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Referral and Transition/Transfer of Care
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Contents
- 1 Introduction
- 2 Referral and Transition/Transfer of Care Project Scope Statement and Resources Proposal
- 3 Definitions
- 4 Relations between "Referral", "Transfer of Care", "Transition of Care"
- 5 Referral and Transition of Care Data Requirements/Data Sets
- 6 Related Documents
- 7 FHIR Resources relevant to Referral project
Introduction
Clinical medicine and health care have evolved from a simple patient-physician-nurse care delivery model to a multi-disciplinary, collaborative care delivery model. Patient's in today's complex care environment are often referred to the care of other specialized or super-super-specialized health care providers or provider organizations; or their care may required to be transitioned from one care setting/facility to another.
For complex care delivery models involving multi-disciplinary and multi-facilities to be effective, it is necessary that activities of the variety of health care providers and provider organisations are effectively coordinated.
The Referral processes and transition of care processes together with supporting administrative/financial and clinical data have been developed internationally to support the effective implementation of complex coordinated care delivery models.
Referral and Transition/Transfer of Care Project Scope Statement and Resources Proposal
- Project Scope Statement:
- Link to Referral FHIR Resource Proposal (on FHIR wiki):
Definitions
Referral
Referral is the process, with the intention of initiating care transfer, from the provider making the referral to the receiver.
NOTE: The essential components of referral are the intent and facilitation of transferring patient care in whole or in part from one health care provider or organization to another provider or organization. Self referral is also possible: a person, the subject of care, may be the referrer or the referee. Referral is normally accompanied by clinical information to responsibly enable takeover of such care by the referee.
Referral can take several forms most notably:
- (a) Request for management of a problem or provision of a service e.g. a request for an investigation, intervention, or treatment.
- (b) Notification of a problem with hope, expectation, or imposition of its management e.g. a Discharge Summary in a setting which imposes care responsibility on the recipient.
- The common factors in all of these are a communication whose intent is the transfer of care.
- (Source: Standards Australia AS4700.6 - HL7 v2.x Referral Messaging Specification. NOTE - the first sentence of this definition is slightly modified: the original statement - "Referral is the communication ..." is modified to - "Referral is the process...")
Transition of Care
- The term "care transitions" refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.
- For example, in the course of an acute exacerbation of an illness, a patient might receive care from a PCP or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition
- A position statement from the American Geriatrics Society defines transitional care as follows:
- For the purpose of this position statement, transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.
- (Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557)
- Meaningful Use Stage 2 Measures - (Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures Measure 12 of 16) defines "Transition of Care" as:
- "The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another"
- The Joint Commission has defined a “transition of care” as the movement of a patient from one health care provider or setting to another
- Key concepts that can be discerned from these definitions of "Transition of Care" are:
- - coordination actions/processes
- - transfer/transition of patient that occurs between
- ~ different levels of care within the same location (e.g. from ICU to general medical unit)
- ~ different locations/care settings (e.g. from acute care setting/facility to long term care or skilled nursing facility); or
- NOTE:
- - "Transition of Care" is different from another concept "Transition Care" (in Australia)
- - "Transition Care" in Australia is a program funded by the Australian Federal Department of Health
- o Transition Care provides short-term care that seeks to optimise the functioning and independence of older people after a hospital stay.
- o Transition Care is goal-oriented, time-limited and therapy-focussed.
- o It provides older people with a package of services that includes low intensity therapy such as physiotherapy and occupational therapy, as well as social work, nursing support or personal care
- o It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely.
- o The Program facilitates a continuum of care for older people who have completed their hospital episode, including acute and subacute care2 (e.g. rehabilitation, geriatric evaluation and management), and who need more time and support to make a decision on their long term aged care options.
