C A L I FOR N I A H EALTH C ARE F OU NDATION Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties Prepared for California HealthCare Foundation by Neil A. Solomon, M.D. NAS Consulting Services May 2009 About the Authors At the time this paper was written, Neil A. Solomon, M.D., was the president of NAS Consulting Services in San Francisco. He is now vice president of quality and medical policy at Health Net and clinical director of the California Quality Collaborative. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. ©2009 California HealthCare Foundation Contents 2 I. Introduction 3 II. Background and Methods 4 III. Overview of Referral Processes, Systems, and Expectations 6 IV. Findings Dermatology Gastroenterology Neurology Orthopedics 1 1 V. Access Strategies to Consider 1 4 Appendix: verview of Common Referral O Scenarios and Strategies for Improving Patient Access 1 7 Endnotes I. Introduction It is well established that uninsured safety-net clinics within difficult-to-access specialty and publicly insured Californians, who generally rely services and discuss strategies that could lead to more on community clinics and other safety-net providers optimal use of specialty resources. for their medical care, face significant challenges A secondary purpose was to provide a framework in gaining timely access to specialty care services.1 for thinking about optimizing specialty resources and The many factors affecting access include low or initiating discussion among the provider community no reimbursement, a limited supply of specialists in for developing, testing, and disseminating effective some geographic areas, and poor communication strategies. between primary care providers and specialists. In addition to policy-level efforts to address provider reimbursement and supply, there are significant opportunities to optimize the use of existing specialty resources in the safety net through innovative use of provider resources, technology, and new care models. This could include expanded primary care provider training to manage common presentations, the introduction of new specialty consultation methods such as telemedicine or electronic consultation, or greater use of physician extenders for common procedures or screenings, among other measures. In order to identify strategies that appropriately address specialty care needs, it is essential to clearly understand the typical clinical scenarios that generate referrals within individual specialties and the specific services or tasks that are requested. In June 2008, the California HealthCare Foundation commissioned a series of interviews with experienced primary care providers at community and public hospital clinics to address these questions and to gain greater insight into typical referral processes, identify specific challenges, and gather ideas about how to address access problems. The primary purpose of this project was to clearly describe the most common clinical presentations for 2 | C alifornia H ealth C are F oundation II. Background and Methods The project focused on four difficult - or from working closely with others over a long to-access specialties: dermatology, gastroenterology, period at the clinic), and were considered innovative neurology, and orthopedics. The 2007 Specialty problem-solvers. Care Access Survey of California community In addition to gathering background information clinics identified these four specialties as among the about the current referral environment and presence most difficult to access for primary care safety-net of on-site specialty services, the interview instrument providers.2 The degree of difficulty varies among queried providers about issues in each of the four regions and between community clinics and the high-problem specialties. Questions focused on the public hospital clinics. common clinical scenarios that produce referrals, Recently Chris Forest, M.D., Ph.D., of the the clinical and patient information shared with University of Pennsylvania, created a typology of the specialist (both content and methods for data- referral models that describes five responsibilities for sharing), and the expected role of the specialist in specialists and referring physicians. This typology each of the common referral scenarios. The final stage was used as a preliminary framework for categorizing of the interview asked respondents to brainstorm referral types. The five responsibilities are: nontraditional ways to receive the advice and services currently delivered through specialty consultations. Cognitive consultation; Interview results were reviewed for common Procedural consultation; themes and innovative programs and ideas. This study is qualitative research, and results should not be Comanagement with shared care; considered quantitative. Comanagement with principal care; and Comprehensive and coordinated care.3 Eleven experienced primary care physicians at public and nonprofit safety-net clinics were selected to participate in structured telephone interviews. They represented a convenient sample of California clinics with a spectrum of profiles, including a wide range in terms of size, populations served, mix of insurance and funding sources, relationship with the local community, history, and geographic location. The physicians were selected because they practice primary care medicine at the site, know the referral experiences of colleagues (either as medical directors Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 3 III. verview of Referral Processes, O Systems, and Expectations A ll the physicians interviewed of consultations, including wait times for a consult acknowledged that specialty access is a problem, in each specialty; identifying patients who fail to and most recognized the four specialties