Unnecessary referrals in Danish hospitals may be contributing to inefficient use of health services already stretched and under pressure and may lead to delayed treatment for patients. Despite a growing awareness in the literature and in practice of issues related to referrals, there has been relatively little research on referrals between specialists in hospital outpatient clinics and how it can be improved. This study aimed to describe the referral patterns to and within the Medical Department at the University Hospital of Southern Denmark. The Medical Department consists of the following medical specialist outpatient clinics; nephrology, pulmonology, endocrinology, cardiovascular, wound outpatient clinic, and a day hospital.
METHODS
Two specialist physicians assessed all referrals to the medical specialist outpatient clinics over one month (from 01 September 2019 to 30 September 2019) using data drawn from the Danish electronic patient record system (Cosmic). Data on referral pattern, and patient age and sex, were statistically analysed to identify and characterise patterns of referral.
RESULTS
Four hundred seventy-one (100%) referrals were included in the study. 49.5% (233) of the referrals were from the hospital and 50.5% (238) from general practitioners (GPs). Of the 233 referrals from the hospitals, 31% (72) were from the Medical Department.
CONCLUSION
The high rate of referrals (31%) from own Medical Department or outpatient clinics may reflect an inefficient internal referral process within the department. Improved collaboration between specialists could have the potential to improve health outcomes, timely access to care and more appropriate healthcare resource utilisation.
Topics: Ambulatory Care Facilities; Hospitals; Humans; Outpatient Clinics, Hospital; Referral and Consultation; Specialization
PubMed: 35209886
DOI: 10.1186/s12913-022-07633-y -
AMIA ... Annual Symposium Proceedings.... 2020Addressing patients' social determinants of health via community resource referrals has historically been the primary domain of social workers and information and...
Addressing patients' social determinants of health via community resource referrals has historically been the primary domain of social workers and information and referral specialists; however, community resource referral platforms have recently entered the market. We lack an account of the process of community resource referrals and the role of technologies within it. Using sociotechnical systems theory, we analyze data from 12 focus groups (n=102) with healthcare providers, and community organization staff and volunteers in Metropolitan Detroit to describe the process of community resource referral. Findings reveal a deeply sociotechnical process including the following steps: assessing patients' social needs; choosing appropriate referral sources; and facilitating connections. We characterize the importance of knowledge and skills, personal relationships, interorganizational networks, and data sources such as service directories in the referral process. Findings suggest that digital platforms may augment referral functions, but should not be seen to replace interpersonal work, relationships, and interorganizational networks.
Topics: Focus Groups; Health Personnel; Humans; Needs Assessment; Public Health; Referral and Consultation
PubMed: 33936432
DOI: No ID Found -
Ghana Medical Journal Sep 2022To describe the capacity of primary health care facilities to manage obstetric referrals, the reasons, and processes for managing obstetric referrals, and how an...
OBJECTIVE
To describe the capacity of primary health care facilities to manage obstetric referrals, the reasons, and processes for managing obstetric referrals, and how an enhanced inter-facility communication system may have influenced these.
DESIGN
Mixed methods comparing data before and during the intervention period.
SETTING
Three districts in the Greater Accra region, Ghana from May 2017 to February 2018.
PARTICIPANTS
Referred pregnant women and their relatives, health workers at referring and referral facilities, facility and district health managers.
INTERVENTION
An enhanced inter-facility communication system for obstetric referrals.
RESULTS
Twenty-two facilities and 673 referrals were assessed over the period. The major reason for referrals was pregnancy complications (85.5%). Emergency obstetric medicines - oxytocin and magnesium sulfate (MgSO) were available in 81.8% and 54.5% facilities, respectively, and a health worker accompanied 110(16.3%) women to the referral centre. Inter-facility communication about the referral occurred for 240 (35.7%) patients. During the intervention period, referrals joining queues at the referral facility decreased (7.8% to 0.0%; p=0.01), referrals coming in with referral notes improved (78.4% to 91.2%) and referrals with inter-facility communication improved (43.1% to 52.9%). Health workers and managers reported improvement in feedback to lower-level facilities and better filling of referral forms.
CONCLUSION
Facilities had varying levels of availability of infrastructure, protocols, guidelines, services, equipment, and logistics for managing obstetric referrals. Enhanced inter-facility communication for obstetric referrals which engages health workers and provides requisite tools, can facilitate an efficient referral process for desired outcomes.
FUNDING
This study was funded by the WHO/TDR Postdoctoral grant number B40347 to the NMIMR.
Topics: Female; Humans; Pregnancy; Ghana; Referral and Consultation
PubMed: 38322747
DOI: 10.4314/gmj.v56i3s.7 -
Journal of Medical Systems Dec 2022Delays beyond recommended wait times, especially for specialist services, are associated with adverse health outcomes. The Alberta Surgical Initiative aims to improve...
