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Table 2 Intervention strategies and outcomes

From: A categorisation of problems and solutions to improve patient referrals from primary to specialty care

Core intervention strategies

Identified Health services delivery interventions

•Strategy, objective, target population, Target impact, Reported Impacts

 

I.1. Interventions to reduce referral error

1. Preventive interventions to reduce the occurrence of false positives, false negatives, triaging errors and communication delays.

Strategy

Objective

Target population

Target impact

Reported impact

Referral Guidelines

Clinical Guidelines: guidance on necessity, appropriateness and timeliness of referrals.

Clerical guidance: guidance on completeness of referrals.

Referring physicians

Improve referral decisions: reduce false positives (unnecessary and inappropriate referrals), reduce false negatives (delayed referrals). Improve the communication of the referral.

Passive introduction of guidelines produces little change [36,37,38,39,40,41,42,43,44,45,46,47]. Guidelines with feedback may be effective [43, 53,54,55,56]. Coordinated introduction of guidelines, with standardized referral process can improve referral appropriateness and potentially lower wait times [64,65,66,67,68,69,70].

Standardized referral process

Set standards for referral quality.

Aids include: standard referral forms, criteria checklists, diagnostic checklists, scoring systems.

Shared/Supported patient assessment

Improved sensitivity/specificity of referral decision through decision support via professional networks: primary care groups, and multidisciplinary groups.

Referring physicians and allied health workers

Improved referral appropriateness while decision support is available [14, 58,59,60,61].

Primary care clinical education programmes and clinical screening tools

Improve sensitivity/specificity of referral decision through improved primary care disease specific knowledge and diagnostic screening tools

Referring physicians

Primary care education programmes and clinical screening tools. Reduction in number of delayed referrals, and improved referral appropriateness [48, 49, 64,65,66,67,68,69,70].

 

2. Screening interventions – to detect false positives, false negatives, triaging errors and communication delays.

Strategy

Objective

Target population

Target impact

Reported impact

Public awareness campaigns, community case finding strategies, community screening programs

Improved public awareness as to when to seek care with primary care provider, or direct public outreach.

Patient population.

Improved identification of patients in need of specialist care and reduction in number of delayed referrals

Improved identification of patients in need of specialist care and reduction in number of delayed referrals [87, 88].

Clerical screening of referrals

Screening of incoming referrals, to ensure referral completeness and triage referrals based on urgency.

Specialty care referral administration

Identify incomplete referrals, and request missing information from referring physician. Reduce scheduling of incomplete referrals.

Reduction of incomplete referrals being scheduled [75]. Improved triaging of referrals based on urgency [77,78,79,80].

Clinical screening of referrals

Confirm necessity and appropriateness of referral based on patient’s diagnostic images/test results that are requisite for the referral. Triage appropriate referrals.

Specialists/consultants

Identify and redirect false positives (unnecessary and inappropriate referrals), triage referrals based on urgency as indicated by diagnostic images/test results.

Redirection of unnecessary/ inappropriate referrals [10, 76].

Clinical screening of patients

Confirm necessity and appropriateness of referral based on clinical assessment of the patient. Identify appropriate care alternatives when specialist care is not required (e.g. conservative management for OA not requiring arthroplasty). Triage appropriate referrals.

Specialists/consultants, referring physicians and allied health workers

Identify and redirect false positives (unnecessary and inappropriate referrals), triage referrals based on urgency as indicated by clinical assessment.

Redirection of unnecessary/ inappropriate referrals

 

I.2. Interventions to improve information management- Information technologies

Electronic referral systems (e-referrals) and electronic medical records (EMRs) to expedite information sharing

Strategy

Objective

Target population

Target impact

Reported impact

Electronic referral systems and Electronic Medical records

Provide a standardized electronic referral process that ensures completeness of relevant information and diagnostics with the referral, and timely communication.

System level change affecting Primary care through specialty care.

Improve efficiency of referral submission. Reduce wait time between the time the referral is made and the time it is received and appointment is scheduled.

Electronic referral systems and electronic health records

Improved workflow efficiency from referral submission, to screening and scheduling resulting from higher quality referral, improved access to diagnostics, and efficient communications [28, 29, 95].

Improved necessity/appropriateness of referrals due improved referral quality and enabling improved clerical/clinical screening of referrals [48, 92,93,94].

 

I.3 Interventions to improve system level patient flows between primary and secondary care – Supply and demand management

1. Care pathway management - streamlining

Strategy

Objective

Target population

Target impact

Reported impact

Direct/open access to diagnostics and specialty services

Provide direct, or open access, to specialty services by eliminating one or more steps along the traditional referral pathway.

System level change affecting primary care through specialty care.

Improved access to diagnostics, and specialty care.

Improved access to diagnostics and or specialty services, reduced waiting times [97,98,99,100,101,102,103,104].

 

2. Human resource management - Scope of practice restructuring at primary-specialty care interface to increase supply of service

Strategy

Objective

Target population

Target impact

Reported impact

Altered scopes of practice

Increased focus on specialty services by specialists supported with expanded scope of practice by non-specialist care providers.

Specialists and non-specialist care providers such as nurse practitioners, allied care and primary care.

Improved access to specialists via creation of capacity through alternative service delivery methods

Nurse led clinics/services: Reduced workload for physicians. Increased attention and timely care to patients. Evidence has shown nurse-led clinics can provide equivalent care with no greater risk of poorer outcomes [113, 114, 116]

Similar outcomes reported for Primary care physicians with extended roles [119, 120].

Multi-disciplinary team based care

Coordinated care providing patient improved access to a broad range of complimentary care services.

Specialists and non-specialist care providers such as nurse practitioners, allied care and primary care.

Improved Quality of care. Improved access to specialists via creation of capacity through alternative service delivery methods.

Multi-disciplinary team based care: Better patient access to a wide range, but increasingly specialized health care services that may be required for effective disease management [123, 124]. Evidence regarding the cost-effectiveness of multidisciplinary team based care is lacking, and further studies are required [148].

 

3. Queue/referral management - Centralized intake of referrals to improve access to specialty care.

Strategy

Objective

Target population

Target impact

Reported impact

Referral management centres

Pooled intake and subsequent scheduling of all incoming referrals for all specialties

System level intervention, requiring critical buy-in from referring physicians and specialists.

Decreased wait times.

Systematic evaluations of referral management centres are needed [73].

Specialty specific triaging clinics

Pooled intake and subsequent scheduling of all incoming referrals for specific specialty (or sub-specialty)

System level intervention, requiring critical buy-in from referring physicians and specialists.

Decreased wait times.

Improved referral processes, improved patient triaging, improved appropriateness, improved wait times to specialist consult [58, 121, 132,133,134], unchanged wait times to downstream benchmarks such as surgery [135, 136], provider satisfaction may be low [135].

 

I.4 Interventions to monitor and improve quality and/or performance

Continuous quality improvement

Strategy

Objective

Target population

Target impact

Reported impact

Quality/performance improvement frameworks

Provide capacity for strategic decision making using information that relates operational and management decisions to their outcomes

System, Hospital, Clinic level targets

Improve strategic decision making, and management of operations.

Performance measures of referral processes and outcomes including the adequacy and appropriateness of coordination of referrals and the quality, resource use and outcomes of referrals are lacking [138]