on which keep appointments; and gauging demand. Electronic we concentrated as among the biggest challenges. systems also enable the use of decision support rules At each clinic a single process is used to make at the time of consult ordering to ensure appropriate all referrals, regardless of specialty. A change in work-up prior to referral. this process could affect many referrals. All but Although referrals can be processed and tracked the smallest clinics use a form (usually developed more conveniently, the clinics with electronic referral internally) that provides the specialist with patient systems cannot yet exchange all clinical information demographic information, clinical questions to be between primary care and specialists. This part of the addressed, relevant medical history, and the level of information transfer is still paper-based for all the urgency. Some clinics include space to make explicit clinics with whom we spoke. To ensure a productive whether the referring physician requests ongoing consultation, clinical information must arrive before management or expects to have the patient returned or with the patient. Today, some patients show up to for future management in primary care. Physicians a consultation lacking referral paperwork or personal at most of the clinics said such communication is knowledge of their medical information to guide unnecessary because the specialist’s expectation is that the specialist. This leads to an unproductive initial all patients will be managed by primary care after visit, requires rework at the specialist office, and the initial consultation, unless otherwise specified. reduces the specialist’s enthusiasm for receiving future Most of the primary care physicians said they are patients from the referring clinic. comfortable managing the clinical problems after the Many clinics address this fundamental problem initial consultation as long as the specialist provides by compiling the clinical information for the consult clear instructions and remains available for follow-up in duplicate, sending one copy ahead through postal if the patient’s condition deteriorates. Many of the or interoffice mail and giving the other copy to the primary care providers took pride in managing all the patient to bring to the visit. Several clinics use a problems of their patients, with guidance from — but referral coordinator (some paid, others volunteer) not delegation of care to — specialists. to personally organize this process. One community About one-third of the clinics interviewed use an clinic even includes with all consult requests the electronic system to initiate consultations. Some use cell phone number of the lead physician in order a Web-based referral tracking system and others use to provide the specialist with access to any missing a referral system embedded in an electronic health information at the time the patient is seen. record (though most with EHRs are still developing Most of the physicians interviewed defined modules for referral tracking). The electronic systems successful consults in three ways. First, they want to have some major advantages over paper, according to ensure that the clinical issue is adequately addressed, users. These systems allow for much better tracking based on symptom resolution, the information 4 | C alifornia H ealth C are F oundation conveyed back to the primary care physician (PCP), and the patient’s own interpretation of the encounter. Second, the patient must be seen in a timely fashion. Most physicians indicated that timeliness varies depending on the type and severity of the clinical problem. When long waits are anticipated, the primary care provider must weigh the benefits of initiating treatment expediently but without full knowledge of the medical management issues versus the potential delay in sending the patient to a specialist who has the extra insight and experience. Third, consult fulfillment is judged on the quality of the specialist’s communication back to the primary care physician — regarding explanation of the clinical problem and, most importantly, providing instructions that allow the PCP to execute and follow through on the management plan. Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 5 IV. indings F T he following section describes the managing the majority of common rashes with most common reasons for referral within four topical steroids and other routine approaches. difficult-to-access specialties, as shared by the primary Only after a series of treatment failures would care providers at 11 safety-net clinics. Additionally, it most PCPs refer these patients to a dermatologist outlines strategies clinics are using to increase access for a more definitive cognitive consultation to specialty services. The appendix to this paper that produces a diagnosis and treatment provides an overview of common reasons for referral, recommendations. PCPs expect that these cases the proportion of referrals each represents, and access will be referred back to primary care for treatment strategies to consider. and follow-up management; hence they desire teaching and treatment coaching spelled out Dermatology in the consult note. These cases account for the majority of the remainder of dermatology Common Clinical Presentations consults. The most common reasons cited for dermatology A smattering of other causes. There are a few consultations were: cases for such conditions as severe psoriasis Masses requiring excision beyond the (in which case the PCP usually does desire capability of the PCP. Almost every PCP comanagement by the specialist). expressed comfort with performing punch, The proportion of consultation needs in these shave, and excisional biopsies. Most also felt categories was remarkably