Applicable to PCPs and specialists. 

14.1

Documented procedures are in place to guide each phase of the specialist referral process – including desired timeframes for appointment and information exchange -for preferred or high volume providers

PCP Guidelines:

1. Practice unit has defined parameters for specialist referral process, including timeframes, scheduling process, transfer of patient information to specialist, and reporting of results from specialist(s), for preferred and high-volume providers
   1. Parameters include procedures to ensure that specialists are being given the information they need prior to appointments, including but not limited to:
      • Care manager name (if one assigned)
      • Names of other specialists seen for same condition
      • Requested service (e.g., single consult, co-management, assumption of care)
      • Please reference introduction, p. 2-3

Specialist Guidelines:

1. Practice unit has defined parameters for specialist referral process, including when patient is being referred from PCP to specialist, and when specialist is referring to another sub-specialty, for preferred and high-volume providers
   1. Parameters must define timeframes, scheduling process, transfer of patient information from referring physician to specialist, and reporting of results
   2. Parameters include procedures to ensure that PCPs are aware of what information is needed by specialist prior to appointments
   3. Parameters include procedures to ensure that when specialist is referring to a different specialist, the referring physician provides information needed prior to appointments

14.2

Documented procedures are in place to guide each phase of the specialist referral process – including desired timeframes for appointment and information exchange – for other key providers

PCP Guidelines:

1. Other key providers are defined as those to whom patient is referred to manage an uncommon condition of special importance to the patient’s well-being

Specialist Guidelines:

1. Other key providers are defined as PCPs who refer patients for management of an uncommon condition of special importance to the patient’s well-being

14.3 

Directory is maintained listing specialists to whom patients are routinely referred

PCP Guidelines:

1. Practice Units have defined and validated the criteria which are most important to them when referring patients to a specialist, and revise or update database of preferred physicians regularly

Specialist Guidelines:

1. For PCPs with whom the specialist shares a meaningful number of patients, specialists will provide PCPs or POs with information needed to maintain the PCP’s directory
   1. Information should include current contact information (phone, address, fax, list of key contacts: office manager, appt scheduler), provider updates (new providers or if providers left practice), new procedures/techniques available, any insurance changes, and a summary of any other key changes in the practice (EMR, patient portal) Specialist must contact PCP or PO to validate information at least annually and update when necessary 

14.4

PO or Practice Unit has developed specialist referral materials supportive of process and individual patient needs

PCP Guidelines:

1. Referral materials for processing the referral in the PCP office and for receipt by the specialist include the following information:
   1. Basic information about the specialist, including name, office location and hours
   2. Expectations about the specialist visit: e.g., consultation, test/procedure, transfer of responsibility for patient management
   3. Expected duration of specialist involvement, if PCP is able to determine in advance
   4. How quickly patient should see the specialist
   5. Referral materials may be provided to specialist and patient (where appropriate for patient) in writing or via email
      • If referral materials are not appropriate for patient, verbal or other communication mechanism may be used to ensure patient understands timeframe and purpose of referral

Specialist Guidelines:

1. Processes are in place to ensure PCP referral materials are used appropriately by the specialist and other team members in the specialist office
2. Specialist practice must provide patient with a summary of the specialist appointment, including:
   1. Diagnosis, medication changes, plan of care
   2. Expected duration of specialist involvement
   3. When the patient should return to the specialist and when the patient should return to the PCP
3. Visit information must be provided to patient in writing at time of visit

14.5 

Practice Unit or designee routinely makes specialist appointments on behalf of patients

PCP Guidelines:

1. Practice Units may coordinate with central scheduling office or specialist office to have appointments made on behalf of patients in timely manner
2. Exceptions may be made if patient prefers to make own appointment, but follow-up should then occur to ensure that patient was able to secure appointment in a timely manner

Specialist Guidelines:

1. Specialist coordinates with PCPs to make appointments for patients when requested to do so by PCP
2. Responsibility for notifying patient of appointment date and time is clearly established
3. Specialists schedule any out of office or sub-specialist referrals and notifies PCP of these appointments

14.6

Each facet of the interaction between preferred/high volume specialists and the PCPs at the Practice Unit level is automated by using electronically-based tools and processes to avoid duplication of testing and prescribing across multiple care settings

PCP Guidelines:

1. Practice Units have built processes into existing patient registry, portal system, or EMR, or utilize other tools (e.g. Fusion by CareFX)
2. Policies have been developed to ensure safe, HIPAA compliant information exchange for all information related to the specialist referral process

Specialist Guidelines:

1. Specialist has capability to accept electronically-generated referrals via patient registry, portal system, or EMR, or other tools (e.g. Fusion by CareFX)
2. Policies have been developed to ensure safe, HIPAA compliant information exchange for all information related to the specialist referral process

14.7

For all specialist and sub-specialist visits deemed important to the patient’s well-being, process is in place to determine whether or not patients completed the specialist referral in a timely manner, reasons they did not seek care if applicable, additional sub-specialist visits that occurred, specialist recommendations, and whether patients received recommended services

PCP Guidelines:

1. System must be in place to determine whether the patient was seen, to identify what was done or recommended and whether the recommendations, including testing, procedures or follow up visits, occurred.
2. The patient’s care plan should be updated to reflect the specialist results and recommendations

Specialist Guidelines:

1. System is in place to inform PCPs when patients are seen, identify what was done or recommended and whether the recommendations, including testing, procedures or follow up visits, occurred.
   1. If patient is not seen, specialist conducts outreach to patient and PCP is notified

14.8

Appropriate Practice Unit staff are trained on all aspects of the specialist referral process

14.9

Practice Unit regularly evaluates patient satisfaction with most commonly used specialists, to ensure physicians are referring patients to specialists that meet their standards for patient-centered care

PCP Guidelines:

1. Evaluation of patient satisfaction may consist of conversations between clinician and patient following specialist visit, patient satisfaction survey results from specialist office, or formal survey conducted by the primary care practice
2. Results must be quantified, aggregated, and tracked over time
3. Evaluation should be conducted at least annually
4. If specialists are not meeting standards for patient-centered care, timely follow-up occurs (e.g., PCP may contact specialist’s office to discuss concerns; referral patterns may be modified)

Specialist Guidelines:

1. Specialist conducts patient satisfaction survey and provides results to referring PCPs​

14.10

Physician-to-physician pre-consultation exchanges are used to clarify need for referral and enable PCP to obtain guidance from specialists and subspecialists, ensuring optimal and efficient patient care

PCP Guidelines:

1. Documented procedures are in place outlining processes to be followed for pre-consultation exchanges, when appropriate, and related documentation

Specialist Guidelines:

1. Specialist practice has mechanism in place to ensure PCP access to timely pre-consultation exchanges

14.11

When patient has self-referred to specialist, specialist obtains information from patient about PCP and informs PCP of patient’s visit so PCP follow-up can be conducted

PCP Guidelines:

1. PCP conducts follow-up with patients who have self-referred to specialist

Specialist Guidelines:

1. Specialist routinely notifies PCP of visits when patients have self-referred