- (Source: Australian Government Department of Health and Ageing: Transition Care Program Guidelines 2011)
Transfer of Care
Transfer of care is the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate
- (Source: http://www.med.wisc.edu/files/smph/docs/compliance/compliance-transfer-of-care-definition-2011.pdf)
- Key concepts that can be discerned from this definition of "Transfer of Care" are:
- - actions/processes
- - relinquish of care responsibility by one provider to another
- - explicit agreement of accepting clinician to take over this responsibility
- - the relinquished responsibility is for some or all of a patient's problems
- - if the relinquished responsibility is for some problems only, the original provider retains care responsibility for patient's all other problems
Relations between "Referral", "Transfer of Care", "Transition of Care"
Referral
"Referral" is a process starts with a request followed by a set of activities/events and completed with a conclusion of the process.
- The types of referral include:
- - Referral for second opinion (aka "consult"/"consultation")
- o There is partial transfer of care responsibility from the referring provider to the referred to provider on the health issue/problem for which the referral is made
- - Referral for specific procedure(s) (e.g. bronchoscopy, gastroscopy, +/- biopsy; endodontic procedures)
- o There is also partial transfer of care responsibility from the referring provider to the referred to provider for the duration of the procedure and any follow-up management considered necessary/appropriate by the referred to provider
- - Referral for management of specific issues/problems
- o There is a complete transfer of care responsibility from the referring provider to the referred to provider with regard to the health issue/problem for which the referral is made.
- o The referring provider retains complete care responsibility of all other health issues/problems that this patient may have
- o The referred to provider may need to manage those other health issues/problems as co-morbilities during the duration the patient is under his/her care (e.g. when the patient requires hospital care away from the referring provider)
- The Referral process has two main components:
- - Referral Request
- o A referral letter/document or referral message will be sent from the referring provider to the referred to provider
- - Referral Fulfillment
- o Acceptance (after triaging by the referred to provider/organization)
- o Request for more information (also after triaging). The type of information requested may include: financial, administrative and clinical
- o Rejection (with reasons given)
- o On referral to a third party provider/organization
- o Recommendation(s)
- o Progress report
- o Separation summary/discharge summary (which concludes the referral process)
Transfer of Care
- "Transfer of Care" (used independent of other contexts such as "referral" or "transition of care") is a process by which the care responsibility of a patient is transfer from a carer/provider/organization to another carer/provider/organization
- Similar to referral, "Transfer of Care" is a process which starts with a request to transfer care responsibility and concluded when the transfer of responsibility to another provider/organization is completed
- Types of Transfer of Care:
- - Short term transfer
- o The transfer of care responsibility is temporary
- o When the care responsibility is returned to the original carer/provider/organization, another transfer of care activity is initiated
- o This may also be referred to "handover"
- o Examples:
- ~ A patient is transferred from an aged care/skilled nursing facility to an acute care hospital to manage a complex short term health problem, e.g. an episode of acute urinary tract infection, brochopneumonia
- ~ A patient is transferred from a carer/family to respite care to give weekend relief to the carer/family
- ~ A clinician provides after hours/overnight or weekend coverage
- ~ (A referral may result in short term transfer of care)
- - Long term/Permanent transfer:
- o A carer/family/provider/organisation agrees to and takes over the care responsibility of a patient permanently or for an extended period of time
- o Examples:
- ~ A provider (e.g. GP, PCP or specialist) takes over the care responsibility of a patient permanently because the patient wants to be cared for by a different provider; or when the primary/specialist provider retires
- ~ A rehabilitation facility/aged care or skilled nursing facility takes over the care responsibility of a patient when discharged from acute care hospital
- The "Transfer of Care" process also has two components:
- - Transfer of Care Request
- - o A Transfer of Care request form/document or message sent from the requesting provider/organization to the receiving provider/organization