consistent across sites, comfortable excising the majority of superficial with the exception of one clinic that has an advanced masses including skin cancers. Few, however, had excision suite and can manage essentially all mass confidence in removing large lesions or ones in removals internally with primary care providers cosmetically important areas or in close proximity trained to perform the procedures. to important organs (such as the eye). Only one community clinic had internal expertise to Access Strategies perform Mohs surgery — an advanced method for The vast majority of referrals appear to be for either removing skin cancers. PCPs expect that once the mass excisions beyond the capability of the PCP or procedural consultation is completed, the patient for rashes that fail to respond to typical treatments. will return to the clinic for all management. This In most cases, the PCP is seeking a one-time category accounted for approximately half of the procedural or cognitive consultation with referral dermatology referrals in most of the clinics. back to the PCP. Strategies for increasing access may Skin rashes that fail to respond to typical include the co-location of dermatology services at treatments and continue to cause discomfort the primary care site, telemedicine or other efficient or problems. All the PCPs expressed comfort in opportunities to consult with a dermatologist, and/or 6 | C alifornia H ealth C are F oundation targeted procedural or cognitive training for PCPs —  hemoccult screening with follow-up colonoscopy though the physicians interviewed noted that these among those who test positive or have warning strategies would not eliminate off-site referrals. signs such as weight loss or change in bowel Strategies currently used by interviewees include: habits — colonoscopy referrals were significantly reduced but still represented one-third to one- On-site specialty services. Several sites have a half of GI referrals. Among those clinics that rely dermatologist practice at the clinic for a half day on colonoscopy for screening, this indication every two to four weeks. Nonetheless, almost all represents well over half the consult needs. In clinics still required some traditional referrals to all cases this is seen as a procedural consult: off-site dermatologists. Primary care providers expect a test result they Telemedicine. Three of the physicians use can subsequently manage. Testing for screening telemedicine services for some or all of their purposes is not considered urgent, and a delay dermatology consults, and all have found that of perhaps up to 30 days is acceptable. If the it works well for the second category of referral test is to follow up warning signs or a positive described above. However, all are skeptical that hemoccult, more rapid consultation is expected. this method could manage all their consults Upper endoscopies. Typically used to evaluate because of the need for surgical support on persistent dyspepsia, upper endoscopies were excision of challenging masses. But even those not the second most common GI consult requested using teledermatology services acknowledge that by all clinics. The majority of these requests it could help address some level of referral needs. were to evaluate patients with persistent upper GI symptoms for cancer or pre-cancer after Gastroenterology prolonged full courses of acid suppression therapy. For this type of endoscopy, the PCP Common Clinical Presentations expects a procedural consultation. The primary By far the most common reasons cited for care physician can then make use of the findings gastroenterology (GI) referrals were to perform to execute a treatment plan. This request endoscopic procedures. Many clinics indicated that represents about a third to half of the GI consults. the shortage of endoscopists in their community was Liver disease management. For about half of the not limited to the safety net. The common scenarios clinics interviewed, patients with liver disease —  are presented below: either hepatitis C or advanced liver disease —  Colonoscopies to screen for colon cancer. This represented the third most common type of was the overwhelming need for about half the referral. The prevalence of hepatitis C in this clinics because this procedure is their primary patient population is high, and treatments are screening test for colon cancer. Because colon complicated and toxic. About half the clinics did cancer screening is recommended for all patients not report this condition to represent a large share starting at age 50, this can represent a very large of referrals due to internal management expertise volume of referrals. In clinics where alternative among primary care clinicians. screening strategies were utilized — typically Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 7 Access Strategies Neurology The majority of GI consult requests are for procedures, while a notable minority of referrals Common Clinical Presentations is for comanagement of patients with hepatitis C/ Neurology referral needs fall into several clinical advanced liver disease. Options for increasing access areas. Some of the physicians mentioned that to screenings may include expanded training of neurologists have the time to conduct more thorough primary care providers and/or mid-level providers to neurologic examinations and to perform certain complete selected procedures (i.e., colonoscopies); diagnostic tests, while the time available in primary and broader use of alternative screening methods. care settings is much more limited. Strategies for addressing liver disease may include Management of seizures, especially initial expanded training of primary care providers and workup and active management for severe other training/partnership mechanisms that facilitate cases. This represents one of the instances effective comanagement. Strategies currently used by where PCPs frequently expressed a desire for the clinics include: comanagement with the specialist, often with Alternative screening methods. Some of the the specialist taking principal responsibility clinics relied on alternative screening strategies, for the clinical problem. The reasons cited for such as a hemoccult screening and, if merited, a referring seizure patients commonly fall into two follow-up colonoscopy. categories. For the initial seizure workup, it is important to diagnose the etiology of the seizures Expanded primary care expertise. About and to classify the seizure type for appropriate half of the clinics reported developing internal treatment decisions. There are also necessary tests, management for hepatitis C/advanced liver such as EEG, that generally cannot be conducted disease patients by creating expertise in one or by PCPs. Newer and more toxic medications two primary care clinicians who essentially ran are often indicated for management of severe their own liver clinics. For these clinics, liver seizure patients, and most PCPs said they are disease represented a small proportion of GI not comfortable prescribing them. Most clinics referrals. In some instances the internal capacity indicated that about half of neurology consults to treat such patients grew out of necessity are for seizure management. because local gastroenterologists declined to see this cohort. Management of severe migraines. The majority of PCPs said they are comfortable managing most On-site specialty services. While several of headache cases, but noted that severe migraine the clinics considered offering endoscopic patients require a greater level of expertise than procedures themselves, they all concluded that they can offer. The volume of consults for the infrastructure required to support such an migranes varied widely, most likely reflecting the approach — physical space, expensive equipment, inconsistent levels of expertise and confidence cleaning processes, sedation expertise, and among primary care providers in managing this procedure training — was prohibitive. condition. The newer migraine medications are very expensive, and some physicians indicated 8 | C alifornia H ealth C are F oundation that referrals to neurologists could help patients community neurology resources and clinic comfort gain access to these drugs. with managing some of the problems outlined above. Movement disorders. Patients with movement Access Strategies disorders such as Parkinson’s disease were cited by Overall, a significant portion of neurology referral about half of the clinics as requiring consultation needs are for the cognitive expertise of the specialist with specialists. As with migraine patients, PCPs to diagnose the patient and develop and comanage seek help with medication management for treatment — including a notable need for medication severely ill patients for whom complex, toxic, and management. To that extent, there is value in expensive medication regimens are employed. exploring strategies that strengthen primary care Diagnoses that require a thorough neurologic expertise and/or provide opportunities outside of exam to elucidate findings and to steer the an in-person visit to access the specialist’s expertise. diagnostic evaluation. Diagnoses that require This may include telemedicine, e-consults, curbside thorough neurologic exams were also cited consults, and other strategies that do not require a as a referral need by some clinics. One clinic patient visit. Strategies currently being pursued by with poor access to a neurologist found a way the clinics include: to eliminate these referrals altogether. The Expanded primary care expertise. As noted, one PCPs book the patient for a long visit at their clinic with poor access internalized the expertise own clinic, during which they conduct a very necessary to conduct a thorough neurologic exam thorough neurologic exam. They then call a with follow-up presentation to the specialist via neurologist in the community to “present” the telemedicine. case and get management feedback in a low-tech form of telemedicine. Telemedicine. As stated, one clinic conducted the initial neurologic exam and presented the case for Electromyelograms and nerve conduction comanagement to a neurologist via telemedicine. studies. Some clinics rely on neurologists to Also, several clinics expressed interest in using perform these tests, particularly for patients with telemedicine services for electromyelograms and repetitive motion injuries (e.g., carpal tunnel nerve conduction studies. syndrome) that are not well controlled with conservative treatments. This need was variable because some clinics found alternative sources Orthopedics for these tests, such as hospital technicians or physiatrists, who can perform them more quickly Common Clinical Presentations and economically. Several primary care providers Orthopedic service referral needs varied greatly expressed interest in a telemedicine service for among the clinics interviewed. This is accounted these tests, though none currently use one. for, to a large extent, by the variation of on-site expertise and service located at individual clinics. The demand and need for neurology services There is no single common pattern, however, and seemed to vary greatly according to availability of the expectations of the clinics for when to consult a specialist varied widely: Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 9 Injuries to large joints such as shoulders, Medi-Cal reimbursements are low. In these cases hips, and knees. These cases, which represent patients are managed non-surgically with pain about a