Where Care Referrals Go Wrong

Referrals are made every day for any number of reasons—from the emergency department to surrounding primary care physicians, from primary care physicians to specialists, among other scenarios. Unfortunately, the standard process of making a referral isn’t a great one, and is typically where care referrals go wrong. To make matters worse, many referrals are meant to help manage chronic conditions that can be treated in less costly outpatient settings – but the care never happens, and the patient ends up in the Emergency Department. A recent study shows that “about 30% of emergency department visits among patients with common chronic conditions are potentially unnecessary, leading to $8.3 billion in additional costs for the industry,” and, “six common chronic conditions accounted for 60% of 24 million ED visits in 2017; out of that 60%, about a third of those visits—or 4.3 million—were likely preventable and could be treated in a less expensive outpatient setting.”

Let’s consider first the example of a patient with a chronic disease who has been admitted to an emergency department to resolve an acute issue. After discharge, they are referred to seek follow up care with a primary care physician or other medical home in the surrounding community to manage the chronic disease and prevent future acute episodes. When being discharged, a staff member may hand the patient a sheet of paper with a list of physician names and contact information and send them on their way without ever knowing if the patient schedules an appointment.

There are a number of problems with this scenario, including the fact that the list rarely includes information about the proximity to the patient’s residence or which providers accept which type of insurance. Ultimately, the biggest problem here is that the responsibility to find and secure follow-up care is entirely up to the patient.

Even if a patient does call to schedule a follow-up, they’re usually met with a less than pleasant experience. Without an accurate, up-to-date and real-time view of appointment availability, call center agents have to waste mountains of time trying to match the patient to the right appointment—and often the appointment that is scheduled is less than optimal. Too often, patients end up waiting two, three, even four weeks to be seen for follow-up care. That’s not only risky for readmissions and further health complications, but with lead times so long, patients may even forget they scheduled an appointment in the first place and not show up.

Between forgetting to follow-up and forgetting to show up, there is clearly a lot at risk when making a referral. Studies have shown that 25-50% of referring physicians do not know whether their patients actually see the specialist they are referred to (we’ve boiled this 30 page study down in a previous blog). To make matters worse, 26% of malpractice claims pertaining to a missed or delayed diagnosis involved a failure to refer. Clearly, we have a referral completion epidemic in this country!

Let’s recap where care referrals go wrong:

  • Patients leave the point of care with no follow-up booked
  • Call centers managing referrals have no efficient way to schedule referrals when patients call in or when they make outreach calls to patients with referral orders
  • Schedulers are flipping through binders of rules to match patients with the right provider which is not time efficient
  • Multiple screens, platforms, and logins are needed to schedule referrals—making it difficult and cumbersome
  • Wait times are really long because referral channels aren’t being analyzed and optimized
  • Referring physicians have limited or no insight into whether patients are following referral orders

Ultimately, patients aren’t getting the care that they are being referred to, which can result in poor health outcomes and even malpractice lawsuits. There has to be a better way!

Thankfully, this is where digital care coordination can assist. With this technology, patients can be given easier access to referral care. Appointments can be booked at the point of care and call center agents can be equipped with a digital platform that allows them to quickly search for providers, guides them with Q&A to the right appointment, and allows them to schedule in real-time—all in one seamless experience.

With sophisticated decision support and automated business rules, referrals can be made quickly, easily, and safely, by any party. Guided search allows individuals to define and select the best care options for each and every patient, which is not only helpful for general care needs, but essential for complex and specialty care scenarios.

More timely access to care positively impacts the patient experience and helps ensure patients get the care they need. This is especially important when legal responsibility can fall on the referring provider if a patient doesn’t book the recommended referral appointment. It is beneficial to ensure that a patient with an issue that needs specialty follow-up care leaves with a confirmed booked appointment instead of merely a number to call.

Thanks to a direct integration with provider EMRs, which allows for real-time calendar views, there is no need for follow-up calls to confirm appointments—bookings go directly onto providers calendars in the practice management system. Call center agents have the same real-time visibility, allowing them to more accurately choose the next available appointment slot for patients and then book that appointment on the spot. Moreover, providers can maintain control over their calendars through the business rules built into the platform that enables them to only offer the slots they want to offer to the call center, hospital ED, online, or other access channel.

Patients, regardless of how the follow-up appointment is scheduled, are immediately sent a smartphone calendar invite as soon as the appointment is booked. This has been hugely impactful in reducing patient no-shows. All these factors work together to improve the patient experience and increase the likelihood that referrals will be completed. There are many situations where care referrals go wrong, but we believe that digital care coordination can make it better.

To learn more, download our guide, Redefining Patient Access.