Delays beyond recommended wait times, especially for specialist services, are associated with adverse health outcomes. The Alberta Surgical Initiative aims to improve the referral wait time-the time between a referral is received at the central intake to the time a specialist sees the patient. Using the discrete event simulation modelling approach, we evaluated and compared the impact of four referral distribution policies in a central intake system on three system performance measures (number of consultations, referral wait time and surgeon utilization). The model was co-designed with clinicians and clinic staff to represent the flow of patients through the system. We used data from the Facilitated Access to Surgical Treatment (FAST) centralized intake referral program for General Surgery to parameterize the model. Four distribution policies were evaluated - next-available-surgeon, sequential, "blackjack," and "kanban." A sequential distribution of referrals for surgical consultation among the surgeons resulted in the worst performance in terms of the number of consultations, referral wait time and surgeon utilization. The three other distribution policies are comparable in performance. The "next available surgeon" model provided the most efficient and robust model, with approximately 1,000 more consultations, 100 days shorter referral time and a 14% increase in surgeon utilization. Discrete event simulation (DES) modelling can be an effective tool to illustrate and communicate the impact of the referral distribution policy on system performance in terms of the number of consultations, referral wait time and surgeon utilization.
Topics: Humans; Waiting Lists; Referral and Consultation; Alberta; Time Factors; Health Services Accessibility
PubMed: 36585480
DOI: 10.1007/s10916-022-01897-x -
International Journal of Medical... Dec 2023Cross-institutional (external) referrals are prone to communication breakdowns, increasing patient safety risks, clinician burnout, and healthcare costs. To close these...
BACKGROUND
Cross-institutional (external) referrals are prone to communication breakdowns, increasing patient safety risks, clinician burnout, and healthcare costs. To close these external referral loops, referring primary care physicians (PCPs) need to receive patient information from consultants at different healthcare institutions. Although existing studies investigated the early phases of external referral loops, we lack sufficient knowledge about the closing phases of these loops. This knowledge could allow health care institutions to improve care coordination and rates of closed referral loops by implementing socio-technical interventions for patient information exchange throughout a referral loop. Human factors engineering (HFE) provides a systematic approach to advance our understanding of barriers perceived by physicians. Using HFE, our objective was to characterize referring and consulting physicians' barriers to closing referral loops and implications for care.
METHODS
This qualitative cross-sectional study included semi-structured interviews with referrers and external consultants. We used the Systems Engineering Initiative for Patient Safety 2.0 framework to conduct rapid qualitative analyses, determining perceived barriers and related implications. Main measures were consultants' and referrers' perceptions of, and experiences with, barriers to external referrals.
RESULTS
Six referring PCPs and 12 consultants participated from two healthcare systems and four medical specialties. Physicians perceived three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals. Consultants reported the ability to provide the same level of care to patients with internal or external referrals. However, consultants described communication breakdowns that prohibited confirmation of follow-up plan retrieval, initiation, or effectiveness.
CONCLUSION
Physicians reported technological and organizational barriers to closing cross-institutional referral loops. Promises of HIE technology for external referrals have not fully materialized. Among physicians and patients, retrieval and exchange of medical information increases perceived workload, burden, and frustration. These increases are not accurately captured by traditional organizational metrics. This study provides evidence that informs future human factors engineering research to address perceived barriers and guide future HIE design or implementation.
Topics: Humans; Consultants; Cross-Sectional Studies; Referral and Consultation; Communication; Health Facilities
PubMed: 37913622
DOI: 10.1016/j.ijmedinf.2023.105265 -
The American Journal of Managed Care Aug 2019Referrals from primary to specialty care are a critical first step in coordination of specialty care, but shortcomings in the appropriateness, clarity, or completeness...
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.
Topics: Adult; Continuity of Patient Care; Female; Humans; Male; Middle Aged; Primary Health Care; Quality Improvement; Referral and Consultation; Specialization; Telemedicine; United States; United States Department of Veterans Affairs
PubMed: 31419100
DOI: No ID Found -
Health & Social Care in the Community Mar 2020The use of non-medical referral, community referral or social prescribing interventions has been proposed as a cost-effective alternative to help those with long-term... (Review)
Review
The use of non-medical referral, community referral or social prescribing interventions has been proposed as a cost-effective alternative to help those with long-term conditions manage their illness and improve health and well-being. However, the evidence base for social prescribing currently lags considerably behind practice. In this paper, we explore what is known about whether different methods of social prescribing referral and supported uptake do (or do not) work. Supported by an Expert Advisory Group, we conducted a realist review in two phases. The first identified evidence specifically relating to social prescribing in order to develop programme theories in the form of 'if-then' statements, articulating how social prescribing models are expected to work. In the second phase, we aimed to clarify these processes and include broader evidence to better explain the proposed mechanisms. The first phase resulted in 109 studies contributing to the synthesis, and the second phase 34. We generated 40 statements relating to organising principles of how the referral takes place (Enrolment), is accepted (Engagement), and completing an activity (Adherence). Six of these statements were prioritised using web-based nominal group technique by our Expert Group. Studies indicate that patients are more likely to enrol if they believe the social prescription will be of benefit, the referral is presented in an acceptable way that matches their needs and expectations, and concerns elicited and addressed appropriately by the referrer. Patients are more likely to engage if the activity is both accessible and transit to the first session supported. Adherence to activity programmes can be impacted through having an activity leader who is skilled and knowledgeable or through changes in the patient's conditions or symptoms. However, the evidence base is not sufficiently developed methodologically for us to make any general inferences about effectiveness of particular models or approaches.
Topics: Attitude to Health; Humans; Referral and Consultation; Social Participation; Social Support; Social Work
PubMed: 31502314
DOI: 10.1111/hsc.12839