- - Transfer of Care Fulfillment
- o Acceptance (after assessment of the request by the receiving provider/organization)
- o Request for more information (also after assessment). The type of information requested may include: financial, administrative and clinical
- o Rejection (with reasons given)
- o Recommendation of another more suitable provider/organization
Referral and Transition of Care Data Requirements/Data Sets
Referral
The following data requirements are identified from detailed analysis of data set of international referral programs (e.g. from Australia, Canada, NHS):
- Administrative Date:
- - Patient and Demographic information (including language, cultural, level of education, ethnic and religious information)
- - Contact details (including guardian and emergency contacts)
- - Pension / entitlements
- - Insurance status
- - Referrer details (provider and organization)
- - Referred to provider details (provider and organization)
- - GP/PCP details (who may not be the referrer)
- - Referral acknowledgement
- Clinical Data:
- - Presenting issues, symptoms, complaints
- - Reasons for referral
- - Alerts
- - Physical examination findings
- - Activities of daily living/self care assessments
- - home and safety assessments
- - Mental status assessment (e.g. behavioral, cognition, perception, mood, affect, sleep, memory, etc)
- - Medical history
- - Relevant family history
- - Relevant social history
- - Medication
- - Allergy/Intolerance and Adverse Reactions
- - Relevant investigations and results
- - Care plan/relevant care plan components
- - Current services/Requested services (including formal and informal [e.g. social clubs, churches, friends] services)
- - Priority of service requested
- - Patient consent to share information
- Sources:
- - Australia-Western Victoria Referral Dataset 2011-08
- - Australian Capital Territory (ACT) referral record
- - Australian (Queensland) mental health referral form
- - Canada Heart Failure Referral Form
- - NHS Referral - minimal data set 2012
- - Irish College of General Practitioner - Referral Template
Transition/Transfer of Care
- MU2 appears to specify that the Summary Care Record is to be used for information exchanges to support Transition of Care
- A summary of care record is specified in the MU2 Measure (2013 Nov) document to include the following elements:
- Patient name.
- Referring or transitioning provider's name and office contact information (EP only).
- Procedures.
- Encounter diagnosis
- Immunizations.
- Laboratory test results.
- Vital signs (height, weight, blood pressure, BMI).
- Smoking status.
- Functional status, including activities of daily living, cognitive and disability status
- Demographic information (preferred language, sex, race, ethnicity, date of birth).
- Care plan field, including goals and instructions.
- Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider.
- Discharge instructions
- Current problem list (Hospitals may also include historical problems at their discretion).
- Current medication list, and
- Current medication allergy list.
- The The Massachusetts Technology Collaborative has published a "Transfer of Care (CDA) Implementation Guide" to support Transfer of Care.
- This implementation guide specifies the following sections:
- 5.1 Advance Directives Section (entries optional)
- 5.2 Allergies Section (entries optional)
- 5.2.1 Allergies Section (entries required)
- 5.3 Assessment Section
- 5.4 Chief Complaint and Reason for Visit Section
- 5.5 Encounters Section (entries optional)
- 5.5.1 Encounters Section (entries required)
- 5.6 Family History Section
- 5.7 Functional Status Section
- 5.8 History of Past Illness Section
- 5.9 History of Present Illness Section
- 5.10 Hospital Discharge Diagnosis Section
- 5.11 Immunizations Section (entries optional)
- 5.11.1 Immunizations Section (entries required)
- 5.12 Medical Equipment Section
- 5.13 Medications Section (entries optional)
- 5.13.1 Medications Section (entries required)
- 5.14 Payers Section
- 5.15 Physical Exam Section
- 5.16 Plan of Care Section
- 5.17 Problem Section (entries optional)
- 5.17.1 Problem Section (entries required)
- 5.18 Procedures Section (entries optional)
- 5.18.1 Procedures Section (entries required)
- 5.19 Results Section (entries optional)
- 5.19.1 Results Section (entries required)
- 5.20 Social History Section
- 5.21 Vital Signs Section (entries optional)
- 5.21.1 Vital Signs Section (entries required)
Related Documents
Storyboards and Use Cases
- Referral and Transfer of Care Scenarios (from Jim McClay, MD)
Relevant References
- Data sets for Transfer of Care - keynote presentation:
FHIR Resources relevant to Referral project
- Link to FHIR Resources Proposals wiki:
- Link to FHIR Clinical Resources wiki:
- This is the link to a blog on Referrals created by David Hay on Referral:
