Health Literacy Universal Precautions Toolkit, 3rd Edition

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

Action

Refer patients to clinicians who coordinate care with you.

• Identify, develop, and maintain relationships with places you refer patients to.
• Try to establish formal referral agreements with key specialist groups and other clinicians.
• Do not continue to refer patients to clinicians who do not send information back to you, do not provide timely appointments for your patients, or consistently get negative reports from patients.
• You can find more information in the guide Referral Management.

Referral Agreements

Referral agreements spell out mutual expectations and responsibilities, such as:

• Which patients are appropriate to refer.
• Use of an e-referral system or other referral procedures.
• What information is shared before and after a referral.
• Setting aside appointments for urgent referrals.
• Roles for both parties after the referral.

Do not rely on patients to relay information.

• Provide a detailed referral to the other clinician that contains all the information needed, such as the reason for the referral, pertinent medical history, medicines, and test results.
• Get information sent directly back to you. Make sure you get a full report back before your patient's next visit.
• Explore making electronic referrals. Check whether your electronic health record is able to make referrals directly to other clinicians. If not, self-standing referral management systems are commercially available for purchase.

Consider language differences.

• When making referrals for patients who use languages other than English, identify clinicians who speak those languages or confirm they use qualified interpreters. Go to Tool 9: Address Language Differences for more information on language access.
• Include information on your patient's language access needs when making the referral.

TIP

Consider whether you could avoid a referral by having a telephone or electronic consultation with a specialist. Advice and guidance may be enough to let you deliver the needed care.

Consider costs when making referrals.

Before making a referral, check whether the:

• Clinician or facility you are referring to participates in the patient’s insurance plan.
• Patient has out-of-network benefits and wants to consider non-participating providers.
• Procedure or test you are referring the patient to requires prior approval with their insurer.

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 they do not go.
• 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, harms, benefits, options. Ultimately, it is up to the patient as to whether or not to undergo any particular test or screening.
• Ask about and discuss any concerns or fears.
• Use the teach-back method to confirm you have been clear.

Offer help with the referral.

• Decide who in the practice will coordinate referrals.
• Ask patients if they would like help making the appointment.
  • If staff members are making appointments for patients, make sure they first find out when the patients are available.
  • If staff members are not making appointments for patients, ask patients to call the practice if they cannot get an appointment soon enough. You may be able to get an earlier appointment or refer to the patient to someone else who has more availability.

  Provide clear instructions.

  • For some referrals, patients will need to prepare in advance (e.g., fast, discontinue a medicine). Go over instructions with them and provide them 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).
  • Go over clear written directions on how to get to the referral location.
  • Use the teach-back method to confirm patient understanding.

  Follow up on referrals.

  • Establish a process for tracking referrals, especially for high-risk or urgent referrals.
  • Confirm and document whether the patient successfully completed the referral.
  • Obtain information on the result of the referral and document in the medical record.
  • Follow up with the patient on the results of any tests or screenings, even normal results. For more information, go to Improving Your Laboratory Testing Process: A Step-by-Step Guide for Rapid- Cycle Patient Safety and Quality Improvement.
  • 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, find out why, review the reasons you think the patient could benefit, and discuss barriers.
  • Determine whether the patient needs additional referrals.

  Track Your Progress

  Select at random the records of at least 20 patients who you referred to other clinicians a month ago. Calculate the percentage of patients whose referral results are in their medical records.

  Select at random the records of at least 20 patients who were sent for lab tests a month ago. Calculate the percentage of patients who have completed the test and the percentage of those who have been notified of the test results.

  Before implementing this tool and 2, 6, and 12 months later, ask a sample of patients who have not completed referrals why they did not follow through. Develop and implement improvement plans to address the reasons they give.

  Before implementing this tool and 2, 6, and 12 months later, collect patient feedback on a selection of questions about this tool from the Health Literacy Patient Feedback Questions.