MANAGING REFERRALS TO SPECIALISTS

1. MANAGING REFERRALS TO SPECIALISTS A BCCC initiative by: Dr. Aziza Bawoodien and Dr. Martha Mpotoane Bonitas Clinical Coordination Committee VC Meeting- 4th October 2013

2. INTRODUCTION BCCC consensus: Change ‘GP’ to ‘Family Practitioner’ (Coordinator of Care) It is the right of a patient to ask for a referral to a specialist (This was briefly discussed at the BCCC meeting on 3rd September & decided that it is true as per The Patient’s Charter) It is the duty of the family practitioner to guide the patient and advise on appropriate referral if necessary. If the patient feels the need to be referred, the family practitioner may need to adhere to the patient’s request from an ethical perspective.

3. FP’s PERSPECTIVE • Confirmation of diagnosis • Treatment • Reassurance of Family Practitioner & patient • Emergency admission where Family Practitioners are not admitting patients themselves. • Requiring hospitalization due to lack of home based or ambulatory care resources. • Lack of complex procedural skills • Feeling that further management may be out of the scope of the treating family practitioner

4. FP’s PERSPECTIVE CONT. • Patient requests (Family Practitioners do not want to be seen/perceived to deny patients specialist care) • Mutual respect for particular medical disciplines & appreciation of the value that other medical disciplines can bring to the outcomes of healthcare • Good experiences with a specific specialist e.g. availability of the specialist, geographic accessibility of the specialist’s rooms, good reporting back from specialist to family practitioner.

5. SPECIALIST’S PERSPECTIVE • Comprehensive healthcare management of patients and the continuum of care. • Specialists are not necessarily interested in primary healthcare, but rather in tertiary level of care. Willing to discharge patients back to their Family Practitioners due to time constraints. (MC stated that this is not true for specialists in KZN. He said that specialists in KZN see as many patients as Family Practitioners do and are not acting primarily as consultants. The majority of their time is spent ‘managing’ the patient’s condition). • The specialist’s interest is to advise Family Practitioners on the latest management of patients & to educate/train the Family Practitioners. • The specialists need the Family Practitioners to assist in post op/post admission of care of patients, because of their time constraints e.g. management of cancer patients etc.

6. PATIENT’S PERSPECTIVE • Some patients believethat Family Practitioners provide lesser quality services than specialists. • Some patients think it’sa waste of time for them to go from one doctor to another, just for one condition. This indicates that they are poorly educated on the different roles Family Practitioners & specialists play in their healthcare. • Some patients don’t understand inter-specialist referrals & that each specialist has a different bill. They felt this was unfair. • Most patients are appreciative of the rapport they have created with their Family Practitioner, their Family Practitioner’s availability and their accessibility. If they get referred to a specialist, their Family Practitioner explains everything to them.

7. FUNDER’S PERSPECTIVE • In the Medscheme environment a number of closed medical schemes (Sasolmed, AECI, MBMed, BMW) have implemented a specialist referral management process system. • With certain exceptions members must consult a Family Practitioner first before having full access to benefits for a specialist consultation • Bonitashave also implemented this process ,however, there are no punitive interventions taken for members who don’t follow this process. • In all of these schemes with this process, a reduction in specialist utilization has been demonstrated. • There are also indications that this has reduced the hospital admission rate. • This process only really starts to address the necessity of referral and not the destination or process; despite this the initial impact is promising as illustrated in the results of referral management in the next slide.

8. RESULTS OF REFERRAL MANAGEMENT

9. THE FINANCIAL IMPACT OF CARE COORDINATION IN HIGH RISK BENEFICIARIES • Medscheme has done analysis on high risk beneficiaries - demonstrates value of care coordination from financial perspective. • Despite evidence, most medical schemes are not prepared to implement this. • Most likely reason: restriction of choice will be unattractive to members & they will leave for a scheme where there is direct access to specialist care. • Relevant in open medical schemes where membership growth is often a strategic imperative. • In order to make referral management & coordination of care attractive, the beneficiaries of medical schemes need to “buy into” this initiative & understand the benefits. • Medical scheme brokers need to be able to articulate the benefits of this & why this is better for them than having direct access to specialists.

10. EXAMPLE OF POTENTIAL COMMUNICATION TO MEMBERS “Your Family Practitioner has been tasked with the coordination of your specialist care and you cannot go to some specialists without a referral from your Family Practitioner. This ensures that all your medical information remains with the Family Practitioner in a central place and that the Family Practitioner has a bird’s eye-view of all the diagnoses you receive, medication you take and treatment you get. Not only does this cut out unnecessary duplication, it will also help prevent medical calamities that could result if you take medication prescribed by one doctor that interacts badly with a prescription from another doctor, or if treatment is unsuccessful because the doctor did not have enough accurate information about your medical history. This does not mean you’re allowed fewer visits to the specialist, only that the Family Practitioner must coordinate your specialist visits in order to keep tabs on the quality of your care and ensure that you go to the most appropriate specialist to treat your condition. This means better health outcomes for you at lower medical scheme contributions”.

