ABC Medical Clinic Policies & Procedures Document ID XXXX Revision 0.1 Effective Date: mm/dd/yyyy SAMPLE Policy Title: Referral Tracking and Follow-Up Print Date mm/dd/yyyy Prepared By Date Prepared mm/dd/yyyy Reviewed By Date Reviewed mm/dd/yyyy Approved By Date Approved mm/dd/yyyy Applicable Standard: PCMH Standard 5: Care Coordination and Care Transitions; Element B: Referral Tracking and Follow-Up. Description: The Practice coordinates referrals for patients including referrals to all medical specialists, mental health and substance abuse specialists and all other services. Policy: It is the policy of the Practice to document and monitor all referrals using an electronic system. The patient’s provider is notified of all unfilled referrals in a timely manner. It is the policy of the Practice to document results and monitor all results or other communication from providers to whom the patient is referred. All referrals are monitored for the successful completion of the referral. Scope: This procedure applies to all office personnel. Procedure: The Practice tracks referrals to specialists, including medical, mental health, and substance abuse specialists, using an electronic reporting system. Referrals tracked are those determined by the patient’s provider to be important for a patient’s treatment or as indicated by evidence-based guidelines. The Practice uses available data from Physician Compare Website, health plans and Iowa Medical Society on the performance of the clinicians and the practice before initiating a referral with the specialist. The Practice establishes an informal agreement with a subset of specialist based on this criterion. The Practice has an agreement with two behavioral health specialists: Dr.XXXXX and Dr. YYYYYYY (locations) The Practice tracks the following factors for referrals: • • • • Date of initiation of referral Originating provider Reason for the referral Timing of the expected receipt of the communication from the referral, or relative urgency of the referral based on the clinical circumstance. Per current protocol, the urgency is 1 ABC Medical Clinic Policies & Procedures • • • • SAMPLE Policy defined by: Emergent — within 24 hours; Urgent — 24 to 72 hours; Routine — 72 hours to 2 weeks. Relevant demographic and clinical information as it pertains to the referral Whether a consultation/referral report is received from specialist General purpose of the referral Required communication or information following the referral The Practice strives to electronically communicate with specialists. The communication includes both ordering consultations and receiving reports. The Practice establishes any alternative mechanisms of timely communication with each specialist or consultant for whom it does not have electronic communications. These alternative or supplemental lines of communication include telephone, fax, secure email, or written correspondence. When referring a patient, the Practice provides an electronic summary-of-care record to the specialist. (Exceptions may be made to the electronic transmission, including the request of the patient for a paper copy to bring with him or her.) The following actions are taken regarding referrals: 1. An encounter with the patient is completed. The decision of the provider to refer the patient to another provider is documented in the patient’s record in a manner that is consistent with medical and legal prudence. 2. The provider or authorized Practice clinical staff enters the order for consultation or referral into the progress notes in the patient’s medical record. 3. A staff member of the Practice schedules the appointment with the designated specialist at a date and time convenient for the patient, but within the time frame as dictated by the clinical circumstances. 4. A staff member of the Practice completes any insurance referral information and records it for entry in the patient’s progress notes. 5. Referral requests are entered into the electronic health record (EHR) system or, if applicable, a tracking system, as items in “pending status.” 6. A communication to the referral provider, facility, etc., is produced using an appropriate standard form or template. The communication is automatically transmitted to the referring provider following the encounter. 7. The patient is notified of the specialist’s name, address and the date and time of the appointment. 8. The patient’s specialty referral appointment — time, date, and location — is recorded in the appropriate data field in the progress notes of the patient’s EHR or referral tracking system, as is the time, date, and method by which the patient was notified of the appointment (e.g., written notification, telephone call). 9. Referral requests are either linked to a referral tracking system through the EHR or entered into an electronic tracking system to ensure that the referral request is not lost. All details of the appointment with the referral specialist are documented in a manner that is consistent with medical and legal prudence. 2 ABC Medical Clinic Policies & Procedures SAMPLE Policy The Practice tracks the orders of all consultations, regardless of the location (e.g., internal or external) of the specialist. All orders are tracked through completion (e.g., receipt of consultative report) in a manner that is consistent with medical and legal prudence. The Practice flags all outstanding orders based on a designated period of expected turnaround time for the consultation as determined by the provider (see above for current protocol). Immediately upon receipt, communications from specialists (e.g., consultation reports, letters of treatment) are scanned into the patient’s medical record by a staff member of the Practice. The patient’s provider is alerted when new communications arrive. The patient’s provider electronically acknowledges or manually initials the report or letter after reviewing it, with notation made in the patient’s medical record in a manner that is consistent with medical and legal prudence. The “open” encounter is closed in the EHR or the Practice’s referral tracking system. On a daily basis, the health coach downloads a report for all “open” encounters that are outstanding for a week or more to ensure that no referrals have been lost or delayed. The health coach contacts the specialists’ office to determine the status of the referral. For example, a patient is scheduled for an appointment with a cardiologist on March 1. The report is expected by March 8. If the report is not received by March 9, the health coach contacts the cardiologist’s office to determine the status of the report. If the patient did not keep the appointment, the patient’s record is updated accordingly, and an electronic alert is sent to the patient’s provider. If necessary, the patient is contacted. All specialists’ encounters are expected to be “closed,” as defined by a communication received or an acknowledgment of a missed appointment, in the EHR no later than 14 days after the scheduled appointment. When consultative reports are received, they are documented in a manner that is consistent with medical and legal prudence. The Practice strives to receive reports electronically from specialists. For patients who are regularly treated by a specific specialist, the patient’s provider and the specialist enter into an agreement that enables co-management of the patient’s care and includes timely sharing of changes in patient status and treatment plan. For co-managed patients, the patient’s provider gives information to the specialist and receives information from the specialist within a period agreed to by both parties. All communications, including the agreement(s), are documented in the patient’s record in a manner that is consistent with medical and legal prudence. When they establish with the Practice, patients are informed that they should communicate with the Practice when they choose to seek care with another healthcare provider. They are encouraged to communicate this information in order to maintain a complete record of their care so that their chosen primary provider can coordinate their care. This encouragement is also made available through the Practice brochure and, when applicable, in other Practice promotional efforts. Providers routinely ask patients if they have seen a specialist or are receiving care from a specialist. If the patient has been treated by a specialist, the report is requested for inclusion in the patient’s medical record. 3 ABC Medical Clinic Policies & Procedures SAMPLE Policy Quality Control: The Practice monitors the policy and procedure in the following manner: 1. Annual monitoring of consultative reports, to include turnaround time and outstanding referrals. If one type of referral is deemed to be untimely in notification, the CMO reviews the situation to determine if an intervention with the specialist is in order or if an alternate specialist will be used. 2. Annual monitoring of the provision of summary-of-care records. The numerator is the number of referrals in the denominator where a summary-of-care record was provided. The denominator is the number of referrals during the reporting period. Revision History: Revision Date 0 mm/dd/yy Description of changes Requested By Initial Release 4