third of orthopedic cases, usually require management and physical therapy, usually by the the specialist to conduct a thorough exam, PCPs. review imaging studies, and sometimes perform a procedure. While most PCPs say they are Access Strategies comfortable injecting steroids into most large Orthopedic referral needs vary by clinic and joints, they refer patients whose joints are either encompass cognitive referrals, procedural referrals, chronically deteriorating or significantly damaged and patient management. The interviews suggest that through acute injury. In these cases the PCP strategies worthy of consideration are the addition expects the orthopedist to manage the case to of on-site orthopedic services, as well as expanded completion if a procedure is required, and then to primary care training to address non-surgical refer back to the clinic for ongoing care. Clinics problems. However, clinics should assess whether with an orthopedist on-site initially handle these this is the best use of a PCP’s time. Strategies being cases, referring them to a surgeon only if an pursued by clinics include: operation is needed. On-site specialty services/use of mid-levels. Casting and splinting of acute injuries. These One model that seems to work for several treatments make up approximately one-third orthopedic groups is to place a member of their of orthopedic cases, although the incidence own group at the clinic site on a weekly, biweekly, varies considerably among clinics. Some are able or monthly basis. This person is often a physician to perform almost all of this work themselves assistant or an orthopedist near retirement. His (especially if one or more of the physicians or her job is to manage most of the non-surgical also works in the emergency department), and cases such as fractures and sprains, and to screen therefore rarely use orthopedic referrals for this cases that are most appropriate for the surgeons purpose. Community clinics with an orthopedist to see. This enables workups of the more severe on-site usually handle these cases without external patients and doesn’t clog the orthopedists’ offices referral. with less severe cases. Back injuries. Only a few clinics said that their Expanded primary care expertise. A PCP at orthopedists are willing to operate on back one clinic is comfortable performing casting injuries in this population, and some orthopedists and other minor orthopedics due to experience don’t want to see these patients at all. In such working emergency department shifts for several situations, particularly when pain is severe and years. The question for other clinics is whether chronic, the patients are usually sent to pain completing this training is an effective use of a management clinics. PCP’s time. Joint replacement. As with back injury cases, some orthopedic groups will not even consider seeing patients in need of joint replacements because the prostheses are expensive and 10 | C alifornia H ealth C are F oundation V. Access Strategies to Consider R eview of the practices used by these electronic referral system to prompt PCPs for 11 clinics reveals a number of strategies to improve appropriate workup prior to referral. specialty care access. Each clinic is different, so not Have specialists triage consult requests. This all strategies are universally applicable; each needs is a variation on the idea of having a PCP screen to be adapted to local circumstances. Another set all consults prior to referral. The advantage of of strategies might be developed by interviewing the specialist triage model is that some cases can the specialty clinics that provide, or could provide, become teaching opportunities. This model has services; this analysis explored the issue only from the been developed at San Francisco General Hospital referring physician perspective. and many of the clinics find it attractive. Ensure Appropriate Referrals Make the PCP (or surrogate clinician) Ensure clean consults for specialists. Ensure available to the specialist in real time. By that all data arrives before or with the patient having a cell phone or hotline to the PCP, the so that every consult is productive. Referral specialist can get any question answered at the coordinators, either employed or volunteer, time of the consult, should the information not can manage this process effectively and prevent be available in the referral request materials. the primary care provider from using lots of time for this administrative function. Referral Expand Primary Care Site Expertise coordinators also can help patients to attend their Only refer cases that really need a specialist. consultations, build and maintain relationships By strengthening the skills of PCPs at a clinic, with specialists, and ensure that specialists return especially for common conditions referred to clinical information in a timely fashion. specialists, specialists can give more attention to Complete the patient’s workup before referring patients in greatest need, rather than to those to the specialist. The primary care physician whose cases are more routine. One method that should initiate the workup and clearly present has been successful is to create a series of teaching the clinical question to the specialist. Some sessions by specialists on common problems they physicians even suggested spelling out their see. The content should include background working differential diagnosis to indicate the level about the medical condition and clarify what of thinking prior to referral. View the specialist’s workup should be conducted prior to any referral. role as spending time synthesizing and analyzing These trainings can be done as learning lunches the data, not ordering it. In some clinics one (sometimes for continuing medical education physician reviews all consult requests before they credits) or through telemedicine education, and are sent, to ensure that appropriate workup has can be codified in handouts, manuals, videos of been conducted. Others use (or plan to use) an the lectures, or Web-based referral guides. Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 11 Increase internal clinic capacity in specific at community clinics, obviating the need for specialty areas. This is most common today in referrals. Some examples include spriometry, hepatitis C, HIV, mental health, and diabetes echocardiograms, biopsies, and possibly nerve management, where one or more PCPs at a conduction studies. It is worth exploring whether clinic gain additional expertise and take on the some endoscopies could be performed without cases. In essence, the PCPs act as local specialists. referral to gastroenterologists. Assuming this role usually requires additional Bring specialists on-site. Most specialties require training at an academic medical center. In some only small amounts of time, so the commitment cases the mentor for such programs continues from specialists is low. This model is particularly to provide backup on difficult cases and can attractive for large surgical specialty groups that be a referral destination for very challenging can send a physician assistant or member of cases the local expert cannot handle alone. This the specialty group to see patients and screen model seems to offer the additional benefit of for surgical cases. Today the specialists who professional satisfaction for the PCP. Other areas most commonly see patients at the clinics are where this could be explored include seizure orthopedists, gynecologists, psychiatrists, and management, rheumatology, and women’s health dermatologists. For specialists, the benefits of issues. going to the clinic include: low or no overhead, less clogging of their own waiting rooms, the Increase Non-Visit Tools to Support ability to teach PCPs in person, the elimination Consult Needs of billing hassles (if paid directly by clinics), Create a method to handle ad hoc questions the opportunity to see “great pathology,” without a full consult. Many cases could and a break from the monotony of the usual be managed by the PCP with a brief, timely practice environment. It is sometimes possible “curbside consult” with a specialist. This to recruit physicians who are near retirement or would eliminate a referral and expedite care. already retired to perform consults on-site on Unfortunately, few clinics have any way to an infrequent schedule. This varies greatly by get such information in a timely fashion, and community. specialists are loath to perform such consults without a means of reimbursement. These Expand the Use of Telemedicine curbside consults could be done by phone or Push for greater adoption. Several clinics using telemedicine. Addressing this problem already use telemedicine, and one rural clinic would require reengineering the referral process, makes extensive use of such services. The but it could have dramatic consequences for opportunity to expand to more sites and more specialty access. specialties is great. These consultations are best for cognitive consults or for reviewing images Bring Specialty Services On-Site and data, and possibly for the “curbside consult” Ensure that procedure equipment is available model described above. Differences between at community clinics. Inexpensive and simple asynchronous “store-and-forward” consults and procedures could be done more frequently real-time videoconferencing lead to important 12 | C alifornia H ealth C are F oundation choices with regard to specialties selected, opportunity for teaching, and the clinics can offer business model, and technology requirements. cases with advanced pathology as an enticement. Local challenges abound for telemedicine to work For most academic medical centers, serving the well, including upkeep of equipment, embedding uninsured is part of their mission. Pursuing the service into the medical office workflow on opportunities to expand relationships with local both ends, timely access to the service, adequate institutions, including academic medical centers, space, and a sustainable reimbursement model for nonprofit hospitals, and other providers, may be a specialists. The University of California, Davis, promising avenue for safety-net clinics to pursue. is the recognized leader in this area, and they and others can be expected to continue to push for greater adoption of telemedicine. Build Institutional Relationships Establish and enrich relationships with local specialists. Many physicians stressed that all medicine is local and relationships with the specialist community are crucial to gaining access for consults. This is especially true for the smallest clinics. Opportunities to forge these relationships in the hospital include rounds (particularly on weekends, when there is more time to interact with other clinicians), during emergency department shifts, and while serving on hospital committees. Other professional activities to foster community with specialists include local medical societies and community task forces. Equally important in small communities are non-medical pursuits. It may be important to appeal to the spirit of community service in everyone. Form alliances with local institutions. Many nonprofit hospitals have community benefit investments and grants to satisfy their community benefit requirements. Such funds can be used to support specialty connections. One nonprofit hospital expects specialists applying for admitting privileges to agree to provide some portion of care to the uninsured. Local academic medical centers can see the community clinics as an Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 13 Appendix: verview of Common Referral Scenarios and Strategies for O Improving Patient Access Referra ls Percentage Strategies to Clinical Presentation /S cenario PC P N eed Type (approximate) Consider Dermatology Masses requiring excision beyond capability Procedure completed Procedure 50% On-site specialty of PCP: and patient returns service • PCP comfortable w/punch, shave, excisional to PCP for ongoing biopsies; most superficial masses including management skin cancers • Limited confidence in removal of large lesions and those in cosmetically important areas or close to important organs Skin rashes that fail to respond to typical Diagnosis provided and Cognitive 25% or more • On-site specialty treatment: treatment completed; consultation, service • PCP comfortable w/majority of common patient returns to procedure • Telemedicine rashes PCP for ongoing management • Referral to dermatologist after series of treatment failures for diagnosis and treatment Severe cases requiring comanagement Diagnosis, treatment, Comanagement Limited (i.e., severe psoriasis) and comanagement of patient Gastroenterology Colonoscopies to screen for colon cancer Screening performed Procedure 50% or more • Alternative screening methods • Conduct procedures at clinic site • Expanded procedure training (PCPs/mid-levels) Upper endoscopies to evaluate persistent Procedure completed, Procedure 33-50% • Conduct procedures dyspepsia: PCP uses findings to at clinic site • To evaluate for cancer/pre-cancer in patients execute treatment plan • Expanded w/persistent upper GI symptoms after full procedure training courses of acid suppression therapy (PCPs/mid-levels) Hepatitis C or advanced liver disease Specialist develops, Comanagement Varies Expanded PCP manages treatment (principal) expertise/ mini-specialists 14 | C alifornia H ealth C are F oundation Referra ls Percentage Strategies to Clinical Presentation/S cenario PCP N eed Type (approximate) Consider Neurology Management of seizures: Support to diagnose Cognitive 50% • Expanded PCP • Need for workup, tests, and management and classify seizure consultation, expertise/ type, complete procedure, mini-specialists • Limited confidence doing initial workup tests, and develop comanagement • Telemedicine to diagnose and classify seizure type for and manage treatment treatment plans, • Curbside consults • Test, such as EEG, cannot be requested by including medication PCP management • PCPs not comfortable prescribing newer, more toxic medications or managing ongoing care without support Management of severe migraines: Management of Comanagement Varies • Expanded PCP • PCP comfortable with most headaches severe migraine cases, expertise/ including medication mini-specialists • Comfort managing severe migraines varies management • Telemedicine widely • Curbside consults • Need for expensive medications Movement disorders: Medication Comanagement Varies • Expanded PCP • Medication management for severe cases management expertise/ needing complex, toxic medication mini-specialists (i.e., Parkinson’s) • Telemedicine • Curbside consults Varied diagnoses requiring thorough neurologic Thorough neurologic Cognitive Varies • Expanded PCP exam assessment and consultation/ expertise/ diagnostic evaluation assessment mini-specialists • Telemedicine Electromyelograms and nerve conduction Series of cognitive Cognitive Varies • Expanded PCP studies: tests/assessments consultation/ expertise/ • Mostly for patients with repetitive motion assessment mini-specialists injuries not well controlled with conservative • Telemedicine treatments (i.e., carpal tunnel syndrome) • Curbside consults • Find alternative sources to perform tests (e.g., physiatrists or hospital techs) Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 15 Referra ls Percentage Strategies to Clinical Presentation /S cenario PC P N eed Type (approximate) Consider Orthopedics Injuries to large joints (e.g., shoulders, hips, knees): Thorough exam, Cognitive 33% • On-site specialty • PCP comfortable injecting steroids in large review of imaging consultation, services/use of joints studies, potential assessment, mid-levels procedure; PCP procedure • Mini-specialists to • Referral of patients with chronically expects specialist deteriorating or significantly damaged joints inject small joints or to manage case to cast (acute injury) to completion if procedure required, then refer back to PCP for ongoing care Casting and splinting of acute injuries Complete procedure Procedure 33% • Expanded PCP (varies according expertise to on-site expertise) • On-site specialty services Back injuries: Ongoing management Procedure, Varies Expanded PCP • Few orthopedists willing to operate on back comanagement expertise injuries for Medi-Cal/uninsured population • Severe and chronic pain cases sent to pain management Joint replacement: Ongoing management Comanagement Varies Expanded PCP • Similar resistance to Medi-Cal/uninsured expertise • Non-surgical pain management and physical therapy (generally managed by PCPs) 16 | C alifornia H ealth C are F oundation Endnotes 1. Felt-Lisk, S., M. McHugh, and M. Thomas. May 2004. Examining Access to Specialty Care for California’s Uninsured. Mathematica Policy Research Inc. for California HealthCare Foundation (www.chcf.org/topics/ healthinsurance/index.cfm?itemID=102587). 2. Specialty Care Access Initiative. January 2008. Preliminary Findings: Specialty Care Access Survey. 3. Forrest, C. March 2008. Transforming the Specialty Referral Process. Webcast. California HealthCare Foundation (www.chcf.org/topics/view. cfm?itemID=133607). Understanding Common Reasons for Patient Referrals in Difficult-to-Access Specialties | 17 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org