11. HOW DO WE ACHIEVE THIS IMPORTANT COMPONENT OF CONTINUUM OF CARE? • Need commitment from specialists a) not to see patients without referral letters b) to read referral letters & communicate with referring doctors. In NHS patients cannot access specialist care without an appropriate referral letter except for emergency care.1 • Family Practitioners need to do appropriate investigations prior to referral (unless it’s an emergency). • The referral letter should contain appropriate history, examination findings, investigations & include the concerns of Family Practitioner or patient. • Specialist has to address concerns unless the specialist feels that there are justifiable reasons for not addressing the concerns & may need to communicate these prior to patient exiting the specialist service . • This type of back & forth communication & transmission of information can occur asynchronously if electronic referral mechanisms are in place.3 In this way the referring Family Practitioner & patient’s concerns may be addressed or additional information can be gained from referring Family Practitioner to get greater clarity on reasons for referral.

12. HOW DO WE ACHIEVE THIS IMPORTANT COMPONENT OF CONTINUUM OF CARE (cont.)? • One study we looked at used a referral tool within electronic records. This can have benefits for the patient, the referring practitioner and the specialist. • You can easily transmit records, investigations & have asynchronous communication between the treating physicians. • Often we give referral letters to the patient and by the time the patient attends the appointment the letter is either forgotten at home, lost or patient confidentiality may not be guarded if there is a lack of privacy of space for storage of the letter. Especially considering that many of our patients live in overcrowded homes. • There must be mutual respect for the different disciplines and the value each discipline can bring to quality health care. • Patient care must be viewed as an interdisciplinary process which includes a team of health care professionals with the patient as the centre of focus and the Family Practitioner as the facilitator. MM: add integration of care/ coordination of care.

13. Family Practitioners should consider giving patients a choice (if possible) and select specialists based on informed decision making not on the basis of social contacts. Responsible Family Practitioner must give patient appropriate advice and sent to the correct specialist if necessary. • Specialist referral must also be done bearing the convenience and ease of travel for the patient in mind. If the patient is admitted it is important for the family to be able to visit during the odd visiting hours imposed by hospitals. • Discharge and follow up plans must be discussed with the referring practitioners where necessary. • The referring doctor must be supplied with a discharge letter outlining the case findings and copies of the investigations or at least where the investigations can be accessed.

14. HOW DO WE ACHIEVE THIS IMPORTANT COMPONENT OF CONTINUUM OF CARE (cont.)? • If there were changes made to medications this must be urgently communicated to the medical aids for supply of chronic medications, ensuring compliance with formularies. • The cost drivers 5of specialist referrals may not be associated with the actual referral consultation with the specialist but with hospitalization of the patient. • This is therefore a specialist driven cost factor to the medical aid. (Direct and indirect costs) • A study by Coulter et al suggests that an appropriate referral must be necessary for the individual patient, timely in the course of the disease, effective in achieving its objectives and cost effective. 5

15. CHALLENGES WITH SPECIALIST REFERRAL • Refusal of specialist care citing non-availability of beds as the reason for refusal. I have not validated this claim in the cases where my referrals have been declined. • Other experiences with specialist referrals occasionally point to poor comprehensive care, not reading referral letters, not taking comprehensive histories and concentrating on single conditions. For example, a patient referred to a general physician will manage the diabetes and not even consider the risk of ischaemic heart disease. • Referral processes requiring pre-authorisation are burdensome for the Family Practitioners. The doctors feel that the pre-authorisationsare screened by non-medically trained persons and involve a lot of paper work. • There are reports of specialists offering poor quality care as examples stated above and being time bonded. Where specialists have negotiated relationships with low cost options, they are delivering different quality services to the higher paying medical aid members as opposed to lower cost options.

17. THE WAY FORWARD • Both Family Practitioners & specialists need to understand that they share the management of patients, & at no point should that management be perceived as fragmented-(Continuum of Care). • Communication between the Family Practitioner, specialist & patient should be improved greatly and the funders also have an opportunity to be part of this. This should be done otherwise there will be poor quality of care, delayed Dx and Mx, unnecessary repeated pathology/radiology investigations, polypharmacy and high litigation risks. • Implementation of electronic health records would greatly assist in improving relations and communication between Family Practitioners, specialists and patients. Standardized/structured referral letters to specialists and report backs to Family Practitioners • Introduction of Video conferencing for doctors and allied health workers in discussions of cases that need to be managed (include Whatsapp/SMS/ Dropbox). • Provision of training for Family Practitioners in improving quality of referrals letters and Specialists response letters to Family Practitioners..

18. REFERENCES • http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/Family Practitioner-referrals.aspx • 2. Piterman, L., Koritsas S. Part II. General practitioner–specialist referral process. Internal Medicine Journal. 2005; 35: 491–496 • 3. Gandhi, T.K.H.; Keating, N.L.; Ditmore M.; Kiernan D.; Johnson R.; Burdick, E.; Hamann, C. Improving Referral Communication Using a • Referral Tool Within an Electronic Medical Record. http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-gandhi_22.pdf • 4. http://www.bankmed.co.za/beat/bankmed/(2_7_2013100140_AM)_FINAL_Referral_Management_Process_-_Family Practitioner_Comms.pdf • 5. O’Donnell C.A. Variation in Family Practitioner referral rates: What can we learn from the literature? Family Practice. 2000; 17:462-471

19. THANK YOU “If you want to walk fast, go alone. If you want to go far, walk with others”